Understanding South Asian Mental Health

Dr Marianne Trent (: 00:00

Why might people from South Asian heritage feel overlooked in mental health or for that matter, physical health care? My guest, Zaynab Khan and I are looking at the unique social, cultural and familial factors that shape the health needs of people from South Asian backgrounds. We're also covering what we can do as healthcare providers to provide better, more effective support. Hope you find this so useful. Hi, welcome along. I am Dr. Marianne and it's lovely to have you here. One of the things I have loved best about this podcast is the kind of learning stuff that I didn't know before, and that is useful for me in being a provider of the podcast, but also useful for me when I'm thinking about client work that I do because I'm still a practising clinical psychologist, I still see client every day is a school day, and it's really important that we stay curious.

(: 01:02

You might be watching this episode because you are a health provider. You might be watching this episode because you are of South Asian descent yourself, and you would like to kind of feel seen, feel heard, and this is really one of the reasons that we are doing this podcast episode because Zaynab herself recognised that she didn't really have that experience herself. So I hope you will find it so useful. And if you do, please do drop me me a comment. If you're on Spotify, please do rate at the episode. If you're listening on Apple Podcasts, please do rate and review. I look forward to catching up with you on the other side. Hi, just want to welcome along our guest for today's Zaynab Khan. Hi Zaynab.

Zaynab Khan (: 01:41

Hi.

Dr Marianne Trent (: 01:43

Thank you so much for being here and for reaching out to me via LinkedIn

Zaynab Khan (: 01:49

Very much. I'm really excited to be here.

Dr Marianne Trent (: 01:53

That's really nice for you to say. Just before we were speaking on camera and in the preparation for this episode, we were thinking about how represented you felt when you were studying at university. Could you tell us a little bit more about what you mean about by that?

Zaynab Khan (: 02:10

Yeah, so it never really occurred to me as a thought until I reached sort of the final year. I think it was mainly prompted because I had sort of narrowed down an interest into doing research in psychology and one of my clinical psychology lectures was talking a lot about culturally appropriate care from a black and Afro-Caribbean perspective, being that was her ethnicity herself. I think it sort of just made me think that I hadn't seen anyone that looked like me throughout my degree in regards to staff, lecturers, researchers. And I also did a placement here while I was doing my degree. And again, within the staff that I liaised with, there was no one that looked like me. I think it just made me think that it would be given that culturally there's a lot of stigma that comes from South Asians around not talking about mental health and psychology isn't even a word that we use in our everyday language, very taboo topic. And I think one of the big things in breaking that down is to see representation of people that look like me and are South Asian in the space of psychology, especially within the uk. Obviously I'm not speaking about interally because when you go abroad there's obviously lots of different South Asian representation, but specifically within the UK I just haven't seen any. And even with my own experience of engaging with any mental health services, I've genuinely never seen anyone that's of a South Asian heritage.

Dr Marianne Trent (: 03:35

Yeah, thank you. That's really, really important. And before we hit record, you were saying that often in terms of demographics and monitoring forms, there won't be an option that feels like it represents you and your heritage. It will be just Asian. And that's kind of enormous, isn't it? That takes in India, that takes in Pakistan, that takes in China, that's enormous. So what areas are we thinking about specifically when we say South Asia?

Zaynab Khan (: 04:05

For me, when I was doing my own dissertation and my target population was South Asian women, I sort of in my head the kind of three large ones that come to mind. Obviously even within South Asia there's so many different places. You've got Tamil people, you've got Indian, Pakistani. For me, the kind of three main ones I was considering were Indian, Pakistani and Bangladeshi because for me they're the three biggest ones that I encounter within my everyday. But also I think statistically they are also the biggest ones within the UK too.

Dr Marianne Trent (: 04:37

Lovely, thank you. And the people watching or listening to this episode might be doing so because they are of this heritage or because they're wanting to learn more about how to support and understand the mental health of people with this background and with this heritage. So we'll try and speak to both aspects really, but what is different about the way that perhaps women specifically might have been brought up to understand mental health or to understand talking about feelings and troubles and things that are concerning them?

Zaynab Khan (: 05:14

So speaking from even personal experience but also just my toe dip into psychological research with this target population. One thing that's so different about South Asian culture specifically, I mean I'm Pakistani with my heritage, so Pakistan and India are quite similar in terms of their cultural practises. But naturally, I mean back in our origin countries, a lot of the time women take on more domestic roles. They're almost a lot more submissive in comparison, which is not necessarily seen as a bad thing in those cultures. I think often when you come to Western cultures, there's so much talk about gender disparity and bridging the gap between gender roles that it's almost seen like it's very negative sometimes within our culture, that's not actually a negative thing to take on those sort of domestic roles within the house and the gender roles and things. It's not to say that women shouldn't be empowered, it's just traditionally that's how we're sort of brought up I guess.

(: 06:09

And even one thing I found myself from doing my own dissertation is that where we get our news and our sources of information and our influences are sometimes slightly different. So there's a huge play on family influence passing down knowledge through generations. And I think that was something that I thought of massively when I was doing my dissertation of to target this population. Sometimes the mainstream way of the passing through psychological knowledge doesn't work. We don't naturally pick up leaflets, we don't naturally pick up things that you see maybe in doctor surgeries, but when it's coming from say religious influences or an elder in the family, they're often, especially ones that don't come from England, that have migrated here from other countries, that can be their primary influence for sources of information. And if it's coming through there that psychological knowledge isn't that important or mental health isn't that important, then that's going to be what stemmed through generation to generation.

Dr Marianne Trent (: 07:08

And it's making me think back to when I was working in a heart of Birmingham Cams service and I was working with lots of families who are of Bangladeshi heritage and some of the young women that I was working with there were really finding it problematic because often their parents didn't speak English or didn't speak English well enough to kind of be able to really get on board with their education with where they were at with the kind of things they were struggling with, but also how to translate the concepts that were coming up for them. And we were almost kind of trying to help them bridge quite to quite separate lives. It felt like that at home with that which their parents would approve of or understand whilst also trying to slot into a really western modern and modern Asian British culture as well. It was just not an easy fit for them and it actually did lead to lots of mental health struggles and kind of wondering who the real them is. Perhaps they feel most vibrantly alive when they are with their friends and they're feeling understood and they're able to be perhaps more exuberant or more carefree and then perhaps also really enjoying aspects of their culture and their family, but finding that that's much more limited and that, I dunno, their limitless potential that they feel within them is not necessarily in base.

Zaynab Khan (: 08:37

Yeah, I mean off the back of that, I think from a research perspective, the one thing that I thought of a lot during my final year was when it comes to, I think one of the reasons why South Asians are quite underrepresented in literature is because they're just hard to reach and it's not necessarily anyone's fault, it's more so they already have a lot of stigma and it's a taboo topic to talk about anything to your psychology and mental health, but then also to be approached by a western or a white Caucasian researcher, you're less likely to simulate with each other. So I think one of the things I mentioned to my supervisor was if I was to for example, go into a mosque or a community centre and say that I'm doing research, I'd probably get a slightly different reaction and response than if a white Caucasian counterpart was to go in and say I'm doing research.

(: 09:26

It's almost been very much shy away from that. I mean that's why I'm very, very passionate about trying to get South Asia representation in the psychology field, whether that's through clinical services or even through research, because you're not going to get to those participants through social media. You're not going to get to the ones well a fair representation anyway, because a lot of the South Asians, I mean I grew up in an area in Manchester called Long Site and that was very, very heavily South Asian dominant. And most of those community members aren't on social media. They've got no idea how they would never find research callouts, recruitment callouts. They're not going to respond to them. But if someone was to hold classes within a community centre or a mosque or a good or any place of worship or place of gathering, it's more likely to believe there's a credible source of information or a credible thing to participate in.

Dr Marianne Trent (: 10:17

Yeah, it's definitely food for thought, isn't it? To think about how we're putting together our research teams actually, and not to discredit or disparage any of the skills of anybody with any background, but thinking about actually authenticity and respect and the chance of actually successfully recruiting to research studies might be dramatically improved if we try to obviously make sure that we've got some representation of that background within our research team.

Zaynab Khan (: 10:49

Yeah, yeah, exactly. I think one of the, in regards to say psychological interventions, one of the points of interest that I remember Etra brought up, this was in response to black and Africa Caribbean individuals, mainly men. It was to do with implementing psychological interventions within barbershops. This was in America and that was part of the research that she had done, but it was to obviously kind of again, mask that stigma that's so often heavily held within different cultures, but it was about going into their places of comfort as opposed to trying to bring them into clinical environments and where people don't feel that comfortable. And that again made me think that the same really should be applied to South Asians. I think especially when you look at a lot of the statistics around South Asian mental health difficulties. I know that black and African Caribbean and also South Asians have two usually have the highest rates.

(: 11:42

But I think one of the reasons why also there aren't actually very many accurate statistics around South Asians is because they're not seen as an entity by itself. I think when you're trying to combine the whole of Asia, especially a content like Asia, the cultural differences between literally every country is so stark that it's almost next impossible to kind of assimilate them all into one and to get an accurate representation. So I think if the statistics were really done represented to each population within Asia, I think the statistics you'd get would be largely different than what's seen in all the different reports nowadays.

Dr Marianne Trent (: 12:16

Yeah, very, very interesting stuff. And if we're thinking about clinical issues and running a service and trying to get better engagement of less DNAs and more show up and more useful clinical interventions, I'm kind of remembering that actually it would be a bad idea to necessarily invite someone on a Friday afternoon if they knew would go to Friday prayers because they are not going to necessarily want to come, they're not going to be able to necessarily swing that to come by. Could you tell us a little bit more about that Zab?

Zaynab Khan (: 12:50

Yes, I think if healthcare providers are more trained to be more culturally attentive and almost be invited to soak up knowledge from the participants and from the clients that they're dealing with, it would just make from more balanced relationship. Because even something as simple as if you are given appointments on a Friday afternoon, just the act of then having to ring up, cancel it, rearrange. I know a lot of people, even myself sometimes just making that phone call is such a headache. So again, it's just putting another barrier in between that. If healthcare providers already knew, okay, for this client who's Muslim, let's say Friday afternoon, they're not going to be available, don't even bother making an appointment for them on that day, you're just making one less barrier and one less thing that they need to do. And you would definitely have a lot less DNAs than they probably already do at the moment.

Dr Marianne Trent (: 13:40

It almost does that. There should be a section on a form, doesn't there when you're filling it in, are there times that you definitely aren't available and then you just put that in the system so that you get it right first time every time.

Zaynab Khan (: 13:55

And even just things like, I mean it's such a largely spoken right topic now with regards to how say psychological disorders or mental health difficulties present in different cultures. But even things like obviously for me personally, religion plays a huge part and I know a lot of my immediate community members, religion is such a huge influence and I actually found through my dissertation work that really should be sort of almost used as a tool. So just really briefly speaking, I know that obviously the WHO recommends women to breastfeed for a certain amount of time. It just so happens that that recommendation is worded exactly in the grand as a recommendation when it talks about breastfeeding. And it made me think that, for example, for someone that's not born in England that hasn't been brought up maybe through Western education or isn't even familiar with the organisation WHO to note for a healthcare provider to then say, well culturally, if you look at your religious book, the grant, it says word for word what's written, there's more influence coming from that source as opposed to WHO for certain people.

Dr Marianne Trent (: 15:04

Absolutely. It's really important. And actually what we know with the WHO is that breastfeeding is supposed to give the child the best chance to thrive because it optimally meets their needs. We're going to have a separate episode where you and I talk about specifically breastfeeding and your research in breastfeeding for South Asian women. So if people are wanting to listen to that, please do listen out for probably the next episode of this podcast that's coming soon. But this is mental health care is more than just breastfeeding and the issues related to that. Could you give us any more insights into how, if we're trying to better serve the needs of the people that we are working with, what we might begin to think about? Dana,

Zaynab Khan (: 15:56

One thing that came up for me when I was just talking about this particular interest of mine with friends and family and things is where you actually do these interventions or where you promote the messages about looking after your mental health. I think one of my friends was talking about say for their mother-in-law who's probably a couple of generations older of Sikh religion. One thing that my friend was saying is that things like trauma-informed classes or group interventions or even just educational content in regards to what services to go to when you need support and things like that. I remember my friend saying was that if that was done in a good war where she goes every single Friday or every single day of the week anyway and has done for the last however many years, she's more likely to listen and to see it as a credible source of information and to actually take notice of what's being said than if she's visiting, say a GP surgery for a general appointment and there's leaflets or the GP themselves hands over a leaflet or brings it up during a consultation, even though we all know that the GP has qualifications and is educated and qualified enough to make those recommendations.

(: 17:10

But having it done in a place where they see as their sort of almost place of comfort and they've just been going there for years and years and years, there's just more credibility for those sorts of individuals than there is for those going to the GP surgery. I think it's about, for me, the one thing that I'm keen to know, and obviously it would just require the research to be done, but is to take the clinical interventions into more culturally safe spaces. I'd probably call it like community centres, mosques, places, other places of worship. And I think one thing I read was kind of similar to this is I think there is some research being done where they're sort of getting on board spiritual leaders of all different regions to almost be trained to deliver certain psychological interventions to see if that would make a difference. And I just from personal insight, think it would just from the credibility of the sourcing, but I think that should be widely looked into and widely tested as to whether changing who's actually delivering the intervention or delivering the message would help.

Dr Marianne Trent (: 18:10

Yeah, it's almost like we need some culturally representative outreach to really look at the demographics of the populations that we serve. So I know that my children go to a school that has 50% SO, and so how are we trying to, for example, in that school look at communicating in a way that represents that? And when we're delivering health services, how are we looking at people's heritage, their culture, their background? And we can't just expect people to come to us where we are.

(: 18:47

We can't necessarily just deliver a one size fits all service. And I've spoken on the podcast before that I know in Birmingham there was actually quite a high Chinese population and yet I had never in my almost four years of working in Birmingham ever seen somebody of Chinese heritage. And so is that the service, just not attracting people from that background? Is this a culture thing that they're not aware of the service or that there's kind of stigma against them entering the service? And I think, I guess that's where research comes in that it lets us look better at what we're doing and who we're serving and who we are not serving.

Zaynab Khan (: 19:30

Yeah, I think it's a combination of everything that you've said. I think services need to do more to engage with what's always considered as hard to reach. I actually don't think they're hard to reach. I just think the approach to reach isn't always correct, so then always going to be classified as hard to reach. But then there's also from the other side, the actual service users or the research participants, there is such a disconnect in what they even think psychological research is what they think the impact is. I think often with different ethnic groups when they're seen as such a minority, I think sometimes there's a risk of when it's words like research and we're exploring what's going on with your mental health, it can almost be seen as, oh, they're like a spectacle. It's seen as such a negative thing when I think, again, if more information was given in a more accepted way to that population group, they themselves would understand more what perspective you are coming from.

(: 20:29

I think it is just about different perspectives aren't almost aligning up, so you're always kind of butting heads. And I think one thing I think about a lot is that with obviously the day and age we're in, we move so much towards social media and online and making everything online because it's more convenient. But I think by doing that, you're also icing. A group that has no concept of being online has no interest in being online, especially ones that don't come from England originally within their own cultures back home when electricity isn't so in convenient. I know for example in Pakistan, when you go to villages and things, electricity isn't a thing. They've got power outs all the time. So for them being online just isn't the same as it is for say myself. So where I'm likely to see digestible content on social media and I'm likely to, I know how to use Google to find out information that I need. You've got a whole host of people that have absolutely no idea. So I think there's almost too much a reliance on moving towards this online life and making everything digital that's almost putting a lot of people at risk of being completely isolated from a lot of psychological services and are a lot of just healthcare services in general.

Dr Marianne Trent (: 21:44

That's a really good point, isn't it? Is we try and move everybody towards attend anywhere appointments, whether that actually is ideal for everybody. And of course if there doesn't feel like there's a safe space or if actually the home environment is part of the problem, it might not feel like it's appropriate to be talking about those issues from a remote setting. I travelled quite extensively in India in 2008 and actually it looked like to me anyway that anybody with mental health problems was just kind of left to fend for themselves. And I dunno if that's actually the case, but kind of culturally there may be a stigma towards people with mental health problems. Could you kind of illuminate that aspect a little bit for it?

Zaynab Khan (: 22:31

Yeah, so certainly, I mean for generations and generations and mental health isn't a topic spoken about within a lot of South Asian cultures. Being that I'm not Indian, I can't certainly say for Indian culture, but I know for Pakistani culture, although we share a lot of similarities, it is the same. It's just not spoken about. Speaking about women in particular, when it comes to things like postnatal depression or postnatal psychosis, anything like that, it's not even a thought. It's not even part of your aftercare. It's not even considered a thing. And if anything, within our culture anyway, there's so much emphasis put on being a good mother and being a mother within your community that almost, if you sort of defer from that gold standard, instead of looking at, okay, what's actually might be causing that? How can we help bring you back up to this golden standard?

(: 23:15

You just outcast it. It's like there's something wrong with you, you're not victim mother. And I know that, for example, a lot of, I read research recently on stillbirth, women that have experienced stillbirth, and I think this research was done in rural areas of Pakistan and the women that had experienced stillbirth, one of the things that they pointed out was that they were just seen as child killers. That was literally the words that were used and they were really, really stigmatised by members of the community. And I think that can very easily, although that research was done in rural areas of Pakistan, it can so easily be seeped into the uk when you get people that come from those backgrounds that move here and build their families here, that's just going to keep getting passed down generation, that sort of way of thinking. Absolutely. And

Dr Marianne Trent (: 24:03

How could we think that wouldn't affect somebody? Yeah, it's making me think about when I was at school and one of my good friends was Hindu, and for her and her mum, when they were menstruating, when they're on their period, they weren't supposed to go in the kitchen because it was seen as being unclean and they shouldn't touch food. That was, for me, hard to get my head around. I did loads of cooking at that stage in my life for my family. It doesn't necessarily matter if we understand it or agree with it, we kind of just need to be aware of it and understand that for the person we're working with that has importance. Is there anything else around, I dunno, menstruation or any wider issues for cultures and faiths and beliefs that perhaps somebody not of that heritage would not know about?

Zaynab Khan (: 24:53

Two actually come to mind. The first one is actually in relation to menstruation. So whilst within my culture and religion, that particular practise isn't a thing, I have heard of it before, but with regards to, I'm a Muslim, so obviously there's a period of time every year we'll be fast for 30 days. And as a woman, if you're menstruating at any point during those 30 days, you're not supposed to fast. You're given that time to have a break. But I know, and this has got nothing to do with the actual religion perpetuating it. It's not mentioned anywhere in religious scriptures, but it is perpetuated a lot by cultural beliefs that have just come from within families. Women within their families. A lot of them are often almost made to feel like they have to hide the fact that they're menstruating from male relatives or male family members and friends.

(: 25:39

And I've read stories before where women feel like they need to pretend that they are fasting just for the sake of saving face and things. I think stuff like that, obviously for someone that doesn't come from that culture and even the one that you mentioned would be so strange. And I think sometimes if those experiences are discussed within a healthcare setting, you always have the risk of the clinician or the healthcare provider almost seeing it as oppressive or using certain language like that, which I think can really mess with the narrative that's actually being told. Because for your friend, for example, that may not be seen as oppressive or as strange or anything of the sort that's just normal for them. But when they're then almost being fed by someone else who's not of the same ethnicity, heritage and no idea using words that's quite oppressive controlling it can really start to mess with the narrative in a really negative way.

(: 26:33

And the second one that came to mind when you mentioned that question was, I actually think this is quite widely spoken about now in comparison to what it was before, but for people of my heritage or people of my same religion, one of the things that we're invited to do from a religious perspective is almost make prayers under sort of like a whispered tongue. So to the outside it might look like we're just talking to ourselves, but it's almost making prayer. But with moving the mouth at the same time. And I know again from reading just stories online and from, I've got family members that work in the healthcare settings and things, one of the risks of that is when you have a patient or a service user that is so strongly connected to their religion, they might use expressions that are related to their religious beliefs or they might be doing that practise of making a prayer under their tongue, under their breath, but that also can be seen as talking to themselves, which obviously then starts to weave into different psychological disorders and mental health problems.

(: 27:37

And I think again, similarly to religious practises or cultural practises that then start to be seen as oppressive and controlling, you then also have the risk of just religious acts being seen as someone's talking themselves or they're hearing voices and things like that. So again, I think for a researchers point of view, a psychological practitioner's point of view, there has to be such a strong knowledge, or not even a knowledge, but just an acceptance of that there are such stark differences across different cultures that it's not always such a negative thing or don't always jump to the DSM and trying to match the things up. I think if there's more time taken just to understand what is the whole picture, what is their day-to-day life, what is the practise that they engage in? There'll be a lot more of a complete story, I think. Sorry to keep rambling on, but another thing that made me think just then is I remember that I have a friend that did a midwife course and one of her clients was, again, south Asian, didn't speak very good English, and so their partner was the person that was in the room with them as their almost representative and spokesperson.

(: 28:44

However you could tell that the partner wasn't really interested in any of the aftercare. And it came to talking about psychological care. And obviously I think my friend was trying to get across information about if you experienced this, if you feel like this, you need to report to this service and things like that. And for obviously the lady, no understanding of what's being said. And also her partner decided to not go ahead with an interpreter and took on that role himself. But obviously once again, when you allow things like that to happen within healthcare, you run the risk of they're not translating the right information across. And I think again, for that example, it just made me think, so for those two individuals, mental health care just wasn't a thought. It wasn't even something to consider. So for the gentleman who was supposed to be that woman's advocate and taking on that information, translating it in something that she could understand, he wasn't doing that because it just, and I don't think it was even in a malicious way. I think it genuinely was because for him it just wasn't something of important. So for me, that just brings up the importance of we have to sort of approach different target populations in a way that suits them.

Dr Marianne Trent (: 29:49

Absolutely. And I think as a service to vision issue in the service, I most recently worked in adult mental health. We didn't allow anyone to interpret other than our official interpreting service, just so that we've got our best chance, hopefully of engaging someone and not perpetuating problems. Zaynab, it's been absolutely fascinating speaking with you. Thank you so much for talking with us about this. And like I said, we are going to be doing another episode together where we talk more specifically about your research into breastfeeding with South Asian women. But thank you so much for your time today. It's been really illuminating and I hope this will be really, really helpful for people. If people wanted to come and connect or learn more about you or your research, where's the best place for them to do that? Is it LinkedIn?

Zaynab Khan (: 30:36

Yes, I would say in LinkedIn I do plan to have a Twitter account at some point down the line for research purposes, but that will come as of when, yeah, LinkedIn would probably be the best place to start with.

Dr Marianne Trent (: 30:47

Perfect. Thank you so much for your time, Zaynab.

Zaynab Khan (: 30:49

Thank you.

Dr Marianne Trent (: 30:51

Oh, thank you so much for your time. Zaynab, it's interesting that after we stopped recording and we're waiting for the uploads to happen, we were talking about imposter syndrome and how for Zaynab and for myself as well, sometimes you have those moments of, oh, who am I to be doing this? And I definitely have that. I'm definitely on board with that. And that is something that I spoke about in episode 1, 5 5 of this podcast thinking about imposter syndrome and how we can win that battle. But Zaynab was saying really from being quite a recent graduate to then suddenly being on this podcast and having a platform to explore these really key and important issues, it just takes a little moment to kind of catch your breath and kind of see where you're at. And I have that all the time as well. I might be about to do some TV work or to go live on the radio and you're just thinking it's this little old me, but it's really important that we feel a fear and we do it anyway.

(: 31:46

So yeah. With that in mind, if you've got an interesting topic that you think would make a great episode, please do get in contact with me. I would love your thoughts around this episode. Please do like, comment, engage, share this with anyone you think might find it helpful. Perhaps your staff team, perhaps your family, perhaps friends, people that you think might find it really useful or might feel seen might feel heard by this episode. If you are watching this as an aspiring psychologist, please do check out my books, the Aspiring Psychologist Collective and the Clinical Psychologist Collective. And if it's your time and you're ready for the next step, the Aspiring Psychologist membership, we are doing beautiful things in that we are helping people to up their game in research in CBT skills and formulation in interview skills, in application form skills in self-belief. People often say to me that it feels like I hold the hope for them when they can't hold it for themselves.

(: 32:50

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Jingle Guy (: 33:34

Psychologist, then let this be this podcast.