Doctor Dinesh Bhugra became interested in psychiatry while dissecting cadavers at medical school in Pune, India. From the inside, the bodies looked very similar, but the people thought and behaved very differently, he thought. He became fascinated with the forces that shape differences in behavior, and eventually focused on culture.
“Most of my active research is about culture and mental illness,” said Bhugra, who previously served as president of the Royal College of Psychiatrists, the World Psychiatric Association (WPA), and the British Medical Association.
Bhugra, who is also emeritus professor of mental health and cultural diversity at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London, has spent much of his career working to improve community mental health. He has worked on gender-based interpersonal violence and has worked to reach underserved populations, including refugees, asylum seekers, the elderly and the LGBTQ+ community. Bhugra, the first openly gay president of the WPA, has also been candid about how prejudiced it is and discriminatory policies impact mental health and suicide rates among LGBTQ+ people.
Live Science spoke with Bhugra before Festival How Light Enters in London, where he will discuss mental health, how we define “normal behaviour” and whether such definitions are actually useful benchmarks in the context of psychiatric care. His talk will took place on September 22.
Related: New ‘brain signature’ discovered linked to multiple psychiatric disorders
Nicoletta Lanese: You emphasize that psychiatry deals with a complex mix of biological, cultural, and socioeconomic components. Do you think those concepts are well integrated into modern psychiatry?
Doctor Dinesh Bhugra: I think there is still a gap. Often as doctors, we don’t have enough time to explore everything. I’ve seen it in places like India, where consultations are very short. So, you know, a patient starts talking, you give them a prescription — but that’s it. [psychiatric care] much more than that.
What I find in clinical practice is that most patients can live with their symptoms as long as they have a job, money in their pocket, relationships and a roof over their head. As doctors, we focus on symptom eradication or symptom management. So there is a tension there, which is much worse in some countries where resources are inadequate. I know colleagues in India who might see 50, 100 patients a day, so you give a five-minute consultation. Whereas in the US and UK you might get a little bit more time, but often it’s not enough. [to really get to know a patient].
Another thing that has caught my attention in the last few years is the idea of identity. We all have many micro-identities, and it’s like a mosaic. Depending on who you’re talking to, pieces of that identity come out — whether it’s gender, religion, sexual orientation, profession. And quite often in the clinical setting, we see identity as “the patient,” not the individual.
And I think that needs to change. … It’s important to look at individuals as individuals and not as a collection of symptoms.
NL: I know you do a lot of work around training the next generation of psychiatrists. I’m wondering what you see as good ways to help them develop that cultural understanding?
Database: First, everyone has a culture. And part of cultural competence is understanding your own culture, its strengths and weaknesses. And then, you know, looking at the individual… through that lens, to understand “Why do they feel this way? Why do they express their distress this way? Do I really understand them?”
You can’t be an expert in every culture, but [what’s crucial is that] you realize that this person is different [from others even within their own culture and geographical setting].
“It’s important to look at individuals as individuals and not as a collection of symptoms.”
Doctor Dinesh Bhugra
Equally important, if you don’t know something, be prepared to admit it. “No, I don’t know this, but I know someone who might be able to educate me, tell me, teach me,” whether it’s a community leader or someone’s family. Family will tell you whether this person is behaving “normally” or “abnormally.” And that’s the crux of the matter: how culture defines what is deviant, what is normal, what is acceptable.
NL: On that note, can you give us an idea of what you might talk about at HowTheLightGetsIn festival?
Database: It’s about “What’s normal?” And again, from a cultural perspective, what’s normal in one culture may not be normal in another. Particularly from a psychiatric perspective, we need to be sensitive to those variations and variables. And it’s also important to consider that what’s normal today may not be normal in a year’s time; what was normal 50 years ago may not be acceptable, may be considered deviant now.
One example I often give in the context of cultural variation: In the United States after the Stonewall riots, in 1973 homosexuality was removed from diagnostic and statistical manuals. So overnight, millions of people were “cured”; they no longer had mental illness. So how do we as clinicians and researchers and interested members of the public make sense of these kinds of things that are sometimes thrust upon us — that this is “deviant,” that this is unacceptable.
Culture influences cognitive development. Culture influences how we see the world. So, we might see the same mosaic from different perspectives. And part of the challenge is, how do we reconcile those two different views? Any definition of “normal” changes.
For mental disorders in particular, it is even more relevant because we have so few objective tests. So understanding the individual experience becomes crucial in the context of family, community, culture, society, national and international norms.
Related: ‘Fossil virus’ embedded in human genome linked to psychiatric disorders
NL: In gaining such cultural understanding, how can aspiring psychiatrists recognize the biases they are learning?
Database: I always start by saying, “Everyone has at least one bias.” So the challenge really is, how do you figure out what that is and what do you do about it? That’s the starting point in the conversation about being aware of your own biases, both conscious and unconscious, both visible and invisible.
One of the other things I’ve been writing a lot about lately is the idea of the “other” — we create the “other” because it gives us identity. I’m not like you; I’m different, you’re different. How do we embrace those differences? How do we make sure that I’m aware of, whether it’s gender bias or religious bias or age bias or socioeconomic bias or skin color bias?
In clinical situations, this is especially important because we can get caught up in unreasonable stereotypes, which give us shortcuts, but are problematic. No two patients with similar symptoms will respond or explain [their experience] in the same way.
NL: What role do you think psychiatry plays in confronting norms that may be bigoted or dangerous? For example, I think of the criminalization of homosexuality.
Database: Psychiatry as a discipline and psychiatrists as professionals have a key role to play in advocating for our patients. Often, patients are not in a position, or may not have the capacity or ability to advocate for themselves. And we are privileged, both in terms of professional experience, context, learning, but also as members of society. [in that psychiatrists hold status and influence]So, we have a dual role in that advocacy to policymakers, to research funders, and to service funders. … We are well-positioned to be advocates.
But it’s important for us to learn from other cultures about how they do things differently, perhaps with better results. Perhaps do so in the context of working together to overcome obstacles — working with religious leaders, working with community leaders, working with teachers, and so on. So how do we learn from each other?
NL: Do you have any final thoughts you’d like to close with?
Database: I will end with two key messages. First, mental health is an integral part of health and should not be seen as someone else’s problem. We all need to look after our mental health and wellbeing so that we can look after our physical health, and vice versa.
The second takeaway is that health cannot be seen in isolation. Education, employment, housing, equity, health, they are all interconnected. And across all ages from childhood to adulthood, there are external factors that will affect our health, including mental health. And we need to be aware of this from a policy perspective, but also from a [the perspective of improving] prevention of disease and mental stress and improving mental health and well-being.
