#9 Mental Health Interfacing with Arts and Ethnicity | with Kam Bhui

This episode introduces Professor of Psychiatry and new Wadham Senior Research Fellow, Kam Bhui! Kam has been a practising psychiatrist, he's advised the government on mental health policy, and he's active in research. We discuss taking psychiatry beyond merely medical approaches to mental health, challenges ethnic minorities face in accessing mental health care, Kam's life and career, and more!

If you'd like to get in touch with Kam, you can reach him over email at kam.bhui@psych.ox.ac.uk

Kam's publications can be accessed via his department page: https://www.psych.ox.ac.uk/team/kam-bhui

You can provide feedback on Wadcast at https://www.wadham.ox.ac.uk/wadcast

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Transcript

Thanks for joining me today. I understand you are relatively new to Wadham - maybe you could explain a bit about your role here and who you are at the college?

I'm a professor of psychiatry here at the University of Oxford, and I'm affiliated both to the Department of Psychiatry and the Nuffield Department of Primary Health Care Sciences. I've been here for about two and a half years. At Wadham, I've been a senior research fellow for the last six months, and my role is really to bring research into Wadham but also mentor early career researchers and support the research environment and infrastructure. 

And obviously it's a very exciting place to be because of interdisciplinarity, which is central to all the work that I do. And there are so many brilliant people who work from Wadham in areas that I have no understanding of, but I enjoy listening to.

Well, we’re very happy to have you here. You mentioned that your field is psychiatry. Could you explain what psychiatry is according to you?

Psychiatry is a branch of medicine. Often it's seen only as a branch of medicine. I think there is some confusion between psychiatry and psychology sometimes. But actually, more recently, there's been recognition of the importance of the social world, the arts and humanities in understanding patient experiences in mental health and well-being to provide overall better treatments.

More recently, psychiatry is also moving into prevention, preventing mental illness. We know that half of mental illness is already present by the age of 11 and three quarters by the age of 24. So really we should be preventing it early in the life course rather than waiting until later when people present in crisis.

So it's a combination of what's been called a bio-psychosocial approach, but also linked closely to the social sciences, arts and humanities, and more recently to geography, ecology and a number of other disciplines.

In psychiatry, there's also an element which is challenging, which is the interface with law, because we do treat people compulsorily sometimes when people are unable to make sense of the world or feel at risk or feel unsafe to themselves or others. So there's a strong interface with being aware of medico-legal practice as well.

The shift from a more medical model to a kind of broader engagement with humanities, social sciences and arts has meant that conventional psychiatric practice in the asylums, for example, which was very medicalized and focused very much on pharmacological treatments or ECT, has shifted so that people think much more about the social world, what sort of adverse childhood experiences people have had, what sort of place they live in, whether they are facing poverty, whether eating well or not, whether they have friendships. And all of that is now part of the assessment process as well as part of the intervention and care process.

It's meant that we have a better understanding of what's been called lived experience, that we are listening much harder to what people are telling us and trying not to simply impose a biomedical model on their distress. For some people, that biomedical model is perfect. It works well for them, but for many they are looking for other things, other ways of finding support to help them out of difficult periods of distress.

Some of what you are describing would be what I would automatically place more in a kind of counselling or psychology bracket. So how do you understand the relationship between psychiatry and psychology or broader mental health care?

So mental healthcare is very interdisciplinary. Psychiatrists, as I say, are trained as doctors primarily, and then specialize in mental health care. They're primarily trained to treat physical and medical illness and then learn to understand mental illness also. But psychiatrists are also trained in psychotherapies as part of the trainees’ experience, and also have to engage with the social world. They do also do research and teaching and are involved in training for doctors of the future.

Psychologists specialize in mental health specifically and look much more at cognitive mechanisms. They're not trained as doctors, so conventionally they didn't prescribe, although recently there has been a change in that. Conventionally, they weren't involved in medical legal practice either. But there are opportunities now to do that. Psychologists are probably better trained in research earlier on in their careers, actually, than doctors are because they're so busy learning so much material. 

But essentially they offer different aspects of the same intervention, if you like, or the total system of care that we offer to patients; and then nurses are an additional specialty. And then social workers as well are very, very important in making sure that welfare is protected, and liberties are protected.

One of the key skills required in working in mental health care is the ability to work with different disciplines and manage the resulting tensions between them. These different disciplines often have very different worldviews on what mental illness is, with psychiatrists typically having a more biomedical focus on the body and organic disorders. They have a responsibility to ensure that when they see someone with mental illness, they are not suffering from a physical illness that is causing the apparent mental illness.

What led you to choose psychiatry in particular as your specialism?

I knew I wanted to be a psychiatrist as a medical student as soon as I had started what at the time was called The Firm, working with a particular consultant on a particular group of inpatient services, outpatient services, and community services. The reason I fell in love with it was because it was the first specialty which properly sat down and talked to people and really understood their whole world, their biography. We ask a lot of questions about people's lives, their histories, their childhoods, their parents, where they live, and in many specialties that isn't the case.

I confess my original career choice was to be an orthopaedic surgeon. But very soon as I went through my training, I fell in love with psychiatry and indeed I'd set up my training scheme before I’d even qualified in medicine. And I've never looked back really.

The reason I love it is because it offers so many opportunities to better understand the human mind philosophically, but also practically, to apply new research to improving treatments. When I was training, there were very few research projects going on in mental health care, and now there are so many. We still need more. We’re well short but we can improve treatment and care if we have much more research which can improve our understanding of the mind and brain, but also improve our treatments overall.

Another reason I love psychiatry is because of this interface with so many other disciplines. Some of my projects are very much sociologically orientated looking at patient experience. Others work with the creative arts, practitioners and other disciplines. So there's a possibility to go into many, many different areas of practice and then there are differences in terms of specialties within psychiatry.

There are many subspecialties, for example, child/adolescent psychiatry, liaison psychiatry working in the general hospital setting. You can work with the elderly, in which case you have to be a very good general physician as well as a psychiatrist when people have multiple health problems. Some people go into psychotherapy and stop doing psychiatry as such, they go only into a psychotherapeutic service and others work very much sociologically.

For example, one of my jobs I did as a consultant included working with street homeless people. And my main task there wasn't to rush in and diagnose and treat, but was to work with people to get them off the street and make them safe, make sure they had the right nutrition and the right welfare system around them, and then begin to provide appropriate mental health care. 

So psychiatry offers lots of opportunities. And I guess we're all different and different people like to way work in different ways and have different sort of sensibilities. It offers many opportunities for people who come from very different backgrounds and have different interests.

Thanks. Maybe we could drill in a little bit on some of the detail. You mentioned that you have worked with homeless people in your prior practice. Is there a case that you worked with that was particularly impactful to you, obviously leaving out any identifying information? Is that the kind of question I'd be happy to address?

Yes, certainly.

So the homeless service that I worked in in East London was extremely interesting and obviously we still have a problem with homelessness. And I think people don't really understand what it is that drives people to become homeless.

What I learned from working in that service was that most people who are homeless are there because they've had terrible early life experiences. They've escaped those experiences, they've ended up street homeless.

Maybe they've made some bad decisions, but they've also not had the people around them and the support to help them. So there are many, many cases I can think of. The one case I will raise, which has definitely been the one that's been most significant in my career, and it's the one as a medical student, in fact, that I was persuaded by, is a young man who was from Nigeria who was sleeping on the streets under a bridge near the Walworth Road.

As a medical student, I was fortunate in that my team and the consultant there encouraged us to go and spend time with patients out on the street. So I spent a lot of time looking at where he slept, how he lived, what welfare services he needed, and helping him negotiate them. And I realised how difficult it was. What a difficult system we have in place. All of that also was reflected in the work that I then later did in the homeless service.

But many people with multiple problems are often diagnosed as mentally ill when the real issue is that the social world around them is unable to adapt to their needs. In that instance, that young man living on the street in Woolworth, he had this label of schizophrenia. I couldn't see any psychotic symptoms. I didn't think he had schizophrenia, but by having that label he was able to get some care.

He was also a young black man, obviously from Nigeria. And we know that in high-income countries, people who are from ethnic minority groups, particularly black people, have a higher incidence of psychosis and severe mental illness, and they have more difficult pathways into care and more coercive care. I'm sure that shaped my entire career, that one case, because that's the area of work that I've been involved in for 30 plus years, trying to understand why that happens and what we can do about it.

If you could share one aspect of the answer or the understanding you've come to, to helping people in these situations, what would you share?

I think the essence of helping is to have a strong therapeutic relationship, and that means being very self-aware as well as taking account of the individual's cultural, ethnic heritage and background, and being willing to see that as a necessary part of your care rather than it being an extraneous factor that is irrelevant to care.

So one of the challenges we have in healthcare is we're preoccupied by our checklists and what we need to do in accord with good practice and governance. And we spend less time really understanding the person. The therapeutic relationship then is very challenging, if individuals don't trust you as you're a figure of authority, or (they) fear the institution because it has powers to detain them, for example.

Building trust in a therapeutic relationship is crucial, especially when working with homeless individuals and those who are marginalized or living in precarity. Listening to their stories, understanding them, and allowing yourself to be affected by them is an essential part of the treatment process.

I learned a lot about psychotherapy and psychoanalytic psychotherapy during my psychotherapy training. In these forms of therapy, you allow yourself to be entangled in the person's world while managing boundaries, experiencing their distress, and become motivated to help them do something about it.

Could you go into more detail about what it has looked like for you to build trust with somebody who has come in not really trusting you or trusting the system? Is there a particular case or example you could talk about?

I would say that practically every person with severe mental illness or mental illness who comes to a service is terrified of what's happening to them. They're terrified about what the doctor is going to say. They're concerned about what interventions are available. They're concerned there may be no intervention. So I suspect that there's always a power imbalance there anyway, with every patient.

But in terms of building trust, what's important is to be self-aware, to balance the power relationship, recognize the power dynamic, and take time to hear the person's story, their biography, and their particular experiences, their understanding of what's happening to them, their identity, their explanatory model, it's been called, before leaping in with any explanation of your own.

And that in itself, being able to give a testimony and have someone listen to it and believe you, and have someone who's really interested in you rather than the disease or the condition that you're looking at is very important to building trust. Then honouring that relationship and maintaining it and continuing to do the best you can for each person is what leads to ultimately a better outcome in the long term.

So I'm interested in your own story. You have had a particular career trajectory, what has surprised you about the way that your life has unfolded and that career trajectory that you've taken?

Almost everything I would say. I started life from a fairly humble background, living on Council estates in London and Aylesbury, and I got to grammar school, went through sixth form. I decided I wanted to do medicine quite early on, rather oddly, mainly because we had lots of medical books at home and I used to spend hours looking at them and gazing at them. I could have done maths, I could have done English, I could have done other things as well. But I was very scientifically focused. I enjoyed the sciences in particular.

I got to medical school and I didn't imagine I'd be an academic. I didn't imagine I'd go into research. I didn't even know when I started I was going to do psychiatry, really. It's only when I did the actual clinical attachment that I realized that's what I wanted to do. I did some pharmacology –  an intercalated BSc and I thought maybe I'll be a pharmacologist within medicine at some stage. And then I did a psychotherapy training and that changed my whole career- my understanding of what mental health care and healthcare actually more generally meant, I was very lucky.

I was fortunate in having some brilliant mentors and colleagues who worked with me and encouraged, nurtured, and gave me opportunities. I was also lucky a few times with grants and opportunities, which allowed me to secure research grants on my journey and enabled me to go into research while completing my clinical and psychotherapy training at the same time. 

And I think it's still unfolding, that sense of awe and surprise in the world, constantly learning about yourself as well as the world we live in, finding new ways of thinking about mental illness, doing research that is revealing and empathic. It has always been a powerful motivator for me. And then being able to apply it in the real world - it's not theoretical. It's actually something that helps you support people in the real world, increasingly through policy, systems change, and organizational change.

So although initially as health care professionals, people work with patients specifically, later on in their career, they're also helping shape policy and through research, shifting policy as well.

I want to ask you two questions off the back of that. First is, what do you think your background has provided in terms of a particular lens through which you approach your work?

Well, I guess my background is, as I say, from fairly humble background and origins. I'm also of Sikh Punjabi heritage. My parents were migrants. I was born in Kenya. They lived in Kenya for many years. And so I obviously have the experience that migrants have of settling in a country. The experience of discrimination and poverty in a particular space makes you very humble, makes you also pretty resilient and determined to continue.

It means you have to be very skilled at managing all that adversity around you and managing hostility and still maintaining good relationships and not being taken hostage by these feelings, which can happen. And coping with that. So I think all of that has given me an insight and lived experience, if you like, into what it's like for people who have health problems and live in precarity.

I hadn't thought about my interest in ethnicity until, as I said, I started medical school and working, and that's when that came more to the fore and it continues, although I have many other interests as well now, but I'm sure all of those demographics, backgrounds, cultural, religious heritage backgrounds are relevant.

And part of when I was growing up, sacrifice and self-service and serving the community was very much a part of the way I was brought up. And it's part of the religious heritage as well that I inherited.

You mentioned that psychiatry in general, but maybe aspects of your work are really plugged into policy and law. If there's one change you could make in mental health policy or law, what would that be?

So that's probably two questions. The policy and the law.

The law is a very, very topical question. For decades we know there have been ethnic inequalities in the levels of care provided under the Mental Health Act. So people are detained and people particularly who are poor or unable to voice, give voice and defend themselves and minorities in particular. I've been trying to understand that for a long time.

I'm currently doing a project funded by NIHR looking at the Mental Health Act and people's experience of being detained, particularly ethnic minorities being detained in seven different cities of the country. From that experience, we're going to co-design potential interventions to reduce those levels of detention. And that work has been commissioned by the Policy Research Programme for Government.

So it has a direct line back into policy to shift policy. I've been involved in advising policymakers specifically on mental health legislation when it's been reformed in the past and there is a bill going through Parliament currently, and I was an independent adviser to the Joint Scrutiny Committee for the Mental Health Act.

Now, changing the Mental Health Act alone is not going to fix everything. But we know it's an important signal for changing the system more generally, for having more resources, for doing the right thing, and shifting other policies linked to mental health care.

So the policies that I think that we need to shift in mental health care, there are probably two. One is to focus much more on prevention at an early stage of life. The second is a much more personalized, culturally grounded, embedded system of care that really takes account of all the things I've been talking about - the person's experience and biography and history. 

You would think this was happening anyway, but it's not. And particularly when we meet people who are from different cultural backgrounds or social backgrounds, it's very, very important to be aware of that. These are the two shifts I'd really like to see.

Policy is a complicated and difficult thing to change. There are critical windows in which change is possible, and it is necessary to take many stakeholders with you. This is where research comes in, as it constantly generates research to always be in a position to influence policy at that critical moment.

So what does the future look like for you? What are you hoping to work on or achieve over this next period at Wadham?

What I've been working on is what's being called a broader framework for understanding inequalities in health status and our passage through the health system and in public health.

So the frameworks I've been using are what's being called syndemic frameworks and eco-social frameworks. Essentially all they mean is that there are multiple adverse webs of causation in the environment, including place and geography. They all interact with personal dispositions and lead to poor health, and we've got to be able to intervene at all those levels.

All of my projects are deep dives into one or other of these particular paradigms.

So I’ll offer two potential projects, one is the Mental Health Act project that I've described. The other project I'm working on at the moment is understanding adverse childhood experiences of diverse communities, different ethnic backgrounds, ages, genders, LGBTQ plus, neurodiversity; and properly understanding the range of experiences they have that are traumatic and how it affects their lives and how they develop illnesses, physical illness, or mental illness, and how they may actually be supported to not develop mental illness.

And we're doing that through a very nurturing, supportive process involving creative arts methodologies and artists working with young people to gather their experiences either through theatre, through dance or performance, or through photography. It's a gentler way to gather their experience than asking them questions which can traumatize them.

And it's a way of informing policymakers about things they’re not listening to, practitioners about things they're not listening to. And these young people are then going to co-design interventions for public health prevention;  for schools, for teachers, for employers, and also, we hope there'll be a ‘serious game’ being developed which will embed some principles of narrative exposure therapy in order to help people who've had serious traumatic experiences, for them to realize what's happened to them and begin to seek help.

That's the biggest project now linked to that, we know that adverse childhood experiences also lead to physical health problems and shorten your life expectancy by up to 20 years if you have had lots of them.

So some of my projects are also looking at physical health and multi-morbidity,  and coming in the reverse direction, seeing how adverse childhood experiences affect that outcome and having a better understanding of how we can provide care in the health system and in the social care system for people with these complex problems. At the moment they are complex, and they don't fit our existing systems. We don't have the systems to properly support them.

So what I'd like to see is change in the entire health service to cater for people with complex mental health problems, with complex identities, and we can more appropriately then provide better support and care and improve quality of life in the long term.

Are there any events or publications or anything else that you would like to point people's attention to with respect to the work that you're doing here? Or more broadly?

So there are several systematic reviews and original database research studies demonstrating those ethnic inequalities and continue to explore how they operate. And I think that that's a good resource.

Despite me saying I've been doing this for 30 years, I know the literacy on this is very poor and people don't know this data exists. That's one thing I'd point people to. 

The other are papers including papers in Nature, Communications and some of the journals on the creative arts and mental health interface and science and arts working together to improve health and wellbeing in all age groups. And there are many areas we're working on.

There is, in fact, a policy dissemination conference coming up on September 14th of this year, and we'll be having many other events over the course of, I hope, my long tenure here at Wadham.

Maybe I can get some of the details of the papers and include them in the show notes. 

Yeah, sure.

I'm aware that you're going to the States to do an event with Wadham alumni. Can you share more about that?

Yes, I happened to be visiting the States for a meeting of the American Psychiatric Association talking about research ethics. And while I am there, I was invited also to attend a meeting at New York for Wadham Alumni. I'm going to be talking about digital interventions in the mental health landscape and bringing to fore particular aspects, including creative arts and mental health.

The Attune study that I've already mentioned, where creative arts practitioners are working with young people to gather their experiences, is going to generate some interventions, public health resources and a serious game. 

There is also a newly funded program from NHR, which is building digital museums for young people, because the preliminary pilot work shows that young people are craving to learn about other people's lives and biographies as a way of understanding themselves and forming connections.

And so that's a really exciting program which will have a massive impact, we hope, in preventing mental illness, but providing a resource for those who are either too frightened to seek help or don't quite understand what's happening to them, but also those who are on waiting lists who aren't able to get help quickly.

If people wanted to get in touch with you, how would they best do that? 

Yeah, I'd welcome people getting in touch to have a chat about any of the work that I do, to discuss projects they want to do, collaborations, and any interfaces. And just to drop me an email. 

I'll include that in the show notes. Final question from me would be based on your time at Wadham so far, what is your favourite thing about the place?

I love the serenity of the place and having an opportunity to meet people from diverse disciplines socially, but also in scholarly settings in a very, very gentle manner so that it's possible to have those interdisciplinary discussions. So that's been absolutely marvellous and just having a place to come and think and work with other people and learn a lot about things I know very little about.

Well, I thank you so much for your time, Kam. It's been great to talk to you.