nhs working with pakistani service users 2011 pp low a4.pdf

A member of Cambridge University Health Partners

Working with Pakistani serviceusers and their familiesA practitioner’s guide

Shama KanwarStuart Whomsley

HQ Elizabeth House, Fulbourn Hospital, Cambridge CB21 5EF.T 01223 726789 F 01480 398501

www.cpft.nhs.uk

NHS Working with Pakistani Service Users 2011 PP.qxd:A4 16/8/11 09:07 Page 20

AcknowledgementsThe authors would like to thank the following people for their assistance in producing this document:

Martin Liebenberg for his support in developing the document’s content and direction.Dr Asif Zia for his contribution to the section on service users travelling to Pakistan. Professor Zenobia Nadirshaw for reviewing a draft of this document and offering supportive comments.Ahmed Ijaz Gilani for allowing us to use his article.Janice Hartley for her advice on spirituality and mental health.

About the authorsShama Kanwar has worked in community relations for over 14 years both at a strategic level advising SeniorManagement on community and equality issues and at grassroots level with specific hard to reach BMER groups. Shamahas worked nationally as an independent facilitator in an initiative involving Police Officers and Muslim communities oncommunity cohesion and has been instrumental in setting up BME Staff Support networks in three organisations. Shama iscurrently working as a Community Development Worker based in Peterborough working with Black Minority Ethnic andRefugee communities, running community based projects that raise awareness of mental health and how to accessservices. Shama also works at length with healthcare practitioners to engage with service users and their families to gainan understanding of the role culture plays in the treatment and recovery of the individual.

Dr Stuart Whomsley is a clinical psychologist who works in an Assertive Outreach Team. In this role he has a longestablished working relationship with a number of clients from the Pakistani community. He is involved in bothcommunity development initiatives locally and good practice guidance for his profession nationally.

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Hilty, A. 2010. Western Psychology,Eastern Cultures – Mismatch? Ezinearticles. Available at:http://ezinearticles.com/?Western-Psychology,-Eastern-Cultures---Mismatch?&id=4130088. [Accessed 21 November, 2010].

Gilani, A. I, Gilani, U.I, Kasi, P.M,Khan, M.M, 2005. Psychiatric HealthLaws in Pakistan: From Lunacy toMental Health. PLOS medicine, PublicLibrary of Science. Available athttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1215469/. [Accessed 29 November, 2010].

Aap ki Awaz. Our Voice: ThePakistani community’s views on mentalhealth and mental health services inBirmingham, 2007. Published byRethink. Available at:www.mentalhealthshop.org/products/rethink_publications/our_voice.html.[Accessed on 29 November, 2010].

Sajid, A. 2003. Death & Bereavementin Islam. The Muslim Council forReligious & Racial Harmony. Availableat:www.mcb.org.uk/downloads/Death-Bereavement.pdf. [Accessed on 3 March 2011].

References Introduction

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How do you capture ‘culture’ accuratelywhen it involves people’s visible andinvisible values and beliefs? Is it possibleto be completely impartial when writingabout your own cultural background asI am doing? Do the experiences I’msharing in this work truly represent thePakistani culture? Furthermore, is it‘fair’ or ‘ok’ to produce guidance onthe culture of a whole nation,particularly one that is as rich anddiverse as the Pakistani culture?

These questions were considered whendeciding to produce this guidance andweighed against the need to raiseawareness amongst practitioners ofhow a service user’s culture may impact on their engagement withservices and their subsequent recovery.Pakistan is made up of different statesthat vary significantly in language,dress and ‘culture’, and it would take a very detailed piece of work to fullycapture the customs of all the statescomprehensively. Considering thebackground of the Pakistanicommunities settled in Peterborough,which reflects the cases used in thiswork as reference, it seems morerealistic and reasonable to say that this guidance has been produced onthe Pakistani culture but with ‘aparticular focus on the Mirpuri andPunjabi communities’, which are themajority Pakistani communities settledin Peterborough.

It is almost impossible to measure theexternal input people have during theirlives that shapes their sense of identity,and to pinpoint the extent to whichsomeone lives their life according tovalues passed down through cultureand the impact of their currentenvironment on them, if that is

different from when they weregrowing up; as in the example of aperson coming to live in the UK as an adult. As demonstrated by thispoint, it is risky to make generalisedassumptions about culture, as culturalvalues may be enforced by familiesand communities but interpreted byindividuals. It is also important to notethat there may be cultural differencesacross generations as there may be aparent or grandparent that came tolive in the UK as an adult and theirchildren and grandchildren may beborn and brought up in the UK,therefore their experiences would bevery different from each other. Anexample is where taking the childrento the cinema may be seen asappropriate by young parents ofPakistani origin but may be frownedupon by older members of the family.

For the reasons mentioned above, thisguidance should not be used as anauthority on all things Pakistani but asa tool that can assist practitionerswhen working with individuals andtheir families in the context of havingpositive regard to the person’s culturalvalues and beliefs to build relationshipsand aid recovery. The individual andfamily should be given the opportunityto express in their own words whattheir cultural and religious1 identitymeans to them as it will be unique foreach person.

The small sample of anonymised casesused in this guidance resulted fromfamily work that I have undertaken inmy capacity as CommunityDevelopment Worker for BMERcommunities. I was able to engagemore freely with families as my ownbackground is Punjabi and I am fluent

Culture is a shared, learned, symbolic system of values,beliefs and attitudes that shapes and influencesperception and behaviour; an abstract mental ‘blueprint’or ‘code’ and must be studied ‘indirectly’ by studyingbehaviour, customs, material culture (artefacts, tools,technology), language, etc.

Professor Kathleen Dahl

1 Although culture and religion are different things, people may talk about them as one or use the terms interchangeably.


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in Punjabi and the surrounding dialectsof the area and work with localfamilies where practitioners felt thatadditional support with language andculture would be beneficial for theservice users and their families. Thecases have been included to illustratethe points being made rather than as ameasure of success, which varied fromthe service user being discharged withvery positive results to very littlechange in condition.

Shama Kanwa

Additional comments from thesecond author

This has been a hugely rewardingproject to be involved in that is largelythe work of Shama. Working withclients and families from the Pakistanicommunity has raised my curiosityabout their culture at both a personaland professional level. Being culturallyblind, though not as bad as racism isstill not good, it is akin to neglectcompared to racism being abuse. Theimportance of cultural awareness is

two fold. First, it enables a betterunderstanding and formulation of theperson's psychological distress andconfusion together with its impact onfamily and carers. Secondly, it increasesthe likelihood that interventionsoffered will be successful as they aretaking account of the cultural factorsfor and against change.

In working with clients from thePakistani community, including peopleborn in England, it has struck me howtheir understanding of mental illnesshas greater components of the role of the body and the spirit in theseconditions, but a lesser appreciation of the mind, than when working withclients of long standing Englishheritage; a challenge for anyonewanting to carry out standardCognitive Behavioural Therapy. Thishas confirmed my bias to suggest that a holistic approach that takesaccount of mind, body and spirit isusually the best.

Stuart Whomsley

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‘pot’ out of which they would pay fortheir wedding. Sometimes the moneymay be used as a deposit for a housewhich may be rented out to generatemore income for the extended family.

What should clinicians do when apatient or the family or friends believethat jinn are the cause of symptoms or unusual behaviour?

In such cases where patients aredeemed to have a medical, psychiatricor psychological disorder but are notreceptive to medical explanations,patients can be encouraged to 'hedgetheir bets’ by taking the prescribedtreatment while continuing withspiritual therapy. This double strategymay be the best hope of securingadherence to prescribed treatments.

There may also be the additional veryimportant benefit that patients andtheir families are willing to enter intodiscussion about the other therapiesthat are being tried. Whilst theseusually consist of repeated readings of certain sacred texts, the concern is that in desperation some familiesmay turn to exorcists who inflictphysical harm in an attempt to free the individual from possession –sometimes with catastrophicconsequences.

It is very important, therefore, toestablish channels of communicationswith the patient, the family and anyspiritual practitioner whose help isbeing sought.

Wider issues around accessingservices

According to a Rethink project focusingon the Pakistani community’s view onmental health and mental healthservices in Birmingham, successivestudies have shown that people fromBME groups experience relativelyhigher levels of mental illness than thewhite British population. Some of thismay be attributed to socio economicfactors such as the experience ofracism, unemployment, homelessness,social exclusion, poor physical healthand living in deprived areas.

Other findings of the research foundthat stigma of mental illness needs tobe overcome to enable mental healthas an issue to be accepted and openlytalked about. People may be ignorantor unaware of the facts of mentalillness and communities may not knowwhich services are available to them orhow to access these services once theydecide to recognise and ‘face theproblem’. It was also found thatcultural and language barriers canhinder people from taking up servicesand there is a ‘keep it to yourself’approach adopted across thecommunity where mental health issuesare concerned.

Conclusion

As discussed during the introduction,the aim of this document is tohighlight important parts of thePakistani culture that will assistpractitioners in working with serviceusers and their families from Pakistanibackgrounds. We have used ourexperiences of working with familiesto highlight the issues raised, and thesubsequent input that was given tosupport the delivery of a service thatwas appropriate. In addition, somecultural values have been explainedsuch as attitude towards relationships,timings and diet that may also assistpractitioners to gain a betterunderstanding of some of the factorsthat may be driving a particularattitude or behaviour.

As the service user will be thinking inholistic terms, including faith, somaticsymptoms and perhaps mental illnessas understood by ‘Western’practitioners, it is important forpractitioners to take a similar approachand elicit an open response about howthe service user and/or their familyviews the situation, even if only clinicaltreatments are available. This willenable the practitioner to learn aboutany alternative treatments beingaccessed such as spiritual healers.

Culture, faith, eastern, western –ultimately these are labels we attach toeach other to help us make sense ofsomething that is new or different, thereal success when working withpeople is if we can understand whatthe labels mean to the individual andhow they interpret their own identity,only then can we truly deliver a servicethat focuses on and responds to theneeds of the whole person.

Points to consider…

The first and most importantstep is to ellicit, in an open andnon-judgmental way, the serviceuser (and if appropriate thefamily’s) ideas, concerns andexpectations.

The second step is to recognisethat symptoms attributed topossession by jinn are commonlymanifestations of a mentaldisorder that will most likelybenefit from medical treatment.

The third step is to appreciatethat, although the patient andrelatives may obviously haveinterpreted symptoms incorrectly,beliefs that are strongly held (andoften socially convenient due toperceived stigma) will be difficultto alter at a time when anxietiesare running high.


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spiritual healers will encourage familiesto think about the possibility of amental illness where they feel that theirfull criteria for possession is not met.

The role of the Islamic therapist in casesof possession, who must have strongfaith in Allah, is to expel the jinn. This is usually done in one of three ways –remembrance of God and recitation ofthe Qur'an (dhikr); blowing into theperson's mouth, cursing andcommanding the jinn to leave; andseeking refuge with Allah by callingupon Allah, remembering him, andaddressing his creatures (ruqyah). Somefaith healers strike the possessedperson, claiming that it is the jinn thatsuffers the pain. The practice of strikingthe person is deplored by Muslimscholars as being far from the principlesof Islam. The general approach ofexpelling evil spirits by convincing themto leave is similar to the passage in theNew Testament (Luke 8:24) where Jesusexpels demons from a man who ispossessed. Though it is not oftenspoken about publicly the Church ofEngland and the Catholic Church retainMinistries of Deliverance for exorcisms.Within mental health services over thelast twenty years there has been agrowing awareness of the spiritualcomponent to the mental illness withthe development of organisations suchas the Spiritual Crisis Network.Although the individual or their familymay believe there to be a spiritualcomponent to a condition, this doesnot always mean they believe theindividual is possessed by a jinn. Abelief in spells and evil eyes could meanthat a mental as well as physical illnessis viewed as having a spiritual elementto it other than possession therefore itis important to engage with theindividual and their family to ascertaintheir views on the condition and itscauses as this often proves instrumentalto recovery.

Through working with families thatbelieved there to be a spiritualcomponent to the service user’s mentalhealth, it has been important not limitourselves to medical treatment, and toconsider the wider options ofpsychological therapies as well asfamily work with those closest to theservice user.

The differences of cross culturalunderstandings of mental health can

be appreciated within the context ofmodels of how beliefs in Asia aredifferent from the ‘Western’ viewssuch as those illustrated in the table below which has been developed from an article by Hilty on culturaldifferences:

In this context it can be difficult to aska person to focus on themselves as anindividual during cognitive behaviouraland solution focused therapy , as theymay consider this a selfish act or maysimply not be accustomed to thinkingof themselves as an individual entity.This echoes some African cultureswhere one is seen to exist throughothers in their family and community.

Often blood ties are seen as moreimportant than money therefore it may not be unusual for a parent tocontrol their children’s finances untilthey are married and sometimes evenafter marriage. On the surface thismay be seen as a selfish act butparents may put all the money theycollect from their children in a joint

Asian Western

Core values of ancient China such ashierarchy, moral development,achievement and social responsibilityas well as a dualistic model medicalsystem based on principles of balanceand harmony.

Pathology driven, overlaid by thevalues of ancient Greece such asindividuation, self control and selfefficacy.

Cognition is abstract, paradoxical,circular and indirect. The universe isseen as a web of infinite connections(holistic cognition).

Cognitive process is one of logic,critical analysis and direct and rationalthought in which the universe isconceptualised as the sum of its parts(analytic cognition).

Socio-centric model of self which isformed within the social context anddefined by it at any given moment. Asense of self requires emotionalconnectedness.

Ego-centric model of self where eachperson’s sense of self is consideredautonomous and unique, individuatedand largely consistent regardless ofcontext.

Orientation is one of interactionism,in which the presence of complexcausalities is assumed and the focus ison relationships and reactionsbetween persons or the person andthe surrounding environment.

Orientation of the individual is one ofdispositionism, in which the internaldisposition of the individual is theprimary consideration.

Health is inclusive of all aspects –physical, mental, emotional, spiritualand social, conceived of as a state ofharmony and balance, illness beingtermed as ‘patterns of disharmony’.

The model of Cartesian duality ofmind and body is adopted where thetwo are separated, hence mentalillness being treated in many areasindependently of physical and spiritualsymptoms.

Pakistani culture and communitiesIslamic influence and culture

Religious beliefs and values have astrong influence on society and itsculture. Even a person of long-standing English heritage who is anatheist is likely still to hold beliefs andattitudes that are Christian in origin as a consequnce of growing up in asociety with a substantial Christianfaith history.

Islam is the main religion practised in Pakistan with around 97% of thepopulation being Muslim and theremaining 3% made up of Christian,Hindu and Sikh communities. AlthoughShari’ah (Islamic law & jurisprudence) isnot strictly practised in Pakistan, Islamgoverns people’s personal, political,economic and legal lives on a dailybasis making religion an importantfactor to consider when working withPakistani families, as the lines betweenfaith and culture are often blurred.

Pakistani culture is made up of amosaic of Islamic traditions and isinfluenced by Hindu culture, which isevident in the way weddings arecelebrated and events such as ‘Basant’(spring festival). Pakistani Muslimfamilies or individuals within them canbe either culturally or Islamically drivenand still identify themselves asPakistani and Muslim. Variations caninclude naming traditions where afamily driven by culture may choose anUrdu name such as Shabnam (morningdew) for a female child and Sahil(seashore) for a male child. A familywith a more Islamic outlook may givetheir child an Islamic name such asMaryam (Mary) for a female child orMuhammed for a male child althoughcultural and religious names may begiven together. Social areas such as the level of free mixing may also differdepending on whether a family ismore cultural or religious as well as the level of access to media in thehome such as Hindi film and television.

Unlike Christian families where thegap between practising and nonpractitising Christians is much wider,the majority of Muslim Pakistanifamilies identify quite strongly withtheir faith and will practice it at somelevel. As a minimum, families may

have a pork and alcohol free diet andpray or read the Holy Qur’anoccasionally whereas a practisingfamily will adhere to the five dailyprayers, observe hijaab (Islamic dress)and may not allow free mixing. Addingto this an influence of the Hindu andBritish culture in Pakistani familieshighlights the level of diversity thatmakes up ‘Pakistanis’ and people froma Pakistani background.

Pakistan and Azad Kashmir

Azad Kashmir is a self governing stateto the North-East of Pakistan which is administered by the PakistaniGovernment. The largest City in AzadKashmir is Mirpur which isneighboured by the province of Punjabin Pakistan. The largest Pakistanicommunity in Peterborough is theMirpuri community coming fromMirpur and the surrounding areas,followed by the Punjabi community.

As Mirpur has no airport, passengersfrom the UK will often use Pakistan’sIslamabad airport from which Mirpur is a 2 to 3 hour journey.

Pakistani dress

When we first meet a person we willbe making rapid judgements of whothey are and where they fit in to ourunderstanding of society. In this rapidaccount the clothing a person iswearing can play an important role.The clothes that we wear can be astrong marker of personal identity,age, class and culture.

The national dress of Pakistan isshalwar kameez which is a long topwith loose, baggy trousers. Men mayalso wear a skullcap and women willusually wear a large scarf with theirshalwar kameez.

In the UK, men often adapt to the‘Western’ style of dress unless theycome to the UK when they are older,where the preference is to wearshalwar kameez. Women will wear a variety of dress ranging from theshalwar kameez worn in the traditionalway or ‘anglicised’ by wearing trouserswith a long top, to totally ‘Western’dress. In recent years there has been an

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Where possible, allow the serviceuser to describe in their ownwords how they view theircultural identity.

This is important considering thecultural diversity of Pakistanifamilies depending on how‘traditional’ or ‘Western’ they are,how much they are influenced bypractices deriving from the Hinduculture and how closely theypractice the Islamic faith.

Gaining this information will helpyou to recognise the level ofimportance the individual’scultural heritage holds for themand how this may influence theirtreatment and recovery.

Point to consider…

Some people from Azad Kashmirmay identify themselves as‘Pakistani’ on ethnic monitoringforms but will considerthemselves as ‘Kashmiri’ or from‘Azad Kashmir’ in everydayconversation.


increase in women choosing to wearthe ‘hijaab’ which is an opaque pieceof material wrapped around the headand held secure with a pin. This can beworn with shalwar kameez, ‘Western’clothes or then with a jilbaab which isa long coat like dress that reachesdown to the ankles. Pakistani dress islinked to modesty which is a value ofIslam and is usually maintained bypeople of Pakistani origin however they may choose to dress.

Gold jewellery

Pakistani communities will havediffering views about men wearing gold jewellery as some men may wear a gold ring, bracelet or chain andothers believe it is not permitted inIslam. Women however areencouraged to possess and wear goldjewellery as a sign of wealth and goodstatus. It is traditional for women towear gold bangles and other jewelleryon a daily basis and daughters will begiven gold jewellery by direct familymembers upon their marriage whichstems from the notion of givingsomething that can be used duringtimes of hardship. Often gold jewelleryis passed down to daughters anddaughters-in-law.

Diet and food

One of the most common markers ofcultural identity is the individual cuisinethat a culture has developed. This isone of the most accessible ways that a person from one culture canexperience and value that of another.Pakistani food fits within the widerculinary framework of Indian food and as such is something that hasfamiliarity and value in the UK.

Food is an industry that excels inPakistan even when the economy isdown, perhaps because this is one of the few areas where people fromlower socio economic groups candemonstrate control and discretion, as affording a car or going on a lavishholiday would not be achievable.

Pakistani food is rich in flavour, spicesand high in cholestrol with sweetdesserts containing a high sugarcontent. The use of meat and chickenis very common at mealtimes and itwould be considered offensive to serve a completely vegetarian meal ata dinner party or to guests, although a vegetarian accompaniment would be acceptable.

Culturally, food is linked to hospitality,seen as a sign of good living and thesharing of food as an act of kindness.It is common to serve food at festivalsand gatherings and is given away tothe poor during times of happinesssuch as a wedding or the birth of achild or grandchild.

Guests will be encouraged to share ameal and may have food put on theirplate and offered seconds or thirdsdespite the recipient’s protest, asillustrated in Parveen’s case. Babies andchildren are seen as healthy if they areon the upper end of the normalweight range and may often receivecomments about their healthdepending on how much weight theyhave gained or lost, which is incontrast to the ‘Western’ culturewhere it may seem inapproriate tocomment on a baby or child’s weight.

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Parveen

Parveen is in her teenage years and has been diagnosed with anorexia. The immediate and extended family’s diet consists mainly of Pakistani food,particularly those that are rich in spices, flavours and cholesterol and thefamily equate being ‘big’ with being healthy and well. The women of thehouse insist on cooking and serving food to Staff whenever they visit, thisbeing seen as a sign of hospitality and graciousness. This includes beingserved fried food with fizzy drinks early in the morning and three coursemeals when visiting to support Parveen to eat during lunch visits. Thefamily often insist that everything on the table be sampled including largequantities of fried food.

Parveen’s family were encouraged by her dietician in supporting her tostick to a food plan that would slowly introduce eating back into her dailyroutine again. The family continued to offer Parveen other foods at thedinner table despite being explained that this would hinder her progress.The family have different ideas about the ‘truth’ regarding diet that wasnot shared with Parveen’s clinicians; and seemed to attempt to introduceextra foods to Parveen whenever the opportunity presented itself. Thishindered Parveen’s progress and she often spoke about an atmosphere inthe family home in which they did not speak openly about problems andissues and how difficult it was for her to share things that were on hermind with her mother or other family members. After months of support,Parveen’s family are now taking part in family therapy with a view toadmitting her into hospital if her weight does not improve.

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Spirituality and understanding of mental illness in Pakistani communities

Mental health and Pakistani communities

In view of the above account ofmental health services in Pakistan,understanding of mental illness inPakistani communities is significantlydifferent from the models commonlyused in the UK. As well as mentalillness being considered in a holisticcontext including environment andphysical health, it is also understood in the context of spirituality.

Belief in supernatural forces isprevalent in Pakistan. Jinn (anglicisedto genies), evil eye and spells are partof daily life in Pakistan and spiritualhealers can be found in most marketsand street corners.

According to Islamic belief, jinn are realcreatures that form a world other thanthat of mankind. There is little detaileddescription of jinn in the Qur'anic andProphetic literature. The term ‘jinn’ isderived from Arabic ijtinan, whichmeans 'to be concealed from sight'.

Although they reside in what are inessence parallel worlds, humans and

jinn are believed by Muslims, to havesome ability to influence each othertowards both positive and negativeends. Satan (who is within the Islamictradition a jinn and not an angel, andhence has the choice to disobey) is themost infamous of the jinn and isprimarily concerned with enticinghumanity to forget its divine origin.According to Islamic writings, jinn livealongside other creatures but form aworld other than that of mankind.Though they see us they cannot beseen. Characteristics they share withhuman beings are intellect andfreedom to choose between right andwrong and between good and bad,but according to the Qur'an theirorigin is different from that of man.

According to Islamic scholars, a personunable to think or speak from theirown will, experiencing seizures andspeaking in an incomprehensiblelanguage may be possessed by jinn;however, more often than not aphysical cause can be found for theunexpected behaviour and many

Excerpt from ‘Psychiatric Health Laws inPakistan: From Lunacy to Mental Health

By Ahmed Ijaz Gilani

There are many players and factors involved in the access, provision,delivery, functioning, and uptake of mental health services in Pakistan.Awareness about mental illness is still poor in Pakistan. Such illness isgenerally attributed to supernatural causes—it is considered to be a curse,a spell, or a test from God.

Those who experience mental illness often turn first to religious healers,rather than mental health professionals, since patients and their familiestend to have great faith in these healers. Religious healers use verses fromthe Qur’an to treat patients. Next, patients turn to traditional andalternative healers, who are also popular in Pakistani society.

Help from the mainstream health-care system is usually sought late in thecourse of the illness; however, the referral system is inefficient and,particularly in the case of individuals who are mentally ill, patients are usuallytaken by their families directly to tertiary or specialist hospitals, rather than toprimary-care practitioners. It is, however, important to note that manymental illnesses can be treated and managed by primary-care practitioners.The private sector also plays a major role in providing psychiatric care. Forthose who can afford it, private psychiatric care is an option frequently used.[Excerpt from section on Mental Health Infrastructure].


Weight gain or loss in adults is viewedin a similar way.

More full bodied actors and actressesare common in the Pakistani filmindustry and weight loss, even whendone in a healthy way is sometimesviewed as a sign that something iswrong physically in the form of anillness or due to mental distress suchas problems in the family; althoughyounger people may identify morewith the ‘Western’ ideals regardingweight and may therefore be moreaware and conscious of gainingweight. In Parveen’s case the familywere concerned that the extendedfamily or community members wouldthink there was something wrong inthe family and that was the reason forParveen’s weight loss, and her lack ofeating was a cause for tension duringfestivals such as Eid.

In many Asian cultures includingPakistani cultures, foods areconsidered in terms of ‘hot’ and ‘cold’.This is not concerned with thetemperature at which the food isserved but rather the ‘effect’ on thebody, which can be harmful if foodcombinations are not balanced. Forexample, almond nuts are ‘hot’ wheneaten as a nut but ‘cold’ if soakedovernight in water providing the outerlayer is removed. Mangoes areconsidered ‘hot’ and should beconsumed with yoghurt milk (lassi) asthis has a cooling effect on the bodytherefore neutralising the heat in themangoes. Although not so prevalent in Pakistani communities, Hinducommunities associate certain foodswith mental and emotional states suchas meat with aggressive behaviour, aswell as recognising the physical ‘hot’and ‘cold’ effects on the body.

The sense of time

‘I remember visiting mygreat grandmother’s housein Pakistan as a child andnot having a clock in thehouse, even if there was itwould have been no good to her as she couldn’t tellthe time.’

How time is understood and valueddiffers between cultures. This is anarea that industrial businesses havehad to pay close attention to in orderto function efficiently in differentcountries. Some cultures valuepunctuality, meticulous planning andstay committed to them. Countriesthat typify this approach, technicallyknown as ‘monochronic’ are the USAand Germany . In contrast there arepolychronic cultures which includePakistan. In these countries multipleactivities occur at once, there is greaterflexibility around time with the focuson the relationship being moreimportant than promptness or the jobin hand.

Timing is very relaxed in Pakistan,particularly in the more rural areasaway from office based companies.Social visits to family and friends aremade unannounced as manyhouseholds have an ‘open door’ policywhere the door is left unlocked duringthe day for people to visit. The mainstructure to the day is around the fivedaily prayers and timings may be givenaround these, for example, ‘I’ll see you after dhuhr’ or ‘make sure itsbefore maghrib’.

Weddings and such functions are veryrelaxed affairs with no set start timeand guests arriving and being servedat various times. Although thestructure of the day is relaxed, thereare customs around visiting a familywhere there has been a birth of a child or a death as soon as possibleand offence could be taken if a familymember or friend were not to visit onsuch an occasion. Similar rules apply to inviting a newly married couplearound for a meal after their wedding,as the first few months are usuallytaken up by being invited by familyand friends to meals where delicaciesare served and gifts given to the newbride and groom.

Accommodation

It is customary in Pakistan to buy andacquire land so that property can bebuilt and extended as the family sizegrows. Often, a house will start offwith two or three rooms and will thenbe extended as per the family’s needswhich is particularly the case in morerural areas. In more suburban areaswhere it is not possible to extend due

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Psycho-education is key whenworking with Pakistani familiesaround eating disorders to helpthem to understand thecondition and support therecovery of the individual.

Talking therapies around eatingdisorders often involve individualand family work. Families may notbe comfortable with talkingabout the family and its dynamicsas this would normally be doneon a one to one basis or with asmall trusted same sex group.

Families will most likely feel underpressure from the widercommunity and may hide theproblem rather than talk about it openly.

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Pakistan. Clozapine is not a commonlyprescribed medication in Pakistan andthe monitoring procedure differs tothat in the UK. The user will need toobtain for themselves a blood test at ahospital or private laboratory for a fullblood count. They or a family memberor carer then phone the drugcompany's monitoring service andinform them of the results. The drugcompany will then deliver to wherethey are staying and will ask to see theresults printout in confirmation beforehanding over the medication.

Pakistani languages & interpreting

The term ‘Pakistani’ includes a mosaicof different cultures. The nationallanguage is Urdu and is spoken in thepublic sector as well as English. Manyother languages are spoken in thedifferent regions of Pakistan such asPunjabi, Siraiki, Sindhi, Pashtu, Balochi,Hindko and Gujurati and the diversityin languages is often reflected indifferences in culture, diet andtraditions. It would be true to say thata significant number of people living inmore isolated or rural areas of Pakistanmay not speak Urdu.

The majority of Pakistani families settledin Peterborough speak Mirpuri orPunjabi. This is an important point tokeep in mind as not all those that speak

Mirpuri or Punjabi will be comfortablewith having an Urdu interpreter eventhough Urdu is the official language ofPakistan. It may be more appropriate torequest an interpreter that specificallyspeaks Mirpuri or Punjabi, as manyinterpreters registered to speaklanguages from Pakistan will almostalways have a good knowledge ofUrdu. Mirpuri and Pakistani Punjabispeakers will use the written form ofUrdu if they need to write somethingdown in their language.


Not all people with a Pakistani background will have a good practicalknowledge of Urdu, therefore it is important to ascertain the particularPakistani language or dialect the service user speaks at home.

Mirpuri and Punjabi are the most popular Pakistani languages inPeterborough. Both languages use the written form of Urdu as there is nowritten form of Mirpuri and Pakistani Punjabi speakers will not be able toread or write the written form of Punjabi.

Most interpreters that speak a Pakistani language will also speak Urdu.

Service users may wish to have a same sex interpreter.

Where the service user is unable to read or write, they can be involved inusing pictures and photos from South Asian media to tell their story.Examples of alternative media include the Asian Bridal magazine, MAG the weekly and the Jung, Nation & Watan newspapers as well asmainstream media.


to lack of space, a property adjacent tothe family home or nearby will bepurchased to keep extended family asclose as possible. In Pakistan it is stillnot widely accepted for a couple tomove out of the husband’s family homeand in such cases this will only happenwhere there is a family rift ordiasgreement. The young couple isalmost always seen as being responsiblefor the separation, for not showingtolerance and patience to their elders.

In the UK, many families follow asimilar model. Families in the CentralWard of Peterborough have preferredto extend small properties to allow forgrowth over moving into larger homeswhich would mean moving out of thearea. Extended families living in thesame home or nearby are respected byother community members as they areseen to be practising true Pakistani

values. For this reason, families oftenresist the urge to separate aftermarriage as they are aware of thestigma associated with moving away.Where couples do separate aftermarriage, significant time is oftenspent at each other’s houses to showthat the family is still a strong unit. Thiscustom usually only applies to sons asdaughters can be married outside thearea but would have the sameexpectations placed on them in theirhusband’s home. This has implicationsfor when clinicans may consider that itwould be benefical for the serviceuser’s mental health to move tosupported accommodation either tohelp their recovery or to manage withrisk issues. Such a move away from thefamily home could produce anadditional stigma in addition to that of mental health, making it an evenharder move to achieve.


An appointment with a clinicianmay not be kept if a familymember or friend arrives at thehouse unannounced as it wouldbe considered rude to ask theperson to return at a differenttime.

Families with very traditionalvalues only plan their calendar fora number of days, therefore it isnot unusual for an appointmentsent weeks in advance to beforgotten or to be confused witha different date. The service useris not being awkward, they simplymay not be used to this,particularly if they do not haveschool age children to providestructure to their day or are newarrivals to the UK.

If embarking on an extendedpiece of work with a service userand/or their family, it may beuseful to emphasise theimportance of keepingappointments, attending on timeand notifying someone if they cannot attend.

8 13

Localities

The majority of Pakistani families inPeterborough are from the Mirpur areaof Azad Kashmir that have beensettled in the UK for over 50 years. In line with national trends, there are a significant number of PunjabiPakistanis followed by people fromother areas such as Sindh. ThePakistani community is concentratedaround the Central Ward areaexpanding out to surrounding areassuch as West Town, Dogsthorpe, NewEngland and more recently Netherton,with a few families living in other areasacross Peterborough.

Travel to and from Pakistan

It is customary for people to keep closeties with family in Pakistan as well asfamily in and around the UK andannual holidays to Pakistan for periodsof four weeks or more are common tomake the cost of travel worth while.Popular reasons for travelling toPakistan apart from visiting family areto familiarise children with their culture,marriage and to promote the traditionalcustoms and values when living in theUK. Visits to Pakistan are usually ahighlight for people of Pakistani originas they may not have regular holidaysas understood in the UK. Familiesspend time shopping for their family inPakistan and family members in the UKtend to visit to say goodbye, making ita time of happiness and anticipationand this was the case for Maliha whobenefited immensely from seeing herfamily in Pakistan for the first timewithout her abusive husband.

Clients from the British Pakistanicommunity frequently travel toPakistan to meet their relatives and for holidays. These trips to Pakistancan last for a number of months andtherefore raise the issue of treatmentwhilst there. When in Pakistan somepeople visit shrines, faith healers andalso see a psychiatrist.

It is prudent to advise clients that whilstthey are in Pakistan they continue withthe medication they are taking and notchange it unless advised to do so by theUK treating team. This is to preventclients from suffering relapse or return

of their illness which would spoil thetime they are in Pakistan. It is worthnoting that there are differences inpractices, medications available anddoses of drugs. It also might not bepossible to continue the medicationstarted in Pakistan.

Pakistan also has a high rate ofHepatitis and other water and bloodborne infections. Caution is requiredwith those medications that areadministered by injection e.g. Depot.Service users and their families shouldbe advised to buy needles fromreputable sources and to dispose ofthem safely.

For clients who are on medication thatrequires blood tests it is important toconsider the following: The blood testsmay not always be reliable, dependingon the type of health care facility inwhich they are taken. There are issueswith used needles being repackaged,so appropriate care should be taken in sourcing clean ones. People takingClozapine will need to register withthe Clozapine monitoring service in

Maliha

Maliha had been diagnosed with depression and had taken medication forher condition for many years. She came to the attention of secondary careservices upon the birth of her child and separation from her husband whichfollowed shortly after. Maliha has other children and had endured domesticand financial abuse from her husband for many years. Although she hadbeen visiting doctors for a long time, Maliha’s husband had been allowed tointerpret for her and she was never seen alone to have the opportunity toshare her ordeal with anyone. Maliha’s eldest daughter was still under 16 butnot in any form of education or training and took on most of the householdchores and looking after her younger brothers and sisters.

I found Maliha very low, isolated and scared of telling anyone about herproblems, spending most of her time feeling very tired and down. Malihasaid she found it difficult to undertake any household chores as her bodyached afterwards. I interpreted some basic information about depression toher in Punjabi and worked in a pictorial way to help her understand herdepression and how the mental state was linked to her physical stateresulting in the pains and aches. Maliha improved over the coming weeks asshe was able to talk about the issues around her marriage in a culturalcontext. During a review, we found a number of things that had beenmisinterpreted such as Maliha hearing water when she had actually beendescribing her depression and how she felt that she was drowning in hersadness. Maliha responded very well to the basic techniques aroundmanaging her depression and within a few months was able to take overmany of the household chores from her daughter and went to visit herfamily in Pakistan and was subsequently discharged.

Pakistani communities in Peterborough


The concept of family

In Pakistani communities the concept of ‘family’ is the basis of socialstructure and individual identityencompassing more than the nuclearfamily and immediate blood relatives.Family is a term that is used todescribe distant relatives as well asthose acquired through marriage andincludes people from the samebaradari (tribe), friends andneighbours. Some people may alsorefer to people from the same villageor general area in Pakistan as part oftheir family. Amongst Pakistanifamilies, there is a greater sense that a person does not only representthemselves but is part of the ‘family’,therefore successes and failure, praiseand shame can be shared by the familyin the wider sense.

Marriage

Who and how we choose to formcouple relationships with, marry andhave children with has a strongcultural component. The relativeweighting of determinants such aspracticality or romantic love differsbetween cultures, within them overtime and varies between individualswithin that culture.

Traditionally within Pakistani cultures,marriage is seen not only as the unionof two individuals but is seen as analliance between families, or often areconfirmation of alliances within thefamily in the broader sense outlinedabove. Within traditional families,suitable partners that meet the family’sexpectations around family, tribe,wealth or education, are suggested tothe individual by a respected memberof the family to seek their opinion onthe match. This process can work inthe reverse order where the individual(more often the male than female)suggests a partner to their parents orother respected member of the family.Providing the person being suggestedmeets with the family’s expectationsand neither of them is alreadybetrothed, the marriage is usuallyarranged in the traditional way.Arranged marriages often have verypositive outcomes and are not to beconfused with a forced marriage.

Sometimes individuals are forced into a marriage where one or both partnersdo not consent. In this case theindividual’s choice is overlookedbecause of the perceived benefits ofthe match to the wider family such asreinforcing family ties, culture or foreconomic reasons. Such arrangementscan be the cause of much distress and there are services available to help people suffering in thesecircumstances.

The process of choosing a partner orhaving a ‘love’ marriage is becomingincreasingly popular in the lesstraditional families living in the largercities where dating or marryingsomeone outside the ‘family’ is nowalso becoming acceptable.

Marriage and mental illness

Where a young family member has adiagnosis of mental illness a marriagemay be sought as a way of solving theproblem and/or share the burden ofcare. This could also be considered as a social inclusion approach whenmental illness is not seen as anexclusion from normal life roles suchas being a partner or parent.

Parents may take the decision to find a partner in Pakistan where a poorerrelative would agree to marry their sonor daughter to enhance the family’seconomic status, particularly with a son where it is felt that he would beable to earn money in the UK andsupport the family back home. Thefamily in Pakistan would then rely ontheir son once he was in the UK toprovide financial support for theirsibling’s weddings and to provideelectrical goods such as laptops andtelevisions in addition to a monthlyallowance. This has been a recurringtheme with families I have workedwith and has been the case for Sadia and Tariq (see case study page 10).

This arrangement may lead to furthercomplications once the spouse comesto the UK and the severity of the illnessis realised by the partner from Pakistan.Where the woman arrives fromPakistan, she often has no way of sharing her experiences of living in a country where she does not


It is not unusual for extendedfamily members to have inputinto matters relating to theservice user.

Sometimes an older child is usedto interpret and talk aboutproblems. This is seen by thefamily as acceptable because anolder child is encouraged to takeon adult duties from a youngage; however, it is important forpractitioners to consider thechild’s wellbeing and use aninterpreter for anything but themost basic interpreting.

Immediate family members ofthe service user can sometimesfeel pressurised by familymembers in a position of poweror authority such as a parent,uncle, aunt or in laws of theservice user. These familymembers could live nearby,elsewhere in the UK or abroad.

9

Pakistani families and communitiesOften titles significant in thecommunity or religious sense may be used such as ‘Haji’ if someone has completed the Hajj pilgrimage or ‘Choudhary’ if someone is alandowner or in a position of power in a village setting system; althoughChoudhary has more recently beenused as a surname.

Names

Names and their meanings are verysignificant in the Pakistani culture. Firstnames are considered to influence theindividual’s personality and life andparents or older family members mayrename a child if they develop ongoingill health or other problems as thename may be seen as ‘heavy’ for theindividual; ‘heavy’ in this contextwould be if the definition of the namehad a negative connotation such as‘sacrificer’ or ‘oppressed’ and also ifthe name was that of a historicalfigure that had lived a difficult ortrying life. Families that are moreculturally driven would usuallysubscribe to this notion.

12


Considering the namingcombinations, it is not unusualfor members of the same familyto have different surnames, forexample a father may be calledMohammed Atif Khan and hisdaughter may be called SaminaBi. Samina would not inherit herhusband’s surname uponmarriage.


understand the language or customswith a husband who is unwell andliving with extended family and lookingafter the household. This may lead thewoman herself to experience mentalhealth problems such as depressionand anxiety and may only come to theattention of services during apregnancy and childbirth where mentaldistress may be picked up in the formof post natal depression.

In the case of the male partner comingto the UK, there may be much familytension between the male and hiswife’s family as he may feel tricked and betrayed once he realises the extent to which his wife may be ill. Due to the perceived stigma andshame of a failed marriage, the wife’sfamily may take over the responsibilityof their daughter’s household includingcooking, care of children and offerfinancial assistance to ensure themarriage is not dissolved once thehusband receives permission to stay in the UK permanently. This was verymuch the case in Sadia’s family as hermother had pushed for Sadia to bemarried to a maternal cousin and felt it would be further shame for her inparticular if her daughter was divorced.

The conclusions to be drawn from thisare obvious: where an arrangedmarriage is to occur between a personwith a diagnosed mental illness fromthe UK and a person from Pakistan,the potential partner from Pakistanneeds to be made fully aware of thecircumstances so that they can makean informed choice. This is not onlythe most ethical position, meaning themarriage remains arranged rather thanforced, but also avoids much potentialheartache in the future.

Death and bereavement

Death and bereavement are timeswhen a family is most likely to followIslamic teachings whether they arepracticing or not in everyday life;therefore Islamic practice will bereferred to in this section with any

variations in Pakistani culture beingmade explicit. Muslims believe thatdeath is divinely willed and when itarrives it should be readily accepted.With this in mind, there is rarely anyquestioning by the bereaved as to why they have lost their loved one;therefore it would not be culturallyappropriate to voice such questionsduring the mourning period orafterwards which could cause a barrierduring talking therapies if the topic ofdiscussion is one’s feelings aboutlosing someone.

Muslims are always buried and nevercremated and the dying person isencouraged to recite and declare his or her faith. Upon death the body istreated gently and with respect, beingwashed or bathed, scented, andcovered with a clean cloth for burial. It is very important that the body isreleased from the hospital, with all thenecessary papers as unnecessarydelays in the burial would causedistress to the family. Muslims aredirected to conduct the burial as soonas possible after death. These Islamicvalues are strong in Pakistani familiesand it is common in Pakistan to burythe person on the day of their death;therefore families accustomed to thispractice may find it particularlydistressing in the event of a delay.While Islamic traditions recommend aperson to be buried in the area theydie, it is usual for a Pakistani personliving in the UK or their family to havetheir body flown to Pakistan as theirfinal resting place. One of the mainreasons cited for this is that Muslims

Sadia

Sadia is a young woman of Pakistani origin who has managed an obsessivecompulsive disorder since her teenage years. Sadia’s family took her toPakistan and married her to her cousin Tariq. This has exacerbated Sadia’sillness to the point that she hasn’t been able to manage her rituals and thedemands of her married life since Tariq came to live with her and her familyin the UK. Tariq is not supportive due to a lack of understanding aroundSadia’s OCD, believing that she is making everything up. Sadia’s family arefearful of the shame that would come to the family if Tariq left and at timeswhile working with the family it was felt that Tariq took advantage of this.Sadia’s family affords Tariq’s living expenses and on one occasion Tariq lefthome after an argument involving extended family members on both sidesof the family, insisting on Sadia apologising to his family before returninghome. Sadia described the incident and talked about how degraded she feltapologising to protect the family’s honour even though she didn’t feel thatshe had been in the wrong. Sadia’s Mother performs many of Sadia’s ritualsfor her such as doing household chores in the way Sadia feels they should bedone and doing them repeatedly to ‘keep the peace’ in the house.

10

are required to be buried wrapped in alarge cloth without the wooden coffinwhich is not permitted in the UK. It mayalso be that people want to be buriedin Pakistan to be buried with otherdeceased relatives. The decision to fly a body to Pakistan for burial can placeundue financial pressure on the familyas it is an expensive process.

When there has been a death in ahousehold, it is common practice forfriends and relatives to visit from allover the UK, the family beingsupported by local relatives with foodand providing overnightaccommodation where necessary.Islamic practice recommends mourningfor a period of three days for any friendor relative, however cultural practicesvary and in some cultures a period ofmourning can be up to forty days. Inthe case of a wife losing her husbandthe period of mourning lasts for fourmonths and ten days. This period oftime is referred to as ‘Iddah’ or ‘periodof waiting’ during which the wife isencouraged to perform only thoseduties that are absolutely necessaryand is not allowed to remarry until her‘iddah’ period is over. There are anumber of reasons for this, amongstthose are giving the wife time to grievewithout the demands of everyday lifeand she is not allowed to marry toprevent confusion of the child’s fatherwere she to fall pregnant if sheremarried. During the mourning periodweeping or crying quietly is permissiblein Islam, but crying loudly or wailing isdiscouraged; however, in somePakistani cultures wailing still takesplace, particularly amongst women.

If a close family member passes awayin Pakistan, their family in the UK maywish to go to Pakistan at short notice.If it is deemed that there would not be suitable care for a service user while caregivers are away, the decisionmay be made to take them alongwithout consulting practitioners aspriority would be given to being united with family in Pakistan duringthe time of loss.

Age

In the Pakistani culture, ‘age’ is not justphysical but is also linked to phases inlife. For example people are consideredto be ‘young’ before marriage andtheir opinion may not be sought infamily matters; however, once they are

married and have children of theirown, their status changes and they arethought of as mature. This is not linkedto age as status in this context wouldnot change until marriage, regardlessof age.

Another phase is when one’s childrenare married and they becomegrandparents. In some cases this couldbe as early as the late thirties when the individual is seen to have fulfilledtheir responsibilities and is elevated in status to be considered an older or more respected person. The finalphase is when people become morereligious and spend more time inworship and resting while the children and grandchildren look aftertheir needs.

Older people

Pakistan is a hierarchical society andone of the commonalities that runsacross all Pakistani cultures is therespect of older people because oftheir age and position. Older peopleare seen as being experienced and wiseand in social settings may be servedfirst and have drinks poured for them.It is widely unaccepted for older peopleto go into a residential care home as itis seen as an honour to look after oldermembers by the young althoughhomecare is usually accepted.

In decision making, the most seniorperson by age or status (this couldinclude being head of the house or in a job viewed as respectable) isexpected to make decisions that are in the best interest of the group.

Some older Pakistani people settled in the UK may choose to spend thewinter months in Pakistan as it isbelieved that spending time in a warm country promotes health and wellbeing.

Titles

Similar to many other cultures, anolder person will not be referred to by name as a mark of respect. Olderpeople will be referred to as uncle,auntie or as grandparents (in theirrespective language) if they are older.The word ‘ji’ is commonly added totitles as an added mark of respect, for example ‘chachaji’ would be a paternal Uncle (chacha) with ‘ji added for respect.


Immediate family members maytry to keep the service user’sillness a secret from other familymembers or in laws to preventstigma and impact in therelationship if the spouse is still in Pakistan. This may add morepressure on the family andservice user to ‘recover’ so theycan get pregnant in the case of afemale or get a job in the case ofa male to show wider networksthat everything is ok.

Family pressures can exacerbatea person’s illness more so than ina person that is not from aPakistani background.

11


As Muslims are taught to acceptthe passing of a loved one andnot question it, people may findit difficult to open up duringtalking therapies as they may feelguilt over their feelings.

Families may travel to Pakistan atshort notice if a relative passesaway there. As these visit can bearranged in a matter of hours,families may not be able tocontact practitioners if a serviceuser is also travelling regardingmedication or other issuesrelating to their care whilst away.


As older family members are sowell supported and cared forwithin the family network, adeterioration in physical healthwill be picked up quickly.Concerns around mental illnessmay not be picked up if theawareness is not there as theolder person will beaccompanied to appointmentsand may not access situationswhere mental health problemscould come to light such as olderpeople’s groups.


The concept of family

In Pakistani communities the concept of ‘family’ is the basis of socialstructure and individual identityencompassing more than the nuclearfamily and immediate blood relatives.Family is a term that is used todescribe distant relatives as well asthose acquired through marriage andincludes people from the samebaradari (tribe), friends andneighbours. Some people may alsorefer to people from the same villageor general area in Pakistan as part oftheir family. Amongst Pakistanifamilies, there is a greater sense that a person does not only representthemselves but is part of the ‘family’,therefore successes and failure, praiseand shame can be shared by the familyin the wider sense.

Marriage

Who and how we choose to formcouple relationships with, marry andhave children with has a strongcultural component. The relativeweighting of determinants such aspracticality or romantic love differsbetween cultures, within them overtime and varies between individualswithin that culture.

Traditionally within Pakistani cultures,marriage is seen not only as the unionof two individuals but is seen as analliance between families, or often areconfirmation of alliances within thefamily in the broader sense outlinedabove. Within traditional families,suitable partners that meet the family’sexpectations around family, tribe,wealth or education, are suggested tothe individual by a respected memberof the family to seek their opinion onthe match. This process can work inthe reverse order where the individual(more often the male than female)suggests a partner to their parents orother respected member of the family.Providing the person being suggestedmeets with the family’s expectationsand neither of them is alreadybetrothed, the marriage is usuallyarranged in the traditional way.Arranged marriages often have verypositive outcomes and are not to beconfused with a forced marriage.

Sometimes individuals are forced into a marriage where one or both partnersdo not consent. In this case theindividual’s choice is overlookedbecause of the perceived benefits ofthe match to the wider family such asreinforcing family ties, culture or foreconomic reasons. Such arrangementscan be the cause of much distress and there are services available to help people suffering in thesecircumstances.

The process of choosing a partner orhaving a ‘love’ marriage is becomingincreasingly popular in the lesstraditional families living in the largercities where dating or marryingsomeone outside the ‘family’ is nowalso becoming acceptable.

Marriage and mental illness

Where a young family member has adiagnosis of mental illness a marriagemay be sought as a way of solving theproblem and/or share the burden ofcare. This could also be considered as a social inclusion approach whenmental illness is not seen as anexclusion from normal life roles suchas being a partner or parent.

Parents may take the decision to find a partner in Pakistan where a poorerrelative would agree to marry their sonor daughter to enhance the family’seconomic status, particularly with a son where it is felt that he would beable to earn money in the UK andsupport the family back home. Thefamily in Pakistan would then rely ontheir son once he was in the UK toprovide financial support for theirsibling’s weddings and to provideelectrical goods such as laptops andtelevisions in addition to a monthlyallowance. This has been a recurringtheme with families I have workedwith and has been the case for Sadia and Tariq (see case study page 10).

This arrangement may lead to furthercomplications once the spouse comesto the UK and the severity of the illnessis realised by the partner from Pakistan.Where the woman arrives fromPakistan, she often has no way of sharing her experiences of living in a country where she does not


It is not unusual for extendedfamily members to have inputinto matters relating to theservice user.

Sometimes an older child is usedto interpret and talk aboutproblems. This is seen by thefamily as acceptable because anolder child is encouraged to takeon adult duties from a youngage; however, it is important forpractitioners to consider thechild’s wellbeing and use aninterpreter for anything but themost basic interpreting.

Immediate family members ofthe service user can sometimesfeel pressurised by familymembers in a position of poweror authority such as a parent,uncle, aunt or in laws of theservice user. These familymembers could live nearby,elsewhere in the UK or abroad.

9

Pakistani families and communitiesOften titles significant in thecommunity or religious sense may be used such as ‘Haji’ if someone has completed the Hajj pilgrimage or ‘Choudhary’ if someone is alandowner or in a position of power in a village setting system; althoughChoudhary has more recently beenused as a surname.

Names

Names and their meanings are verysignificant in the Pakistani culture. Firstnames are considered to influence theindividual’s personality and life andparents or older family members mayrename a child if they develop ongoingill health or other problems as thename may be seen as ‘heavy’ for theindividual; ‘heavy’ in this contextwould be if the definition of the namehad a negative connotation such as‘sacrificer’ or ‘oppressed’ and also ifthe name was that of a historicalfigure that had lived a difficult ortrying life. Families that are moreculturally driven would usuallysubscribe to this notion.

12


Considering the namingcombinations, it is not unusualfor members of the same familyto have different surnames, forexample a father may be calledMohammed Atif Khan and hisdaughter may be called SaminaBi. Samina would not inherit herhusband’s surname uponmarriage.


to lack of space, a property adjacent tothe family home or nearby will bepurchased to keep extended family asclose as possible. In Pakistan it is stillnot widely accepted for a couple tomove out of the husband’s family homeand in such cases this will only happenwhere there is a family rift ordiasgreement. The young couple isalmost always seen as being responsiblefor the separation, for not showingtolerance and patience to their elders.

In the UK, many families follow asimilar model. Families in the CentralWard of Peterborough have preferredto extend small properties to allow forgrowth over moving into larger homeswhich would mean moving out of thearea. Extended families living in thesame home or nearby are respected byother community members as they areseen to be practising true Pakistani

values. For this reason, families oftenresist the urge to separate aftermarriage as they are aware of thestigma associated with moving away.Where couples do separate aftermarriage, significant time is oftenspent at each other’s houses to showthat the family is still a strong unit. Thiscustom usually only applies to sons asdaughters can be married outside thearea but would have the sameexpectations placed on them in theirhusband’s home. This has implicationsfor when clinicans may consider that itwould be benefical for the serviceuser’s mental health to move tosupported accommodation either tohelp their recovery or to manage withrisk issues. Such a move away from thefamily home could produce anadditional stigma in addition to that of mental health, making it an evenharder move to achieve.


An appointment with a clinicianmay not be kept if a familymember or friend arrives at thehouse unannounced as it wouldbe considered rude to ask theperson to return at a differenttime.

Families with very traditionalvalues only plan their calendar fora number of days, therefore it isnot unusual for an appointmentsent weeks in advance to beforgotten or to be confused witha different date. The service useris not being awkward, they simplymay not be used to this,particularly if they do not haveschool age children to providestructure to their day or are newarrivals to the UK.

If embarking on an extendedpiece of work with a service userand/or their family, it may beuseful to emphasise theimportance of keepingappointments, attending on timeand notifying someone if they cannot attend.

8 13

Localities

The majority of Pakistani families inPeterborough are from the Mirpur areaof Azad Kashmir that have beensettled in the UK for over 50 years. In line with national trends, there are a significant number of PunjabiPakistanis followed by people fromother areas such as Sindh. ThePakistani community is concentratedaround the Central Ward areaexpanding out to surrounding areassuch as West Town, Dogsthorpe, NewEngland and more recently Netherton,with a few families living in other areasacross Peterborough.

Travel to and from Pakistan

It is customary for people to keep closeties with family in Pakistan as well asfamily in and around the UK andannual holidays to Pakistan for periodsof four weeks or more are common tomake the cost of travel worth while.Popular reasons for travelling toPakistan apart from visiting family areto familiarise children with their culture,marriage and to promote the traditionalcustoms and values when living in theUK. Visits to Pakistan are usually ahighlight for people of Pakistani originas they may not have regular holidaysas understood in the UK. Familiesspend time shopping for their family inPakistan and family members in the UKtend to visit to say goodbye, making ita time of happiness and anticipationand this was the case for Maliha whobenefited immensely from seeing herfamily in Pakistan for the first timewithout her abusive husband.

Clients from the British Pakistanicommunity frequently travel toPakistan to meet their relatives and for holidays. These trips to Pakistancan last for a number of months andtherefore raise the issue of treatmentwhilst there. When in Pakistan somepeople visit shrines, faith healers andalso see a psychiatrist.

It is prudent to advise clients that whilstthey are in Pakistan they continue withthe medication they are taking and notchange it unless advised to do so by theUK treating team. This is to preventclients from suffering relapse or return

of their illness which would spoil thetime they are in Pakistan. It is worthnoting that there are differences inpractices, medications available anddoses of drugs. It also might not bepossible to continue the medicationstarted in Pakistan.

Pakistan also has a high rate ofHepatitis and other water and bloodborne infections. Caution is requiredwith those medications that areadministered by injection e.g. Depot.Service users and their families shouldbe advised to buy needles fromreputable sources and to dispose ofthem safely.

For clients who are on medication thatrequires blood tests it is important toconsider the following: The blood testsmay not always be reliable, dependingon the type of health care facility inwhich they are taken. There are issueswith used needles being repackaged,so appropriate care should be taken in sourcing clean ones. People takingClozapine will need to register withthe Clozapine monitoring service in

Maliha

Maliha had been diagnosed with depression and had taken medication forher condition for many years. She came to the attention of secondary careservices upon the birth of her child and separation from her husband whichfollowed shortly after. Maliha has other children and had endured domesticand financial abuse from her husband for many years. Although she hadbeen visiting doctors for a long time, Maliha’s husband had been allowed tointerpret for her and she was never seen alone to have the opportunity toshare her ordeal with anyone. Maliha’s eldest daughter was still under 16 butnot in any form of education or training and took on most of the householdchores and looking after her younger brothers and sisters.

I found Maliha very low, isolated and scared of telling anyone about herproblems, spending most of her time feeling very tired and down. Malihasaid she found it difficult to undertake any household chores as her bodyached afterwards. I interpreted some basic information about depression toher in Punjabi and worked in a pictorial way to help her understand herdepression and how the mental state was linked to her physical stateresulting in the pains and aches. Maliha improved over the coming weeks asshe was able to talk about the issues around her marriage in a culturalcontext. During a review, we found a number of things that had beenmisinterpreted such as Maliha hearing water when she had actually beendescribing her depression and how she felt that she was drowning in hersadness. Maliha responded very well to the basic techniques aroundmanaging her depression and within a few months was able to take overmany of the household chores from her daughter and went to visit herfamily in Pakistan and was subsequently discharged.

Pakistani communities in Peterborough


Weight gain or loss in adults is viewedin a similar way.

More full bodied actors and actressesare common in the Pakistani filmindustry and weight loss, even whendone in a healthy way is sometimesviewed as a sign that something iswrong physically in the form of anillness or due to mental distress suchas problems in the family; althoughyounger people may identify morewith the ‘Western’ ideals regardingweight and may therefore be moreaware and conscious of gainingweight. In Parveen’s case the familywere concerned that the extendedfamily or community members wouldthink there was something wrong inthe family and that was the reason forParveen’s weight loss, and her lack ofeating was a cause for tension duringfestivals such as Eid.

In many Asian cultures includingPakistani cultures, foods areconsidered in terms of ‘hot’ and ‘cold’.This is not concerned with thetemperature at which the food isserved but rather the ‘effect’ on thebody, which can be harmful if foodcombinations are not balanced. Forexample, almond nuts are ‘hot’ wheneaten as a nut but ‘cold’ if soakedovernight in water providing the outerlayer is removed. Mangoes areconsidered ‘hot’ and should beconsumed with yoghurt milk (lassi) asthis has a cooling effect on the bodytherefore neutralising the heat in themangoes. Although not so prevalent in Pakistani communities, Hinducommunities associate certain foodswith mental and emotional states suchas meat with aggressive behaviour, aswell as recognising the physical ‘hot’and ‘cold’ effects on the body.

The sense of time

‘I remember visiting mygreat grandmother’s housein Pakistan as a child andnot having a clock in thehouse, even if there was itwould have been no good to her as she couldn’t tellthe time.’

How time is understood and valueddiffers between cultures. This is anarea that industrial businesses havehad to pay close attention to in orderto function efficiently in differentcountries. Some cultures valuepunctuality, meticulous planning andstay committed to them. Countriesthat typify this approach, technicallyknown as ‘monochronic’ are the USAand Germany . In contrast there arepolychronic cultures which includePakistan. In these countries multipleactivities occur at once, there is greaterflexibility around time with the focuson the relationship being moreimportant than promptness or the jobin hand.

Timing is very relaxed in Pakistan,particularly in the more rural areasaway from office based companies.Social visits to family and friends aremade unannounced as manyhouseholds have an ‘open door’ policywhere the door is left unlocked duringthe day for people to visit. The mainstructure to the day is around the fivedaily prayers and timings may be givenaround these, for example, ‘I’ll see you after dhuhr’ or ‘make sure itsbefore maghrib’.

Weddings and such functions are veryrelaxed affairs with no set start timeand guests arriving and being servedat various times. Although thestructure of the day is relaxed, thereare customs around visiting a familywhere there has been a birth of a child or a death as soon as possibleand offence could be taken if a familymember or friend were not to visit onsuch an occasion. Similar rules apply to inviting a newly married couplearound for a meal after their wedding,as the first few months are usuallytaken up by being invited by familyand friends to meals where delicaciesare served and gifts given to the newbride and groom.

Accommodation

It is customary in Pakistan to buy andacquire land so that property can bebuilt and extended as the family sizegrows. Often, a house will start offwith two or three rooms and will thenbe extended as per the family’s needswhich is particularly the case in morerural areas. In more suburban areaswhere it is not possible to extend due

7


Psycho-education is key whenworking with Pakistani familiesaround eating disorders to helpthem to understand thecondition and support therecovery of the individual.

Talking therapies around eatingdisorders often involve individualand family work. Families may notbe comfortable with talkingabout the family and its dynamicsas this would normally be doneon a one to one basis or with asmall trusted same sex group.

Families will most likely feel underpressure from the widercommunity and may hide theproblem rather than talk about it openly.

14

Pakistan. Clozapine is not a commonlyprescribed medication in Pakistan andthe monitoring procedure differs tothat in the UK. The user will need toobtain for themselves a blood test at ahospital or private laboratory for a fullblood count. They or a family memberor carer then phone the drugcompany's monitoring service andinform them of the results. The drugcompany will then deliver to wherethey are staying and will ask to see theresults printout in confirmation beforehanding over the medication.

Pakistani languages & interpreting

The term ‘Pakistani’ includes a mosaicof different cultures. The nationallanguage is Urdu and is spoken in thepublic sector as well as English. Manyother languages are spoken in thedifferent regions of Pakistan such asPunjabi, Siraiki, Sindhi, Pashtu, Balochi,Hindko and Gujurati and the diversityin languages is often reflected indifferences in culture, diet andtraditions. It would be true to say thata significant number of people living inmore isolated or rural areas of Pakistanmay not speak Urdu.

The majority of Pakistani families settledin Peterborough speak Mirpuri orPunjabi. This is an important point tokeep in mind as not all those that speak

Mirpuri or Punjabi will be comfortablewith having an Urdu interpreter eventhough Urdu is the official language ofPakistan. It may be more appropriate torequest an interpreter that specificallyspeaks Mirpuri or Punjabi, as manyinterpreters registered to speaklanguages from Pakistan will almostalways have a good knowledge ofUrdu. Mirpuri and Pakistani Punjabispeakers will use the written form ofUrdu if they need to write somethingdown in their language.


Not all people with a Pakistani background will have a good practicalknowledge of Urdu, therefore it is important to ascertain the particularPakistani language or dialect the service user speaks at home.

Mirpuri and Punjabi are the most popular Pakistani languages inPeterborough. Both languages use the written form of Urdu as there is nowritten form of Mirpuri and Pakistani Punjabi speakers will not be able toread or write the written form of Punjabi.

Most interpreters that speak a Pakistani language will also speak Urdu.

Service users may wish to have a same sex interpreter.

Where the service user is unable to read or write, they can be involved inusing pictures and photos from South Asian media to tell their story.Examples of alternative media include the Asian Bridal magazine, MAG the weekly and the Jung, Nation & Watan newspapers as well asmainstream media.


increase in women choosing to wearthe ‘hijaab’ which is an opaque pieceof material wrapped around the headand held secure with a pin. This can beworn with shalwar kameez, ‘Western’clothes or then with a jilbaab which isa long coat like dress that reachesdown to the ankles. Pakistani dress islinked to modesty which is a value ofIslam and is usually maintained bypeople of Pakistani origin however they may choose to dress.

Gold jewellery

Pakistani communities will havediffering views about men wearing gold jewellery as some men may wear a gold ring, bracelet or chain andothers believe it is not permitted inIslam. Women however areencouraged to possess and wear goldjewellery as a sign of wealth and goodstatus. It is traditional for women towear gold bangles and other jewelleryon a daily basis and daughters will begiven gold jewellery by direct familymembers upon their marriage whichstems from the notion of givingsomething that can be used duringtimes of hardship. Often gold jewelleryis passed down to daughters anddaughters-in-law.

Diet and food

One of the most common markers ofcultural identity is the individual cuisinethat a culture has developed. This isone of the most accessible ways that a person from one culture canexperience and value that of another.Pakistani food fits within the widerculinary framework of Indian food and as such is something that hasfamiliarity and value in the UK.

Food is an industry that excels inPakistan even when the economy isdown, perhaps because this is one of the few areas where people fromlower socio economic groups candemonstrate control and discretion, as affording a car or going on a lavishholiday would not be achievable.

Pakistani food is rich in flavour, spicesand high in cholestrol with sweetdesserts containing a high sugarcontent. The use of meat and chickenis very common at mealtimes and itwould be considered offensive to serve a completely vegetarian meal ata dinner party or to guests, although a vegetarian accompaniment would be acceptable.

Culturally, food is linked to hospitality,seen as a sign of good living and thesharing of food as an act of kindness.It is common to serve food at festivalsand gatherings and is given away tothe poor during times of happinesssuch as a wedding or the birth of achild or grandchild.

Guests will be encouraged to share ameal and may have food put on theirplate and offered seconds or thirdsdespite the recipient’s protest, asillustrated in Parveen’s case. Babies andchildren are seen as healthy if they areon the upper end of the normalweight range and may often receivecomments about their healthdepending on how much weight theyhave gained or lost, which is incontrast to the ‘Western’ culturewhere it may seem inapproriate tocomment on a baby or child’s weight.

6

Parveen

Parveen is in her teenage years and has been diagnosed with anorexia. The immediate and extended family’s diet consists mainly of Pakistani food,particularly those that are rich in spices, flavours and cholesterol and thefamily equate being ‘big’ with being healthy and well. The women of thehouse insist on cooking and serving food to Staff whenever they visit, thisbeing seen as a sign of hospitality and graciousness. This includes beingserved fried food with fizzy drinks early in the morning and three coursemeals when visiting to support Parveen to eat during lunch visits. Thefamily often insist that everything on the table be sampled including largequantities of fried food.

Parveen’s family were encouraged by her dietician in supporting her tostick to a food plan that would slowly introduce eating back into her dailyroutine again. The family continued to offer Parveen other foods at thedinner table despite being explained that this would hinder her progress.The family have different ideas about the ‘truth’ regarding diet that wasnot shared with Parveen’s clinicians; and seemed to attempt to introduceextra foods to Parveen whenever the opportunity presented itself. Thishindered Parveen’s progress and she often spoke about an atmosphere inthe family home in which they did not speak openly about problems andissues and how difficult it was for her to share things that were on hermind with her mother or other family members. After months of support,Parveen’s family are now taking part in family therapy with a view toadmitting her into hospital if her weight does not improve.

15

Spirituality and understanding of mental illness in Pakistani communities

Mental health and Pakistani communities

In view of the above account ofmental health services in Pakistan,understanding of mental illness inPakistani communities is significantlydifferent from the models commonlyused in the UK. As well as mentalillness being considered in a holisticcontext including environment andphysical health, it is also understood in the context of spirituality.

Belief in supernatural forces isprevalent in Pakistan. Jinn (anglicisedto genies), evil eye and spells are partof daily life in Pakistan and spiritualhealers can be found in most marketsand street corners.

According to Islamic belief, jinn are realcreatures that form a world other thanthat of mankind. There is little detaileddescription of jinn in the Qur'anic andProphetic literature. The term ‘jinn’ isderived from Arabic ijtinan, whichmeans 'to be concealed from sight'.

Although they reside in what are inessence parallel worlds, humans and

jinn are believed by Muslims, to havesome ability to influence each othertowards both positive and negativeends. Satan (who is within the Islamictradition a jinn and not an angel, andhence has the choice to disobey) is themost infamous of the jinn and isprimarily concerned with enticinghumanity to forget its divine origin.According to Islamic writings, jinn livealongside other creatures but form aworld other than that of mankind.Though they see us they cannot beseen. Characteristics they share withhuman beings are intellect andfreedom to choose between right andwrong and between good and bad,but according to the Qur'an theirorigin is different from that of man.

According to Islamic scholars, a personunable to think or speak from theirown will, experiencing seizures andspeaking in an incomprehensiblelanguage may be possessed by jinn;however, more often than not aphysical cause can be found for theunexpected behaviour and many

Excerpt from ‘Psychiatric Health Laws inPakistan: From Lunacy to Mental Health

By Ahmed Ijaz Gilani

There are many players and factors involved in the access, provision,delivery, functioning, and uptake of mental health services in Pakistan.Awareness about mental illness is still poor in Pakistan. Such illness isgenerally attributed to supernatural causes—it is considered to be a curse,a spell, or a test from God.

Those who experience mental illness often turn first to religious healers,rather than mental health professionals, since patients and their familiestend to have great faith in these healers. Religious healers use verses fromthe Qur’an to treat patients. Next, patients turn to traditional andalternative healers, who are also popular in Pakistani society.

Help from the mainstream health-care system is usually sought late in thecourse of the illness; however, the referral system is inefficient and,particularly in the case of individuals who are mentally ill, patients are usuallytaken by their families directly to tertiary or specialist hospitals, rather than toprimary-care practitioners. It is, however, important to note that manymental illnesses can be treated and managed by primary-care practitioners.The private sector also plays a major role in providing psychiatric care. Forthose who can afford it, private psychiatric care is an option frequently used.[Excerpt from section on Mental Health Infrastructure].


16 16

spiritual healers will encourage familiesto think about the possibility of amental illness where they feel that theirfull criteria for possession is not met.

The role of the Islamic therapist in casesof possession, who must have strongfaith in Allah, is to expel the jinn. This is usually done in one of three ways –remembrance of God and recitation ofthe Qur'an (dhikr); blowing into theperson's mouth, cursing andcommanding the jinn to leave; andseeking refuge with Allah by callingupon Allah, remembering him, andaddressing his creatures (ruqyah). Somefaith healers strike the possessedperson, claiming that it is the jinn thatsuffers the pain. The practice of strikingthe person is deplored by Muslimscholars as being far from the principlesof Islam. The general approach ofexpelling evil spirits by convincing themto leave is similar to the passage in theNew Testament (Luke 8:24) where Jesusexpels demons from a man who ispossessed. Though it is not oftenspoken about publicly the Church ofEngland and the Catholic Church retainMinistries of Deliverance for exorcisms.Within mental health services over thelast twenty years there has been agrowing awareness of the spiritualcomponent to the mental illness withthe development of organisations suchas the Spiritual Crisis Network.Although the individual or their familymay believe there to be a spiritualcomponent to a condition, this doesnot always mean they believe theindividual is possessed by a jinn. Abelief in spells and evil eyes could meanthat a mental as well as physical illnessis viewed as having a spiritual elementto it other than possession therefore itis important to engage with theindividual and their family to ascertaintheir views on the condition and itscauses as this often proves instrumentalto recovery.

Through working with families thatbelieved there to be a spiritualcomponent to the service user’s mentalhealth, it has been important not limitourselves to medical treatment, and toconsider the wider options ofpsychological therapies as well asfamily work with those closest to theservice user.

The differences of cross culturalunderstandings of mental health can

be appreciated within the context ofmodels of how beliefs in Asia aredifferent from the ‘Western’ viewssuch as those illustrated in the table below which has been developed from an article by Hilty on culturaldifferences:

In this context it can be difficult to aska person to focus on themselves as anindividual during cognitive behaviouraland solution focused therapy , as theymay consider this a selfish act or maysimply not be accustomed to thinkingof themselves as an individual entity.This echoes some African cultureswhere one is seen to exist throughothers in their family and community.

Often blood ties are seen as moreimportant than money therefore it may not be unusual for a parent tocontrol their children’s finances untilthey are married and sometimes evenafter marriage. On the surface thismay be seen as a selfish act butparents may put all the money theycollect from their children in a joint

Asian Western

Core values of ancient China such ashierarchy, moral development,achievement and social responsibilityas well as a dualistic model medicalsystem based on principles of balanceand harmony.

Pathology driven, overlaid by thevalues of ancient Greece such asindividuation, self control and selfefficacy.

Cognition is abstract, paradoxical,circular and indirect. The universe isseen as a web of infinite connections(holistic cognition).

Cognitive process is one of logic,critical analysis and direct and rationalthought in which the universe isconceptualised as the sum of its parts(analytic cognition).

Socio-centric model of self which isformed within the social context anddefined by it at any given moment. Asense of self requires emotionalconnectedness.

Ego-centric model of self where eachperson’s sense of self is consideredautonomous and unique, individuatedand largely consistent regardless ofcontext.

Orientation is one of interactionism,in which the presence of complexcausalities is assumed and the focus ison relationships and reactionsbetween persons or the person andthe surrounding environment.

Orientation of the individual is one ofdispositionism, in which the internaldisposition of the individual is theprimary consideration.

Health is inclusive of all aspects –physical, mental, emotional, spiritualand social, conceived of as a state ofharmony and balance, illness beingtermed as ‘patterns of disharmony’.

The model of Cartesian duality ofmind and body is adopted where thetwo are separated, hence mentalillness being treated in many areasindependently of physical and spiritualsymptoms.

Pakistani culture and communitiesIslamic influence and culture

Religious beliefs and values have astrong influence on society and itsculture. Even a person of long-standing English heritage who is anatheist is likely still to hold beliefs andattitudes that are Christian in origin as a consequnce of growing up in asociety with a substantial Christianfaith history.

Islam is the main religion practised in Pakistan with around 97% of thepopulation being Muslim and theremaining 3% made up of Christian,Hindu and Sikh communities. AlthoughShari’ah (Islamic law & jurisprudence) isnot strictly practised in Pakistan, Islamgoverns people’s personal, political,economic and legal lives on a dailybasis making religion an importantfactor to consider when working withPakistani families, as the lines betweenfaith and culture are often blurred.

Pakistani culture is made up of amosaic of Islamic traditions and isinfluenced by Hindu culture, which isevident in the way weddings arecelebrated and events such as ‘Basant’(spring festival). Pakistani Muslimfamilies or individuals within them canbe either culturally or Islamically drivenand still identify themselves asPakistani and Muslim. Variations caninclude naming traditions where afamily driven by culture may choose anUrdu name such as Shabnam (morningdew) for a female child and Sahil(seashore) for a male child. A familywith a more Islamic outlook may givetheir child an Islamic name such asMaryam (Mary) for a female child orMuhammed for a male child althoughcultural and religious names may begiven together. Social areas such as the level of free mixing may also differdepending on whether a family ismore cultural or religious as well as the level of access to media in thehome such as Hindi film and television.

Unlike Christian families where thegap between practising and nonpractitising Christians is much wider,the majority of Muslim Pakistanifamilies identify quite strongly withtheir faith and will practice it at somelevel. As a minimum, families may

have a pork and alcohol free diet andpray or read the Holy Qur’anoccasionally whereas a practisingfamily will adhere to the five dailyprayers, observe hijaab (Islamic dress)and may not allow free mixing. Addingto this an influence of the Hindu andBritish culture in Pakistani familieshighlights the level of diversity thatmakes up ‘Pakistanis’ and people froma Pakistani background.

Pakistan and Azad Kashmir

Azad Kashmir is a self governing stateto the North-East of Pakistan which is administered by the PakistaniGovernment. The largest City in AzadKashmir is Mirpur which isneighboured by the province of Punjabin Pakistan. The largest Pakistanicommunity in Peterborough is theMirpuri community coming fromMirpur and the surrounding areas,followed by the Punjabi community.

As Mirpur has no airport, passengersfrom the UK will often use Pakistan’sIslamabad airport from which Mirpur is a 2 to 3 hour journey.

Pakistani dress

When we first meet a person we willbe making rapid judgements of whothey are and where they fit in to ourunderstanding of society. In this rapidaccount the clothing a person iswearing can play an important role.The clothes that we wear can be astrong marker of personal identity,age, class and culture.

The national dress of Pakistan isshalwar kameez which is a long topwith loose, baggy trousers. Men mayalso wear a skullcap and women willusually wear a large scarf with theirshalwar kameez.

In the UK, men often adapt to the‘Western’ style of dress unless theycome to the UK when they are older,where the preference is to wearshalwar kameez. Women will wear a variety of dress ranging from theshalwar kameez worn in the traditionalway or ‘anglicised’ by wearing trouserswith a long top, to totally ‘Western’dress. In recent years there has been an

5


Where possible, allow the serviceuser to describe in their ownwords how they view theircultural identity.

This is important considering thecultural diversity of Pakistanifamilies depending on how‘traditional’ or ‘Western’ they are,how much they are influenced bypractices deriving from the Hinduculture and how closely theypractice the Islamic faith.

Gaining this information will helpyou to recognise the level ofimportance the individual’scultural heritage holds for themand how this may influence theirtreatment and recovery.

Point to consider…

Some people from Azad Kashmirmay identify themselves as‘Pakistani’ on ethnic monitoringforms but will considerthemselves as ‘Kashmiri’ or from‘Azad Kashmir’ in everydayconversation.


4

in Punjabi and the surrounding dialectsof the area and work with localfamilies where practitioners felt thatadditional support with language andculture would be beneficial for theservice users and their families. Thecases have been included to illustratethe points being made rather than as ameasure of success, which varied fromthe service user being discharged withvery positive results to very littlechange in condition.

Shama Kanwa

Additional comments from thesecond author

This has been a hugely rewardingproject to be involved in that is largelythe work of Shama. Working withclients and families from the Pakistanicommunity has raised my curiosityabout their culture at both a personaland professional level. Being culturallyblind, though not as bad as racism isstill not good, it is akin to neglectcompared to racism being abuse. Theimportance of cultural awareness is

two fold. First, it enables a betterunderstanding and formulation of theperson's psychological distress andconfusion together with its impact onfamily and carers. Secondly, it increasesthe likelihood that interventionsoffered will be successful as they aretaking account of the cultural factorsfor and against change.

In working with clients from thePakistani community, including peopleborn in England, it has struck me howtheir understanding of mental illnesshas greater components of the role of the body and the spirit in theseconditions, but a lesser appreciation of the mind, than when working withclients of long standing Englishheritage; a challenge for anyonewanting to carry out standardCognitive Behavioural Therapy. Thishas confirmed my bias to suggest that a holistic approach that takesaccount of mind, body and spirit isusually the best.

Stuart Whomsley

17

‘pot’ out of which they would pay fortheir wedding. Sometimes the moneymay be used as a deposit for a housewhich may be rented out to generatemore income for the extended family.

What should clinicians do when apatient or the family or friends believethat jinn are the cause of symptoms or unusual behaviour?

In such cases where patients aredeemed to have a medical, psychiatricor psychological disorder but are notreceptive to medical explanations,patients can be encouraged to 'hedgetheir bets’ by taking the prescribedtreatment while continuing withspiritual therapy. This double strategymay be the best hope of securingadherence to prescribed treatments.

There may also be the additional veryimportant benefit that patients andtheir families are willing to enter intodiscussion about the other therapiesthat are being tried. Whilst theseusually consist of repeated readings of certain sacred texts, the concern is that in desperation some familiesmay turn to exorcists who inflictphysical harm in an attempt to free the individual from possession –sometimes with catastrophicconsequences.

It is very important, therefore, toestablish channels of communicationswith the patient, the family and anyspiritual practitioner whose help isbeing sought.

Wider issues around accessingservices

According to a Rethink project focusingon the Pakistani community’s view onmental health and mental healthservices in Birmingham, successivestudies have shown that people fromBME groups experience relativelyhigher levels of mental illness than thewhite British population. Some of thismay be attributed to socio economicfactors such as the experience ofracism, unemployment, homelessness,social exclusion, poor physical healthand living in deprived areas.

Other findings of the research foundthat stigma of mental illness needs tobe overcome to enable mental healthas an issue to be accepted and openlytalked about. People may be ignorantor unaware of the facts of mentalillness and communities may not knowwhich services are available to them orhow to access these services once theydecide to recognise and ‘face theproblem’. It was also found thatcultural and language barriers canhinder people from taking up servicesand there is a ‘keep it to yourself’approach adopted across thecommunity where mental health issuesare concerned.

Conclusion

As discussed during the introduction,the aim of this document is tohighlight important parts of thePakistani culture that will assistpractitioners in working with serviceusers and their families from Pakistanibackgrounds. We have used ourexperiences of working with familiesto highlight the issues raised, and thesubsequent input that was given tosupport the delivery of a service thatwas appropriate. In addition, somecultural values have been explainedsuch as attitude towards relationships,timings and diet that may also assistpractitioners to gain a betterunderstanding of some of the factorsthat may be driving a particularattitude or behaviour.

As the service user will be thinking inholistic terms, including faith, somaticsymptoms and perhaps mental illnessas understood by ‘Western’practitioners, it is important forpractitioners to take a similar approachand elicit an open response about howthe service user and/or their familyviews the situation, even if only clinicaltreatments are available. This willenable the practitioner to learn aboutany alternative treatments beingaccessed such as spiritual healers.

Culture, faith, eastern, western –ultimately these are labels we attach toeach other to help us make sense ofsomething that is new or different, thereal success when working withpeople is if we can understand whatthe labels mean to the individual andhow they interpret their own identity,only then can we truly deliver a servicethat focuses on and responds to theneeds of the whole person.


The first and most importantstep is to ellicit, in an open andnon-judgmental way, the serviceuser (and if appropriate thefamily’s) ideas, concerns andexpectations.

The second step is to recognisethat symptoms attributed topossession by jinn are commonlymanifestations of a mentaldisorder that will most likelybenefit from medical treatment.

The third step is to appreciatethat, although the patient andrelatives may obviously haveinterpreted symptoms incorrectly,beliefs that are strongly held (andoften socially convenient due toperceived stigma) will be difficultto alter at a time when anxietiesare running high.


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Hilty, A. 2010. Western Psychology,Eastern Cultures – Mismatch? Ezinearticles. Available at:http://ezinearticles.com/?Western-Psychology,-Eastern-Cultures---Mismatch?&id=4130088. [Accessed 21 November, 2010].

Gilani, A. I, Gilani, U.I, Kasi, P.M,Khan, M.M, 2005. Psychiatric HealthLaws in Pakistan: From Lunacy toMental Health. PLOS medicine, PublicLibrary of Science. Available athttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1215469/. [Accessed 29 November, 2010].

Aap ki Awaz. Our Voice: ThePakistani community’s views on mentalhealth and mental health services inBirmingham, 2007. Published byRethink. Available at:www.mentalhealthshop.org/products/rethink_publications/our_voice.html.[Accessed on 29 November, 2010].

Sajid, A. 2003. Death & Bereavementin Islam. The Muslim Council forReligious & Racial Harmony. Availableat:www.mcb.org.uk/downloads/Death-Bereavement.pdf. [Accessed on 3 March 2011].

References Introduction

3

How do you capture ‘culture’ accuratelywhen it involves people’s visible andinvisible values and beliefs? Is it possibleto be completely impartial when writingabout your own cultural background asI am doing? Do the experiences I’msharing in this work truly represent thePakistani culture? Furthermore, is it‘fair’ or ‘ok’ to produce guidance onthe culture of a whole nation,particularly one that is as rich anddiverse as the Pakistani culture?

These questions were considered whendeciding to produce this guidance andweighed against the need to raiseawareness amongst practitioners ofhow a service user’s culture may impact on their engagement withservices and their subsequent recovery.Pakistan is made up of different statesthat vary significantly in language,dress and ‘culture’, and it would take a very detailed piece of work to fullycapture the customs of all the statescomprehensively. Considering thebackground of the Pakistanicommunities settled in Peterborough,which reflects the cases used in thiswork as reference, it seems morerealistic and reasonable to say that this guidance has been produced onthe Pakistani culture but with ‘aparticular focus on the Mirpuri andPunjabi communities’, which are themajority Pakistani communities settledin Peterborough.

It is almost impossible to measure theexternal input people have during theirlives that shapes their sense of identity,and to pinpoint the extent to whichsomeone lives their life according tovalues passed down through cultureand the impact of their currentenvironment on them, if that is

different from when they weregrowing up; as in the example of aperson coming to live in the UK as an adult. As demonstrated by thispoint, it is risky to make generalisedassumptions about culture, as culturalvalues may be enforced by familiesand communities but interpreted byindividuals. It is also important to notethat there may be cultural differencesacross generations as there may be aparent or grandparent that came tolive in the UK as an adult and theirchildren and grandchildren may beborn and brought up in the UK,therefore their experiences would bevery different from each other. Anexample is where taking the childrento the cinema may be seen asappropriate by young parents ofPakistani origin but may be frownedupon by older members of the family.

For the reasons mentioned above, thisguidance should not be used as anauthority on all things Pakistani but asa tool that can assist practitionerswhen working with individuals andtheir families in the context of havingpositive regard to the person’s culturalvalues and beliefs to build relationshipsand aid recovery. The individual andfamily should be given the opportunityto express in their own words whattheir cultural and religious1 identitymeans to them as it will be unique foreach person.

The small sample of anonymised casesused in this guidance resulted fromfamily work that I have undertaken inmy capacity as CommunityDevelopment Worker for BMERcommunities. I was able to engagemore freely with families as my ownbackground is Punjabi and I am fluent

Culture is a shared, learned, symbolic system of values,beliefs and attitudes that shapes and influencesperception and behaviour; an abstract mental ‘blueprint’or ‘code’ and must be studied ‘indirectly’ by studyingbehaviour, customs, material culture (artefacts, tools,technology), language, etc.

Professor Kathleen Dahl

1 Although culture and religion are different things, people may talk about them as one or use the terms interchangeably.


AcknowledgementsThe authors would like to thank the following people for their assistance in producing this document:

Martin Liebenberg for his support in developing the document’s content and direction.Dr Asif Zia for his contribution to the section on service users travelling to Pakistan. Professor Zenobia Nadirshaw for reviewing a draft of this document and offering supportive comments.Ahmed Ijaz Gilani for allowing us to use his article.Janice Hartley for her advice on spirituality and mental health.

About the authorsShama Kanwar has worked in community relations for over 14 years both at a strategic level advising SeniorManagement on community and equality issues and at grassroots level with specific hard to reach BMER groups. Shamahas worked nationally as an independent facilitator in an initiative involving Police Officers and Muslim communities oncommunity cohesion and has been instrumental in setting up BME Staff Support networks in three organisations. Shama iscurrently working as a Community Development Worker based in Peterborough working with Black Minority Ethnic andRefugee communities, running community based projects that raise awareness of mental health and how to accessservices. Shama also works at length with healthcare practitioners to engage with service users and their families to gainan understanding of the role culture plays in the treatment and recovery of the individual.

Dr Stuart Whomsley is a clinical psychologist who works in an Assertive Outreach Team. In this role he has a longestablished working relationship with a number of clients from the Pakistani community. He is involved in bothcommunity development initiatives locally and good practice guidance for his profession nationally.

2


A member of Cambridge University Health Partners

Working with Pakistani serviceusers and their familiesA practitioner’s guide

Shama KanwarStuart Whomsley

HQ Elizabeth House, Fulbourn Hospital, Cambridge CB21 5EF.T 01223 726789 F 01480 398501

www.cpft.nhs.uk


nhs working with pakistani service users 2011 pp low a4.pdf

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