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Mental health: ethnic minority experiences

Views about causes of mental health problems: social & environmental factors

Research suggests that various factors may interact and cause or contribute to the development of mental health problems, including physical, social, environmental and psychological factors. Here, people talk about what they believe caused their mental health problems. This summary focuses on social and environmental factors; individual factors are discussed elsewhere (see 'Views about causes of mental health problems: individual factors).

Many people we talked to believed that various social and environmental factors led to the development of their mental health problems. Some people identified a range of factors building up over time rather than any one single cause, whereas others pinpointed one specific factor or incident. People also said that there was a difference between 'triggers' and 'causes', an underlying predisposition to mental health problems that can be set in motion by any one of a number of factors (see Edward's story).

Work, finances and housing
Some thought that they developed mental health problems because of work or business problems and the associated stress. For a few people, being unemployed or unable to work was a factor. One woman believed that wealth and inequalities in society contributed to ill-health and thought that her degree level education and attempts to escape poverty were unnatural and caused her nervous breakdown.

 

Raj was unable to work following a heart attack and says this made him depressed. (Audio in...

Raj was unable to work following a heart attack and says this made him depressed. (Audio in...

Age at interview: 55
Sex: Male
Age at diagnosis: 54
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When I was discharged from [general hospital], the psychiatrist told me to visit the doctor and he would give you medication, so I made an appointment and I told him that I been told to get medication from you but he said, “Sorry, my budget doesn't allow it, it's too expensive per month, all I can do is give vitamin tablets,” what he has asking to give me on the… I have red vitamin capsules but it doesn't matter if I have them or not.

How did it feel when you were told no to the medication?

It hurt a lot, that gave me depression. If a person can go to work then he should be supported by the medication then at least he is able to work. At least he will do something for the county, employment, if we are British we do something for the country, then if we work then we will earn. Now taxi work is not great but I still tried, rather than sitting around. If a government man is saying that he can't give medication and to sit at home it's all right then it's not my fault. But since I heard this I got depressed, no-one has an idea.

So this is a cause of your depression? 

Yes.

Were you forced to say that you shouldn't do this as I need it?

No, I wasn't forced, since I been to this doctor, this surgery. This doctor has treated us better than the other doctors. What he told us about the budget I tried to understand it, as they treat us well, give us good medication, when we need a test then straight away they say it, 15, 16 years they haven't messed about. We were happy that we even recommended other patients to them and when we call them they have our details on their computers. Like now I have a cold and told them I have a cold and I want to see the doctor and they checked the computer and said come tomorrow. When someone looks after you well, you don't want to say anything wrong about them or even have argument, everything is taken for granted.

Do you know the name of the medication?

The medicine was written directly to him and told us go and visit your doctor after 10 days, then when we went he said that he can't afford it, but I can't remember the name of the medication. [Interruption] But the doctor looks after you so well, he saved my life, you don't want to go and argue with him. No.

Did you talk with the psychiatrist, to say that the doctor will not give medication?

The psychiatrist is retired and is not there. I saw the doctor in town and thanked him that he looked after me and he said that he's retired now. He isn't there.

Do you feel if you had this medication you could have gone back to work?

Yes I did have hope, but look since 1994 up until now, much damage has been done now and muscle have set and I don't think the medication will work now. He then said that it's new, the artery will be opened he said the soft tissues and soft muscles, when they get damaged they are not repairable. It's now long term damage and I don't think the medication will work. The reassurance that I could go to work and got the letter, it's all down in the dumps.

You don't think you can manage it?

No not now, and the medication they give me now when I see how I manage day to day, it's not possible to work now. The reassurance has gone not my health and then if I go to work then I worry about my wife, the matter will get worse not better. T

 

Nelsy feels she became unwell because it was "unnatural" to try to get richer and higher up in...

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Nelsy feels she became unwell because it was "unnatural" to try to get richer and higher up in...

Age at interview: 56
Sex: Female
Age at diagnosis: 48
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And to come into this country to clean houses earning '5 what people who go to school only can get, and I gradually built up what I can say my own business teaching Spanish and Latin American dance. And I was doing very well but to my shock I was doing so well that I fell down very badly. So I end up thinking that the problem is not just me, this, the problem is society. When I accept society I'm contributing to put myself in the wrong place because society is only the division of people by property so it is the poor, the bit richer, and richer and richer, and those who never was, who never had any material property. The opportunity to get it is through the system of education and the higher you study the higher in the tree you are. So to me the fact that society divides people, that is sick. The way I see my, my journey is having gone to the society in my country, trying to scale the tree, climb up the tree in this society, in this country, in this rich country. I was making an awful effort and to me there is the ground where the only place where people can be equal, climbing and climbing we are never equal, we have to get down to the ground and be equal. So to me, health, it only exist in the, in the Natural Community. To me, we are all mad, we are all wrong, all of us need therapy but it's not therapy to go back to the trees, it's therapy to stay on the ground because we, I believe that we are designed to be healthy in equality'

What I had done in my life, [laughs] because when I see my diagram I, I'm meant to be just a Natural Person but I did abuse myself going through this system of education as high as possible. For me that is abuse to a Natural Person that I'm meant to be Naturally.

Others mentioned money problems - although one man said he didn't think poverty was a factor in his case - and either losing their home or living in poor quality housing. Although some thought migration “or the hardship adapting to British society” might have contributed to their mental health problems, others emphasised that they didn't think this was a factor for them. 

 

Hanif doesn't think migration contributed to his mental health problems.

Hanif doesn't think migration contributed to his mental health problems.

Age at interview: 49
Sex: Male
Age at diagnosis: 23
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Just the last thing on, on that point then I, because you mentioned that you experienced that episode just after you, you came here, do you think that your migration played any part in, in that?

Migration often is a, is kind of mentioned as a factor' I'm not convinced that my migration was a factor on its own. It could be another, could be a contributory factor but on its own, I don't think so' You know, certainly, you know, lots of, some studies have shown that, you know, that migration does affect individuals or societies or, you know, groups of people. But yeah it's a, it's out to jury really. So, I mean, you know, either that was a, could be a contributing factor, yeah.

 

Rehana says her problems began when she came to the UK and was separated from her family; her...

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Rehana says her problems began when she came to the UK and was separated from her family; her...

Age at interview: 49
Sex: Female
Age at diagnosis: 44
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Well from the beginning, I came to England, I came with fiancé to England to get married to him, and then 1979, and we got married, you know. And after I got married, you know, it's a disaster in my life, you know, because my brother came with me as well to get married and they didn't get on well and he went back. He got married with my husband's sister so it was a give and take so from that, you know, and that's my married life. My life, you know, a lot, and I have to take the blame for a lot of things, you know, which me and my husband never done, or my brother didn't do anything like that. And when he went back and same week my father-in-law died with a heart attack and I was expecting my daughter same time, it was only a few weeks and I was very ill, you know. I don't have a family here, I don't know where to go to, go for help, yeah. And I was all alone here and I didn't speak English at that time. I didn't know even ABC. I couldn't spell my name, at that time. And I was like a handicap, couldn't do anything, can't get help, what I need.

Anyway, and my sister-in-law, my mother-in-law's, everybody, you know, upsetting me a lot, even though my sister-in-law used to hit me, who got married with my brother. And I have to go out when she's coming to see her mother and then she used to hit me in my stomach, you know, to kill my baby, and which then my husband phoned the police because this baby [inside there?] because she want to kill the baby, you know, and so I survived. I survived, and my daughter was born 1981 and I've been suffering a lot like family problems and after four years my son was born. And when he was born, after two years, he was only two, we went to see my dad. He was ill in Pakistan, and when we got there he was, he had died. So I didn't see my dad. That was shock. That's from, my depression start from that. Since, yeah.

And I came back and having the same problem here with the in-laws. My brother-in-law take advantage of us. He thought I was slave, and I used to look after his children. [Coughs, takes a drink] He's got a wife and that they used to take advantage of me, you know, cooking and cleaning, look after their children and accusing, abusing, you know, for no reason because there's a, you know, they thought I'm from Pakistan and I'm not a human, you know, I'm just a slave. I've just come to do their things they need, you know, then after that there was symptoms coming like a blackout and I used to faint a lot and I used to feel like, you know, kill myself. I mean about five times, you know, I tried to kill myself, you know.

Relationships & upbringing
Many people thought that their family and social relationships had affected their mental health. Some mentioned having bad relationships, marital problems or splitting up from partners. [See Jay below] They also believed that not having a partner or friends, being lonely and feeling unsupported or unloved contributed to their mental health problems (see Devon's story). A few people thought not having anyone close enough to talk to about their problems played a part: “I could not express my sorrows and that's why it was not going away from my mind”.

Lots of people we interviewed felt that their upbringing and relationship with their parents was an important factor. They described being subjected to strict rules and being under pressure to do specific things, for example doing well academically or losing weight. A few people described their mothers treating them particularly harshly, including forcing them to eat or diet, accusing them of having inappropriate sexual relations and punishing them physically. One woman described being rejected by her father because he didn't believe she was his biological daughter.

 

Jay believes her schizoaffective disorder developed as a way of coping with her upbringing and...

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The realisation that my parents didn't particularly like each other, at about 13, was quite traumatic for me. Because they had a great big row and lots of awful nasty things were being said between the two of them. And it was this big awful scene that I'd never experienced in my life and I didn't know how to compute it. [Noise in background] It just, it just didn't compute, it didn't make any s-, I didn't understand it, it didn't make any sense. There was screaming, there was throwing things, there was harsh words. You know, my sister was crying. And I'm just kind of sitting there thinking, 'This is awful,' and not quite knowing what to do, apart from, 'If I get to hug my dad, then it will be better and he'll calm down.' Yes, that was a very traumatic time. 

I think, prior to that I think, just before that or just after, I can't remember which way it went, my mother informed me that the only reason that my name is as it is, is because my dad had two girlfriends called what is really my full name which is on my birth certificate, Joyce. So she decided to give him a Joyce. And lo and behold she had a girl and she named me Joyce. And my dad fell in love with me and pushed her away even more. And so we had an extremely strained relationship. To the point that if my mother wanted my dad to do something, she'd ask me to ask him because he would say, 'Yes' to me and not to her. And it has never changed right to this very day, that relationship. But me and my dad are very, very close. 

That in itself was traumatic, that she, basically he told me this story where it wasn't that she wanted me, she wanted to get her own back. She wanted to have something to hold on to my dad as opposed to having a child to love and nurture. So I was kind of on a left foot most of the time with her.

 I was, when I was, I think I was, must have been about, I must have been about 5, when I had walked into a shop like we always do and I took a bag of crisps off the shelf. And my sister didn't see me take the bag of crisps off the shelf. I just walked out. I was 5. This is what always happened. They gave me a packet of crisps off the shelf and we left the shop. The whole bit about paying, I didn't know that bit. But anyway the shopkeeper, you know, stopped me, you know, 'What are you doing? I'm going to tell your mother.' Back in those days he knew who my mother was, not like today. And he did. He, he, he came round and he, he told my mum that I, I had stolen a bag of crisps. And so my mother beat me to an inch of my life with a belt and welted my skin with a belt. And then she put me in a hot salt bath and I was screaming my head off. And my dad came in and realised what she'd done and punched her, and she lost her two front teeth. Which she then, she's always had to wear dentures because of it. And, you know, this woman reminded me of this at least once a month, all my growing-up life. And that whole relationship was a trauma as, in itself, because I had to develop many defences against her. Like I think now I have a problem with eating, because of the way my mum behaves around my eating. I didn't want to eat something that she put for dinner and I sat there for hours and it never went. And the next morning it appeared and I never ate it. And the next evening it appeared and I never ate it. And then she forced me to eat it, force fed me. And I was sick and she made me eat it. And so my relationship with food is very strange up to this day'

 I was pretty well I think, looking back, growing up. I had some interesting experiences that I perhaps hadn't given as much, I don't know what the word is, I hadn't, I hadn't given it as much notice or consideration as I should have done and that they were traumatic experiences that my mind dealt with

Other people had been separated from their parents or surrogate parents as children and felt their mental health problems stemmed from this (also see 'Onset of mental health problems'). 

 

Marlene was separated from her parents and brought up in Pakistan by her grandmother and thinks...

Marlene was separated from her parents and brought up in Pakistan by her grandmother and thinks...

Age at interview: 38
Sex: Female
Age at diagnosis: 24
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When I were nearly 7 years old I went to Pakistan, and I've been brought up with my grandma and my grandad and me aunties. And my mum, she were here, and my dad. And then we stayed there and we, we didn't, we've been brought up in the Asian way. And my mum, she's English'

And with my parents, I didn't have any love from my parents. And I think that has more affected what I've been through. Since I, still nobody understands me. Only my husband, my kids. Me and my mum, I love my mum but we never, we didn't get touched like should daughters and mums been. And my dad the same thing. And now it's, we've a family problem. I lost my grandma and my uncle because with family's problem. They brought me up and everything. And when, every time I think that, I think every time I love somebody, I have to lose that person. And then I've got fear that I might lose my husband. I might change for my husband and I think about bad stuff. And the thoughts come in my mind'

But when I came back, my, backwards, like I didn't have any love from my mum and my dad. It could be that. And it's the worse thing to not know your mum and your dad. You know them, but you, you don't have that love. And you don't want to share that love to your mum and your dad, because you don't know them. They're saying different things, I'm saying different things. And they don't understand me and I don't understand them. And it's very difficult for me. And I, I, sometimes I start getting anxiety. And now, it's, it's not anxiety, it's feel like I'm tired. I've got, like when I eat I feel full. I can't eat, digesting my food. And then I start thinking bad stuff.

Some people experienced confusion about their identity, especially where their upbringing was at odds with their ethnic and cultural background, sometimes following migration (theirs or their parents). People talked about the difficulties of growing up amongst the White majority and not being able to identify with the culture of their background; sometimes this was because of their parents' choice to adopt a 'White, western culture' - as one woman said, “my mother was very adamant that we should live an English existence and we should eat sausages and mash rather than yam and plantain”. Being of mixed heritage created problems for the identity of some people. For others, confusion about their identity arose as a result of being in local authority care. 

 

David says various factors contributed to his mental health problems, including an unstable...

David says various factors contributed to his mental health problems, including an unstable...

Age at interview: 37
Sex: Male
Age at diagnosis: 37
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Would you mind telling what, what you think did cause your mental health problems?

An unstable family, I think. I think it was a number a factors. My mother not being a very motherly type of character, being basically a kid who had a kid, at seventeen years old. I think that's way too young to be having children. My father not being there. My grandfather, my grandfather being in denial about me, I, I mean if I get called Black this and so and so, he, he'd just say, you're white all the time and he'd keep on saying that. And after awhile I believed, I started believing that. I actually, I almost came to the point where my vision changed. 

And, and emotionally and culturally I still feel that I'm a white person but I know that I'm not. So in a way I'm caught in a limbo between these two worlds because I can't speak Arabic and I don't live in an Arabic country. But I don't look like an English person. So like most people of mixed race I think this is a separate ethnic group all in its, all in its own right. Like most people of mixed race I'm trapped in limbo. And for questions of identity which are very important for people, you just, you just feel trapped and you feel lost. And that's, that's not a very nice place to be at, at anytime in your life.

So is there I mean you, you don't have a, a feeling that you identify more with the, your father's side or with now?

I don't feel I have any identification or indeed any ability to relate to anybody at all in significant way.

Another woman felt that being labelled as “abnormal and in need of psychiatric treatment” became a self-fulfilling prophecy which meant that she saw herself as different from other people. She also felt that the pressures on women in society may have contributed to her having an eating disorder.

One woman reported many traumatic experiences that together led to her schizoaffective disorder, including witnessing her parents' arguments and having her own baby before she felt ready to become a mother. Other people described how conflicts, tensions and lack of contact with members of their immediate and extended family, including in-laws, contributed to their mental health problems. One man said that the difficulties he experienced after arranging two marriages (one for his brother and one for his son) caused him so much worry that he became depressed.

Spirituality
People also had other beliefs about what may have caused their mental health problems. Some felt that God was trying to “torture” them or had put a curse on them. One woman felt that she had been rejected by God and this had triggered her depression (see 'The role of faith, religion & spirituality for people with mental health problems'). Others thought that hearing the voice of God might trigger psychosis, or that reading religious texts could add to feelings of depression. 

 

Ali sometimes wonders whether God is out to get him. (Played by an actor).

Ali sometimes wonders whether God is out to get him. (Played by an actor).

Age at interview: 27
Sex: Male
Age at diagnosis: 26
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And personally my relationship with God hasn't been very smooth. I tend to complain a lot, but I do tend to believe that God does exist, although I don't offer my prayers and I don't do the usual religious stuff, but I do tend to believe that God does exist, and he's probably there to get me or something [laughs] torture me, give me a bad life.

Yeah, this is actually my belief that if God goes after someone then he just completely annihilates their life. It's like, you're born poor, and without legs, and you'll have all sorts of tragedies going on in your life. It's like, I don't know, you'll be born in a famine-ridden country and this and that. It's just absurd. It's, I don't know if God does that or, but, it's, I can't explain it. You'll probably have to improvise on my relationship with God, but it's sometimes, I don't know, I believe he doesn't exist. I want to believe that he doesn't exist, but I can't believe that he doesn't exist. I think that's, that's probably the correct statement.

Traumatic events
Many people felt that traumatic events in their life had triggered their mental health problems: “my brain, it was just in overload”. They mentioned being subjected to bullying and violence, being violent towards others and witnessing violence and murder. A few women had experienced domestic violence, which one woman described as “like a stain spreading through my life”. 

 

David says he experienced a lot of trauma while he was growing-up that made his personality ...

David says he experienced a lot of trauma while he was growing-up that made his personality ...

Age at interview: 37
Sex: Male
Age at diagnosis: 37
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I mean the borderline personality disorder hasn't been given to me as a straight BPD [borderline personality disorder] but they said I'm showing most of the traits of it. So there's that I've got a personality disorder leaning towards BPD. So for the sake for convenience it's been called BPD. Post traumatic stress disorder definitely, I would say. I would say I've seen quite a few traumatic things in my life. This is interesting because a lot of people will then bring out the argument well, people have survived Auschwitz. People have survived Darfur, Kosovo, Cambodia, Vietnam, etcetera, etcetera, etcetera. But what my diagnosis is a series of low level traumas basically stretch over a period of years. And I can think of many traumatic events, being beaten up, seeing my mother having sex with people in, in a spare room. All kinds of stuff, the conflicts with my grandfather who's, the guilt, the shame, a lot of things I've had to carry. And lot of things have, have really made my personality quite distorted I think. 

Hmm. And that, the guilt and the shame that you refer to what, what was that in relation to?

I feel quite guilty that, you know, that I was born in a way because, you know, if I hadn't been born I keep thinking my mother would've had a different life. Although I've come to realise that's not quite true. All that happened was that she passed the responsibility on to my grandparents. I never saw her for a lot of the time when I was younger. She spent most of her time going to parties, going up to London coming back with a new boyfriend. It was quite horrendous really. And, well the shame, is, you know, back at that time if you're father wasn't around you, you get called a lot of very unpleasant names. And people say like, you know, you're father doesn't give a damn about you etcetera, etcetera. Now that sort of stuff doesn't really bother me at all. But then it was just another really blow at someone who's trying to grow to up.

Lots of people mentioned bereavement, including one woman who experienced 6 miscarriages and a few who had relations who'd been murdered. As one man said, bereavement “just gets hold of you, you can't shove it off”. 

Many people we talked to felt that their mental health problems were connected to experiences of being sexually and physically abused in childhood at the hands of their family or whilst in the care of the local authority.

 

Ugo says the abuse she experienced as a child caused her mental health problems.

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Ugo says the abuse she experienced as a child caused her mental health problems.

Age at interview: 38
Sex: Female
Age at diagnosis: 31
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Do you have any other ideas about maybe why, why you get ill, you know, why you've gotten ill rather than other people?

I think I take on to much as well because I just don't want to stop and that and I just get too busy and then forget about it all and then I get tired and worn out because you don't want to stop because you don't want to think about the abuse. You have to live the abuse because I'm burnt, I've got burns so I'm covered in scars so each day you see them and it doesn't go away'

And do you feel that the abuse that you suffered as a child is central to your experience?

Yes.

Okay, do you think things would have been different for you had that not happened?

Yeah.

How would they have been different?

I don't think I'd have had a mental health problem.

Others mentioned experiences of racism in the form of bullying, physical and verbal assaults and other kinds of attacks. One woman said that the BME hostel where she stayed 'diagnosed' racism as a cause of her mental health problems. One man however, who also experienced racism, did not feel that this played a part in his mental health problems.

 

Niabingi realised that racism had played a part in her developing schizophrenia when she stayed...

Niabingi realised that racism had played a part in her developing schizophrenia when she stayed...

Age at interview: 42
Sex: Female
Age at diagnosis: 25
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When I got into the BME hostel and they sort of like, you know, you know, they diagnosed, as well as anything else they diagnosed racism as part of my, had affected my mental health'

Well for me that was, that was a positive experience because I hadn't, because I think they thought, one of the diagnosis apart from anything else that had happened you know, in my life and my background they said a lot, that some, some, that my, so you know, what contributed significantly to my mental ill health, and I will use ill health rather than, or mental distress because that would be very good in this case, was, was racism. And you know, you know, you know, you know, that I, looking back I things I think that that was quite an accurate diagnosis'

Well in, in, the name calling, it was just the name calling that was just, I mean you grow up with that sort of thing you know, this, at school and all that kind of thing like coon and all that kind of thing, you know, the N word. and then there was you know, then there was you know, sort of attitudes at, well at school a lot of my friends and myself were told we were only good enough for factory jobs, oh yeah we were only good enough for factory jobs, do you know what I mean you know, things like that. I know of a lot of , males in my generation where we grew up that weren't allowed, you know, just a little bit older than me, about four or five years older than me who were told they weren't allowed to take O levels because you know, they weren't, you know, they weren't intelligent enough. And they've gone on later in life to get degrees so you know, there was that. Then you know, there was, then there was going for a job when you did leave school there was going for a job you know, you know, just never getting the job, just never getting a job you know, like a shop assistant or something where you're going to be seen in public. If you were in the back stuck in, you know, stuck in the stockroom that would be alright but not on the shop floor. sort of you know, the, and just generally knowing you know, growing up you know, you know, being told, 'Oh.' You know. I mean where I, I grew up there was only two black people on our road and that was, yeah and the other black person was the only house I went into, you know, the neighbours didn't really talk to me, they didn't invite me in, they didn't let their children play. Well sometimes some of the children played with us but in general it wasn't you know, an easy, you know, you hear about all this thing on EastEnders oh you're in everybody's else's house and everybody's else's business you know, it just wasn't like that, it wasn't like that growing up, it wasn't like that, not for me anyway. 

And you know, so you know, and then you know, obviously you've got, you know, your parents sort of telling you about their experience and you grow up thinking that and you live according to that, you know, you don't overstep the mark, do you know what I mean, you live within your boundaries so you know, so you don't get attacked or something. I remember, I remember sort of like you know, sort of growing up and seeing you know, in those days, I mean now it's the BNP but in those days it was the National Front you know, having you know, and you know, growing up thinking oh don't go down there because that's an area where lots of them live or you know, or you or you know, so, you know, or you know, or you know, or they'll be around tonight be careful and all that kind of thing you know, living in fear. You know, that's just, you know, and you're a little child growing up, you've got, you know, you can't explore your world. One thing about, you know, children they need to explore their world and identify with it, you know, and, you know, and you're cut off from half of it, you're told, you know, this is n
 

Shaukat says racism did not contribute to his anxiety, although he was attacked.

Shaukat says racism did not contribute to his anxiety, although he was attacked.

Age at interview: 36
Sex: Male
Age at diagnosis: 30
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Because it was in a park that I got attacked and whatever and I'd be anxious about walking through that park on my own again, for a while But, you know, nothing more. You know, I, I would still go to the same places I used to go. I used, I'd still go to the same school, same class and I knew the people, well a lot of the people that were, you know, racist. A lot of them would be in my class as well and I knew who the people were. I mean, not the ones that attacked me but their friends. And so, I mean, all the people that were like that, would usually hang out in a group together. But, you know, that wasn't a major thing for me then. 

And the other thing was that I wasn't always picked on as well, in, in my class. Apart from those times or some, you know, verbal abuse or whatever about, you know, being Asians or whatever, there was always something else that, you know, these people could pick on. So I wasn't always the one that was getting picked on, so it wasn't, that wasn't a major thing. I was more anxious about not having any friends than being picked on. Because when I did that, I just sort of used to ignore it anyway. Well, you know, I'd get angry, but mainly at myself for not, you know, saying anything back. But then I knew that I hadn't got any friends so, you know, if I do get into a fight or something then, you know, I'd get jumped on by a few people. So, you know, I was scared of that So, yeah, it was, it was a, you know, the idea of like being anxious or being, you know, not having friends that was always, you know, more stronger than sort of the, the thing about getting abused.

Last reviewed September 2018.

Last updated February 2013.

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