**3. Structural racism is structural exclusion from the priorities of intercultural concern.**

Racism and other forms of stigmatisation in Western mental health systems creates delays and failures in access via self-stigmatisation [11, 35]. Actual and perceived structural racism exists throughout the depth and breadth of national political-cultural traditions and institutions, so racialised people do not necessarily expect to be humanised by mental health practitioners who are, for the most part, seen as one separable dimension in a *white* matrix of domination [36]. Research suggests that racism is associated with a lack of trust and satisfaction with services provided, as well as a lack of willingness to engage in the first instance and reduced adherence to recommended prescriptions [37, 38]. This *white* matrix of domination, according to Bell Hooks (quoted in Hill-Collins [39], p. 222), refers to.

*"the ideological ground that they share, which is a belief in domination, and a belief in the notions of superior and inferior, which are components of all of those systems. For me it's like a house, they share the foundation, but the foundation is the ideological beliefs around which notions of domination are constructed."*

The mental health system is just one system of many in which we live, all of whom have become constructed over time within a *white* politics of domination, which *white* society established, sustains, and condones [40]. As such, our systems *Perspective Chapter: Cultivating Environments of Belonging in Psychiatry, Clinical Psychology… DOI: http://dx.doi.org/10.5772/intechopen.99925*

have been formed and continue to be maintained by an ethnocentric dominance structure that makes *whiteness* the default standard against which all racialised groups are contrasted [41]. It is in this juxtaposition that *whiteness* dismisses decolonial equality, diversity, and inclusion [42]. Black mental health professionals speak about an 'unspoken level of comfort' when it comes to connecting with the "anger of exclusion, of unquestioned privilege, of racialised distortions, of silence, ill-use, stereotyping, defensiveness, misnaming, betrayal and co-option" [43] that their Black patients bring to therapy sessions [44]. Black patients and Of Colour patients speak about how *white* privilege overrides good intentions in theory with *white* mental professionals and creates a lack of willingness to engage further about the topic of racism [45].

When it comes to clinical care, racialised patients want to be seen and treated by therapists who recognise their humanity, presence, and spirituality in all their diversity. Mental health professionals racialised Black and Of Colour make up a disproportionately small percentage of the workforce [32]. With the current emphasis on the value of lived experience expertise and the potential for including it throughout the research process, it should be clear that therapists who are racialised as Black and Of Colour are, to some extent, lived experience experts when it comes to the topic of racism. Many mental health professionals are positioning Black Lives Matter as a framework for supporting Black and Brown patients by focusing on reversing the impact of traumatic historical and current racism on mental health [22, 46, 47]. However, often this position is met with benevolent racism [48]. Such as the assertion that care provided by professionally competent *white* practitioners in racism-insensitive, non-diverse teams should be good enough to treat the kaleidoscopic origins, episodes, and expressions induced by racism, as well as the needs of racialised patients despite gaps that patients themselves have voiced. Recognition of socio-cultural formations - fundamental humanity - alongside an ability to give voice to patients is a crucial tenet of decolonial intercultural competency [49]. Kivel [50] describes a critical approach to intercultural competency as.

*"…realizing the limits of your understanding. It should make you less arrogant and more humble. It should provide you with skills for promoting the leadership of those from the cultures in which you are competent. As we become more multiculturally competent, we increase our effectiveness in working with diverse populations, but we cannot substitute for people who are experts in their own culture".*

A decolonial framework of workplace belonging tries to comprehend group identification negotiations and how racism on various levels links with broader discriminatory experiences in the workplace [51]. Furthermore, more specifically, these cumulative experiences function as conditions of saturated disadvantage, negatively affecting workplace relationships, productivity, and mental health [52]. Romero's [53] Rubik's cube metaphor can help further to understand the relationship between several layers of racist encounters and compounded risk of having unfavourable mental health effects (**Figure 2**). In its entirety, the Rubik's cube depicts the macrocosm of belonging (e.g., to Germany). Each of the Rubik's cube's 21 separable cubes represents a microcosm of belonging (e.g., to the city, to work, to a generation, to community and to family). Each face of a microcosm of belonging is assigned a colour representing an ascribed social identity (for example, orange represents racialised identity, blue represents gender identity, *whit*e represents socioeconomic status, yellow represents national identity, green represents age identity, and red represents sexual identity). A privilege-disadvantage continuum and a superiority-inferiority hierarchy exist inside each ascribed social identity (**Figure 2**). The privilege-disadvantage

**Figure 2.**

*One microcosm of belonging situated with the macrocosm.*

continuum refers to the structural advantage that one group gains over another by systemic exploitation, which one group continues to benefit from to the exclusion of another group who is structurally disadvantaged due to a lack of access to the same possibilities [54]. The inferiority-superiority hierarchy describes how one group is treated by another group in terms of importance, as well as the dominant group's control over the subordinate group [55]. The geographical location and socio-historical-political context determine where an individual fits inside this nexus (**Figure 2**).

The meaning and expression of privileges and penalties intersecting across and within networks of probable social inequalities have sparked increased intellectual understanding among political allies who have chosen to stand together in solidarity in new geopolitical settings [56]. These profound forms of solidarity are not, however, indestructible: these relationships of compassion and understanding need constant care and attention to be maintained [57]. Racialised immigrants and refugees in European cultures have expressed frustrations surrounding the 'potential space' between embodied phenomenological experiences of racism and theoretical comprehension of racism [58, 59].

Many interculturalists (also known as '*white* political allies') are embarking on self-reflection journeys to find ways to bridge the socially constructed 'us vs them potential space', thereby contributing to unity rather than antagonising tensions [60, 61]. However, there is a growing sense of dissatisfaction among racialised people who become burdened with teaching would-be interculturalists about racism without the appropriate infrastructure to support the duty [62]. Racialised patients describe having to teach their intercultural therapists in mental health services about their lived experiences of racism, with little assurance that their testimonies will be deemed reliable [63]. They describe how exhausting it is to explain one's existence at a first point, especially to those who cannot connect fully with the lived body of knowledge, suffering, and struggle [36].

An emerging generation of racialised Black and Of Colour young people have begun to articulate why it is far less stressful to communicate about racism among *Perspective Chapter: Cultivating Environments of Belonging in Psychiatry, Clinical Psychology… DOI: http://dx.doi.org/10.5772/intechopen.99925*

people who share the lived essence of these experiences [64]. Patients who need to talk about racism often prefer to talk to racialised mental health providers because they have genuine, on-the-ground information [65]. Having a preference is not to suggest that *white* mental health practitioners cannot learn to work sensitively with people for whom racism has caused them harm [66, 67]. Many *white* practitioners, particularly those working from an intersectional perspective, are learning that the success of an intercultural competency movement in mental health related to racism relies upon their willingness and ability to embark on a journey of self-reflexivity [68]. Amid all these consciousness-building processes, however, it is argued by the decoloniality movement that intercultural competency as a tool for disrupting systemic violence and eliminating racism lost its utility because interculturalists have not gone far enough to question mental health sciences' dominant epistemology, ethnocentrism.

### **4. Ethnocentrism: western mental health science's dominant epistemology**

The international resonance of the Black Lives Matter movement, and in Germany, the racist attacks in Halle and Hanau, have revived longstanding arguments concerning the negotiation of solidarities and the diversity of racist definitions [69]. For some, racism is a worldwide phenomenon in the sense that identical patterns of institutionalised racism are found around the world; others would, on the other hand, say that specific forms of racism are the result of historical disparities and political forces in the context of racism [70, 71]. The need for contextualisation is one of the reasons why some prefer to use the term racisms rather than racism to imply diversity rather than uniformity [72–75]. In an era of digitalisation in media, communication, and information technology, one of the consequences of the COVID-19 pandemic is that our world and societies are becoming even more rapidly submerged in a level of interconnectedness that we have never been accustomed to, and for which there is no precedent [76, 77]. As history unfolds before us, for some, it is clear that the dominant ideology of the Western World monopolises the context of geopolitical power dynamics, including the cultural fluidity of lifestyles, health and well-being pursuits, ethics and spirituality in the non-Western World [78]. Because history is time in motion, culture is in flux. Within this monopoly, socio-political systems conceived in the Western World form a Euro-American macro-culture that continues to invalidate indigenous epistemologies in non-Western World countries. The history and continuing system of mental health theory and care is one example of one such monopolisation.

With the mental health of African heritage patients as an example, African psychology matters in the examination and reconciliation of the time, space, and body of lived knowledge in the African Lifeworld - to achieve psychological equilibrium [79]. African colonial education transports socio-political systems of thinking conceived in Europe and Europeanised America to communities in the Majority World, where they may have little relevance [80]. Elements of such Western approaches became invented for a more efficient teamwork approach to exploiting landscapes, agricultural harvests, and precious resources in other parts of the world to benefit the 'elite' Minority against the well-being of the 'second-class' Majority. As such, "the blood that has dried in its codes" legacy refers to the history of racism and colonial brutality that Western mental health science is rooted in ([81], p. 56). The erasure of socio-political systems of African thinking such as indigenous repertoires including preparationism, functionalism, communalism, perennialism and holiticism is contributing to a sizeable gap between actual economic growth, human development trajectories and the predictions made by human capital theory (cited in [82], p. 25; [83]). The canonisation of only *white* (political)intellectual achievements and the curating of reading lists containing only *white* knowledge and knowers, which can make the study of Western mental health science seem irrelevant for many racialised students, does not happen by chance: it is a deliberate move by those who benefit from this epistemological injustice [84].

In Western mental health science, ethnocentrism contributes racialised, gendered, and classed binaries of between-group cultural difference such as "native/migrant", which are used to measure and explain harmful "us/them" comparisons of the human psyche, self-concept, and personhood (e.g., [33, 85–90]). Structural racism persists due to mental health service's failure to recognise and confront its existence and causes through policy, example, and leadership openly and sufficiently. Racism can become entrenched in a mental health service's ethos or culture if it is not recognised and addressed [33]. Thus, structural racism in Western mental health science reflects the occupational culture historically delineating the geopolitical "zone-of-being" bestowed upon the subjectivities, epistemologies, and identities emanating from Europeans and Europeanised Americans that these disciplines are built around (see [91]). In contrast to the geopolitical "zone-of-non-being" ascribed to all racialised Others "born with less" - if any at all - access to environmental resources and quality, material capabilities, and domestic/international socio-political power; thus, their subjectivities, epistemologies, and identities dubbed "primitive", "inferior" and "uncivilised" are erased [92–95]. Furthermore, eliminating structural racism is to eliminate *white* societal investment in sustaining power disparities, both individually and collectively [96–99].

Influenced by the discourse of postcolonial scholars such as Frantz Fanon (1925–1961) [100–104], Edward Said (1935–2003) [98], and Gayatri Chakravorty Spivak, Ake [105] argues, like Fernando [33], that the dominant European epistemology underpinning social science - that is, the ethnocentrism of scientific knowledge - is the most pernicious form of structural racism [106–108]. According to Ake [105], the Western social sciences comprise a bourgeois ideology meant to serve capitalism principles and institutions, resulting in the capitalistic underdevelopment of non-Western communities [107]. Theorising decoloniality as an antidote to ethnocentrism, Bulhan [109], in a similar vein, argues that the dominant European epistemology of Western mental health science is a neo-colonial strategy that ignores the diversity of social and cultural variants, as well as their local meanings. In contrast to decolonial perspectives on the human psyche, self-concept and personhood, Western mental health science implants Eurocentric 'universal' scientific truths onto judgements of postcolonial people, postcolonial land and postcolonial states and societies [110]. It was, moreover, colonising non-Western people and penalising them for not fulfilling Western master narrative expectations [111]. International diagnostic criteria developed in the Western model of mental health are the epitome of stated Western master narrative [109–112]. In the current systems of diagnostic classifications, it is vital to know what constitutes 'normal' social behaviour and moral philosophical consciousness in each community context when using diagnostic criteria, as even supposedly objective disease criteria are defined with respect to social norms (for a criticism see Heinz [113]).

As Mfutso-Bengo [114] puts it, the continual 'push-and-pull' or finding an ethical balance between moral absolutism and moral relativism, presents awareness of social constructionism as a duty of care in therapists' virtuous decision-making processes. Ethical balance orchestrates bridging capital for inclusive and intersectional links across approaches to 'normality' and 'abnormality', 'health' and 'sicknesses', and the sanctity of decolonial humanism and human rights [115–123]. The Azibo Nosology II (ANII) is an example of a classification scheme for the mental

#### *Perspective Chapter: Cultivating Environments of Belonging in Psychiatry, Clinical Psychology… DOI: http://dx.doi.org/10.5772/intechopen.99925*

health of people of African heritage that is based on African cultural knowledge and traditions, as well as and on the understanding that the curriculum and pedagogy of Western diagnostic manuals are hegemonic. Moreover, that the learned helplessness that results in the internalisation of epistemological injustice has harmful mental health consequences [124]. Some writers argue that Azibo [124], rather than DSM or ICD, provides a more culturally suitable diagnostic system for people of African heritage [125]. Local non-Western knowledge should be appreciated, but relativists should be wary of assuming that all local values must be honoured. Azibo's [124] nosology includes some misogynistic terms for women who have multiple lovers, as well as many other problematic categories including sexual misorientation and unwillingness to procreate.

When practitioners see mental health problems as arising from local socio-political contexts rather than from individual intrapsychic malfunctions, ethical balance is achieved [126]. For people of African heritage, these local contexts contain regional versions of systems of dominance such as racism, sexism, homophobia, ableism, and transphobia, as a reading of Azibo [124] would clearly point out. However, such approaches are rarely reflected upon in the currently dominant classification systems. Although the globalised Western nomenclature's science of praxis clearly has its origins in Europe and Europeanised America, European ethnocentric concepts have been widely and uncritically adopted in intercultural therapy with non-Western patients because they are believed to have universal applicability and philosophical value [85]. Improving diagnostic accuracy requires an ethical-political framework within which socio-cultural formations of moralised reasonings are deliberated upon to reach a consensus on what constitutes a clinically relevant mental illness for a patient and what are sickness-related social consequences within his/her/their system of community values as part of efforts to strive for more beneficence, nonmaleficence, and justice [127, 128].
