The first time I sat foot on a psychiatric ward was just under 10 years ago. I was engaged in doing Community Development and Community Research work within Medium Secure Units (MSU) in London. This was my first day on a MSU and indeed my first time visiting any kind of psychiatric hospital. Following a brief introduction to the all White psychology team by the clinical lead and consultant forensic clinical psychologist (a White man); I was taken round the ward where a multi-ethnic, but still mainly Black staff base, composed the nursing team who was in turn, overseeing the care of a virtually all Black inpatient/clinical population. Upon entering the ward, I was so overwhelmed by the sea of Black faces staring at me in utter stoicism, that I had to work very hard to contain my urge to cry.
The visit felt surreal and oppressive in an almost suffocating way and; this had nothing to do with the (respectful) way I was being treated by staff. At the time, I was not entirely sure why this sight had provoked such a strong response in me. I had some knowledge of the extent of race inequalities within mental health services and had also been briefed on the clinical population upon my induction. Yet, something happened in my very first few moments on the ward which took me by complete surprise. Although this ‘Elephant’ remained at the back of my mind as I did further work on the Unit, I became somewhat desensitised to its presence, particularly as the subject was hardly ever discussed with colleagues. Hence, what I set out to do in the present post is to try and make sense of my experience and to consider some potential clinical implications.
The power of symbolism and representation
As human beings we all make use of symbols to categorize, convey and extract meanings from events and social interactions. From a systems perspective, to start with, the staff composition mirrored traditional power distributions so that at the top of the hierarchy was a White man and at the very bottom of the pyramid of power, were of course the Black staff, followed by Black patients. Thus, at team level, there was a representation of social inequalities in relation to income across staff roles. Further, the Psychologist role is one of authority that socially occupies the sphere of expertise and; in the context of MDUs; as the role encompasses the assessment of patients’ readiness for release, another layer of power is therefore inherent to the role.
The meaning attributed to the role of the patient (or more accurately patient-offender) and that of the Psychologist cannot be interpreted outside of the racial make-up of the ward. Connotations and associations whether consciously accessible or not; firmly remain when it comes to race dynamics. Certain images have the power to tap directly onto this rich symbolic heritage. Indeed, looking through history, one would not have to search for very long for many constructions of Black people as dependent and as psychologically, socially and intellectually deficient to surface (debates around such constructions are to some degree continuing today). Consequently, and in the context described, the sight of a virtually all Black patient population having been assessed as needing treatment, rehabilitation and indeed control cannot but evoke the historical inferiorization and pathologization of Black people.
Projection and Identification
Returning psychoanalytically to what had happened in my ‘here and now’ experience of the ward, Projective Identification may offer an alternative and viable framework to make sense of the dynamics. In that line of argument, it may be notable that as the detained Black men appeared to display no feeling and emotion, I experienced an overwhelming sadness and a sense of suffocation. Such feelings appear consistent with experiences which may be triggered by compulsory detention, restraint and freedom deprivation. Thus, it could be envisaged that through my experience, I was acting out the patients’ s disowned and/or unacceptable feelings and wishes which had been projected into me.
There is a long psychoanalytical tradition of viewing racism as a mechanism by which dominant groups project intolerable aspects of themselves into racial minorities. From an internalised racism perspective, those projected qualities can be said to become accepted as one’s own. The imagery evoked by the racial representation clearly echoes the worst things Black people are all too often socialised to believe about themselves. From a psychoanatytical standpoint, the projections from dominant groups. The Ward context may thus evoke the same images that often give rise to many identity difficulties and other internal conflicts amongst some of us. Thus, whilst working toward ‘Recovery’, Black mental health service users may be exposed to the very painful dynamics that may be be part of their parcel of suffering and that may have contributed to bringing about and/or exarcebating their psychological distress.
Working with the Elephant in the room.
Taking on the role of mental health patient, in the current context, may also means psychically, taking on a role which is consistent with racial stereotypes and which may be experienced as buying into the constructed racial hierarchy which naturally part of the self may resist. From that perspective, it may follow that the role of mental health patient may be an extremely conflictual one for many Black men which may bring to the fore feelings of inferiorisation, marginalisation, exclusion, subjugation, distrust and possibly self-loathing. Although I have not come across many Black mental health patients/service users who have described their experience using symbols, systems representation and psychoanalytical concepts as frames of reference, the sense of suffocation and oppression I experienced has recurrently appeared in my sessions with Black service users as did their experience of being stereotyped on psychiatric wards.
There is ample research evidence suggesting that Black mental health service users have the most conflictual relationships with their clinicians, that they are the most dissatisfied group of all mental health service users and that they continue to report experiences of racism (including racism within services) but; despite these well-established findings; it appears that the Elephant in the room remains too overbearing to acknowledge and to work with for many of us. The dearth of discussion, clinical and empirical attention to the extent of the impact of race dynamics in relation to the psychological functioning and the service use, experiences and outcomes of racialized minorities seems to me to be of particular concern. Not only because it may be part of the reproduction of existing hierarchical structures that perpetuate the invisibility of race and of White privilege, but also because it prevents opportunities for race related wounds and institutional suffering to be seen and addressed. I believe it may well have been these wounds and suffering I was apprehending and reacting to on my first day on the ward.
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