Stigma and multiple oppression: Some implications for clinical psychology

A discomforting proposition

I attended a diversity meeting a few weeks ago and although this was not the focus; the on-going underrepresentation of Black and minority ethnic trainees (BME) within the profession was briefly touched upon. I was taken aback and quite disturbed when it was posited that the stigma around mental health issues within BME communities was the reason for the difficulties in recruiting a more representative workforce. This proposition was not elaborated upon and went unchallenged. Instead, it seemed to be taken as a given. It felt wrong. I spent much of the remainder of the meeting considering the proposition and trying to access the logical part of my brain but, such was the level of discomfort I experienced, that I was not able to return to a more rational place and put forward some arguments to challenge the proposition. I chose to remain silent. This post is essentially about articulating a reasoned response to the embodied one.

Could stigma really be a factor?

In all honesty, it was not the first time I had heard stigma put forward as a reason for the lack of diversity within clinical psychology. I have also seen colleagues suggest with much conviction that ‘cultural issues’ were responsible for the lack of Black and Brown faces within the profession. There are various reasons why such notions, which can be stigmatising themselves, may provoke the sort of anxious arousal I experienced within the strategic meeting. It seems those who have put forward the above explanations may not have considered how much of the variance it is suggested, could actually and reasonably be explained by stigma alone, bearing in mind the fact that the acceptance rates for Black and Asian groups are up to thirty times lower than that of White English applicants. Explanations that indirectly put responsibility for inequalities at the feet of disadvantaged groups may act as barriers to curiosity and to more systematic evidence generating.

We have such a wide range of sophisticated research methodologies and much research expertise at our disposal, thus, that so many of us seem quite happy to justify stark and enduring inequalities with reasons that lack precision and/or empirical basis, is in my sense both oppressive and defensive. Indeed this stops us from considering, if only hypothetically, the potential presence and influence of less palatable and more anxiety provoking dynamics such as discrimination (both direct and indirect) and bias (both conscious and unconscious). These processes have after all been widely documented within a wide range of environments and activity sectors. Critically, the above explanations further problematize disadvantaged/marginalized groups.

BME groups are overrepresented in medicine and within branches of the discipline which specialise in mental health such as psychiatric nursing and psychiatry. They also appear over-represented in mental health social work. If stigma (or ‘cultural issues’) were a key variable for such groups’ difficulties in accessing clinical psychology; contact with which is arguably a lot less stigmatising than the above, surely this would not be expected. The ‘Stigma Shout’ survey carried out by Rethink’s research department a few years ago and which is the largest ever survey of people with direct experience of mental health problems on the issue (n=4000), found no ethnic difference on service users’ reports of mental health stigma and discrimination.

Considering the impact of multiple oppression

Of course that is not to say that there is no mental health stigma and discrimination within BME groups, there clearly is. There is mental health stigma within every ethnic group. Thus, like many others, many individuals from BME communities will sadly have negative feelings about mental health services and in addition may show low levels of service awareness. Many will have limited understanding of the signs and manifestations of mental health distress or see psychological difficulties as character flaws. Some would have been influenced by sensationalistic media portrayal of mental health problems and as a result come to believe fallacious associations between mental health problems and dangerosity. It is also true that wihin some sub-sections magico-spiritual explanatory models will be found.

Nonetheless, assuming that stigma may well be a significant factor recruitment wise, it may perhaps be helpful to take our intellectual and reflection efforts further and start being more questioning in this regard, for example, by asking what could we learn from the social context which could be useful in addressing the said inequalities? What practices, at systemic and individual level could perpetuate those inequalities within the profession? How do race, class, and possibly gender oppression (and sexual orientation or trans oppression for some) and the negative stereotypes associated with each subjugated identity, potentially combine and collude with the stigma associated with mental health problems and/or disability?

Maintaining relevance

The above are complex questions but questions we may need to grapple with as trainees/clinical psychologists if we are going to effect and sustain any form of genuine change in relation to access to our profession at both training and service level. Psychology and mental health services have for too long been charged with failing to maintain a sense of relevance to marginalised groups’ lived experiences and worldviews, arguably fuelling suspicion, distrust and anger; leading to both poor uptake and disengagement. Not only does this disengagement may increase the likelihood of more adverse and coercive pathways into mental health services and thus further negative experiences by some marginalised groups, they may perpetuate the stigma and fear that surround mental health problems and services.

Stigma is two-directional. It must be recognised that mental health professionals are not immune to the internalisation of stigma and of other oppressive beliefs. Many people with mental health problems report experiencing stigma and discrimination within health and mental health services, so much so, that the largest anti-stigma campain dedicated part of its activities to tackling such stigma (please see ‘Education not discrimination’ of the ‘Time to Change’ campaign). I was involved in some of these projects as a consultant a few years ago and as part of this, facilitated a range of discussions and training. The latter brought home to me that many myths are still going strong within the mental health sector.

Dealing wih on-going myths

For example, the posited submissiveness of South Asian women and their alleged oppression in their homes or the ‘resistance’ of Black men to experiencing depression and their presumed violence/aggressivity have been repeatedly raised as reasons for race inequalities within the mental health system and difficulties in engaging these groups. Those stigmatising beliefs together with the common denial and/or dismissal of experiences of racism (and the limited cultural competence of services) would naturally deter some BME groups from seeking help from us and from engaging with services; particularly when such contact may be frown upon within one’s environment or community, arguably for good reasons.

Of course too, such dicoursive notions may become internalised and present either social and/or ego threats so that people may understandably consciously reason : ‘I am already facing so much discrimination as a minority in the world, I cannot afford to expose myself to mental health discrimination and stigma’ or ‘I will not give the dominant group the chance to subjugate me some more’. More unconsciously perhaps, some may come to feel : ‘I am inferior/worthless and do not want to evidence or to expose this’. It may be useful to consider potential social and intra-psychic dynamics when discussions around mental health stigma in ethnic minorities are had. Stigma is relational and functional too. At a very basic level, for people to experience or internalize stigma, there needs to be, at least to some degree, others who stigmatize and project. Taking collective responsibility for the on-going stigma and discrimination many face both personally and professionally may help ensure more attention is dedicated to reducing the devastating impact of mental health stigma and discrimination in the lives of people who are often already vulnerable, socially isolated and disempowered. And, that we do not perpetuate stigmatising or othering discourses unintentionally.

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Want to learn more?

Please see…

Brindle, D. (2013, April 30). Mental health anti-stigma campaign fails to shift health professionals’ attitudes. The Guardian. Retrieved from http://www.theguardian.com/healthcare-network/2013/apr/03/mental-health-anti-stigma-campaign.

Clearing House for Postgraduate Courses in Clinical Psychology http://www.leeds.ac.uk/chpccp. (2013). Equal Opportunities Numbers.

Department of Health (2005). Delivering Race Equality in Mental Health Care. Retrieved on 06/11/2014 from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4100773

Keynejad, R., (2008). Barriers to seeking help: What stops ethnic minority groups in Redbridge accessing mental health services? London: North East London NHS Foundation Trust.

Littlewood, R., Lipsedge, M. (1982). Aliens & alienists: Ethnic minorities and psychiatry. Routledge London.

SCM (2002) Breaking the circles of fear: A review of the relationship between mental health services and African and Caribbean communities. London: The Sainsbury Centre for Mental Health.

TTC(2008) Stigma Shout: Service user and carer experiences of stigma and discrimination. London: Time to Change.

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