Clinical Issues

Posts focused on race issues from a clinica//practitioner perspective.

Trauma Informed Care & people of colour

“If you are silent about your pain, they’ll kill you and say you enjoyed it”                

                                         Zora Neale Hurston

There are different kinds of wounds. Not all pain is deemed legitimate. Oppression causes trauma. Amidst the (fairly) obvious, debates around what really constitutes trauma as laid out in criterion A of the Diagnostic Statistical Manual (DSM)’s diagnosis for Post Traumatic Stress Disorder (PTSD); are alive and well. Criterion A now requires that an individual has been ‘confronted with: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence’ in order to qualify as having experienced trauma. In contrast with the DSM-IV and previous versions, the DSM-V notably includes sexual violence but not racial violence…troublingly evoking the fight for racial justice.

Looking back in history, (white) women’s rights have always taken precedence over the rights of people of colour. For example, in the US white women were afforded the right to vote in both state and federal elections in 1920 but, it was only in 1954 that people of Asian heritage could vote and; well into the 60s that measures specifically designed to bar African Americans from voting (e.g. voting taxes, literacy tests or intimidation) were rendered unlawful. The recognition of racial violence and injustice historically takes much longer than the recognition of sexual violence. It is important to bear that in mind. With some luck, we may get some intersectional thinking within mainstream mental health systems within 50 years.

Still…many of us continue to exist under the weight of racial (and intersectional) violence and more critically; continue to be affected by smaller, less extreme but repeated traumatic experiences. They rarely involve threat to life or to the integrity of our body but, they nonetheless create threat to livelihood, affect life course and limit life chances. They may not cause us to be confronted with overt violence, all the same, they create unsafeness and insecurity, pain and, a sense of futility and resignation or helplessness. Often too, they lead to internalised silencing or self-censorship due to repeated experiences of denial, invalidation or minimisation.

I am amongst those who believe in speaking of our pain.  As marginalised people when we are silent when violence is done to us, we offer a hiding place to perpetrators and to oppressive systems. Oppression and abuse often create a felt sense of shame. And, shame thrives in silence. This is also how oppressive systems reproduce themselves, they locate the pathology, dysfunction or anomaly within those they harm. We do the master’s work when we internalise these (projective) beliefs. Moreover, when one cannot speak of the violence they experience or have experienced, they are done violence all over again. Silence is violence. Often.

Insidious trauma

There is nothing new in considering oppression as a traumatic agent, nothing new at all. Feminist scholars have long critiqued DSM conceptualisations of trauma. Many have advocated for a theoritical expansion so as to locate the experience of trauma within socio-political contexts. The concept of insiduous trauma is born out of this scholarship. Insidious traumatisation (Root, 1992) is centred on the daily ‘subthreshold’ traumatic stressors marginalised people experience which, when taken cumulatively, amounts to trauma because they are constant reminders of one’s precariousness and unsafeness in the world. Some feminists have sought to include insidious trauma within PTSD criteria or put forward conceptualisations of oppression-related psychiatric disorders.

Understanding insidious traumatisation is vital. Nevertheless, I am not sure that some sort of pathologisation parity is required or would be helpful. Nor that pathologising responses to trauma more generally is desirable. This is not because I uphold a hierarchy of suffering or injustice or, because I think, insidious trauma necessarily produces dissimilar physical or psychological reactions to more ‘classic’ traumatic events or experiences. I am simply not convinced that the legitimisation of the psychological harm of racial violence should be via an extension of the DSM/psychiatric classification systems; systems that are based on alleged ‘deviation’ from unpacked and unproblematised norms (and let’s be real which themselves have a long history of doing violence to marginalised groups and indeed may easily be charged with actively living up to that legacy) when being deemed ‘abnormal’ and treated as such in the world is, by definition, the root cause of insidious trauma.

Trauma Informed Care?

When a traumatic event is extreme or when we are able to identify a specific event, it is easier to see and recognise the need for support and care. When the damage is done covertly or more subtly over months, years or decades or; when it is part of the fabric of society culturally or ideologically, it can be much more difficult to attend to our suffering or to legitimise the need for support; even to ourselves. Such violence becomes the norm and our responses the pathology, our inability to cope. Smaller but repeated acts of denigration, of discrimination, of othering; constant reminders of structural inequalities and injustices do culminate into significant psychological distress. The evidence is there. There is nothing abnormal or deviant in survivors. The deviance lays in the violence.

There has been a global push towards what is often referred to as Trauma Informed Care (TIC). Various definitions of Trauma Informed Approaches (TIA) exist; all have at their core, a will to configure services and/or care around the developmental impact of trauma on all level of human functioning including on the psychological, neurological and on social development. TIA, further; seeks to ensure all social systems understand the impact of trauma on families, groups, communities and other social systems. TIC may be less stigmatising and, there are many benefits to understanding how trauma can affect attachment, worldviews and more generally people’s experience of the world and thus how structures can retraumatise.

I remain cautious though, when it comes to uncritically embracing the approach. I am not sure there is a huge conceptual difference between envisaging people as traumatised rather than as ‘mentally ill’.  For starters, most proponents of the medical model would probably argue that both propositions are not mutually exclusive. Indeed, it is precisely what has been proposed of late ‘there is something wrong with you… (in your brain, your emotional responses, your personality, your perceptions, your cognitive or relational processes etc…) because of what you have been through’. Thus, saying or implying, you are damaged because of trauma is no more humanising as a narrative, to me, than saying or implying you are damaged because of faulty brain structures.

Both explanatory models locate the disturbance or pathology within the individual.  In other words, you are still saying to me that there is something wrong with me as opposed to, there is something wrong with the way that I have been treated and everything ‘right’ in the way I have responded to try to survive. Further, and more importantly, the main focus remains on ‘treatment’ rather than on prevention, at least not on holding structures of power to account.  I have seen very little of this within TIA. ‘What has happened to you’ is infinitely more compassionate than ‘what is wrong with you’ no doubt, better still is asking ‘what has happened to you’ then, turning to oppressive systems and those with more social power; to ask ‘what are you doing to stop harming people’ or ‘how are you abusing your power’. Much more difficult questions of course but, necessary ones to balance the focus here and not lay our gaze exclusively or even primarily, onto individuals who survived violence or try to survive the harm done onto them but onto those who abuse their power, individuals and systems.

Trauma Informed Care and oppression

Psychiatry and mental health systems do not own distress or trauma. Or how it is defined. Or how it is or should be experienced. Trauma is not patented by the American Psychiatric Association (APA). Our experience of the world does not cease to exist simply because a group of white American men at the APA, or dominant systems more generally have decided, the daily violence we suffer is not that traumatic or worthy of a name or of a mention in their (conceptually and empirically flawed) book. Or because mental health systems, by and large, continue to struggle to make themselves relevant to so many of us.

I note that despite the recognition that racism constitutes trauma within most TIA I have come across and, the expressed link between trauma and historical and cultural contexts as one the principles of TIC,  I am still to see a single intervention within the framework specifically addressing the damage of whiteness within any mainstream mental health system in the UK. This, I find quite ironic. Racism reproduced at cultural-symbolic level is a source of trauma too. This invisibilisation or disinterest is consequently quite rich.  There is thus no evidence that TIC would be more relevant and/or more centred on people of colour’s needs or experience. Although the potential that it could is certainly there.

Although I am still ambivalent but open about TIC in relation to people of colour and their experience of oppression particularly, I do believe that we could benefit from using insidious trauma to make sense of our lived experience and to render visible and legitimate, the psychological effects of racial oppression. Although here too, the danger of individualising social trauma by narrowing analytical lenses looms very near indeed, constant efforts are required to avoid this process. Sill, by claiming the term, irrespective of dominant groups or systems’ approval, we are choosing self-definition. We are too, asserting our right and power to define reality. We are choosing to centre our experience of the world and hopefully to orientate ourselves towards self-care. And, to be clear, self-care in my book absolutely entails organising and resisting. History, teaches us that it makes little sense, to seek social approval for our struggles before taking action. Eventually, we tend to be proved right.  TIC and particularly, oppression-focused TIA may well prevent more debilitating manifestations of oppression-related or insidious trauma in people of colour, but the evidence base is simply not there and, I cannot say I have seen a rush for it.

References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.)

Root M. P. (1992). Reconstructing the impact of trauma on personality. In Brown L. S., Ballou M. (Eds.), Personality and psychopathology: Feminist reappraisals (pp. 229-265). New York: Guilford.

Thank you for reading.

If you have found this article useful or interesting, please spread the word. All work published on Race Reflections is the intellectual property of its writers. Please do not reproduce, republish or repost any content from this site without express written permission from Race Reflections. If you wish to repost this article, please see the contact section for further details.

 

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Neutrality, power and psychiatry: Shifting paragdim through praxis

 

The challenge of shifting current psychiatric conceptualisations

The British Psychological Society’s Division of Clinical Psychology (DCP) issued a position statement on psychiatric diagnoses in May 2013. The statement highlights many of the limitations of psychiatric classification systems, theoretically, empirically and clinically.  In making the case for a ‘paradigm shift’, the DCP’s statement draws attention to the impact of psychiatric diagnoses on the life of those in distress including: the marginalisation and decontextualisation their lived experiences, stigmatisation and dehumanisation.  Further, the statement alerts readers to the ‘Ethnocentric bias’ inherent to current conceptualisations which can lay the foundation for discriminatory practices.

Debates around the statement and the usefulness of psychiatric diagnoses more generally, continue to rage. Many have been heated and passionate. They have been located both within and outside clinical psychology. Much of these have been constructive and necessary. Some, I have struggled with. Many have qualified attempts at problematising current diagnostic practices as ‘turf war’ stemming from clinical psychology’s long term ‘competition’ with psychiatry. Others, have posited that as long as service users find psychiatric classifications useful, then psychologists and others ought to lay issues of reliability and validity to rest. It has been also argued that those ‘pushing’ for this ‘paradigm shift’ may be politically motivated.  Some have even attempted to frame the issues at stake in terms of language positing that focussing on the ‘names’ we give to mental health problems matter little. That if they do matter, they should matter a lot less than our core business, the business of supporting people in distress.

Vested interests and criticisms

Whilst issues of professional identity, boundaries and power are no doubt engaged here, some healthy rivalry between psychology and psychiatry can and has historically brought several clinical and theoretical advances many of which have translated into service improvements, for example the more widespread use of formulation. As to the point about ignoring issues of scientific rigour if diagnoses help service users make sense of their experience, such a position would seem quite difficult to sustain ethically. The charge of ‘enforcing’ or pushing a particular worldview onto service users, has left me quite perplexed, though it is often argued that more socio-political conceptualisations of distress are ‘agenda based’ and propagate an ideology or worldview. And that this is of course, undesirable.

Such criticisms imply that current conceptualisations of mental health problems do not impart particular worldviews and ideologies. That they are simply neutral reiteration of what is, of what exists objectively. These criticisms perpetuate the fallacy of neutrality and propose that personal experience of distress and conceptual ‘preferences’ can be extracted from socio-political contexts and separated from issues of power, agency, and history and from their deriving social relations. Despite the fact many theorists from a wide range of scientific (and non-scientific) backgrounds have unequivocally demonstrated the myth of neutrality, it persists. And, it persists for various reasons. Firstly, neutrality provides practitioners with a ‘pass’ from exploring some of the ethical dilemmas that arise from more socially situated mental health practice. In other words, it narrows the focus of our ethical reflections.

Secondly, it legitimises the status-quo. It does so by obscuring the very fact that the relationship to the world assumed by current conceptualisations and the scientific stance which is illustrated by our positions on mental distress, are themselves products of particular worldviews and epistemologies.  In other words, it erases the socio-political and historical location of neutrality and its underlying worldviews. Thirdly, and arguably more importantly, neutrality masks the particular interests of both social and professional groups who claim it.  In doing so, it increases professional (and social) credibility, legitimacy and thus power.  For example, decisions on mental health matters (such as funding priorities, service configurations, ‘treatment’ options etc.…) are deferred to those who are seen to be neutral since after all, their collective interests both professionally and socially are presented as being inconsequential, there is thus no need to reflect on potential conflict of interests, beyond the most obvious.

Cultural hemogeny and choice

Cultural hegemony refers to the belief systems and explanatory models which primarily serve the interests of privileged or dominant groups but which become imposed and accepted as the cultural norm. It universalises ideologies that encompass the nature of things and, underlie the social, political, and economic status-quo which is in turn rendered natural, inevitable and in service of everyone (rather than a system based on artificial social constructs which benefit certain groups). Within mental health services the dominant ideology includes very fundamental precepts such as the existence of mental ‘illnesses’, the pathologisation of certain behaviours/beliefs deemed socially unacceptable and the location and the causes of mental distress.

But of course, as has been argued quite powerfully by many, locating mental health problems within individuals, means the unequal and unjust social order which benefits the most privileged and, at the very least, provide the conditions for psychological distress to arise, remains out of focus. Thus, the cultural hemogeny, within mental health services similarly serves the interests of socially powerful groups. In that sense, having the masses buy the idea of biological defects or dysfunction serves the status-quo. But…, what of people who use services and choose to use psychiatric diagnoses? Why are psychologists set on ignoring that mental health service users do find psychiatric diagnoses helpful subjectively? Well, I don’t think we are.

Firstly, it is problematic to assume that amongst psychologists who challenge psychiatric classifications, there is not amongst them, people who have used or use mental health services. Further, the above questions, raise even more fundamental questions: how does one know the proportion of service users who find diagnoses helpful, damaging and indeed re-traumatising? There is little empirical data to give an answer to such a question positively. And, assuming that only a small minority of people with lived experience of distress found current classification systems damaging, would it be ethical to ignore their needs and experiences-do we close our eyes on the fact some people will take their own life upon being diagnosed?  Indeed, is there space to reject psychiatric classifications within current mental health configurations? What of social ethical issues or of concerns beyond individuals’subjectivities? And more crucially perhaps, can we really presently sustain the notion of choice?

Using praxis to help shift psychiatric conceptualisations

We are all socialized into dominant discourses and we internalize them often believing we do so by choice.  I can chose to accept a diagnosis of psychosis and find it useful. However, the fact remains that not doing so may well mean that I cannot access services, that I am deemed to lack insight and thus subjected to more oppressive forms of ‘treatment’. That is to say, there are serious social consequences and costs for those who resist hemogenic forces and interrogate prevailing dominant ideologies and significant privileges for those who uphold them; both in society generally and in mental health services, specifically. As a result, the cultural hemogeny becomes part of our socialisation and influences our belief systems. It shapes the ways in which we think about ourselves and others, and how we relate to the world.

It seems futile to ask anyone to interrogate the hemogeny of mental health services without providing them with the tools to do so and, unless people who use services and others are able to critically interrogate current structures without suffering adverse consequences, I would argue that it is simply misconceived and indeed unethical to flaunt the notion of choice. Freire argued that marginalised groups may accept individualistic explanations of their experiences because of a need to identify with those with more power. A (Freirian) praxis based approach would involve reconciliating subjective aspects of mental health distress with more objective structurally based realities so that individuals can gradually perceive their personal and social realities as inherently intertwined and in constant dialectical communication.

This is the precondition of the praxis: a critical engagement with change through reflection and social action. Indeed, increasing a sense of ourselves as socially situated persons or as members of an oppressed group, will make us less likely to be satisfied with explanatory models which ignore the socio-political and take away our agency. A praxis based approach would thus necessarily entails a co-intentional and co-constructed conceptualisation of experience with both practitioners and mental health service users coming together to apprehend reality and to re-create the knowledge necessary to take action to ameliorate the unequal and unfair social order which creates and exacerbates distressed subjectivities. This is far from simply being a matter of language. To many of us, that is our core business. That should be an intrinsic part of the business of supporting people in distress.

 

Thank you for reading.

 

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All work published on Race Reflections is the intellectual property of its writers. Please do not reproduce, republish or repost any content from this site without express written permission from Race Reflections. If you wish to repost this article, please see the contact section for further details.

 

When the oppressed turn into oppressors: Parenting & internalised racism

The privilege of being lighter skinned

I am a lighter skinned Black woman. I am light enough to benefit from shadism but dark enough to still be accepted as Black. A uniquely privileged position. Throughout my upbringing I have received messages in my environment that this made me more desirable, more worthy, and/or more significant than my darker skinned counterparts. These messages were both covert and overt and articulated in the home and outside the home, at school, in the media etc… Pretty much everywhere.  There is no doubt that I was, at times, spoken to in kinder voices or treated with more patience than my darker skinned peers or sisters by both people of colour and by White people, all things being equal.  In time, I have learnt that my femininity and womanhood would be more easily accepted.

That my humanity would be slightly less frequently questioned.  Giving birth to a darker skinned girl forced me to revisit some of these unearned privileges. It brought home to me that because I was and would be treated with more consideration; my daughter would invariably be treated in more problematic ways, more often.  I had to grieve over the fact that whatever little respite and refuge my lighter skin had afforded me, it would not be enjoyed by her, that I had not transmitted these privileges to her. This was painful. It was scary too. The thought of her going through even more hardship because of the darker shade of her skin was difficult to come to terms with.   It led me to wonder about the role of parents in the process of internalisation of racism.  It also made me confront my own internalised racism.

Parenting and internalised racism

Some see internalised racism as one of the most common yet least studied feature of racism.  The subject is fraught with taboo, shame and avoidance leading to many misconceptions and unmet psychological needs. Most people of colour would have grown up in houses within which the narratives of ‘working harder’, ‘being smarter’, were repeatedly enacted. ‘You have to be twice as good as your White equivalent to simply be deemed good enough to stand underneath him/her’ or words to that effect will likely resonate with many non-Whites.   Similarly, it is not unusual for Black parents to mirror (consciously or otherwise) the harsh treatment society befalls onto Blacks males. To respond with punishing harshness to any lapse in conduct or behaviour, particularly those associated with racial prejudices. Out of fear that negative societal expectations and the dreaded stereotypes may materialise.

I have on occasions caught myself looking at my sons’ behaviour through the contemptuous gaze of society.  Perhaps too I have in these moments responded more harshly than necessary in an effort to help ensure my boys would not fall victim of others’ prejudices. I have seen young children whose skin had been lightened. In some families, children may be socialised to avoid partnering with darker skinned individuals or taught to distance themselves from their minoritised or cultural identities or to put the needs and experiences of White people above their own.  Though in good faith, the violence contained within such parenting practices is worth reflecting upon. In essence in our efforts to compensate for racism, we socialise children into injustice, compliance and complicity and instil a sense of inferiority in them. In doing so we may limit children’s scope to be themselves. We may reduce our capacity to respond to them with compassion and kindness. We may attend to stereotypes of what our children could be or could be seen as, rather than attending to them as unique beings. In a nutshell, we may contribute to racism’s self-fulfilling prophecies, perpetuate racial inequalities and more worryingly, may increase their risk of psychological  distress.

The perpetuation of oppression is everyone’s business

Nevertheless, it would be ridiculous to blame or demonise parents for their wanting to increase the survival chances, privileges and life opportunities of their children or to prepare them for the racism they will encounter so as to minimise its effects. Internalising racism is adaptive.  It is no pathology.  It is no personality, genetic or biological flaw. Nor is it the consequence or evidence of inferiority in the oppressed.  So where does it originate from and what function might it serve?  Foucault proposed that the construction of reality through the production of ideologies or knowledge is controlled by the dominant group and circulated throughout society. This construction is posited to inform social norms, common sense and all aspects of organisational and structural life.

The fundamental consequence of such knowledge transmission is that the interests of the oppressors are presented as actually reflecting everyone’s best interests so that those who are oppressed come to internalise the dominant group’s interests as their own.  The ‘double bind’ experience has been used to make sense of internalised racism. It refers to the illusionary and implicit promise by the dominant group that oppressed groups can escape the consequences of their otherness by disowning their ‘difference’.  It lures racial minorities into agreeing to the very rules which Other them. In essence, the double bind exclaim: ‘become more like us and you too will have access to structures of power, you will become one of us’.  A tempting proposition for anyone, particularly for racialised parents eager to shelter children from the impact of racism.  The trouble however is, that achieving the promise of the double bind is impossible. This is because the construction of a superior class is dependent upon the existence of an inferior one.

Making internalised racism and its manifestations the problem of racialised groups is a further act of violence. This  equates not only to victim-blaming but also to erasing the very fact that the dominant group remains both the primary beneficiary and source of such internalisation. It is akin to saying ‘you need to be like us to be human or not to be Other’ whilst similarly positing ‘trying to be like us is evidence that you are not human or that you are Other’.  A ‘lose lose’ tautologically absurd proposition.  Being a parent is the toughest job on the planet.  Parenting in the mist of oppression and marginalisation is even harder.  Perhaps it is time that we collectively stopped shying away from internalised racism and gave it the clinical and empirical attention it deserves.  For mental health professionals this would naturally entail sharing a little bit of power and giving away some privileges. The privileges of not knowing, of not understanding or perhaps of not wanting to understand.

Thank you for reading.

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All work published on Race Reflections is the intellectual property of its writers. Please do not reproduce, republish or repost any content from this site without express written permission from Race Reflections.  If you wish to repost this article, please see the contact section for further details.

By challenging racism: could we actually be perpetuating it?

The Function of racism

‘The function, the very serious function of racism is distraction. It keeps you from doing your work. It keeps you explaining, over and over again, your reason for being. Somebody says you have no language and you spend twenty years proving that you do. Somebody says your head isn’t shaped properly so you have scientists working on the fact that it is. Somebody says you have no art, so you dredge that up. Somebody says you have no kingdoms, so you dredge that up. None of this is necessary. There will always be one more thing.’ Toni Morrison

There seems to be two different kinds of people when it comes to dealing with experiences of racism or at least two main types of response.  On the one hand, we may react; indeed we may make it a point to react. People who react tend to be those who argue, who wish to demonstrate the folly of racial prejudice to those who utter offending comments. These may be principled people, conscious people, and/or rational or reasonable people.  People who may feel that they have an ethical or liberatory obligation to respond, to correct, to evidence or to have their voice and experience heard.

On the other hand, there are those who seemingly chose not to engage, those who ignore the offensive or bigoted comments or theories or who seem to turn a blind eye to them. They either appear to take no notice or seem not to care.  Naturally, most of us oscillate between these two poles and may spend much time somewhere in the middle.  Many believe that speaking out is an intrinsic part of the liberatory process.  That it is absolutely necessary and indeed that being silent amounts to complicity, to letting people off the hook and in doing so, to contributing to the perpetuation of oppression.  Not everyone however, is aware of the emotional demands of both challenging and being silent.

Reinforcing racism

Though mindful of the courage both positions require and of the potential material risks and perils associated with challenging racism, it has always felt as though there were higher psychological costs to being silent.  I had too been certain that in the longer term, gains in terms of equality and dignity could only be achieved if we spoke individually and collectively. Thus, for long, speaking out seemed a pre-condition to tackling racism. Tony Morrison’s quote somewhat challenges this position.  It proposes that such actions serve the function of racism.  Whilst she posits that distraction is the core function of racism and we may or may not agree, one issue I will reflect upon here is whether responding intellectually or emotionally to racism may be in the interest of those directly impacted upon by racism.

So, what if actually, some or all of our actions to combat racism actually perpetuated it, inadvertently?  I am aware that this is often a defensive premise which may be advanced by those with social power who are unwilling to contemplate the thorniness of the subject matter or to sit with their own racism or privilege. But do bear with me… As is plain to see from the above quote, Toni Morrison does not believe that expanding energy rationally disproving racist claims is necessary. Doing so according to her is futile because there will always be one more claim to disprove. I believe doing so is also a lost cause because racism does not belong to the realm of the rational. Critically, challenging racism may also be unhelpful if not harmful…Firstly, from a behaviourist perspective, every human behaviour serves a function.  Behaviours can naturally have multiple functions, some (or all) of which may well be obscure.

The core issue here is that when the function of a particular behaviour is served, then that behaviour will likely remain.  It would have been reinforced thus, maintained.  This is a fundamental behaviourist principle. This simple tenet may have significant implications for how we tackle racism. For example, if the function (or one of the functions) of racist ideologies is to inferiorize people of colour and, people of colour as a result of such ideologies internalise this inferiority, this function would have been fulfilled and racist ‘ideologizing’ reinforced thus likely to be perpetuated. Or, if a function of racist language is to offend or to hurt and, such language does get to us, then behaviourists would argue, the likelihood or such language being used again would have been increased.

Self-care and boundaries 

I am aware the above propositions have the potential of being seen as victim blaming. This is far from my intention. The responsibility for racist and discriminatory acts, in my book, remains firmly in the hands of perpetrator(s). However, if it is or can be within our control to reduce the occurrence or the impact of racism on us, then, we may start to reclaim some of the power oppression robs us of. It is clear to me that the impact (or consequences) of racism feeds into its existence, it is what gives it its potency.  Though I realise this may betray the dim view I have on humanity, my sense is, in a nutshell, that as long as racism works or hurts, it will invariably continue to exist.

This may help explain why in spite of major gains made in terms of race equality, it is quite evident that processes of othering and marginalisation remain and seem the most difficult to address.  Perhaps this is because the hostility, contempt and fear we have for the Other now manifest in more subtle and covert ways. So, if much racial bias and prejudice find their refuge in our unconscious and, become externalised without our awareness, could it be hypothesised some equally unhelpful processes may become triggered outside our awareness, as racial minorities, when we respond, argue, defend, and evidence our humanity, again and again?

Could it not be hypothesised that arguing our way out of racist encounters and discourses may actually also allow something in? And that perhaps, our psychic integrity or boundaries may somehow become compromised?  To challenge a proposition entails a degree of internalisation since we need to hold it in mind to consider it.  When such propositions are hate based and carry with them projections, trauma and violence one may be rightly concerned about potential impact of such repeated internalisation (in addition of course to the more observable psychological and health consequences).  Even though this internalisation may only be momentary, perhaps its potential impact on our psyche, on the struggle for liberation and also on the possible unconscious needs or processes which may get fed ( in those who other us) may need more attention.

Thank you for reading.

If you have found this article useful or interesting, please spread the word.

All work published on Race Reflections is the intellectual property of its writers. Please do not reproduce, republish or repost any content from this site without express written permission from Race Reflections.  If you wish to repost this article, please see the contact section for further details.

The cycle of oppression: A psycho-socio-cultural formulation (DRAFT 1).

Bringing the social and psychological together

A common critique of mainstream psychotherapy models is that they take little account of social and cultural forces and of their effect upon psychological structures and relational processes. This is a significant limitation in terms of culture competence. Many minority and marginalised groups continue to see mainstream therapy and mental health services as irrelevant.  More concerning is that some may come to experience the therapeutic process as one which exposes and weakens them into powerlessness and; which renders invisible the power of the social context and its related wounds and traumas. It is not unusual for therapists and other helping professionals to feel overwhelmed and helpless in relation to the idea of actively working with social and cultural forces within the therapeutic encounter.

However, any genuinely emancipatory and culturally competent approach to therapy must strive to make visible the impact of oppression and help support service users’ efforts to free themselves from its destructive power relations. Relations that exist structurally, socially and psychologically for people who continue to be othered, marginalised and oppressed.  More culturally and socially informed formulations may therefore offer tools to validate marginalised groups’ experience of the world and thus contribute to change.  Although extremely useful, I have personally been frustrated by purely social formulations which have not commonly highlighted deriving psychological correlates and thus have located themselves within a level of analysis and intervention which may arguably be outside the remit of mainstream psychotherapeutic practice. This post is an attempt at bridging the gap. It provides an introduction to a preliminary psycho-socio-cultural formulation framework (figure A), its rationale and some possible questions to aid reflection.

Figure A:  Draft diagrammatical formulation of the cycle of oppression.

photo (1)

Description of the formulation framework: The cycle of oppression.

At the centre of the draft formulation is a cycle of oppression.  This cycle is made of four interrelated components varying in proximity to the present or to the ‘here and now’.  Those components are: discrimination and oppression, inequality/access to material resources, proximal images/discourses and, distal and intergenerational narratives and events. The oppression cycle is posited to impact on both worldviews and on psychological functioning so that another cycle of psychological correlates is located outside it. The proposed deriving psychological processes are status anxiety and evaluative stress, the internalisation and replication of oppression, the (cognitive) salience of historical traumatic narratives/events and finally the sense of cultural mistrust or paranoia and (affective) distance to the dominant culture. The formulation thus firmly puts the influences of the social and cultural at the centre of psychological functioning.

Discrimination, oppression and cultural mistrust

Perception and experiences of oppression such as discrimination and harassment in the workplace (or in other life domains) are commonly reported amongst all members of minority groups. The link between such experiences and chronic stress, poor psychological wellbeing and ill physical health are well established. Perceived and actual discrimination can elicit what has been termed cultural paranoia, a healthy and adaptive response to experiences of oppression. Nonetheless, cultural paranoia can give rise to feelings of hopelessness, helplessness and bias against members of the dominant groups. It can also produce hyper-vigilance and fear.

It is thus likely that those who are experiencing it to a high level, will be in some form of distress. From the therapeutic perspective it may be helpful to consider how cultural paranoia may impact on trust and on the working alliance. Mental health services are a microcosm that, it can be argued, represents the social world. A service user who expects that he/she will be discriminated against within services or by therapists and/or that his/her account of such experiences will be dismissed, silenced or pathologized will understandably be guarded and reluctant to disclose relevant difficulties. A degree of hostility may become apparent if the therapist is seen as a representative of the dominant culture, the state and/or authority.

How does the Service User (S.U). locate himself/herself, his/her immediate family and distant family culturally and historically?

How does the S. U. define oppression and discrimination?

To what extent has the S.U. experienced oppression and discrimination?

How is sense made of the above?

What part do such experiences play/played in current/past psychological distress?

What has the S.U. found useful in managing such experiences?

What is the S.U. experience of power and powerlessness?

Social/material inequality, status anxiety and evaluative stress

Social inequalities have a significant impact on our psychological wellbeing. On a basic level they perpetuate the uneven distribution of protective factors and of stressful life events. Evidence suggests that more unequal societies tend to suffer from poorer mental health. England is one of the most unequal countries in the world. As consumerism is reaching new heights, the gap between the rich and poor is increasing. The relationship between mental health distress and social inequalities is bi-directional so that each has the potential to exacerbate the other. Additionally, although causality and directionality is not always clear, most marginalized groups tend to be socio-economically disadvantaged.

The psychological consequences of inequalities are central to the psychological functioning of those who are economically and materially disadvantaged. Wilkinson and Pickett (2009) argue that the impact of income inequality is psychologically mediated by ‘status anxiety’ in that inequality creates social hierarchies which increase status competition, stress and thus poor psychological health. Yet, another psychological mechanism that seems relevant is social-evaluative threat (SET). SET is believed to occur when a central component of our identity is, or could be, negatively evaluated so that we fear rejection. Within such potentially rejecting situations our fundamental need for social acceptance is threatened and a discrepancy between our actual and our ideal self is created giving rise to feelings of worthlessness, reduced relational value and/or shame.

How is respect and disrespect framed and conceptualized?

Are there significant debts?

To what extent does the S. U. feel pressure to conform to consumerism?

Is there a discrepancy between the actual economic situation and the idealized one?

Is there access to well established friendships and social support networks?

Is there shame and stigma associated with the socio-economic situation?

Images, discourses and the internalisation/replication of oppression

Unsurprisingly a proportion of minoritized individuals will internalize oppression. Internalized oppression can affect relationships within and between minority groups and between minority group members and those who are from the dominant group. This internalisation may manifest in mistrust toward the in-group, idealisation of the dominant culture, distancing from minoritized identities or the holding of stereotypical views about members of the in-group. Further, internalised oppression can, In extreme cases, lead to low self-esteem, self-hatred and even violence towards members of the in-group.

Assessing internalised oppression can be difficult because it is associated with high levels of shame and stigma and may therefore not be readily disclosed nonetheless; careful questioning may elicit such processes. Thus, any recurrent negative statements made about the in-group(s) may need further probing as may any negative emotion evoked by questions about the subjugated identity.   Various standardised questionnaires exist to assess internalised oppression which may be useful when the therapeutic relationship is firmly established. Acculturation and stages of identity development may also influence the relationship with the dominant group (in addition to the one which may be formed with the therapist) and whether the therapeutic values and norms may be acceptable.

What community/group(s) does the S.U. feel most affiliated with?

Are there difficulties with fitting-in or with belonging?

What is the relationship with members of the in-group(s)/out-group(s) like?

Are there weak/strong cultural or other ties with members of other minority identities?

Is there a history of immigration or displacement?

Is there evidence of shame and stigma associated with the culture of origin?

Historical and intergenerational context and distal narratives and events

Many theorists have put forward concepts that aim to capture the psychological impact of historical trauma on oppressed groups. For example, Alleyne (2004) has proposed the concept of ‘The internal oppressor’. The internal oppressor is theorized to be a psychic part of the self which can become activated when members of oppressed groups are confronted with oppressive situations in their day to day lives so that painful and emotionally charged historical events gain salience in their awareness. Examples of such painful historical events/processes may include the Holocaust for people of Jewish origin, imperialist processes (eg. slavery, colonisation) for other members of minority ethnic groups or the pathologization of homosexuality for some sexual minorities. In essence, the ’internal oppressor’ triggers a process of interpretation of contemporary oppression in light of historical trauma and injustice. This amplifies the distress experienced.

Experiences of oppression can also be reinforced or triggered by public images and media portrayals. Marginalized groups’ representations in the media tend to be distorted. Some groups are particularly prone to misrepresentation e.g. Black males, those who claim benefits, travellers, those with mental health problems and Muslims. A number of studies have identified patterns in media representations of marginalised groups including an overall underrepresentation, an over-emphasis on negative associations (e.g. criminality, unemployment…) whilst at the same time relatively few positive associations. Consequently, public portrayal of minorities tend be one-dimensional, negatively framed or problem focussed. Biased representations leave out significant aspects of minoritized communities’ lives, contributions and experiences.

What historical and contemporary narratives has the individual been exposed to?

What impact have such narratives have/have had?

Are there alternative/competing stories?

How are negative images/discourses managed?

Has there been exposure to positive role models from the subjugated identity group?

Is there shame and stigma associated with negative images/narratives?

Conclusion

This post is a first attempt at putting together a formulation framework that is based on a social explanatory model but which also identifies possible deriving psychological processes upon which potential psychological interventions may be based. The framework is not married to any school of psychotherapy. It simply aims to offer a possible starting point to reflect and consider relevant socio-cultural forces, their possible psychological impact and potential interactions.  I do not see praxis and social change based epistemologies as incompatible with psychological interventions particularly if they are located within a social model of psychological distress. In fact I believe that both are necessary to facilitate resistance and liberatory efforts. The diagrammatic formulation is based on common themes and theories related to oppression and inequality as well as some relevant empirical findings.  Although the framework may be most useful when applied to racialized minorities, it may equally be helpful to support other marginalised groups. I welcome comments and feedback which will allow the improvement and further development of the tool.

Thank you for reading.

If you have found this article useful or interesting, please spread the word.

All work published on Race Reflections is the intellectual property of its writers. Please do not reproduce, republish or repost any content from this site without express written permission from Race Reflections.  If you wish to repost this article, please see the contact section for further details.

 

What to learn more? Please see…

Alleyne, A. (2004). Black identity and workplace oppression. Counselling and Psychotherapy Research, 4(1), 4 – 8.

Dickerson, S. S., Gruenewald, T. L., & Kemeny, M. E. (2004). When the social self is threatened: Shame, physiology, and health. Journal of Personality, 72, 1191–1216.

Hutchinson, E. O. (1996). The Assassination of the Black Male Image. New York, New York: Touchstone.

Rowlingson, K. (2011). Does income inequality cause health and social problems? York: Joseph Rowntree Foundation.

Wilkinson, R. and Pickett, K. (2009). The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Penguin.

Wilkinson, R. and Pickett, K. (2010). The Spirit Level: Why Equality Is Better For Everyone. London: Penguin.

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.

Thank you for reading. If you have found this article useful, please share it with others.

Thank you for reading, If you have found this article useful or interesting, please spread the word.

All work published on Race Reflections is the intellectual property of its writers. Please do not reproduce, republish or repost any content from this site without express written permission from Race Reflections.  If you wish to repost this article, please see the contact section for further details.

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.

From School Exclusion to Mental Health Hospitalisation: Pathways to Mental Health Care for Black Men?

Mike’s story

Mike* who had just turned 21, was a young man from Africa**. He arrived in the country aged 7 with his family to seek asylum and had lived in London ever since. Mike was expelled from school at age 14 or 15 for truanting. He was convinced the teachers recurrently picked on him because they did not like him.  The day Mike got expelled he did not go back home.  He was scared. Instead, he started staying with friends and quickly became involved in petty crimes and in smoking cannabis.

Mike then got arrested several times for theft and possession of cannabis but was not sent to prison.  Quickly after Mike started smoking cannabis; at about 16, he developed what he called an ‘episode’ (Mike was initially diagnosed with ‘Drug Induced Psychosis’ and later with ‘Paranoid Schizophrenia’).  He was eventually taken to hospital by his mother and was discharged after one month. Once discharged, he stopped taking his medication, was readmitted within days and discharged again within a month.

Mike felt it was too early for him to be out and that he was not well enough. He also felt he lacked insight into his condition (his ‘own’ words) and was suspicious about taking medication. Once home Mike filled the days with smoking cannabis and worked out complex patterns as to when and how much cannabis he could smoke without it affecting his wellbeing. A month after his second hospitalisation, he got into trouble. He claimed to have been stopped and searched by the police 3 times in the same day. He became angry and defiant with the third Officer.  He reported to have been stopped the day before and demanded an explanation from the Police Officer who he said refused to provide one.

Mike ended up in a physical conflict with the Officer and was brought to his local police station where he was eventually charged with common assault.  Once convicted, Mike fell ill in prison and ended up on a Medium Secure Unit (MDU) on a Section 37, 41 of the Mental Health Act (a previous post here considers the potential experiences of Black mental health service users on MSUs).  Mike had been in the Unit for about 3 years when I spoke to him.  When I asked him what could have made a difference in his life he said the teachers ‘they gave up on me too easily’.

Some personal experience of the Education System

I was invited to the first parent-teacher evening to meet with my son’s tutor who taught science at the school. My eldest son had started secondary school a few weeks previously.  As we waited outside her room, I watched parent-child pairs entering the classroom looking slightly anxious but leaving it with a smile. This quietly reassured me.  When our turn arrived we were invited to come in and to sit at a pupil desk where we met a young looking White female teacher.  Upon brief introductions, the teacher buried her head in some kind of record book.  She re-established eye contact with me and then looking directly at my son declared with a beaming smile: ‘based on your current level of achievement, you can expect to achieve a grade C at your GCSEs’.

This statement was not an invitation to discuss potential remedial actions or support. Indeed there was no attempt at creating a dialogue on the mediocre prediction and I did not detect any concern or any indication of disappointment.  Instead, a definite sense of congratulatory determinism.  This was one of those awkward moments when the Psychologist in me has to wrestle with my ghetto side (in my head).  I am not going to lie; a vision of me slapping some sense into her did enter my mind.  Nonetheless, I reciprocated the smile for what seemed a very long time, long enough to compose myself and say to her ‘well that would not be good enough for us, we place a lot of importance on education at home and expect a lot more from him. He’s a very bright boy’. As I kept a smile on my face, I saw the smile on hers morph into an awkward grin betraying her embarrassment.

This was the beginning of year 7.  GCSEs were a few years away. There had been limited opportunities to test children.  I felt there was very little merit in the teacher’s prediction. What caused me the most concern was not the determinism but the sense of celebration which emanated from her voice. To me the subtext of the exchange read something like: grade C is perfectly commendable for a Black boy.  The relationship between school underachievement and social deprivation is well established as is the academic achievement/attainment gap between black boys and their peers (although it is important to remember that White boys coming from similarly socially disadvantaged backgrounds now fare worse academically than Black boys).  The influence of stereotypes and expectations on current educational attainments is receiving increasing attention.  There appears to be a link between low expectations and school exclusions and, although the relationship between school performance and the risk of being diagnosed with schizophrenia has been explored, one aspect that is less scrutinized is the relationship between school disengagement/exclusion and mental health care pathways. This is why Mike‘s story came to mind.

Black Service Users’ lived experiences

One of my research projects a few years ago focused on the pathways to care of Black mental Health Service Users in South London. Mike’s story is derived from this qualitative data analysed using IPA (Interpretative Phenomenological Analysis). The results revealed that for all interviewees (n=16) remaining in education was valued and perceived as important in terms of avoiding contact with mental health services for Black men. The majority of participants cited their dropping out of school or their being expelled as the main factor leading to offending and getting into contact with mental health services.  There was a deep sense of regret and of missing out too which can be perceived in the following quotes from different interviewees:

‘Because I missed quite a bit (of school) I’m suffering the consequences now’

‘I could have done a lot more if I wasn’t truanting from school’

‘Looking back on it, if I could turn back the time I would go back to school’

Schools should not give up on kids too easily’

Of course the above accounts are retrospective and subject to the usual biases. But, perhaps they give us an indication as to where we might start to explore further investigation and/or investment in preventative support? This article is not written as a rant against schools. Many a teacher do a fantastic job in immensely trying circumstances. Some have had a life changing influences on me.  However, like the rest of us, teachers have prejudices and use the same human categorizing and labeling processes. The difficulty is that by virtue of the position of power and trust they hold in relation to children, such processes may well have more potent and further reaching consequences. Incidentally, 3 months after the meeting with the science teacher, mid-year, my son had already achieved all of the year targets in science and was working at grade A level (albeit, after he changed class and science teacher). Similarly, I remember my mother leading many battles against schools where my sisters and I were repeatedly dissuaded from going to university and from studying the subjects we were interested in because we were not deemed ‘academically gifted’ enough for them.  Particularly those of a (hard) scientific nature. These would have been too ‘challenging’ for us (I am sure our gender and social origin also had an influence)…

A decade or two later and after much defiance from my mother, two of my sisters are financial analysts; one is an accountant, one a physicist (the only female in her cohort when she completed her postgraduate studies).  Not bad for a bunch expected to struggle academically. I believe most young people have the capacity to resist low and stereotypical expectations but; this may well be more difficult for those with lower levels of social support and/or with other psychological or social vulnerabilities. Some Black children may only be able to frame what they are experiencing as ‘the teacher picks on me’, ‘the teacher does not like me’. Invariably, some children will be misguided in their interpretation and for some, such views may betray unhelpful thought patterns or other relational difficulties. However, teachers ‘expectations are powerful and many children will de-select themselves from academic pursuits by truanting or otherwise disengaging purely because the message they receive and internalise is, you do not belong here or you are not smart (sorry I meant ‘academically gifted’) enough…

Chicken and egg proposition?

Having spent much time speaking to Black men within the Mental Health System, I noted that difficulties with teachers, particularly exclusions, often seemed to precede their (coercive) pathways into the mental health system and/or contact with the criminal justice system.  School exclusion is strongly correlated with offending. Black boys are at least three times more likely to be excluded than their peers (for similar infringements). The incidence of behavioural difficulties and occupational/school disruption can be associated with various psychiatric diagnoses, including schizophrenia so there may be a potential circular (chicken and egg) dilemma. In any event, if low expectations contribute to underachievement and school exclusions which in turn increase the likelihood of offending (and of being exposed to other stressors or ‘precipitating’ factors for some) and; we know that offending in Black groups is more likely to result in contact with mental health services (and subsequent diagnoses of schizophrenia), isn’t there a potential case to explore how we might better equip schools to support truanting and disengaging Black boys? Might it not also be helpful to pay closer attention and to address the factors leading to school disengagement for this group? In the absence of relevant studies scrutinising life events and adverse pathways to care and assessing the weight of relevant variables; it is difficult to establish relationships and the potential unique influence school exclusions/disengagement may carry in terms of future, and more importantly, type of Mental Health Service use for Black men.

So…What do you think, do schools give up on (some groups of) children too easily?

Have low or high expectations influenced your academic achievements or those of your children?

Do you think that providing more timely support to children who encounter difficulties at school could help reduce inequalities within the Mental Health System, particularly in relation to Black and Minority Ethnic groups?

*Mike is a pseudonym. **I have chosen not to specify the country Mike originates from to minimize risks of him being identified. As part of the research project, consent for wide dissemination and internet publication was sought.

Thank you for reading, If you have found this article useful or interesting, please spread the word.

All work published on Race Reflections is the intellectual property of its writers. Please do not reproduce, republish or repost any content from this site without express written permission from Race Reflections.  If you wish to repost this article, please see the contact section for further details. 


Want to learn more?

To access The Poverty Site – A UK site for statistics on poverty and social exclusion – ‘s section on school exclusions (click here)

Black Mental Health UK has compiled a range of reports on race inequalities within both criminal justice and mental health systems, to access (Click here)

To speak or not to speak: Can Children From Racialized Groups be Prepared for Racism?

I have wanted to write about this delicate (even by my standards) topic for some time and been doing a bit of digging on the topic but have not identified any evidence based professional guidelines that touched upon how best to prepare children from racialized groups for racist experiences.  This has been a question I have pondered upon for years because of my personal experience.  Being exposed to racism is no unusual experience for those within whom ethnic/racial difference is located. As young children many will learn about people being hostile to them because of their skin colour and/or culture.  Facing incidents of inferiorization, pathologization and/or problematization either directly or indirectly by witnessing racist and discriminatory acts experienced by parents, siblings, friends and/or other members of their communities or; enduring them personally; can have long lasting consequences. In this post, I will present my introduction to racism as I raise a few questions.  This is a topic I am quite tentative about for reasons which may become clear in the article.

Discovering racism…in France

My discovery of racism was quite a brutal one.  I was perhaps 4 or 5 and had been playing with my sister and some of the neighbourhood kids in front of our Parisian cité block as was customary during school holidays or week-ends. There was quite a few of us; 15 perhaps even more.  Children of all backgrounds and creeds.  We were skipping, running around and laughing the summer afternoon away.  A (White) man erupted from a ground floor flat in the tower. After complaining about the noise, he ran directly toward my elder sister and pushed her from behind.  He pushed her so violently that she fell forward and scraped the floor for a few meters. Once immobile, much of the skin at the back of her arms had gone.  A bunch of children quickly ran to our second floor flat to alert my parents.  A few seconds later my mother appeared downstairs to find my sister, me and a few other children in tears and my sister covered in blood.  Within moments she was at the assailant‘s door furious and demanding an explanation.

She was greeted by a barrage of vile racist insults including the N word (of course), followed by ‘go back to your country’ and ‘you lot only ‘lay’ children (sorry, this is a literal translation from the French expression to lay eggs used to refer to women who have many children) for child benefits. Once his monologue over, the man proceeded to punch her on the head with such force that her skin turned blue-black, one of her eye became red with blood and half her face swelled up almost instantly.  Expectedly, all children by this point were crying hysterically; probably with terror.  I am not sure whether it was the sight of my mother‘s grotesque looking face or the hatred in the man’s eyes which caused us the most turmoil.  Things after the punch have blurred in my memory but I can still see my mother standing still after the punch.  Standing tall, defiant and in dignified silence.  Although I do not remember this; perhaps unsurprisingly; I am told the man was apprehended by the police minutes later as he was brandishing a knife threatening to kill her.

My sister’s injuries were in the end only superficial but it took several months for the swelling and hematomas to disappear from my mother’s face and she suffered recurrent headaches for years.  The psychological scars for all those who witnessed the incident, most of us children under 10, probably remained for longer.  I was not spoken to about racism before the assault; or just after, for that matter. In fact the incident was rarely discussed either at home, at school or even amongst people on the block.  No one it seemed could put words to what had happened even as the trial went on (the perpetrator was eventually jailed for ‘racially aggravated’ assault, I believe). Yet, like my mother’s beautiful face (she was a stunning woman) which had been deformed by her injuries, the world had suddenly turned ugly and scary because we were Black.  This was France, inner city Paris to be precise; in the mid/late eighties. It could easily have been anywhere in the ‘western’ world.  It was only several years after this incident that my mother broached of subject of racism. By then I had recurrently experienced it first hand and witnessed its various manifestations.

The impact of the ‘new’ racism

Naturally, racist incidents of that nature are admittedly rarer today. Hence, I thought I had no reason to speak to my son about racism when he was just five,  until he came home from school in tears because he was being called monkey, ‘darkie’ and mocked because he looked ‘too’ African. This was only a few years ago in London.  As he wept in my arms, decades after I had myself sobbed because of racism (and in a different country), I wondered whether I had failed him by not preparing him for the reality of racism and prejudice.  I thought that perhaps, he or I would have been hurt a lot less when first exposed to racism; if we had somehow been prepared or been told of its existence.  The honest answer is I don’t really know if it would have made any difference.  It seems the opinions of those around me are divided.  Although I tend to; almost instinctively; air on the side of talking to the child-and we do discuss racism at home now- I am also mindful of the huge potential to increase a child’s anxiety, unhealthy paranoia and of creating self-fulfilling prophecies.

It is evidently desirable for children to form their own worldviews and experience the world without being unduly influenced by parental expectations and fears.  Nevertheless, there is also ,of course, the real danger of a child becoming seriously disillusioned, for expectations of fairness to be shattered and indeed for deeper psychological wounds to be experienced if the subject is not addressed and experiences of racism ensue, particularly if they occur frequently (I have previously written about young Black men’s experience of the police in a previous post here which may add some insight to the current article).   I realise that the form of racism my son suffered may seem less traumatic. Indeed for most children of colour today when they face racism, there will be no threat to life. There will be no physical injury. It is unlikely the police will be involved.  Still, there will likely be inferiorisation. There may be alienation.  There will most probably be suffering.  As first generations of migrants, my parents’ expectations of justice and equality in their host country were probably low.  Certainly lower than mine and those of my children.  Perhaps this supported my mother’s psychological resilience after the attack.

Thus, I wonder whether racial slights which might have been experienced as minor infringements by first generations may in later generations, become more psychologically damaging because of potential feelings of entitlement to fair treatment, justice and equality. Indeed although racism may have changed its face so that, in the main, more covert and institutional forms of prejudice have replaced behaviours displaying overt prejudice and open racial hostility, some evidence suggests that those exposed to racism‘s ‘new’ manifestations may indeed pay a higher psychological cost.  The children of migrants are much more likely to suffer psychological distress than their parents.  Of course there are various factors that may be at play.  Nevertheless, some have argued that the increase in the incidence of psychological and psychiatric distress in second and possibly third generations of migrants may be in part attributable to the fact that younger generation’s expectations often do not match their reality…

So what to do?

Do we instill lower expectations when it comes to fairness and justice or; do we continue to project an aspirational version of a world? How many may come to painfully experience such a version as a sham, what might the psychological impact be for those who are disillusioned be and, what type of support might be appropriate? Sadly, yet again, such questions have not received much empirical attention and very few Psychotherapists and Clinical Psychologists specialise in this area. As a result, as a parent and as a professional I feel it is difficult to give evidence based guidance. I would be extremely grateful for people to share their views or refer me to relevant guides, articles on the issues.

What do you think? Have I missed something of importance? Have people/professionals done anything to try and prepare children from racial minorities for racism and if so; what type of conversations have people had and when?

Please comment if you feel able to or get in touch to share your views/experiences.

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The Angry Black Woman: Covert Abuse, Overt Anger?

A Big Black woman on the train…

I had been on my train back home from University a year or so ago for about one hour when a Black woman entered the train carriage I was sitting in. She was of a fairly large built and was struggling to make her way through the carriage to get to a seat. She was casually dressed but looked somewhat umkept. As I noticed her, I started to observe the behaviours and faces on the train.  I picked up a sense of discomfort and I imagined that passengers may have been anxious about the possibility of her sitting next to them.  As she walked past, most people looked firmly down.

She took a seat within a section of the carriage which was unoccupied a few meters away from my seat and sat directly opposite me. To my left was a group of six middle aged women. They appeared to be friends or possibly work colleagues.  They were quite formally dressed. They were all White.  A few of their faint whispers attracted my attention. Upon observation, I noted smiles, sneers and ever so discreet short looks toward the other Black woman.  This went on intermittently for about 10 minutes. She and I were the only Black people in the carriage. I felt angered and disrespected. The Black woman’s face was looking increasingly aggravated as she was being denigrated-ever so subtly and politely.

Unexpectedly, the Black woman got up and walked up to the group. She asked them to stop what they were doing and said that she could see them. I could hear from the trembling in her voice that she was close to tears. The women looked surprised, denied any wrongdoing and took turn looking at each other and at other passengers feigning cluelessness. This infuriated the Black woman further who burst into screams, naturally, attracting looks of disapproval from most passengers.  She eventually walked back to her seat alone and in complete silence stared at by almost everyone as the women who were taunting her escaped scrutiny.  As the train was approaching my stop, I got up to exit and purposefully walked toward her. I said to her that I had seen what the women had been doing and put my hand on her shoulder at which point tears rolled down her face. She thank me.

Intersectionality

In popular culture and discourses, Black women are often characterized as angry, hostile, difficult and/or rude.  The stereotype of the ‘Angry Black Woman’ is a persisting one in many western countries that not only portrays Black women as one-dimensional beings but also prevent their voices and often painful experiences from being acknowledged and validated. I believe this stereotype has impacted on many of my social interactions, that of countless Black women and that of the Black woman on the train.  When she screamed, there is no doubt in my mind that she became the ‘Angry Black Woman’.  Nothing in that woman’s behaviour justified the treatment she received from the group of friends/colleagues. Nothing at all.  Except her being overweight and Black.

Being both of those things meant she had ceased to be a person the moment she was spotted by the group of women.  Not being a person meant derisory behaviour toward her stopped being reprehensible and, her experience could simply be denied. Becoming angry when denigrated and disrespected seems perfectly understandable to me.  In most circumstances, no one would bat an eyelid if someone who had just been abused screamed in indignation and in pain or in an attempt to seek the support of onlookers. It seems to me that, often, Black women are not afforded such liberties.  I accept that women’s anger is disapproved of socially in part because it threatens gender norms and role expectations. Nevertheless, the privilege of getting angry without fear of being stereotyped is also race dependent. Oppression does not act independently of the various social categories and axes of identity capable of their own of contributing to injustice and inequality.

Instead, it interrelates and create systems that reflect the combination of multiple forms of discrimination each in turn amplifying the other. It is notable that I was not targeted for ridicule. Perhaps being lighter-skinned, slimmer and thus (in the eyes of many) a more ‘attractive’ Black woman, mean I am afforded more ‘privileges’, one of which may be to escape abusive treatment because of my appearance.  Hence, whilst White women’s anger may similarly be disapproved of, it is not mocked or ‘Othered’ in the same way that Black women’s anger is.  Thus, it appears the lower your ‘rank’ the less tolerable your anger is and the more problematic your resistance to subjugation will be deemed.  The reality of the interaction was defined by the group of respectable looking White women and seemed to have been tacitly accepted by the rest of the carriage. What chance did that Black woman have to get her version of reality across when she became nothing but a stereotype?

On Invisibility

As she screamed perhaps in an attempt to get some form of validation of her distress; she disturbed the peace and became the problem within the train carriage. In this moment, whilst her presence became ever so visible, her pain and experience fell into oblivion, essentially annihilated by the stereotype. Symbolically, to me, the collective silence in the face of her dehumanization and the looks of disapproval she received when she raised her voice sent a very clear message to that woman: we see you but we do NOT want to see you, stop forcing us to notice you.

Some may find reassurance in the possibility that perhaps, the passengers onboard had not noticed that she had been taunted and was distraught, sadly, this does not fill me with much comfort.  Some people’s suffering simply does not appear to get noticed. In the hours preceding David Bennett*’s death, he was distraught because he had been racially abused but nursing staff did not notice the high level of his distress or the cumulative impact of the racism he had been subjected to on the ward. When his life was slipping away as he laid on the floor, face down, thrashing about trying to break free, the nurses involved in restraining him did not notice this either. He had also become a stereotype.  That of ‘The Big Dangerous Black Man’ also known as ‘big, bad and mad’. It thus appeared perfectly befitting that he was restrained by four to five men.

The common failure to recognise  ‘depression’ amongst Black groups is a serious public health concern. Many Black people do present to primary care services but, it appears that often, their distress is not seen so that many end up not receiving the support and care they require in a timely fashion, if at all.  My sense is that Black people are simply not seen as vulnerable, are all too often left to cope alone and problematised by any manifestation of anger which can then attracts further dehumanisation. Who would dare ask someone being kicked on the floor to turn the volume down? Some forms of violence are extremely subtle and seemingly innocuous but their cumulative effects can be more toxic and equally traumatic. Next time you see a Black woman angry, please consider what you may not have noticed. This may help ensure our life’s journeys stop mirroring the train journey of that big Black Woman.

* David ‘Rocky’ Bennett was a Black mental health service user who died in 1998 at a medium secure mental health unit. An independent inquiry found that he died as a direct result of prolonged face down physical restraint and the amount of force used by members of staff during the incident. The inquiry made specific recommendations about the use of physical restraint, especially with regards to face down or prone position restraint and in relation to the need for culture competence training for Mental Health Staff. Critically, the enquiry accepted the presence of institutional racism within Mental Health services.

To access the Independent Enquiry Report into the death of David Bennett (click here).

Thank you for reading, If you have found this article useful or interesting, please spread the word.

All work published on Race Reflections is the intellectual property of its writers. Please do not reproduce, republish or repost any content from this site without express written permission from Race Reflections.  If you wish to repost this article, please see the contact section for further details.