Clinical Psychology Service Issues

Issues affecting mental health and/or psychology services.

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.

 

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.

 

Advertisements

Psychiatric diagnoses: does forcing a medical framework onto people problematise informed consent?

Informed consent and clinical psychology

 

Informed consent underpins everything we do as psychologists.  It is an essential ethical principle.  Whether we assess, formulateintervene, evaluate or carry out research. Irrespective of our skills or level of experience ethical dilemmas will arise and, resolving them defensibly, to the best of our abilities, is a central part of our practice.  Regardless of the setting, client population or type of intervention, we are bound to have to make decisions engaging multiple and conflicting ethical principles often, not easily reconcilable.

 

Seeking meaningful consent involves informing potential or actual clients of the basis for our intervention and its rationale. Sharing theoretical and empirical underpinnings and, explaining the anticipated process and possible challengesThough we may not routinely explore challenges to the core assumptions underlying our practice most of us would, hopefully, routinely explain to clients that our model or our way of working is one of many ways of deriving meaning and of supporting people.  

 

As such, we are in a very privileged position.  We are not wedded to any school of thought/therapy or worldview. In theory. This allows us to work with clients using their own explanatory model (s) and attribution style and to some degree, adapt our practice accordingly.  Further, because we (usually) use formulations rather than diagnoses to co-construct the meaning of the experiences that have led people to our doors and to make sense of their distress, we can work from multiple epistemologies. In theory.

 

Outside the therapy room, things are less malleableFor example, if someone is diagnosed with psychosis, it won’t matter much how they formulate or make sense of their distress when they are out in the real world.  In the real world, this diagnosis will be documented onto their medical notes.  Their personal explanatory model (s) or story may matter even less to the people who hold the most social power. Their psychiatric label will likely take precedence over much else.  This is because in the real world, bio-medical explanations are still considered real and are the norms through which human experiences of distress are categorised. Still.

 

Meanwhile in the real world…

 

Thus, it matters very little that one might have been and continues to be oppressed or that one might have been repeatedly abused. This is background or additional information to the core issue that one hasdepression, psychosis, a personality disorder or any other psychiatric diagnosis.  So, when looking for a job, most potential employers will ask ‘have you suffered from/received treatment for any psychiatric illness’ or something along these lines. Such occupational health questions would typically be closed, inviting a ‘yes’ or ‘no’ answer. There may be space to elaborate or to even enclose a formulation done in therapy but, it would not stop many employers considering those who answered  ‘yes’ potential liabilities in terms of sickness absence and think twice about making/confirming an offer of employment (though this may be unlawful).

 

Nothing of course forces anyone to disclose a psychiatric diagnosis but, failure to do so may not only deprive people of potentially valuable support, it may leave vulnerable individuals succeptible to accusations of breach of trust and confidence and/or of dishonesty; should it later emerge that  information related to their psychiatric ‘history’ was withheld.  In addition, of course, the additional stress generated by having to worry about the ‘truth’ coming out needs bearing in mind. I became sorely aware of the limits of informed consent when I was asked to sign a discharge before my son could have surgery.

 

Informed consent and adverse events/consequences

 

The discharge listed the main risks and potential complications from the surgical intervention. It made clear that I was consenting to the possibility of adverse events both short and longer term by signing the discharge and allowing my son to have surgery.  The discharge made no mention of the risks associated with the other options available or of any cost-benefit analysis in relation to the alternative interventions. However, there had been some pre-operative discussions around alternative treatments and the no treatment option upon which the surgical team was relying when presenting me with the information focussing on the intervention at hand. This experience got me thinking.

 

True informed consent can only be given if clients can compare the risks and benefits of each and every course of action available to them and consider them in the short, medium and long term. Typically, when people access our services they have already been diagnosed or are suspected of having some form of mental ‘illness’ (suspicion alone carries consequences, especially if recorded)This is documented onto their medical notes as a matter of course. But does this practice not amount to forcing a medical framework onto people’s experiences? And if so, does it not problematise informed consent; if patients are not made aware of the of the risks and likely adverse consequences associated with having such a diagnosis?

 

Though by the time people get to us their health records have already been amended, they may not necessarily have been made aware of the (medium to long term) impact of being diagnosed with a psychiatric ‘illness’ particularly those seen as more ‘serious’ or ‘enduring’.  They may never have even heard of alternatives to diagnoses or been made aware of their significant empirical and theoretical limitations. How might we argue then that those diagnosed have given their full informed consent?  Isn’t it odd that patients are often given the choice as to whether they want their health records to reflect that they have had a pregnancy termination, sexually transmitted diseases or other stigmatising conditions/interventions but that such consideration is not routinely given to those with mental health problems?

 

On consenting for stigma

 

Given the very real, serious and debilitating consequences of stigma and discrimination, isn’t it ethical to seek fuller consent and as part of that, to give patients a choice as to how they make sense of their distress; including within their own health records? In the mist of our distress we may not have the headspace to consider such questions and of course some people may simply not have the capacity to assimilate this information or to decide.  However, upon recovery, for the majority who did/could, the reality of having been diagnosed with a psychiatric illness may hit home.  People may well find that the psychiatric diagnosis they were given mattersThat it matters enormously.  At which point of course giving informed consent will no longer be an option.

 

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.

There is no racism in clinical psychology: Personal reflections from another Black trainee.

This article asks whether the majority ethnic group may have a tendency to dismiss experiences of racism. Considering my lived experience, I reflect on some processes which may become engaged when racism is evoked and propose some potential implications for clinical psychology.

Subjective realities and embodied experiences

When individuals speak about their experiences of racism, they are often challenged about their interpretations and encouraged to consider more ‘objective’ reasons which may account for the behaviours or words that caused offense or hurt. Invariably, as there are multiple ways to interpret events, particularly in the realm of human interactions, experiences of prejudice and of discrimination can easily be discounted. Such dynamics are well documented and I, like other Black and minority ethnic (BME) trainees have encountered them in Training. Navigating a racist society may equip individuals from racialized minorities with the ability to recognize subtle pre-verbal and para-verbal cues of racism.

This embodied apprehension of prejudice may be the result of inner adaptations to the external reality of racism yet, it can easily be dismissed as it may not lead us to easily verbalise our experiences. There have been repeated calls for increased cultural competence within clinical psychology but, trainees continue to be socialised into rhetorics of social and power awareness. Diversity indeed commonly features within our professional discourse. A ‘better than’ position may be adopted whereby racism and discrimination become minimised and eventually envisaged as being ‘out there’ rather than ‘in here’. Being able to remain oblivious to the experiences of those who are racially subjugated and deny responsibility for racism may be the hallmarks of White privilege.

Expectedly, following experiences of racism from a supervisor, I painfully reflected upon my experience before alleging that the supervisor was prejudiced and racially offensive. When my concerns were raised, they were instantly discounted. I was interrupted in my account then coached into considering other possible motives for the conduct. The differential treatment and offending words did not provide ‘evidence’ of discriminatory intentions. Nevertheless, when the same supervisor questioned areas of my competence and intelligence without evidence, an epistemological shift occurred so that the supervisor’s perspective and judgement alone became sufficiently evidential. Meeting a positivist threshold was no longer necessary.

Managing cognitive dissonance

It is well documented that people tend to use prior beliefs to interpret personal experiences. This is the essence of Cognitive Dissonance Theory. Festinger (1957) posited that powerful motives to maintain cognitive consistency often give rise to irrational or unhelpful behaviours and that when excessive dissonance is produced intellectual defences can be triggered. Such defences may manifest in the refusal to accept the discomforting information, or in unduly questioning its validity. Refusing to consider the possibility that racial prejudice may indeed have been involved within the supervisory relationship, may help protect the safety of existing assumptions and truths whilst unabling a reflexive consideration of privilege. More disturbing perhaps, may be the implications that the purported competence/intelligence deficiencies seem to have been accepted in the absence of supporting evidence. Cognitive Dissonance Theory would posit that prior beliefs or worldviews were therefore not disturbed in this instance.

The denial of racism

Behaviours displaying overt prejudice are now relatively rare. They have been replaced by more covert forms of racism. Such behaviours although more subtle have been posited to betray deeply rooted prejudices. When BME trainees have spoken about their experiences of training, experiences of both overt and covert racism have been documented. The latter may be met with more scepticism however, when potentially painful and/or anxiety provoking information is instantly rejected, one may suspect that some level of denial may be at play. Denying racism may indeed serve multiple functions. Institutionally, and it may help avoid liability for potentially unlawful acts. Socially, it may be part of a strategy of positive in-group presentation and demonstrate adherence to social norms and values. Moreover, such self-presentation, may also serve to defend the in-group as a whole or its dominant discourse.

Thus, the failure to fully hear, document and investigate race related concerns may be interpreted as reiteration of the professional consensus and public discourse: ‘there is no racism in clinical psychology’ or ‘we are not racists’. This social denial has been theorised to also fulfil an individual defence. ‘She is not racist’ may therefore mean ‘I am not racist’ whereby staff rather than empathising with the trainee’s distraught come to identify with the supervisor accused of racism. This interaction between the institutional, social, and individual may make accusations of racism highly discomforting. Possibly more so than the potentially discriminatory acts complained of. To discharge such discomfort; counter-accusations are usually made e.g. ‘playing the race card’, ‘having a chip on the shoulder’, ‘being paranoid’, ‘being oversensitive’ or indeed ‘jumping to conclusions’.

Individual and/or institutional racism?

In the mist of scepticism and cognitive ‘reframing’ attempts, my distress became invisible. I was left with little support. Engaging with the pain might have shifted ‘the gaze’. Perhaps I was being punished unconsciously. Trainees, who challenge racism may be at risk of being ostracised, dismissed or penalised. The McPherson enquiry uncovered institutional racism within the police force which it defined as:

‘The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racial stereotyping’. (McPherson, 1999, 6.34)

Although this definition is not without problems, it does offer a framework to reflect on how systemic and unintentional discrimination may become manifest within institutions. The independent enquiry into the death of David Bennett found institutional racism within the psychiatric system, including persisting race inequalities, the widespread use of stereotypes and of particular relevance here, failures to take allegations of racism seriously. Its recommendations led to the ‘Delivering Race Equality in Mental Health’ programme. The action plan came to an end in 2010 thus; race inequalities may have fallen down the political agenda. However, they remain. In this context of suffering and alienation, BME service users’ experiences of racism continue to receive little empirical and clinical attention. Perhaps parallels may be drawn.

Final Reflections

Although multiple versions of events and reality can and do co-exist, the most privileged amongst us may have vested interests in maintaining oppressive biases which locate truth where power is and assure that only those with power can define reality. The inter-connection between agency and systemic structures may mean trainees from racialized minorities are at risk of being silenced and dismissed in their experiences. It was to help ensure that they have a voice that I created ‘The Minorities in clinical psychology Training Group’. Indeed, in the context of continuing challenges in recruiting a more representative workforce and enduring difficulties in adequately serving BME communities; a failure to pay close attention to such voices may not only deprive the profession of opportunities to better understand and meet the needs of service users from traditionally marginalised groups, it may leave clinical psychology vulnerable to accusations of institutional racism.

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

Want to learn more?

Please see…

Adetimole, F., Afuape, T., & Vara, V. (2005). The impact of racism on the experience of training on a clinical psychology course: Reflections from three Black trainees. Clinical Psychology Forum, 48, 11-15. 6.

Care Quality Commission and National Mental Health Development Unit (2010). ‘Count Me In 2009 – Results of the 2009 national census of inpatients and patients on supervised community treatment in mental health and learning disability services in England and Wales’. Care Quality Commission: London.

Constantine, M. G., & Sue, D. W. (2007). Perceptions of Racial Micro aggressions among Black Supervisees in Cross-Racial Dyads. Journal of Counselling Psychology, 54(2), 142-153.

Department of Health (2005). Delivering Race Equality in Mental Health Care, Department of Health: London.

Fanon, F. (1967). Black Skin, White Masks. London: Pluto Press.

Festinger, L. (1957). A Theory of Cognitive Dissonance. Stanford, CA: Stanford University Press.

Hardy, K, V. (2001). Family therapy: Exploring the fields past, present and possible futures. Adelaide: Dulwich Centre Publication.

Hook, D. (2006). ‘Pre-discursive’ racism. Journal of Community and Applied Social Psychology. 16, 207-232.

Patel, N., Bennett, E., Dennis, M., Dosanjh, N., Mahtani, A., Miller, A., et al. (2000). Clinical Psychology, Race and Culture: A Resource Pack for Trainers. Leicester: BPS Books.

Patel, N. (2004). Difference and Power in Supervision: The case of culture and racism. In Fleming, I. & Steen, L. (Eds.), Supervision and Clinical Psychology: Theory, Practice and Perspectives. Hove: Brunner-Routledge.

Macpherson, W. (1999). The Stephen Lawrence Inquiry: report of an inquiry by Sir William Macpherson of Cluny. London. Home Office Cm 4262-I.

NSCSHA (2003). Independent Inquiry into the death of David Bennett. An Independent Inquiry set up under HSG (94)27. Norfolk, Suffolk and Cambridgeshire Strategic Health Authority: Cambridge.

Tan, R., & Campion, G. (2007). Losing yourself in the moment: The socialisation process of clinical psychology training. Clinical Psychology Forum (180), 13-16.

Van Dijk, T. A. (1992). Elite Discourse and Racism. Discourse and Society 3(1): 87-118.

Unspoken challenges of clinical psychology training? A view from inside. PART 1

Becoming a clinical psychologist has been likened to a process by which a new identity is incorporated into an existing sense of self whereby unique physical and mental experience, attributes, and a position within social roles, relationships and discourses is transformed. This process, although rewarding in the main, is not experienced without challenges and pain. What one might struggle with on the professional pathway is to some degree personal and idiosyncratic nevertheless, some processes may become engaged and/or significant for many. Further, often it is the things we do not expect to find difficult that come and pose the most challenges. This post aims to present some of the processes and dynamics which can become challenging for trainees within the professional socialization process. Those who are aspiring clinical psychologists or new trainees may find reflecting on some of the issues it highlights helpful. Hopefully too, it will be of some use to those with supervision responsibilities.

Feeling deskilled

Feeling deskilled at the start of training or learning journeys is a common experience. However, in the context of clinical psychology training such feelings may well become amplified. The demand for clinical psychology training places has always outstripped the supply. The possible difficulties trainees may have faced to gain places due to the inherently competitive nature of the recruitment process may bear an influence on the professional socialisation process. Trainees may feel pressured to ‘prove’ that they are deserving of a training place or that they are good enough. Unsurprisingly, many will come to experience self-doubt, some loss of confidence and even ‘impostor syndrome’ during the training journey.

The Conscious Competence Ladder model (Burch, 1972) may provide a helpful framework to better understand and reflect on how trainees may respond to learning processes and activities. This model essentially posits that two factors: consciousness and competence, affect our thinking and emotions as we acquire a new skill. According to the model, we move through four different levels or phases as we build competence. The initial level: ‘unconsciously unskilled’, occurs when we do not know that we are not competent. We then move onto the ‘consciously unskilled’ phase as we realise the limitation of our competence.

Thirdly, it is posited that we become ‘consciously skilled’ when we are aware that we have acquired the skills/ competence required (though conscious effort is still required). Finally, the ‘unconsciously skilled’ level is reached when the said skills and competence have become so assimilated that they demand little or no conscious awareness to be practiced. This model is not linear and we may for instance after having become unconsciously skilled, revert to feeling consciously unskilled for instance because we fail an assignment. Of particular relevance, training wise, may be the fact that trainees are required to complete placements in different specialized areas and thus may recurrently find themselves in the consciously unskilled phase, the most emotionally demanding position; as they develop their competencies.

Managing power imbalances

We all have peculiar relationships with power and authority based on various factors including: our personal history, our cultural and social backgrounds and to some degree our social positioning. In addition, how we may deal with potential feelings of disempowerement and powerlessness can also be related to professional experiences and in particular, the level of past autonomy, responsibilities and/or organisational cultures accustomed to prior to starting training. Whilst for most ‘traditional’ applicants gaining a training place will entail an increase in status and with it an improvement in terms of employment and work conditions, for those who held relatively senior posts and worked autonomously before starting training, the training environment and trainee role may take some adjusting to and indeed involve a decrease in status and in autonomy.

Trainees can often (though mostly tacitly) be positioned as naïve, dependent and/or passive. Such implicit infantilisation can occasionally become explicit. On one occasion, for example, the positive feedback from a placement review I received included ‘doing as I am told’. Clearly, the supervisory relationship is not an equal one as clinical supervisors hold evaluation and marking responsibilities and thus have actual power (to pass or to fail) over the trainee. An unusual dynamic may be created when trainees because of their past experiences/responsibilities, qualifications and/or behaviours may not meet some supervisors’ potential expectations of dependency. Whilst actual power may not be disrupted, for some, perceived power may well be.

Power dynamics are of course further complicated when trainees belong to minority and/or marginalised groups. Their presence in the training arena alone can challenge or evoke social/personal expectations and stereotyped notions. Self-fulfilling hyper-vigilance may thus become an issue for such trainees who may become anxious about the (real) possibility of being discriminated against or of facing prejudicial attitudes. On the other hand, difference may also impact on some supervisors who may not have prior experience of working with ‘non-traditional’ trainees and who may be unsure about how and whether or not to raise issues of difference within the supervisory relationship and/or be unduly preoccupied with the (also real) eventuality of being perceived or experienced as prejudiced.

The challenge of adopting a questioning attitude

Clinical psychology trainees hold dual statuses as trainees thus, employees of specific NHS trusts which usually provide an employment contract, associated terms and conditions and the placements within which practical skills are developed and; as students within universities which host the courses, deliver the academic components of the training programme and thus the student identity. With the professionalization of the discipline, the adoption of the trainee role over that of the student one seems to have been preferred. Such preference would appear to give higher status to the trainee role.

However, the exclusion or reduction of the student identity may set particular dynamics and impact on how trainees see themselves, their learning and how they are perceived. Whilst students may be actively encouraged to be questioning and irreverent toward prior practices, theories and of taken for granted wisdom, such a stance may not be specifically sought after or strongly emphasized within the trainee role, arguably necessarily so. Indeed training is, by definition, centred on applying and demonstrating practical competence often by copying or mirroring others.

Given the unbalanced power distribution and the potential high risks of getting into conflict with those who hold a responsibility for assessing you, it is perhaps unsurprising that trainees often simply decide to ‘go along’ with theories and models of working that are experienced as oppressive, are incongruent/incompatible with their worldviews or appear to lack empirical support. Additionally, people in cohesive groups typically experience greater pressure to conform than those in non-cohesive groups. Consequently, homogeneity and conformity may not only present challenges for trainees, they may problematize innovation and creativity within the profession (more on that in due course).

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.

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.

Improving access to Psychology Services for marginalised communities: Where might we start?

I have come into contact with many remarkable clinical teams. Teams whithin which levels of commitment and clinical expertise were outstanding and from which I have learnt immensely. Yet, even amongst these, when it came to increasing equality of access to the service for traditionally marginalised groups; feelings of powerlessness and anxiety appeared to dominate discussions. The task seemed too vast, too impregnable (these sentiments were not aided by the length and/or complexity of some of the relevant documents available on the issue) or; beyond’s one’s remit and/or expertise. The activities below may be a helpful starting point for those who may not have engaged with the matter.

1. Improving Equality data collection/monitoring

Addressing inequality has to start with the systematic collection and analysis of demographic data across all nine protected characteristics within all services. Collecting such demographic information at several points may help increase response and recording rates (which are notoriously low). It may also be helpful to include agreed definitions as part of any data collection exercise e.g. people vary in their understanding of what may be a disability, so including the Equality Act (2010) ‘s definition and asking in relation to it ‘Do you consider that you have a disability’ may be more productive than simply asking ‘do you have a disability?’ This may help ensure a shared understanding. Similarly, in terms of ethnicity, meaningful comparisons between service use data and local demographic information can only take place if similar categories are in use.

2. Carrying out of Equality Analyses and Equality Impact Assessments at micro level?

NHS Trusts are required to publish evidence of the analysis they have undertaken to establish whether their policies or practices would further or would have furthered the aims of their Public Equality duty*; to provide details of the information considered and describe the engagement(s) they have undertaken when doing the analysis. Thus, Equality Analyses have become a standard part of policy and decision making processes at Trust level. Many Trusts have developed Equality Impact Assessment (EqIA) tools to assist staff in assessing and addressing potential unintended adverse consequences. Access to Clinical Psychology Services could be vastly improved by the completion of such analyses at micro level. This may support the regular consideration of the effects of team practices on different groups by clinicians.

3. Establishing stronger links with community organisations

Partnership work with organisations that represent and/or work with diverse communities may be a means to ensure more equitable and inclusive services. Perhaps undertaking mapping exercises to locate such community resources/groups in the locality may be helpful for some services. There is no doubt that Clinical Psychologists have much expertise and knowledge to offer community groups but similarly; community groups and culture/identity specific services could impart valuable skills and experience in terms of working with minority groups and marginalised communities.

4. Supporting staff learning and development needs around Equality

Increasing staff knowledge of the Equality Act (2010), their responsibilities and that of the service under the same may be similarly important. All NHS staff have to attend Equality and Diversity training. In my experience however, such mandatory training is often relatively basic and can be somewhat removed from service level/delivery issues. The workings of unintentional, institutional and structural discrimination, key issues in terms of inequality of access; tend not to feature much, if at all. It is difficult to see how services may start to tackle inequalities without having a firm grasp on such dynamics. In practice, service specific training on Equality and Diversity could be much more helpful in terms of facilitating a dialogue on the issue and ideally, staff at all level of the service should be involved. Given the standard distribution of power within the services, it may be that those at the ‘bottom’ of the hierarchy and service users have particularly useful contributions to make.

Evidently, not all services have issues with equality of access and many may well have become experts in managing it. Nevertheless, such inequities (in addition to inequalities of outcome and experience) remain national concerns. The above list is not exhaustive and many services and clinicians will have undertaken different actions (I would be grateful for the sharing of such examples of practice). It must be borne in mind that increasing access to Psychology Services is only one part of fostering better psychological wellbeing for marginalised groups. Getting engaged in helping reduce inequalities at societal level and diversifying the models and interventions available within services may also encourage the inclusion of Service Users from marginalised groups and support their engagement once they access Psychology Services. Naturally services’ capacity to manage any potential increase in demand and thus in workload, are added complicating factors that would need careful planning.

*Under the Public Sector Equality Duty, NHS Trusts must have due regard to the need to:
• Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Equality Act 2010;
• Advance equality of opportunity between people who share a protected characteristic and those who do not; and
• Foster good relations between people who share a protected characteristic and those who do not

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.