Clinical Psychology Training

Related to the pathway, experience , outcome within CP Training.

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.

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The impact of difference PART 2: The silent influence of Cultural Capital.

A renewed momentum?

I have made no secret of the fact that clinical psychology training has been fraught with challenges, many unexpected and most related to difference. The Division of Clinical Psychology is currently drafting its first ever Equality & Diversity strategy which emphasises the necessity to increase cultural competence within clinical psychology. It seems quite topical then to further the reflections first laid out (here) within the first part of this article and to start to explore some potential mechanisms which may bear an influence on professional processes. In the next few posts of this series, I will ask the reader to consider more implicit or tacit variables and their potential impact in terms of difference. I start here with cultural capital.

The influence of prior experience

Having 6-12 month relevant experience prior to applying for training is an essential criterion for all clinical psychology courses. In reality however, due to the competitive nature of the recruitment process and for most, the resulting need to apply more than once before obtaining a training place, most successful applicants would have worked a number of years prior to being accepted onto the doctoral course. Forming realistic views of the demands of clinical psychology training and of clinical psychology as a career prior to embarking onto its demanding (and costly) studies is naturally of crucial importance to applicants, recruiters and funders alike.

Nonetheless, some inequalities have been noted in the acquisition of relevant experience. In comparison to their White counterparts for example, BME applicants appear less likely to meet the ‘relevant experience’ requirement. Some evidence also suggests that applicants belonging to minority groups may face some additional difficulties securing assistant psychologists (AP) and research assistant (RA) posts, a key barrier, it seems, in terms of training accessibility for such groups. It still appears that those who have followed more traditional routes in terms of ‘relevant experience’ remain more likely to be accepted onto training.

Although there could be various mediating variables involved (including differences related to reference, degree classification, supervision, previous experience of psychologically informed clinical work etc.), there seems to have been no systematic study scrutinising the impact of past professional experience. I have therefore been curious about the potential influence of less visible, softer but possibly more insidious factors related to the above and, been wondering about the possible impact applicants and trainees ‘prior professional experience may bear upon their professional socialisation and in term of recruitment and assessment outcomes.

Professional socialisation and cultural expectations

Becoming a clinical psychologist necessarily entails the assimilation of in-group worldviews and the adoption of certain ways of thinking, speaking and ultimately being. For applicants and trainees who have held traditional roles, this professional socialisation would have been initiated well before their application for training. On the other hand, those who may have acquired their ‘relevant experience’ outside clinical psychology teams may not have or not have to the same degree, been socialised into presenting, communicating and indeed thinking the way clinical psychologists do (or at the very least as they are expected to).

But, is such socialisation necessary for candidates to successfully complete clinical psychology training or in other words, are there essential attributes that are acquired or believed to be acquired, during this socialisation? Could it contribute to perfectly well qualified applicants being assessed as less suitable for training? Is sufficient attention presently paid to differences in presentation which may be related to past professional socialisation and which may be further complicated by candidates’ cultural and social origins? There is currently no empirical basis upon which to base firm answers to the above questions.

However, there is an extensive body of empirical evidence demonstrating that we are more likely to like, to recruit and to support people who we perceive as being ‘similar to us’. As someone from a ‘different’ cultural and social background and with a relatively unusual professional profile, I have experienced first-hand the violence of normative expectations within training. It has been incredibly difficult to draw a line between such cultural norms and the assessment of some competencies. I have secretly harboured the hope of becoming able to distinguish with certainty the essence of clinical competence from the ‘fluff’ of cultural norms and expectations although; I recurrently question the feasibility of such a task.

Cultural Capital

Bourdieu and Passeron’s concept of cultural capital may be helpful to consider the potential difficulties which may come to light in assessing those who are ‘different’. Cultural Capital refers to the collection of symbolic elements such as tastes, posture, dress sense, mannerisms, etiquette etc. that one acquires through being part of a particular social group. Sharing similar forms of cultural capital with others such as the same taste in music or the same worldview is believed to create a collective identity and a group position in relation to others. Critically, differences in cultural capital are believed to be a major source of inequality in that they can help or hinder one’s social mobility.

This is because some forms of cultural capital are valued over others and in particular the possession of the dominant culture as capital often translates into access to wealth and to structures of power. In that sense, it can be said that the more familiar one is with the dominant culture, the more cultural capital one has. The education system is posited to assume that pupils possess the same cultural capital (as those from upper and middle ‘classes’). This is one of the reasons children from lower socio-demographics backgrounds may face particular disadvantages to succeed in the education system.

The relevance of cultural capital

Bourdieu has at times been criticised for the lack of precision of some of his concepts, nonetheless, his emphasis on the non-material/economic resources possessed by socially privileged groups is noteworthy and has generated much theoretical and empirical literature within education and occupational fields. I am not aware that the framework has formed the basis of any empirical studies within professional psychology nonetheless; differences in cultural capital may be important to reflect upon in relation to current inequalities of access to the profession.

The concept invites selectors and assessors to be on the look out for ways in which dominant capital (here White and middleclass) may become normalised at systems level and therefore expected during recruitment and assessment. The framework is not only useful to consider the ways non-traditional applicants may be disadvantaged through not having acquired the expected (professional) cultural capital on their pathway to training, it also encourages us to consider the tacit knowledge which may escape those who diverge from the typical White English middle class clinical psychologist (who also tends to be female, heterosexual, and able bodied).

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…

Bourdieu, P. & Passeron, J. C.(1990). Reproduction in Education, Society and Culture. London: Sage Publications.

Division of Clinical Psychology (2014). The Alternative Handbook for Postgraduate Training Courses in Clinical Psychology: 2014 Entry. Leicester: British Psychological Society.

Hemmings, R., & Simpson, J. (2008). Investigating the predictive validity of the Lancaster DClinPsy written shortlisting test on subsequent trainee performance: Final Report to the Clearing House. Doctorate in Clinical Psychology: Lancaster University.

Phillips, A., Hatton, C., & Gray, I. (2004). Factors predicting the short-listing and selection of trainee clinical psychologists: A prospective national cohort study. Clinical Psychology and Psychotherapy, 11, 111–125.

Scior, K., Bradley, C. E., Potts, H. W. W., Woolf, K. and Williams, A. C. (2014). What predicts performance during clinical psychology training?. British Journal of Clinical Psychology, 53: 194–212.

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.

The impact of difference PART 1: Personal reflections on clinical psychology training.

The stress of clinical psychology training

The stressful nature of clinical psychology training is well established. The intellectual and emotional demands it places on most trainees cannot be overstated. Nonetheless, there is increasing evidence suggesting that training may be even more challenging for those who are ethnically and/or racially different from the dominant group. Experiences of exclusion and marginalisation for such trainees are not uncommon, as a result, it has been posited that many courses may still be failing to meet the needs of Black and Minority Ethnic (BME) trainees be it in terms of systemic curriculum inclusion of issues of (ethnic) diversity, the management of overt and covert experiences of racism and, the provision of appropriate support to help BME trainees cope with the additional emotional demands which may be placed upon them. This is the first in a series of posts within which I aim to engage in a process of reflection upon my experience of difference within training. I hope to provide some illustrations of some of the ways difference may affect personal behaviours, trainees’ experiences and the training environment (and vice-versa).

How does difference manifest itself in training?

Individuals are, to a large extent, products of their life-experiences. It is well documented that as human beings we tend to have a natural affinity towards other individuals with similar backgrounds. Although some differences are bound to be reflected within training cohorts, those born and raised outside the UK, those who are not British citizens, those who do not speak English as a first language or are otherwise ethnically, culturally and/or racially different from the dominant group; are likely to find themselves in teams of one within their year group. The above cultural factors together with the potential non-traditional professional and/or educational pathways into training (Black and Minority Ethnic trainees seem more likely to be ‘non-traditional’ in terms of pre-training professional experience and education) may have an impact relationally, mean standing out as ‘different’, having to contend with hypervisibility and/or holding epistemological positions which may be at odd with those held by many in training.

Normative influences and expectations in relation to White (English) middle class norms and values abound. If one is neither, conforming, ‘fitting in’ and being open about one’s views can be extremely demanding. As an example, as someone who has stood out for all of the above reasons, my personal perspective into discussions has often been defined as ‘critical’, labeled ‘radical’ and at times as ‘irrelevant’, an isolating and invalidating experience particularly when there has been no intention to challenge. Often, simply speaking about my experience or that other BME groups would be deemed (unduly) challenging or create palpable discomfort. For example, when I questioned the posited collaborative nature of Cognitive Behavioural Therapy for those who do not hold intrapsychic views of mental health distress or individualistic worldviews- a good section, if not the majority, of people of African and African Caribbean descent, amongst others- this was deemed inappropriate or ‘too critical’ for some (the view that such people were simply not suitable for therapy was even put forward). As I failed some coursework in part for being ‘too critical’, passing assignments for me involved conscious attempts at not being perceived as too challenging and thus exercising careful self-censorship. An exhausting process.

I have experienced clashes of worldviews. Many of the beliefs and assumptions that most trainees in my cohort hold as fundamentally true have been at odd with my value system and life experiences (and probably vice-versa) often, the underlying values of concepts and tools which appeared invisible to most around me did violence to me. Naturally, eurocentric notions are more noticeable to those who belong to minority ethnic groups. Because shared cultural, life and professional experiences have been limited, part of my professional socialisation has felt like accepting claims which appear to have entered the professional discourse without question. Such as the view that clinical psychologists make good leaders, that we are good at tolerating anxiety, that our formulations are empowering ect… Many such assumptions (or aspirations?) seem to be banged on about in discussions without much evidence to back them up; questioning truths most closely related to our professional discourse and identity was not the done thing, it seemed.

I quickly learnt that there are some realities that are not to be tempered with, problematized or challenged. Perhaps the more ‘traditional’ applicants had already been socialised into this ‘etiquette’. The reported experiences of marginalisation, racism and eurocentricity within training may deter individuals from BME groups from entering the profession. Further, any theoretical exclusion of race, racism and culture issues may paradoxically (in the context of hypervisibility because of one’s visible difference e.g. skin colour) bring to the fore feelings of invisibility and oppression in BME trainees and in doing so, reproduce social inequalities. It may in addition impact on patients ‘care. Indeed, the overrepresentation of some BME communities within the mental health system and the enduring inequalities in terms of BME people’s access, outcomes and experiences within it have been in part attributed to the lack of cultural competence of mental health professionals. These reported omissions may also have a wide range of potential legal implications encompassing courses ‘duty of care towards BME trainees as well as equality considerations.

Variations in experiences?

There appears to be wide variations in clinical psychology courses’ ability and readiness to work with difference, this may in part explain why the experience of minoritized trainees can be so different and why some BME trainees will report experiencing training as inclusive and welcoming. It must be the case that some courses create less dilemmas for minority trainees and, it is regrettable that more efforts are not made to share examples of good practice in terms of diversity between courses. Of course too, BME trainees ‘sensitivity to such issues vary as do the willingness to engage with them. The defensive or protective stance of ‘see no evil, hear no evil, speak no evil’ holds true for many of us when it comes to difference (yes, even for those who are minoritized). It is certain that many trainees will simply not want to rock the boat. My conversations with other trainees from different minority groups across the country, made me realise that the challenges I had faced were far from unique or idiosyncratic. Sadly, this is evidenced by an increasing number of studies.

Discovering how widespread experiences of marginalisation, inferiorisation and/or of being the ‘Other’ were for minority trainees was both liberating and troubling. What I found the most disturbing was the apparent taboo and silence surrounding such experiences. Perhaps out of shame or fear many minority trainees are reluctant to ‘come out’ about their experience. Given our vulnerability due to the interplay of power with both the trainee role and our race/ethnicity (and for many, other minority characteristics) and; the arduous journeys many would have faced to obtain a training place (last year only about 2% of Black and 3% of Asian applicants were accepted onto the Doctorate comparing to over 60% for White English applicants), this is unsurprising. Of course others have at times been more vocal. There are high personal costs associated with being silent and likely professional ones if one breaks the silence.

For me, the personal costs have often felt too great. I am grateful to have had the support of incredible mentors both within and without the profession who have encouraged and supported me to ‘speak out’ when I felt I needed to -often this felt like self-preservation- this support has allowed me to stay connected to the profession, remain hopeful (this can be unbelievably trying at times) to care for myself in this highly challenging and often alienating context and to develop a professional identity and methodology that are congruent with my worldview and those of marginalised communities. Beyond sustaining me, this energises me and reminds me of the very reasons I started my studies. Without all of this, there is no doubt that I would have exited the profession.

Thank you for reading.

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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.

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.

Hardy, K.V. (2008). On becoming a GEMM therapist: Work harder, be smarter, and never discuss race. In M. McGoldric & K. V. Hardy (Eds.), Revisioning family therapy: Race, culture, and gender in clinical practice(pp. 461-468). New York, NY. US: The Guilford Press.

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.

Rajan, L., & Shaw, S. K. (2008). ‘I can only speak for myself’: Some voices from black and minority ethnic clinical psychology trainees. Clinical Psychology Forum, 190, 11-16.

Shah. S. (2010). The Experience of being a trainee clinical psychologist from a Black and minority ethnic group: A Qualitative Study Submitted in partial fulfilment of the requirements of the University of Hertfordshire for the degree of Doctor in Clinical Psychology.

The Rocky Road to Clinical Psychology training for BME applicants: A personal Perspective.

The question I am the most often asked when I meet people considering a career in Clinical Psychology (CP) or preparing their applications for CP training courses is: how did you make it -meaning how have you managed to obtain a training place?  When the person asking the question, like me, is from a Black and Minority Ethnic (BME) background, an added sense of bewilderment can often be sensed from their gaze.  The subtext being communicated is instantly understood.  In the non-verbal communication what is left unsaid essentially reads as:  ‘How did you make it as a Black person’.  Of course, many a time people have been less subtle and made explicit reference to my race/ethnicity.

The latest figures reveal that for last year’s entry only 2 % and 3% of Black and Asian applicants were respectively accepted onto CP training. It appears it may be about 10 times more difficult for Black and Asian people to get accepted onto CP than to get into medicine! I do believe that there are systemic issues which make gaining a training place more difficult for BME applicants (more on this in due course) some of these may become evident in the rest of this post.  Nevertheless, in the first instance, I simply aim to share my experience and learning in the hope that they may be of some use to someone.

So I did I ‘make it’?

I often think that I got into the field through the back door. I decided relatively late that I wanted to train in clinical psychology which meant I had to return to university to obtain the degree needed, work toward acquiring the required ‘relevant experience’ later than average and in the main via non-traditional routes.  I have never been an Assistant Psychologist (AP) or a Research Assistant (RA) as I had to focus on getting jobs which paid the bills, with children and living in London at the time, the salary of an AP or RA post was not an option for me, let alone volunteering on equivalent ‘Honorary’ posts (the overwhelming majority of applicants selected for training have held such posts).

Most of my pre-training experience was acquired working at management level in the field of community engagement.  Many recruiters may simply not have given my application a second look.  Indeed, I was told several times by, I have no doubt, well intentioned people; that I did not ‘fit the mould’. Some of those helpful individuals were University tutors.  I could understand that a more mature Black mother of a different cultural background with English as a second language may be at odd with the training mould.  However, why it seemed so important that I fitted it baffled me as did the apparent lack of reflection upon such expectations. Aware that my work experience would not tick the boxes of many courses (or at the very least not earn me sufficient points to hope to get an interview) I sought to incorporate AP and RA skills and activities within my roles.

What did I do?

I gathered the courage to knock on the door of people I did not know; told them about me and my work and sought support and opportunities.  Most people* were beyond supportive, heard me, suggested some strategies and strongly encouraged me to apply and to persevere. They helped me own and appreciate the skills and experiences I had acquired professionally outside psychology and to realize how valuable they could be to clinical psychology practice. Eventually, I managed to get some research supervision by a clinical forensic psychologist on a couple of community research projects I was leading on within my main Job. Subsequently, and through my newly established network, I obtained an additional paid part time post (as a Carers ‘s Group Facilitator) under the supervision of another CP within an Early Intervention in Psychosis service.  It was tough going.  I had two jobs, one full time and one part time; both demanding.  I was also doing my MSc full time and running a home with two kids well under 10 at the time.  After completing my Masters, I decided to enrol on a counselling psychology course as a possible alternative career plan. I was able to do this because I had managed to secure a revenue stream doing some consultancy and management work. Counselling psychology allowed me to get further supervision from yet another CP within a Medium Secure Unit where I completed a yearlong placement (I also simultaneously completed a shorter placement with a bereavement service).

So, what have I learnt that could be passed on to aspiring clinical psychologists who may not fit the mould?

Relationships, professional connections and being kind go a long way.  Being friendly may be the easiest to manage but relationships and connections can be built even if you start from not knowing anyone in the field. Brush on your networking skills! An easier place to start for those expecting a First Class Degree may be to ask their research project‘s supervisor(s) at University for any volunteering opportunities and/or for ways to continue with some aspect(s) of their research thesis under his/her supervision or that of a colleague, even if only for a few hours. Aim to get to know everyone within the teaching team.  There is no doubt about your academic skills if you’ve achieved a First Class degree (yes, I do believe anyone serious about CP should aim for a First Class degree especially those who belong to groups whose academic abilities have traditionally been questionned). It is a lot less competitive to get research experience in this fashion. For those who wonder, I did not get a First (I ended up with a mid 2.1).

Clinically, if you cannot get an AP post, do not be disheartened aim instead to work toward gaining clinical and/or research supervision by clinical psychologists. Try and prioritise posts that will give you direct contact with service users ideally; within the NHS.  It is easier to have or establish some contact with clinical psychologists if you’re in the NHS. However, it is possible to work outside mental health services or within the voluntary sector and to forge links with (and even obtain supervision by) local NHS clinical psychologists but, you may have to be more pro-active and/or creative.  Make yourself known.  Gather staff’s research interests, develop proposals in these areas and ask them for some input/supervision.  Any fear of rejection definitely needs to be under control. If you come across as prepared, professional, confident and clear in terms of the level of input you require, I believe most people will try and help.

The most valuable lesson I have learnt is to strategize.  The odds are largely against you. Thus,  having a clear strategy will help you identify ways to increase the odds in your favour.  I suggest taking a project management approach and working toward a plan.  You may also find that having clear objectives and targets support you when you feel like you are not getting anywhere. This will help you keep the small victories in mind. Do not sell yourself short however, remember every job opens the door to the next one and provides learning opportunities.  It is incredibly important that the profession becomes more representative of the population it serves.  Your skills, experience and knowledge are extremely valuable.

Having an alternative career plan does not make you any less committed or suitable for training.  If you’re developing one, consider sister disciplines.  Many professional psychology and psychotherapy courses offer Practitioner Doctorates that have various exit points and are modular or flexible.  Such disciplines would also offer the possibility of acquiring relevant experience and may therefore strengthen any potential CP application.  Naturally and best of all, you could then work toward a plan B simultaneously.  If successful in your application to CP training, you can always exit plan B and possibly even obtain dual qualifications ( if you’re willing to continue with plan B where you left off when you qualify as a CP, assuming you’re not sick of books by then).  There are of course cost implications and I realize I was quite fortunate to be able to put some money towards further studies. However, studying part-time may make the payment of fees more manageable. Further, the impact of working in low paid jobs potentially for years in the hope of getting onto CP training also has financial consequences namely, on earning potential, especially if you eventually do not acquire a professional qualification.

Finally, be prepared for the arduous journey ahead.  Being different may not get easier once you get onto training …more on this in a different post.

* I feel hugely indebted to South London and the Maudsley and the Institute of Psychiatry as this is where the people who answered my knocks on their door were based. Thank you.

To download the Clearing House 2013 Equality Monitoring Data for Clinical Psychology Training Acceptance Rates (click here)
To download the British Medical Association 2009 Equality Report (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.