clinical psychology

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.

 

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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.

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…

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.