education

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.

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

Mike’s story

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

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

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

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

Some personal experience of the Education System

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

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

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

Black Service Users’ lived experiences

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

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

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

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

Schools should not give up on kids too easily’

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

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

Chicken and egg proposition?

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

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

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

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

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

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

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


Want to learn more?

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

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