Equality

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)

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

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

Discovering racism…in France

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

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

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

The impact of the ‘new’ racism

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

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

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

So what to do?

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

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

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

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.

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

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

1. Improving Equality data collection/monitoring

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

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

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

3. Establishing stronger links with community organisations

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

4. Supporting staff learning and development needs around Equality

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

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

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

Thank you for reading.

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

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