oppression

The cycle of oppression: A psycho-socio-cultural formulation (DRAFT 1).

Bringing the social and psychological together

A common critique of mainstream psychotherapy models is that they take little account of social and cultural forces and of their effect upon psychological structures and relational processes. This is a significant limitation in terms of culture competence. Many minority and marginalised groups continue to see mainstream therapy and mental health services as irrelevant.  More concerning is that some may come to experience the therapeutic process as one which exposes and weakens them into powerlessness and; which renders invisible the power of the social context and its related wounds and traumas. It is not unusual for therapists and other helping professionals to feel overwhelmed and helpless in relation to the idea of actively working with social and cultural forces within the therapeutic encounter.

However, any genuinely emancipatory and culturally competent approach to therapy must strive to make visible the impact of oppression and help support service users’ efforts to free themselves from its destructive power relations. Relations that exist structurally, socially and psychologically for people who continue to be othered, marginalised and oppressed.  More culturally and socially informed formulations may therefore offer tools to validate marginalised groups’ experience of the world and thus contribute to change.  Although extremely useful, I have personally been frustrated by purely social formulations which have not commonly highlighted deriving psychological correlates and thus have located themselves within a level of analysis and intervention which may arguably be outside the remit of mainstream psychotherapeutic practice. This post is an attempt at bridging the gap. It provides an introduction to a preliminary psycho-socio-cultural formulation framework (figure A), its rationale and some possible questions to aid reflection.

Figure A:  Draft diagrammatical formulation of the cycle of oppression.

photo (1)

Description of the formulation framework: The cycle of oppression.

At the centre of the draft formulation is a cycle of oppression.  This cycle is made of four interrelated components varying in proximity to the present or to the ‘here and now’.  Those components are: discrimination and oppression, inequality/access to material resources, proximal images/discourses and, distal and intergenerational narratives and events. The oppression cycle is posited to impact on both worldviews and on psychological functioning so that another cycle of psychological correlates is located outside it. The proposed deriving psychological processes are status anxiety and evaluative stress, the internalisation and replication of oppression, the (cognitive) salience of historical traumatic narratives/events and finally the sense of cultural mistrust or paranoia and (affective) distance to the dominant culture. The formulation thus firmly puts the influences of the social and cultural at the centre of psychological functioning.

Discrimination, oppression and cultural mistrust

Perception and experiences of oppression such as discrimination and harassment in the workplace (or in other life domains) are commonly reported amongst all members of minority groups. The link between such experiences and chronic stress, poor psychological wellbeing and ill physical health are well established. Perceived and actual discrimination can elicit what has been termed cultural paranoia, a healthy and adaptive response to experiences of oppression. Nonetheless, cultural paranoia can give rise to feelings of hopelessness, helplessness and bias against members of the dominant groups. It can also produce hyper-vigilance and fear.

It is thus likely that those who are experiencing it to a high level, will be in some form of distress. From the therapeutic perspective it may be helpful to consider how cultural paranoia may impact on trust and on the working alliance. Mental health services are a microcosm that, it can be argued, represents the social world. A service user who expects that he/she will be discriminated against within services or by therapists and/or that his/her account of such experiences will be dismissed, silenced or pathologized will understandably be guarded and reluctant to disclose relevant difficulties. A degree of hostility may become apparent if the therapist is seen as a representative of the dominant culture, the state and/or authority.

How does the Service User (S.U). locate himself/herself, his/her immediate family and distant family culturally and historically?

How does the S. U. define oppression and discrimination?

To what extent has the S.U. experienced oppression and discrimination?

How is sense made of the above?

What part do such experiences play/played in current/past psychological distress?

What has the S.U. found useful in managing such experiences?

What is the S.U. experience of power and powerlessness?

Social/material inequality, status anxiety and evaluative stress

Social inequalities have a significant impact on our psychological wellbeing. On a basic level they perpetuate the uneven distribution of protective factors and of stressful life events. Evidence suggests that more unequal societies tend to suffer from poorer mental health. England is one of the most unequal countries in the world. As consumerism is reaching new heights, the gap between the rich and poor is increasing. The relationship between mental health distress and social inequalities is bi-directional so that each has the potential to exacerbate the other. Additionally, although causality and directionality is not always clear, most marginalized groups tend to be socio-economically disadvantaged.

The psychological consequences of inequalities are central to the psychological functioning of those who are economically and materially disadvantaged. Wilkinson and Pickett (2009) argue that the impact of income inequality is psychologically mediated by ‘status anxiety’ in that inequality creates social hierarchies which increase status competition, stress and thus poor psychological health. Yet, another psychological mechanism that seems relevant is social-evaluative threat (SET). SET is believed to occur when a central component of our identity is, or could be, negatively evaluated so that we fear rejection. Within such potentially rejecting situations our fundamental need for social acceptance is threatened and a discrepancy between our actual and our ideal self is created giving rise to feelings of worthlessness, reduced relational value and/or shame.

How is respect and disrespect framed and conceptualized?

Are there significant debts?

To what extent does the S. U. feel pressure to conform to consumerism?

Is there a discrepancy between the actual economic situation and the idealized one?

Is there access to well established friendships and social support networks?

Is there shame and stigma associated with the socio-economic situation?

Images, discourses and the internalisation/replication of oppression

Unsurprisingly a proportion of minoritized individuals will internalize oppression. Internalized oppression can affect relationships within and between minority groups and between minority group members and those who are from the dominant group. This internalisation may manifest in mistrust toward the in-group, idealisation of the dominant culture, distancing from minoritized identities or the holding of stereotypical views about members of the in-group. Further, internalised oppression can, In extreme cases, lead to low self-esteem, self-hatred and even violence towards members of the in-group.

Assessing internalised oppression can be difficult because it is associated with high levels of shame and stigma and may therefore not be readily disclosed nonetheless; careful questioning may elicit such processes. Thus, any recurrent negative statements made about the in-group(s) may need further probing as may any negative emotion evoked by questions about the subjugated identity.   Various standardised questionnaires exist to assess internalised oppression which may be useful when the therapeutic relationship is firmly established. Acculturation and stages of identity development may also influence the relationship with the dominant group (in addition to the one which may be formed with the therapist) and whether the therapeutic values and norms may be acceptable.

What community/group(s) does the S.U. feel most affiliated with?

Are there difficulties with fitting-in or with belonging?

What is the relationship with members of the in-group(s)/out-group(s) like?

Are there weak/strong cultural or other ties with members of other minority identities?

Is there a history of immigration or displacement?

Is there evidence of shame and stigma associated with the culture of origin?

Historical and intergenerational context and distal narratives and events

Many theorists have put forward concepts that aim to capture the psychological impact of historical trauma on oppressed groups. For example, Alleyne (2004) has proposed the concept of ‘The internal oppressor’. The internal oppressor is theorized to be a psychic part of the self which can become activated when members of oppressed groups are confronted with oppressive situations in their day to day lives so that painful and emotionally charged historical events gain salience in their awareness. Examples of such painful historical events/processes may include the Holocaust for people of Jewish origin, imperialist processes (eg. slavery, colonisation) for other members of minority ethnic groups or the pathologization of homosexuality for some sexual minorities. In essence, the ’internal oppressor’ triggers a process of interpretation of contemporary oppression in light of historical trauma and injustice. This amplifies the distress experienced.

Experiences of oppression can also be reinforced or triggered by public images and media portrayals. Marginalized groups’ representations in the media tend to be distorted. Some groups are particularly prone to misrepresentation e.g. Black males, those who claim benefits, travellers, those with mental health problems and Muslims. A number of studies have identified patterns in media representations of marginalised groups including an overall underrepresentation, an over-emphasis on negative associations (e.g. criminality, unemployment…) whilst at the same time relatively few positive associations. Consequently, public portrayal of minorities tend be one-dimensional, negatively framed or problem focussed. Biased representations leave out significant aspects of minoritized communities’ lives, contributions and experiences.

What historical and contemporary narratives has the individual been exposed to?

What impact have such narratives have/have had?

Are there alternative/competing stories?

How are negative images/discourses managed?

Has there been exposure to positive role models from the subjugated identity group?

Is there shame and stigma associated with negative images/narratives?

Conclusion

This post is a first attempt at putting together a formulation framework that is based on a social explanatory model but which also identifies possible deriving psychological processes upon which potential psychological interventions may be based. The framework is not married to any school of psychotherapy. It simply aims to offer a possible starting point to reflect and consider relevant socio-cultural forces, their possible psychological impact and potential interactions.  I do not see praxis and social change based epistemologies as incompatible with psychological interventions particularly if they are located within a social model of psychological distress. In fact I believe that both are necessary to facilitate resistance and liberatory efforts. The diagrammatic formulation is based on common themes and theories related to oppression and inequality as well as some relevant empirical findings.  Although the framework may be most useful when applied to racialized minorities, it may equally be helpful to support other marginalised groups. I welcome comments and feedback which will allow the improvement and further development of the tool.

Thank you for reading.

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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.

 

What to learn more? Please see…

Alleyne, A. (2004). Black identity and workplace oppression. Counselling and Psychotherapy Research, 4(1), 4 – 8.

Dickerson, S. S., Gruenewald, T. L., & Kemeny, M. E. (2004). When the social self is threatened: Shame, physiology, and health. Journal of Personality, 72, 1191–1216.

Hutchinson, E. O. (1996). The Assassination of the Black Male Image. New York, New York: Touchstone.

Rowlingson, K. (2011). Does income inequality cause health and social problems? York: Joseph Rowntree Foundation.

Wilkinson, R. and Pickett, K. (2009). The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Penguin.

Wilkinson, R. and Pickett, K. (2010). The Spirit Level: Why Equality Is Better For Everyone. London: Penguin.

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Stigma and multiple oppression: Some implications for clinical psychology

A discomforting proposition

I attended a diversity meeting a few weeks ago and although this was not the focus; the on-going underrepresentation of Black and minority ethnic trainees (BME) within the profession was briefly touched upon. I was taken aback and quite disturbed when it was posited that the stigma around mental health issues within BME communities was the reason for the difficulties in recruiting a more representative workforce. This proposition was not elaborated upon and went unchallenged. Instead, it seemed to be taken as a given. It felt wrong. I spent much of the remainder of the meeting considering the proposition and trying to access the logical part of my brain but, such was the level of discomfort I experienced, that I was not able to return to a more rational place and put forward some arguments to challenge the proposition. I chose to remain silent. This post is essentially about articulating a reasoned response to the embodied one.

Could stigma really be a factor?

In all honesty, it was not the first time I had heard stigma put forward as a reason for the lack of diversity within clinical psychology. I have also seen colleagues suggest with much conviction that ‘cultural issues’ were responsible for the lack of Black and Brown faces within the profession. There are various reasons why such notions, which can be stigmatising themselves, may provoke the sort of anxious arousal I experienced within the strategic meeting. It seems those who have put forward the above explanations may not have considered how much of the variance it is suggested, could actually and reasonably be explained by stigma alone, bearing in mind the fact that the acceptance rates for Black and Asian groups are up to thirty times lower than that of White English applicants. Explanations that indirectly put responsibility for inequalities at the feet of disadvantaged groups may act as barriers to curiosity and to more systematic evidence generating.

We have such a wide range of sophisticated research methodologies and much research expertise at our disposal, thus, that so many of us seem quite happy to justify stark and enduring inequalities with reasons that lack precision and/or empirical basis, is in my sense both oppressive and defensive. Indeed this stops us from considering, if only hypothetically, the potential presence and influence of less palatable and more anxiety provoking dynamics such as discrimination (both direct and indirect) and bias (both conscious and unconscious). These processes have after all been widely documented within a wide range of environments and activity sectors. Critically, the above explanations further problematize disadvantaged/marginalized groups.

BME groups are overrepresented in medicine and within branches of the discipline which specialise in mental health such as psychiatric nursing and psychiatry. They also appear over-represented in mental health social work. If stigma (or ‘cultural issues’) were a key variable for such groups’ difficulties in accessing clinical psychology; contact with which is arguably a lot less stigmatising than the above, surely this would not be expected. The ‘Stigma Shout’ survey carried out by Rethink’s research department a few years ago and which is the largest ever survey of people with direct experience of mental health problems on the issue (n=4000), found no ethnic difference on service users’ reports of mental health stigma and discrimination.

Considering the impact of multiple oppression

Of course that is not to say that there is no mental health stigma and discrimination within BME groups, there clearly is. There is mental health stigma within every ethnic group. Thus, like many others, many individuals from BME communities will sadly have negative feelings about mental health services and in addition may show low levels of service awareness. Many will have limited understanding of the signs and manifestations of mental health distress or see psychological difficulties as character flaws. Some would have been influenced by sensationalistic media portrayal of mental health problems and as a result come to believe fallacious associations between mental health problems and dangerosity. It is also true that wihin some sub-sections magico-spiritual explanatory models will be found.

Nonetheless, assuming that stigma may well be a significant factor recruitment wise, it may perhaps be helpful to take our intellectual and reflection efforts further and start being more questioning in this regard, for example, by asking what could we learn from the social context which could be useful in addressing the said inequalities? What practices, at systemic and individual level could perpetuate those inequalities within the profession? How do race, class, and possibly gender oppression (and sexual orientation or trans oppression for some) and the negative stereotypes associated with each subjugated identity, potentially combine and collude with the stigma associated with mental health problems and/or disability?

Maintaining relevance

The above are complex questions but questions we may need to grapple with as trainees/clinical psychologists if we are going to effect and sustain any form of genuine change in relation to access to our profession at both training and service level. Psychology and mental health services have for too long been charged with failing to maintain a sense of relevance to marginalised groups’ lived experiences and worldviews, arguably fuelling suspicion, distrust and anger; leading to both poor uptake and disengagement. Not only does this disengagement may increase the likelihood of more adverse and coercive pathways into mental health services and thus further negative experiences by some marginalised groups, they may perpetuate the stigma and fear that surround mental health problems and services.

Stigma is two-directional. It must be recognised that mental health professionals are not immune to the internalisation of stigma and of other oppressive beliefs. Many people with mental health problems report experiencing stigma and discrimination within health and mental health services, so much so, that the largest anti-stigma campain dedicated part of its activities to tackling such stigma (please see ‘Education not discrimination’ of the ‘Time to Change’ campaign). I was involved in some of these projects as a consultant a few years ago and as part of this, facilitated a range of discussions and training. The latter brought home to me that many myths are still going strong within the mental health sector.

Dealing wih on-going myths

For example, the posited submissiveness of South Asian women and their alleged oppression in their homes or the ‘resistance’ of Black men to experiencing depression and their presumed violence/aggressivity have been repeatedly raised as reasons for race inequalities within the mental health system and difficulties in engaging these groups. Those stigmatising beliefs together with the common denial and/or dismissal of experiences of racism (and the limited cultural competence of services) would naturally deter some BME groups from seeking help from us and from engaging with services; particularly when such contact may be frown upon within one’s environment or community, arguably for good reasons.

Of course too, such dicoursive notions may become internalised and present either social and/or ego threats so that people may understandably consciously reason : ‘I am already facing so much discrimination as a minority in the world, I cannot afford to expose myself to mental health discrimination and stigma’ or ‘I will not give the dominant group the chance to subjugate me some more’. More unconsciously perhaps, some may come to feel : ‘I am inferior/worthless and do not want to evidence or to expose this’. It may be useful to consider potential social and intra-psychic dynamics when discussions around mental health stigma in ethnic minorities are had. Stigma is relational and functional too. At a very basic level, for people to experience or internalize stigma, there needs to be, at least to some degree, others who stigmatize and project. Taking collective responsibility for the on-going stigma and discrimination many face both personally and professionally may help ensure more attention is dedicated to reducing the devastating impact of mental health stigma and discrimination in the lives of people who are often already vulnerable, socially isolated and disempowered. And, that we do not perpetuate stigmatising or othering discourses unintentionally.

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

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

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

Want to learn more?

Please see…

Brindle, D. (2013, April 30). Mental health anti-stigma campaign fails to shift health professionals’ attitudes. The Guardian. Retrieved from http://www.theguardian.com/healthcare-network/2013/apr/03/mental-health-anti-stigma-campaign.

Clearing House for Postgraduate Courses in Clinical Psychology http://www.leeds.ac.uk/chpccp. (2013). Equal Opportunities Numbers.

Department of Health (2005). Delivering Race Equality in Mental Health Care. Retrieved on 06/11/2014 from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4100773

Keynejad, R., (2008). Barriers to seeking help: What stops ethnic minority groups in Redbridge accessing mental health services? London: North East London NHS Foundation Trust.

Littlewood, R., Lipsedge, M. (1982). Aliens & alienists: Ethnic minorities and psychiatry. Routledge London.

SCM (2002) Breaking the circles of fear: A review of the relationship between mental health services and African and Caribbean communities. London: The Sainsbury Centre for Mental Health.

TTC(2008) Stigma Shout: Service user and carer experiences of stigma and discrimination. London: Time to Change.

The intergenerational trauma of the oppressor: A few thoughts

 

A few months ago, I met with a very good friend of mine: a community activist, race equality campaigner and artist. She and I go some way back. Our passion for equality and community work together with our shared experience of immigration (she’s white and of Latin American origins) meant we have built a strong bond over the years. I was invited to her art studio where I met a friend of hers for the first time, a white English man of a certain age who despite his humble social origins, had successfully established his own business. I felt his warmth and openness and, he and I clicked instantly. We quickly bantered and took turn critiquing the artwork on display by proposing outrageously random interpretations. The atmosphere was relaxed and friendly. The three of us eventually settled at a table for a glass of wine. I cannot remember what brought the subject on but the conversation turned to immigration.

Resisting disconnection

Before I knew it, I was listening to some of the most disturbing views I had seen expressed openly in a long while. The gentleman started by recounting an event at work within his previous role as bank manager when he had been accused of racism by an Asian client for whom he had declined a mortgage. He became somewhat agitated as he described what he thought was an attempt by the client at using the ‘race card’. He put to me that people of colour tended to use the race card when things did not go ‘their way’ and subsequently spoke about an incident during which he had got into a dispute with a Jewish man who he said had taken offense at the Christmas decorations inside the bank. Ironically, he lamented what he felt was intolerance on the part of the Jewish man particularly as he, an English man in his ‘own’ country, had to tolerate Jewish decorations on the streets of London.

The talk ended with him discussing the threat of a foreign invasion through immigration, England’s unrecognizable face and the fight the country was required to lead in order to preserve its culture and identity. I was so troubled by this plainly prejudiced tabloid-like rant; which emerged with no prior warning; that my heart started to palpitate. Nevertheless, I felt the strong impulse to stop the conversation had to be resisted.  As he went on (and on); I painfully managed to stay with the anxiety and outrage the tirade had triggered in me. I shifted my focus outward by attending to the emotions and feelings he was displaying which to some degree paralleled what I was experiencing. This slowed my heartbeat down. Helplessness and anger became apparent, but in the main, it was fear and anxiety which dominated. These feelings were palpable and appeared authentic to me. It struck me that it seemed they had been bottled up for some time and; for whatever reason; our very brief relationship had provided an outlet for them.

Empathy and compassion

Why he had felt the need for this cathartic release still evades me. One thing is for sure though, he was addressing me rather than my friend and I almost intuitively refrained from intervening, elucidating and/or challenging him. By not doing so, I bore witness to an experience that is often dismissed. When I shared with him some of my experiences of our conversation, he appeared genuinely taken aback. I noted glimpses of shame as he withdrew into a more socially acceptable and politically correct stance. He apologized profusely and more importantly, became reflective rather than defensive. He said he had not wanted to cause any offense to me; which incidentally I believed; and that he had felt it was ‘okay’ to discuss these things with me. I was surprised by the relatively high level of empathy and compassion I was able feel toward this man.

Although I despised his attitude toward foreigners and immigration and could hardly tolerate his apparent bigotry physically or psychologically, I could not but be touched by his display of emotions regardless of how misguided and irrational he came across. This interaction provided me with an invaluable learning opportunity which I would probably have missed had I taken the moral or intellectual high ground. I have (typically) dissected this exchange in my head and theorized over it hundreds of times using different frames of reference. My aim here is not to offer a commentary on his overflowing raw (male and white) privilege, to condemn his views or to expose the fallacy of his points but rather to try and propose a theoretical interpretation.

Neuroticism and paranoia?

Many may see neuroticism and paranoia in the seemingly disproportionate concerns over identity/cultural losses and the reported fear of being overpowered by some alien enemy. Rationally of course such fears cannot be sustained. Some may argue that the media coverage and political attention immigration receives, would invariably create such unfounded anxieties. It would in my opinion, be difficult to generate such anxieties if something of a nucleus of a pre-existing fear was inexistent. There needs to be something to be tapped into, something onto which political and media agendas and rethoric may be hooked onto.

Fears of invasion precede the invention of the mass media and have been widely documented across centuries and ‘western’ cultures. Undeniably then, such fears have existed for some time independently of media and political influences. Several theories may be advanced to frame such anxieties which may have multiple origins. Here, they will be considered in relation to our imperialist past. Indeed, when one considers processes of imperialism such as colonisation and slavery, fears related to loss of identity, invasion, and imposed enculturation lose their neurotic/paranoid aspects and instead seem to acquire a ‘déjà vu’ quality. Intergenerational trauma may thus offer an interesting framework to consider this resonance.

The Intergenerational Trauma of the oppressor

Intergenerational trauma may be defined as the cumulative and collective transmission of historical oppression and of its negative consequences across generations. It is believed to manifest itself emotionally and psychologically in members of different cultural groups who have not directly been exposed to the traumatic stressor in question. Most of the studies on the phenomenon have concentrated on the offspring of survivors of the Holocaust. Nevertheless, the concept has been used to illuminate the experiences of various racialized and indigenous groups. Here naturally, I am not concerned with the intergenerational trauma of the oppressed but with that of the oppressor.

The trauma the latter suffered as a result of active and passive participation in oppression is less documented and less theorized upon, all the same, there is evidence that terror existed on both sides of the power divide. In view of the abuse oppressed groups endured, rebellion and the possibility of “payback” are bound to have instilled great fears. Many oppressors were indeed hunted by the belief that they would suffer the very fate they had imposed upon oppressed groups, if overthrown. This belief terrorized the hearts of generations and of course led to unspeakably brutal repressions throughout history. As an example, when the collapse of the apartheid system became imminent, many Whites in South Africa violently fought for its maintenance fearing its end would lead to retaliatory genocide by Black South Africans on White populations.

The extreme defensiveness and hostility many feel towards foreigners have been postulated to be manifestations of the guilt evoked by the crimes committed against indigenous and racialized groups. If intergenerational trauma as a conceptual tool can be useful to cast light upon the experiences of those who have historically been at the receiving end of oppression, may it also help make sense of the apparent paranoia and neuroticism evoked by immigration in those who have tended to fulfil the oppressor role? I am not aware that the concept has previously been considered for this purpose. Nonetheless, the hypothesized residual trauma could help account for the appeal of political parties which play on such angst.

On Nigel Farage…

There is really nothing new about the rise in popularity of Nigel Farage. There have been plenty of Farages throughout history particularly during times of economic crises.  The knee jerk muting of the experiences of those we have come to characterize as bigots, with the whip of political correctness, seems unprecedented. However well intentioned, such silencing may lead to feelings of victimisation and alienation and thus result in the entrenchment of prejudice in addition to distracting from more silent forms of racism. If we can truly engage with all experiences then perhaps meaningful dialogues on race, racism and immigration can start to take place both politically and therapeutically (I have previously written on some of the difficulties of creating such exchanges, here). Learning to attend to the suffering of the ‘oppressor’ may consequently provide tools to combat bigotry and prejudice.

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…

Connolly, A. (2011). Healing the wounds of our fathers: intergenerational trauma, memory, symbolization and narrative. The Society of Analytical Psychology, 56, 607-226.

Portney, C. (2003). Intergenerational trauma for the clinician. Retrieved from http://www.psychiatrictimes.com/articles/intergenerational-transmission-trauma-introduction-clinician.

The Elephant in the room: Race Representation, Symbolism and Silenced Wounds.

The first time I sat foot on a psychiatric ward was just under 10 years ago.  I was engaged in doing Community Development and Community Research work within Medium Secure Units (MSU) in London.  This was my first day on a MSU and indeed my first time visiting any kind of psychiatric hospital. Following a brief introduction to the all White psychology team by the clinical lead and consultant forensic clinical psychologist (a White man); I was taken round the ward where a multi-ethnic, but still mainly Black staff base, composed the nursing team who was in turn, overseeing the care of a virtually all Black inpatient/clinical population. Upon entering the ward, I was so overwhelmed by the sea of Black faces staring at me in utter stoicism, that I had to work very hard to contain my urge to cry.

The visit felt surreal and oppressive in an almost suffocating way and; this had nothing to do with the (respectful) way I was being treated by staff. At the time, I was not entirely sure why this sight had provoked such a strong response in me.  I had some knowledge of the extent of race inequalities within mental health services and had also been briefed on the clinical population upon my induction. Yet, something happened in my very first few moments on the ward which took me by complete surprise. Although this ‘Elephant’ remained at the back of my mind as I did further work on the Unit, I became somewhat desensitised to its presence, particularly as the subject was hardly ever discussed with colleagues.  Hence, what I set out to do in the present post is to try and make sense of my experience and to consider some potential clinical implications.

The power of symbolism and representation

As human beings we all make use of symbols to categorize, convey and extract meanings from events and social interactions. From a systems perspective, to start with, the staff composition mirrored traditional power distributions so that at the top of the hierarchy was a White man and at the very bottom of the pyramid of power, were of course the Black staff, followed by Black patients. Thus, at team level, there was a representation of social inequalities in relation to income across staff roles.  Further, the Psychologist role is one of authority that socially occupies the sphere of expertise and; in the context of MDUs; as the role encompasses the assessment of patients’ readiness for release, another layer of power is therefore inherent to the role.

The meaning attributed to the role of the patient (or more accurately patient-offender) and that of the Psychologist cannot be interpreted outside of the racial make-up of the ward.  Connotations and associations whether consciously accessible or not; firmly remain when it comes to race dynamics.  Certain images have the power to tap directly onto this rich symbolic heritage.  Indeed, looking through history, one would not have to search for very long for many constructions of Black people as dependent and as psychologically, socially and intellectually deficient to surface (debates around such constructions are to some degree continuing today). Consequently, and in the context described, the sight of a virtually all Black patient population having been assessed as needing treatment, rehabilitation and indeed control cannot but evoke the historical inferiorization and pathologization of Black people.

Projection and Identification

Returning psychoanalytically to what had happened in my ‘here and now’ experience of the ward, Projective Identification may offer an alternative and viable framework to make sense of the dynamics.  In that line of argument, it may be notable that as the detained Black men appeared to display no feeling and emotion, I experienced an overwhelming sadness and a sense of suffocation. Such feelings appear consistent with experiences which may be triggered by compulsory detention, restraint and freedom deprivation. Thus, it could be envisaged that through my experience, I was acting out the patients’ s disowned and/or unacceptable feelings and wishes which had been projected into me.

There is a long psychoanalytical tradition of viewing racism as a mechanism by which dominant groups project intolerable aspects of themselves into racial minorities.  From an internalised racism perspective, those projected qualities can be said to become accepted as one’s own. The imagery evoked by the racial representation clearly echoes the worst things Black people are all too often socialised to believe about themselves. From a psychoanatytical standpoint, the projections from dominant groups. The Ward context may thus evoke the same images that often give rise to many identity difficulties and other internal conflicts amongst some of us. Thus, whilst working toward ‘Recovery’, Black mental health service users may be exposed to the very painful dynamics that may be be part of their parcel of suffering and that may have contributed to bringing about and/or exarcebating their psychological distress.

Working with the Elephant in the room.

Taking on the role of mental health patient, in the current context, may also means psychically, taking on a role which is consistent with racial stereotypes and which may be experienced as buying into the constructed racial hierarchy which naturally part of the self may resist. From that perspective, it may follow that the role of mental health patient may be an extremely conflictual one for many Black men which may bring to the fore feelings of inferiorisation, marginalisation, exclusion, subjugation, distrust and possibly self-loathing. Although I have not come across many Black mental health patients/service users who have described their experience using symbols, systems representation and psychoanalytical concepts as frames of reference, the sense of suffocation and oppression I experienced has recurrently appeared in my sessions with Black service users as did their experience of being stereotyped on psychiatric wards.

There is ample research evidence suggesting that Black mental health service users have the most conflictual relationships with their clinicians, that they are the most dissatisfied group of all mental health service users and that they continue to report experiences of racism (including racism within services) but; despite these well-established findings; it appears that the Elephant in the room remains too overbearing to acknowledge and to work with for many of us. The dearth of discussion, clinical and empirical attention to the extent of the impact of race dynamics in relation to the psychological functioning and the service use, experiences and outcomes of racialized minorities seems to me to be of particular concern.  Not only because it may be part of the reproduction of existing hierarchical structures that perpetuate the invisibility of race and of White privilege, but also because it prevents opportunities for race related wounds and institutional suffering to be seen and addressed. I believe it may well have been these wounds and suffering I was apprehending and reacting to on my first day on the ward.

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The Angry Black Woman: Covert Abuse, Overt Anger?

A Big Black woman on the train…

I had been on my train back home from University a year or so ago for about one hour when a Black woman entered the train carriage I was sitting in. She was of a fairly large built and was struggling to make her way through the carriage to get to a seat. She was casually dressed but looked somewhat umkept. As I noticed her, I started to observe the behaviours and faces on the train.  I picked up a sense of discomfort and I imagined that passengers may have been anxious about the possibility of her sitting next to them.  As she walked past, most people looked firmly down.

She took a seat within a section of the carriage which was unoccupied a few meters away from my seat and sat directly opposite me. To my left was a group of six middle aged women. They appeared to be friends or possibly work colleagues.  They were quite formally dressed. They were all White.  A few of their faint whispers attracted my attention. Upon observation, I noted smiles, sneers and ever so discreet short looks toward the other Black woman.  This went on intermittently for about 10 minutes. She and I were the only Black people in the carriage. I felt angered and disrespected. The Black woman’s face was looking increasingly aggravated as she was being denigrated-ever so subtly and politely.

Unexpectedly, the Black woman got up and walked up to the group. She asked them to stop what they were doing and said that she could see them. I could hear from the trembling in her voice that she was close to tears. The women looked surprised, denied any wrongdoing and took turn looking at each other and at other passengers feigning cluelessness. This infuriated the Black woman further who burst into screams, naturally, attracting looks of disapproval from most passengers.  She eventually walked back to her seat alone and in complete silence stared at by almost everyone as the women who were taunting her escaped scrutiny.  As the train was approaching my stop, I got up to exit and purposefully walked toward her. I said to her that I had seen what the women had been doing and put my hand on her shoulder at which point tears rolled down her face. She thank me.

Intersectionality

In popular culture and discourses, Black women are often characterized as angry, hostile, difficult and/or rude.  The stereotype of the ‘Angry Black Woman’ is a persisting one in many western countries that not only portrays Black women as one-dimensional beings but also prevent their voices and often painful experiences from being acknowledged and validated. I believe this stereotype has impacted on many of my social interactions, that of countless Black women and that of the Black woman on the train.  When she screamed, there is no doubt in my mind that she became the ‘Angry Black Woman’.  Nothing in that woman’s behaviour justified the treatment she received from the group of friends/colleagues. Nothing at all.  Except her being overweight and Black.

Being both of those things meant she had ceased to be a person the moment she was spotted by the group of women.  Not being a person meant derisory behaviour toward her stopped being reprehensible and, her experience could simply be denied. Becoming angry when denigrated and disrespected seems perfectly understandable to me.  In most circumstances, no one would bat an eyelid if someone who had just been abused screamed in indignation and in pain or in an attempt to seek the support of onlookers. It seems to me that, often, Black women are not afforded such liberties.  I accept that women’s anger is disapproved of socially in part because it threatens gender norms and role expectations. Nevertheless, the privilege of getting angry without fear of being stereotyped is also race dependent. Oppression does not act independently of the various social categories and axes of identity capable of their own of contributing to injustice and inequality.

Instead, it interrelates and create systems that reflect the combination of multiple forms of discrimination each in turn amplifying the other. It is notable that I was not targeted for ridicule. Perhaps being lighter-skinned, slimmer and thus (in the eyes of many) a more ‘attractive’ Black woman, mean I am afforded more ‘privileges’, one of which may be to escape abusive treatment because of my appearance.  Hence, whilst White women’s anger may similarly be disapproved of, it is not mocked or ‘Othered’ in the same way that Black women’s anger is.  Thus, it appears the lower your ‘rank’ the less tolerable your anger is and the more problematic your resistance to subjugation will be deemed.  The reality of the interaction was defined by the group of respectable looking White women and seemed to have been tacitly accepted by the rest of the carriage. What chance did that Black woman have to get her version of reality across when she became nothing but a stereotype?

On Invisibility

As she screamed perhaps in an attempt to get some form of validation of her distress; she disturbed the peace and became the problem within the train carriage. In this moment, whilst her presence became ever so visible, her pain and experience fell into oblivion, essentially annihilated by the stereotype. Symbolically, to me, the collective silence in the face of her dehumanization and the looks of disapproval she received when she raised her voice sent a very clear message to that woman: we see you but we do NOT want to see you, stop forcing us to notice you.

Some may find reassurance in the possibility that perhaps, the passengers onboard had not noticed that she had been taunted and was distraught, sadly, this does not fill me with much comfort.  Some people’s suffering simply does not appear to get noticed. In the hours preceding David Bennett*’s death, he was distraught because he had been racially abused but nursing staff did not notice the high level of his distress or the cumulative impact of the racism he had been subjected to on the ward. When his life was slipping away as he laid on the floor, face down, thrashing about trying to break free, the nurses involved in restraining him did not notice this either. He had also become a stereotype.  That of ‘The Big Dangerous Black Man’ also known as ‘big, bad and mad’. It thus appeared perfectly befitting that he was restrained by four to five men.

The common failure to recognise  ‘depression’ amongst Black groups is a serious public health concern. Many Black people do present to primary care services but, it appears that often, their distress is not seen so that many end up not receiving the support and care they require in a timely fashion, if at all.  My sense is that Black people are simply not seen as vulnerable, are all too often left to cope alone and problematised by any manifestation of anger which can then attracts further dehumanisation. Who would dare ask someone being kicked on the floor to turn the volume down? Some forms of violence are extremely subtle and seemingly innocuous but their cumulative effects can be more toxic and equally traumatic. Next time you see a Black woman angry, please consider what you may not have noticed. This may help ensure our life’s journeys stop mirroring the train journey of that big Black Woman.

* David ‘Rocky’ Bennett was a Black mental health service user who died in 1998 at a medium secure mental health unit. An independent inquiry found that he died as a direct result of prolonged face down physical restraint and the amount of force used by members of staff during the incident. The inquiry made specific recommendations about the use of physical restraint, especially with regards to face down or prone position restraint and in relation to the need for culture competence training for Mental Health Staff. Critically, the enquiry accepted the presence of institutional racism within Mental Health services.

To access the Independent Enquiry Report into the death of David Bennett (click here).

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