Decolonisation among clinicians

I was stunned. I could not believe the words just uttered by a member of the senior management team at the Improving Access to Psychological Therapies (IAPT) service I worked in as an assistant psychologist:

We [Senior Management] just don't feel that where you are in your career right now, that this training course is relevant for you. Maybe when you progress here or in a different service you could attend the training.

The 'Diversity in Recruitment Champion' training programme in question was part of this NHS Trust's five-year plan to improve career progression for Band 4-7 staff from BAME backgrounds, inspired by the damning results of Roger Kline's 2014 report on the 'Snowy White Peaks' of the NHS. I was a Band 4 BAME member of staff, so how was the training not relevant?

Diversity in staff at all levels within the NHS is essential, especially within mental health services. There is evidence of inequality of access to treatment and poor quality of care for BAME service users (Care Quality Commission, 2010; Lubian et al., 2016). Services should reflect the communities that they serve, and whilst only 13 per cent of the UK population belong to a Black, Asian, Mixed or Other ethnic group, the statistics for ethnicity of staff, particularly in leadership roles are not reflective of this. The 'Snowy White Peaks' report showed that 40 per cent of London's NHS Trust Boards had no BAME members on them at all and that the proportion of senior managers who are BAME had not increased since 2008.

However, more needs to be done than services simply 'looking diverse'. A diverse leadership team can bring a variety of experiences and cultural knowledge to promote better service organisation and care for all service users. Knowledge of historical culture and sociocultural factors that can impact different communities is essential when attempting to understand and treat mental health difficulties in BAME individuals. For example, within the Black British community, mental health issues may be experienced differently across generations. First generation migrants who had to integrate into British culture whilst being victims of visceral racial abuse and discrimination will have experienced a different type of psychological trauma compared to second and third generation migrants, who face fights with a more implicit racism, White curriculums and Eurocentric standards of beauty.

Educating professionals

The issue is two-fold. Not only is there a dire need for a diverse workforce at all levels in psychology and psychiatry, but the curriculum that forms the training of such professionals requires decolonising. As a psychology undergraduate then postgraduate student I experienced a lack of education on the historical context of psychology, culture in the context of mental health and information on non-Western therapeutic practices. One might ask why such teaching is essential in a Western society. Systems of knowledge within psychology and psychiatry are inevitably a product of the milieu from which they emerge and whilst the UK is one of the most diverse countries in the world, this diversity comes with an ugly history of colonialism.

To demonstrate, standardised IQ tests such as the Wechsler are widely used despite their fundamental flaws. Their creation, standardisation and popularisation were deeply rooted in eugenics with explicit biases against Black communities. Early psychologists involved in psychometric testing and the quantitative study of intelligence, such as Spearman, Pearson and Thorndike, were prominent members of several eugenicist groups like the Eugenics Education Society (Guthrie, 2004). Wechsler stated that due to their omission in the normalisation sample the test could not be used for 'the colored population of the United States' for the measurement of intelligence. This advice was ignored, and the test was used for mental measurement and clinical diagnosis of minority group populations (Guthrie, 2004). IQ tests, therefore, attempt to measure the intellectual capabilities of BAME individuals using measures that were created to validate their inferiority.

Change is needed. Theories of intelligence and other psychological concepts need to be taught with honesty, acknowledging their racial and colonial history. This will advance the inclusivity of psychological understanding and practice, through learning from the methodological and scientific inaccuracies of those before us. Traditionally, discussions on the impact of colonialism in scientific disciplines have been limited to specialist dissertations or reports. These academic discussions, papers and text can be jargon heavy with inaccessible language, and often feel far removed from the day-to-day work of clinicians. This can make decolonisation appear abstract and unimportant – to non-BAME clinicians at least. For psychology to become a more rounded discipline that meets the needs of those it seeks to support, we need to ensure that conversations on decolonisation are also taking place outside of academia, amongst clinicians.

Towards an inclusive workplace

Psychology as both an academic discipline and clinical field has failed to explore issues of race, culture and colonialism when considering diagnoses and treatment. This not only results in 'race-blind' researchers and clinicians who fail to design studies, services and forms of support that go beyond Western concepts of wellbeing, but also creates a culture within clinical environments where BAME staff are undervalued. I later left the service mentioned above, after less than a year, as did five other members of staff from BAME backgrounds. All of us had hopes of progressing onto the Doctorate in Clinical Psychology training, but due to the lack of support and CPD opportunities none of us did. In contrast, five non-BAME assistant psychologists from the same service progressed. This is a common example of how inequality and institutional racism in the NHS can impact the career development of BAME staff, which subsequently impacts the quality of care provided to service users.

An inclusive workplace values and utilises individual and intergroup differences within its workforce, cooperates and contributes to its surrounding community and alleviates the needs of disadvantaged groups in its wider environment (Barak, 2016). Whilst schemes such as the NHS Leadership Academy's 'Stepping Up' programme and the 'Diversity in Recruitment Champion' training programme have been launched across several NHS Trusts in an attempt redress the paucity of BAME staff in higher bands and leadership roles in the NHS, the onus is placed on BAME staff to resolve the inequality in services for BAME populations. This is a lot to ask for staff who are historically the most undervalued and least rewarded section of the NHS workforce, who also experience discrimination within the workplace (Kline, 2014). Psychology has a long way to go in both acknowledging the implicit bias in theories that form treatments for a diverse community of service users, to supporting BAME staff to become leaders and providing more culturally appropriate services.

Building a professional community

So, what needs to be done? From my experience as both a psychology student and mental health practitioner it is evident that reshaping both the curriculum and organisation of services is essential in tackling mental health inequality in the NHS. This is where organisations such as the BAME in Psychiatry and Psychology Network (BIPP Network) come into play. I joined the network as a managing director because I want to help build a community of support within a field that can be challenging for BAME individuals, from our days as undergraduates studying a White curriculum through to the workplace where we may struggle to advance through being overlooked for CPD opportunities and promotions. The Network aims to increase access to mental health treatment for BAME individuals, whilst also prioritising BAME staff who are often marginalised within psychology and psychiatry.

A key remit of the BIPP Network is to hold regular events, facilitating intra-community conversations whilst also educating those from non-BAME backgrounds. Recently we focused on men's mental health within the BAME community, exploring how stereotypes or damaging narratives can negatively impact the mental health experiences of BAME men and their help-seeking behaviour. The event was attended by a wide range of students, professionals, key stakeholders including members of different psychological training courses, and senior members of the British Psychological Society – from both BAME and non-BAME backgrounds. Whilst the people with power won't be the ones who come up with solutions, it is important that they are in the room when these conversations take place.

In March, we have a series of educational workshops called 'Race and Racism in Mental Health: Diverse Models and Approaches of Psychiatry and Psychology' delivered by anti-racist practitioners and African-centred therapists (see tinyurl.com/spe7pet). These workshops provide an essential introduction to the historical context of Western psychology and psychiatry, race and race-thinking, decolonisation in psychology and an overview of models of Black and African-centred therapies in psychology. I feel privileged to be part of an organisation that provides the space and education that I missed out on in my own psychological training.

Sarah Atayero is Managing Director of BAME in Psychiatry and Psychology Network, London. Find them on LinkedIn, and on Twitter
@BIPPNetwork

Key sources

Barak, M.E.M. (2016). Managing diversity: Toward a globally inclusive workplace. Sage Publications.
Care Quality Commission. (2010). Count me in 2010: Results of the 2010 national census of inpatients and patients on supervised community treatment in mental health and learning disability services in England and Wales. Care Quality Commission, London.
Guthrie, R.V. (2004). Even the rat was white: A historical view of psychology. Pearson Education.
Kline, R. (2014). The "snowy white peaks" of the NHS: A survey of discrimination in governance and leadership and the potential impact on patient care in London and England.
Lubian, K., Weich, S., Stansfeld, S. et al. (2016). Chapter 3: Mental health treatment and services. In S. McManus et al. (Eds.) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.