‘We need to bring unconscious bias into the open’

Ilona Singer believes her experience as a service user 'has made me a better practitioner'. She now works on an NHS Community Mental Health Team, having also worked in Improving Access to Psychological Therapies and as Clinical Lead for a third sector organisation. 

Ilona tells me that she experiences dyspraxia, dyslexia, dyscalculia, chronic fatigue syndrome, Irlens syndrome and depression among other conditions. These affect what she can do and how she does it, in a variety of both positive and negative ways. It has all led to strong views on how taking neurodiversity into account can improve the training and practice of psychology.

'Neurological conditions have huge emotional effects', Ilona tells me. 'I wasn't diagnosed as dyslexic until I was 20, and undiagnosed dyscalculia both messed up my first attempt at Maths GCSE and initially put me off studying psychology. It took a while to move from feeling I was stupid to seeing myself as valuable and unique! My experiences prove that early diagnosis is critical.'

To get to university, Ilona had to do A-levels, which she found 'surprisingly easy. In retrospect this was partly because I chose to study sociology, religious studies and English literature – none of which involved numbers. Later, when I did an OU psychology degree, I worked as a freelance oral history researcher for a feminist archive. I thought I'd do more of that sort of work but, again, struggled with numbers. Many research jobs were quite quantitative.'

Before studying psychology, Ilona took a joint degree in philosophy and sociology, though her dyspraxia and other conditions rendered her 'basically unemployable on graduation. I did retail, bar and call centre work, pretty badly… I hadn't developed computer skills, among other issues.' Treatment for depression by a clinical psychologist suggested to Ilona that she might be able to study psychology and work with it, but first she took a sociology MSc 'which made me more politically aware, with a greater understanding of issues such as marginality, diversity, labelling and their effects'.

After gaining her OU degree, Ilona applied for assistant psychologist jobs. This raised issues about the route into psychology. 'My son was born during my first degree and I was asked interview questions about my childcare arrangements. In the early 2000s this line of questioning hadn't been legal for many years! Then, one of the unacknowledged requirements of a lot of clinical posts is that you must be able to drive. This is often put into person specifications. I am used to getting around but I've not been considered for certain jobs because, as a dyspraxic with additional visual processing difficulties, I simply can't drive. During my doctorate this became a real problem: I was travelling three to five hours a day to get to placements. My training would have been impossible without a partner to support me, which can't be right.'

Toxic environments

Ilona raises another issue that needs more open debate. 'Supervisors have a lot of power in clinical psychology. The route into psychology training is very competitive, and competition for qualified posts can also be quite fierce. Put these things together and you can create savagely critical environments: bullying by supervisors can render them toxic. I believe this to be a big issue affecting assistant and trainee psychologists, especially those from minority groups.'

Neurodiversity can make it harder to 'fit the mould and show competence across the board', Ilona says. 'Disability behaviours are seen as evidence of lack of professionalism and enthusiasm. For instance, I get tired very easily, have to write a lot of things down and struggle with IT systems and technical equipment. Even the fact that I don't drive has sometimes been mistaken for a lack of professionalism! Sometimes people think that making the process of becoming a clinical psychologist hard ensures we get the best people. But people with disabilities, health conditions and caring commitments are already stretched so these hurdles don't affect everyone equally. People seem suspicious of unconventional career paths; I was overlooked for a lot of clinical psychology jobs early in my career because I had taken longer to qualify, which reflected the obstacles I'd had to overcome.'

I asked Ilona what positive steps universities, placements, assistant psychologist roles and psychology courses need to take. 'First, we need to have some sort of body working with the DClin courses to ensure they understand the needs of trainees with neurodiversity and health conditions. There is a good conversation going on about BAME applicants and we need something similar for other groups. We need to bring unconscious bias into the open and create more flexible training routes and part-time options. Courses must offer good quality local placements to everyone and travel expectations should be reduced. We tend to expect a tick list of relevant experience without looking at whether that is equally accessible to all sectors of society. We expect trainee psychologists to have a lot of self-belief: this is far easier if you are from a certain type of background. Confusing confidence for competence is damaging. We also need to address bullying of assistants and trainees and in the NHS in general. This all involves working towards a more compassionate culture.'

'Fundamentally, all psychologists need better education about neurodiversity; plenty of us don't seem to know what dyspraxia is, for instance. There's been a good focus on autism and ADHD, but it has led to other conditions being downplayed. Neurodiverse conditions don't just change behaviour, they change the way you see the world: they also bring advantages as well as deficiencies. This sort of knowledge would avoid labelling and help us to adapt teaching and therapeutic practice to the needs of individuals. Some individuals react well to spreadsheets, others to pictures, others to words and we need to be able to factor this sort of issue into how we practice and train in psychology. Overall, we should give as much attention to neurodiversity as to cultural, gender, ethnicity and age diversity.'

'Secondly academics, trainers and employers should be aware how neurodiverse conditions make certain "taken for granted" experiences difficult. Take driving again… there are other ways of getting around, and psychology should be more aware of the environmental impact. And stop using statistics as a gateway to therapeutically-based areas of psychology. They often crop up in course admission exams; you have to be able to analyse research but there are any number of ways of doing that.'

'Thirdly, let's start an open discussion of bullying and extreme competition in the psychology professions. The culture of psychology training and employment needs to catch up with the law: a good understanding of reasonable adjustment is essential.'

Therapy is doing with, not doing to

Has experience as a service user made Ilona a better psychologist? 'I think so. It makes you more empathetic and approachable, somehow. I think my neurodiversity even helps sometimes. For example, I have a bad short term memory, so I take a lot of notes. When I explain why, it creates a bond, establishing me as someone fallible and human. I'm particularly interested in the therapeutic alliance. There simply isn't enough emphasis in our training on the importance of warmth and empathy, on the equalisation of power. Therapy is doing with, not doing to.'

'From an early age neurodiverse people may have felt that they don't fit in. They may have the experience of finding easy things difficult and difficult things easy, making the world seem less comprehensible. Neurodiversity also attracts lots of criticism and labelling such as being told you're "stupid" or "lazy". This has a major impact on self-esteem. And, given what I've experienced, I ask clients how they want therapy delivered. "Are you visual, do you like metaphors, are you good with words?"'

Marginality has pervaded Ilona's conversations. 'Psychologists can't remain neutral on matters of social justice. We must always be on the side of the marginalised and those who are damaged by economic pressures and a society obsessed with perfection. We must be so careful not to simply reflect this back by excluding various types of people, such as the neurodiverse, from our profession… they have so much to bring.'