'We’re pulling bodies out of the river, we need to ask why they’re falling in’

When we meet, Dr Dawn Edge asks me: 'Do you really want to interview me? I'm not a psychologist.'

My answer was that as a Senior Lecturer within Manchester University's Division of Psychology and Mental Health and the University's Academic Lead for Equality, Diversity and Inclusion, she has some unique insights for trainees and practising psychologists.

Dr Dawn Edge describes her work as 'at the place where mental health intersects with a range of social factors such as culture, gender and markers of deprivation. Inequalities in the provision, experience and outcome of mental healthcare are issues of social justice – efforts to tackle such disparities are among my most passionate interests.'

In addition to leading her own research and interdisciplinary collaborations, Dawn teaches undergraduates and postgraduates as well as supervising master's and doctoral students. 'My role as the university's Academic Lead for Equality, Diversity and Inclusion, operates within the Office for Social Responsibility. This is one of three university-level academic lead roles that are integral to the organisation setting and delivering its social responsibility objectives. Having social responsibility as one of our three corporate goals is unique to the University of Manchester.'

I asked Dawn how she got involved in these sorts of issues. 'My initial training in the 1990s was in a range of areas, for instance as a Chartered Physiotherapist; a degree in health, care and welfare and a Certificate of Higher Education.  During this time, I was also co-opted onto the Board of Trustees of African and Caribbean Mental Health Services (ACMHS), Manchester. A voluntary/third sector organisation, ACMHS was established in 1989 to address the obvious disparities in mental healthcare experienced by black service users (African, Caribbean, British, 'other') and those of "mixed" ethnic origin compared with white British people. Despite several national policy initiatives, there has been little progress in almost 60 years of research and service evaluations highlighting the problems.'

Dawn points to the 2005 Department of Health launch of Delivering Race Equality (DRE) in Mental Healthcare: An Action Plan for Reform Inside and Outside Services and the Government's Response to the Independent Inquiry into the Death of David 'Rocky' Bennett. 'This policy and implementation plan, including appointing Community Development Workers, was supposed to eradicate raced-based inequalities in statutory services within five years. Sadly, inequalities, including disproportionate rates of service access using the Mental Health Act and discharges on Community Treatment Orders as well as deaths in services, are still very much in evidence.'

There have been consistent reports over many decades of significantly higher diagnosis rates of psychosis and schizophrenia and under-diagnosis of others, such as depression, among African-Caribbean people. Several theories have been proposed. 'From the perspectives of service users and carers who have participated in our research,' Dawn says, 'negative stereotypes and unconscious bias often invokes automatic coupling of blackness with dangerousness, especially with male service users, among health professionals.

'Additionally, predominantly white or Asian staff often lack insight/awareness into the structural issues that affect black people, such as racism in general and institutional racism in particular: which is taboo, a kind of "elephant in the room". Let me give an example there. It's a fairly common experience for African-Caribbean people to be followed around by store detectives and security guards. Black service users have said that if this is raised in therapeutic conversations, professionals do not believe their accounts of "everyday racism", dismissing them as far-fetched or seeing them as evidence of paranoia. Consequently, many service users simply won't mention their experiences of racism and discrimination even though these might be central to their illness models. I want to stress that I see these as societal and organisational versus individual issues.'

In some previous issues of The Psychologist, interviewees have raised the issue that it has become so expensive and time-consuming to train as a psychologist that there's been a reduction in the diversity of people who can afford to do it. For instance, interviewees have suggested a preponderance of white, middle-class students with parents who can afford to support them qualifying as clinical psychologists. Dawn comments on this. 'I think this is problematic when psychological care is being delivered in a multicultural context. To illustrate, if black service users receive psychological therapies at all, this is likely to be delivered by a white therapist. But it's not just an issue of colour: many therapists are also middle-class and/or females and/or straight and/or do not regard themselves as having a disability. Of course, it's important to acknowledge that irrespective of our backgrounds, we all hold prejudices. So, I'm not saying that therapists with any particular background can't understand the issues experienced by service users from diverse backgrounds. However, from discussions with my colleagues and looking at curricula, it seems to me that we don't talk enough, if at all, in training about how therapists' biographies and lived experiences might impact their views and approaches to working with diversity and difference. This is a structural issue that needs to be addressed in the context of factors like power, patriarchy and what comes to be accepted as "normal" or "deviant/pathological" and, importantly, how this intersects with social factors like race/ethnicity, class, gender, etc.'

In this context, I asked Dawn whether she felt that psychology in 2018 was fit for purpose. 'Whilst there have been changes in curricula, I tend to think psychologist training hasn't changed sufficiently over the years. Comparing the 2001 and 2011 National Census shows how much the make-up of the UK population has changed. These changes are not just in terms of demographics but also in expectations and attitudes. Importantly, what's currently on offer in mental healthcare simply doesn't work for some groups of people accessing psychology and other services. Furthermore, with globalisation it's highly likely that some trainees from the UK will migrate to other countries. I accept that you can't train people to be knowledgeable about every nuance of cultural and individual differences. My current work to develop culturally appropriate psychological therapies and education suggests that black service users recognise that this or other approaches like "ethnic matching" are not practical and, in some instances, undesirable.'

So, what is needed? 'In my experience, what service users from all backgrounds want is to work with therapists and other health professionals who are prepared to listen actively enough to hear and understand them, versus dismissing or pathologising their experiences. It might sound obvious, but people want to be treated with dignity, respect and compassion. Training in the 21st century surely ought to be capable of equipping psychologists and others to be culturally confident without necessarily feeling they need to know everything about every ethno-cultural group or protected characteristic?'

Should training change? 'In my view, yes. I think we should be actively working to develop diverse and inclusive curricula, enabling students to address issues like the intersections between gender, culture, power and therapeutic engagement more fully. At the moment, it seems to me that when some students come across these issues on their placements, the extent to which they can develop competencies in working with them varies hugely. A more systematic approach to embedding cultural competence into curricula is not only needed but long overdue.'

Researching Dawn's background, I was really interested in her Winston Churchill Memorial Trust Fellowship, an experience that seems to be continuing to inform the ideas we discussed. She travelled to Canada and the USA in 2014 and Jamaica and Barbados in 2015 to explore different approaches to supporting black people with mental health issues. 'The fellowship approach can be summed up in its strapline "Travel to learn; return to inspire". It involves people travelling abroad and bringing back ideas to improve UK society. I saw some very inspiring things. Visiting Midnight Mission on Skid Row in LA was one – I couldn't believe "Skid Row" was actually named on a map!' [You can find out more about the organisation at www.midnightmission.org.] 'In Jamaica, it was revelatory to see mentally ill clients in a ward with physically ill patients, supported by specialist psychiatric staff as part of their programme to improve integration of physical and mental healthcare.'

Dawn has since returned to Jamaica to work with colleagues at the University of the West Indies, the Ministry of Health and a range of other key stakeholders on developing community mental health hubs in places of worship. These are intended to: facilitate mental health promotion/education; expedite access to diagnosis and care; and reduce stigma. 'This builds on work I've been doing in the UK over the past few years, highlighting the importance of faith and communities for service users and the untapped potential of faith-based organisations to improve engagement and outcomes for groups often labelled "hard-to-reach" but who are "seldom heard" from their perspectives.'

Do you feel things are getting better? 'I am a born optimist – glass half-full – so I'd say "yes". I regard the Royal College of Psychiatrists issuing a statement on institutional racism a few months ago as a step forward. It's great to see BME psychology raising issues of race and whiteness but it would be good to see this becoming more "mainstream" and directly influencing curricula, from undergraduate all the way through to doctorates and beyond into CPD.'

Dawn concludes by returning to her earlier point: 'The issues and solutions are society-wide, but that doesn't absolve us as individuals, professions and organisations from doing what we can to make a difference. Indeed, the Public Sector Equality Duty to tackle all forms of discrimination (direct and indirect) is enshrined in law as part of the Equality Act 2010. I am currently part of the National Mental Health Act review, instituted by Prime Minister Theresa May, into what she describes as "the burning injustice" of the rising use of the Mental Health Act. Many readers will be aware that the Act is used disproportionately with black people and other ethnic minorities. The significance of this inquiry is not to be underestimated. However, we cannot review the Act in isolation. To do so would be to ignore the context in which it is being used and therefore missing the point: we're pulling bodies out of the river, we need to ask why they're falling in, what can be done to prevent that happening in the first place and how to help those who do fall in, to recover instead of drowning.'

For further information on some of these issues see: www.manchestercommunitycentral.org/news/african-and-caribbean-mental-health-services and http://research.bmh.manchester.ac.uk/ReACH