Jessie Emilion, psychotherapist & Co-Chair UKCP HIPC EDI committee, offers a personal response to the report of the Commission on Race and Ethnicity Disparity (1)
Paula Heimann the psychoanalyst once famously asked ‘Why is the patient now doing what to whom?” (2). I am inclined to take a cognitive analytic view, a relational approach and ask, “To whom is this report addressed?” It is certainly not addressed to me, as a woman of colour. I cannot connect with it. So, who is speaking, what is it for and how do I or ‘the other’ position ourselves reciprocally to the content and the purpose of this report? I can certainly see how easy it is for me to get into a set of reciprocal roles between me and the report which is annihilating and dismissing to annihilated and dismissed.
Statements made in the report including: “We no longer see a Britain where the system is deliberately rigged against ethnic minorities” will only compound the racial trauma experienced by Black, Asian and minority ethnic people.
It is deeply disappointing, hugely impactful and a lost opportunity. And just as when my clients present for therapy I wonder about the timing of their presentation, I now wonder with the ‘timing’ of this report – ‘why now’?
Contradiction, inconsistencies, and confusing discussions are the presenting symptoms of this report. There is clearly a struggle to defend and manage the unmanageable feelings of shame, guilt and blame evoked by the recent BLM movement, Public Health England COVID report (3) and the BPS DCP Racial and social inequalities in the times of COVID-19 working group position paper Racial and social inequalities: Taking the conversations forward (4). These all state and highlight that inequalities are embedded within society in the form of structural racism and are toxic to one’s health and mental health.
The ethnic diversity of the commission is emphasised. Somehow having this BAME group (an acronym described as not helpful by the report) of people writing this report adds extra validity to the findings. This often happens in many in organisations where people from BAME groups are selected and offered tokenistic positions as a tick box exercise. However, in such roles they really cannot speak with conviction or honesty, but instead appease the system by disowning their own identity in order to feel valued. Organisations position these individuals to maintain the status quo and power, while creating an illusion that something (‘something’ but not inequality or power) is being addressed.
The issue around access and uptake in mental health is also confusing. The report highlights ‘that Black and Asian people with mental health needs were less likely to be receiving treatment’ but it does not believe that this is linked to discriminatory practices within the mental health systems. It locates the problem in people’s mind by “convincing vulnerable people in ethnic minorities that mental healthcare provision is neither a threat nor a punishment” instead of validating their experiences within a discriminatory system. This approach is outdated and draconian?
Barriers in access to mental health services for the BAME communities is not new. However, in the last year, since the COVID Report and BLM movement many services and Health Trusts are actively thinking of new ways of engaging and addressing this inequity in access, treatment and patient care for the BAME communities. The Patient Race Equality Framework (PCREF 2020) has facilitated these discussions. Access, and barriers to access are complex and multi layered and certainly not linear. The services offered often fail to recognise the stigma and shame associated with mental illness for many BAME communities. They are seldom sophisticated enough to offer the cultural conceptualisation needed to motivate, engage, or make the intervention meaningful for the people from the BAME communities.
When we describe patients as ‘not motivated’ or ‘not psychologically minded’ it is akin to victim blaming. In many ways, like this report, it is comforting, a lazy way out, and lets us off the hook. It stops us from thinking about our vulnerabilities, inadequacies, neglect of individuals' and communities' needs, and the abuse of power.
The society we live in shapes us from early on in life. Our sense of self, our psyche and our personalities are hugely shaped by the values we hold and by which we are held in our societies. Through the process of enculturation, we learn to embody our history and culture through signs and language. Stiles (5) describes how signs have a life of their own. They embody both past and present. Each time a new meaning is added, the events are reproduced across time and place, with slight variations but still feeling (and doing) what others before us have felt. This explains how historical procedures around race, power and colonisation are still present amongst us as systemic but with slight variations sometimes as policies and protocols.
Having scanned through the 258 pages, it definitely provides the evidence we need as a society that structural racism and institutional racism are real and are staring at us in the form of this report. One could hypothesise this as a systemic procedure or a collective defence, perhaps. As psychotherapists we will need to address this as we would with any dysfunctional procedures or defences. It is crucial not to be seduced by just focussing this report. It is timely to take a stand and collectively recognise that all our institutions and professional bodies need to be galvanised by this report, be willing to open the dialogue.
Whose voice are we hearing in this report? Is it the oppressed or the oppressor? Who is it speaking for? How can we truly do justice to our patients and offer the healing required when the system or the society in which we are operating reiterates a dysfunctional procedure? Time and time again we as a society find ways to avoid unmanageable feelings of pain, anger, shame and blame. We revert to familiar roles, speak with the voices of our forefathers, our masters. Society tries to re-write the narrative, to change certain discourses which are enabling change, to maintain power and status quo. This is a narrative which will be ongoing as long as there are those amongst us who will not accept a status quo which maintains the inequalities which hurt and harm sections of our communities.