Breaking down racism in mental health care

Dawn Estefan 15 February 2018

"I have encountered enraged deities, curses, witches and devils on the couch, none of which made an appearance in the case studies or academic papers of my training," writes psychotherapist and cultural awareness trainer Dawn Estefan. "Psychotherapy has not seriously addressed the fact that African and African Caribbean clients speak from a place which is embedded in our own cultural, historic and social reality."

The inequalities found in mental health service use and outcomes have been heavily documented in various reports, policies and audits over the last few decades in a bid to reform and monitor services. However, there is a noticeable reluctance in labeling these services as institutionally racist, the argument being that the problems encountered lie within the hands of individuals rather than the institutions themselves.

Methods make cultures

As a psychotherapist I often find myself reframing this narrative within a construct where theoretical theories and methods come to represent the institution. An institution, which hinders the accurate understanding and care of the mental health needs of African and African Caribbean individuals, primarily because there seems to be little focus on the fact that Western psychologies, incorporated with West – European post enlightenment ideologies have dominated mental health systems in Europe. And these fail to recognise the existence of the “other” and the indispensability of understanding difference in ethnicity, race and culture when in the hands of the individual therapist, and how this impacts on the poor engagement of historically marginalised groups.

"The definition of mental health or illness is essentially a culturally determined construct."

It has been my experience that great tensions are encountered when little known and largely incompatible notions of mental health are brought into the therapeutic dyad (relationship). In my work with clients from these regions I have encountered enraged deities, curses, witches and devils on the couch, none of which made an appearance in the case studies or academic papers of my training but are nonetheless alive in my clinical work and constantly challenge the boundaries of the theory, which I had been taught.

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Mental health within African and African Caribbean communities is expressed in terms of mind, body and most poignantly spirit. The latter is often shrouded in secrecy and to some extent shame, which adds another dimension to whether the client can be truly heard when asked to share the intimacies of their psychological discomfort in the presence and judgement of their colonial past.

Can they be truly heard in the knowledge, through the history of colonisation, that belief systems such as the veneration of ancestral worship and multiple deities is at odds with more Eurocentric systems and perhaps even viewed as being primitive or unevolved compared with, say, Christianity. A client once asked me: “Why is drinking the blood of Christ so different from our use of animal sacrifice?”

Despite the fact that we have been present in the UK since at least Roman times there is a persistent cultural ambivalence and lack of knowledge or awareness of our culture, methods of healing and belief systems. This in turn determines our own understanding of mental health and illness, what defines and causes it. The restorative process of the therapeutic relationship often eludes, excludes and alienates African and African Caribbean clients because of this lack of understanding.

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There is also a critique that those from African and African Caribbean communities are not appropriate for psychotherapy because not only are they not deemed to be psychologically sophisticated, they also apparently, lack verbal fluency, motivation and are unable to deal with emotional issues, a reductionist and debateable argument, which in my opinion is based on racial bias, generalisation and lack of empirical evidence.

The fact that African and African Caribbean clients [often] fail to successfully engage with and work through their problems in accordance with the dominant psychological models is a no-brainer. How can they when the definition of mental health or illness is essentially a culturally determined construct?

Exclusion - who listens?

The fact that these communities do not express or verbalise their psychological distress in the same way as whites is not in dispute. For, me the fundamental argument is that psychotherapy even in its culturally appropriate/sensitive form has not seriously addressed the fact that African and African Caribbean clients speak from a place which is embedded in our own cultural, historic, and socio – reality. Does this justify the fact that African and African Caribbean people are significantly less likely to be offered talking therapies? In my opinion it simply serves to highlight the fact that there are cultural barriers to understanding why people from these communities are less likely to access them.

The assumption that one size fits all and that everyone has a similar experience is a failure to understand the existence of racial disparities. To my colleagues I ask this question: Do our clients' socio- cultural and geo - political histories automatically position them not only outside of the cultural metaphors and conventional theoretical epistemologies (philosophies) of psychotherapy, but also outside of the therapeutic process and into another more familiar process of domination, diaspora, dehumanisation and displacement.

The question of who speaks, in terms of the psychotherapeutic narrative, constantly raises for me the greater question of who listens? I understand that it is all about hard outcomes and that the continuing cutbacks render anything that falls under a soft outcome valueless. But I am also convinced that a better understanding of these communities would, I’m sure, be more cost effective than sectioning someone under the Mental health Act for long periods of time or several times over.

Are we as mental health professionals ready to interrupt and rephrase the well rehearsed narratives and adapt to a “cultural literacy”, to help improve the efficacy of our practice, improve clinical outcomes and to ensure that we do not fall short of the ethical claims to ensure social justice, equity and non oppressive practice?

@dawnestefan