Therapy and mental treatment are, and have for a long time been, run by white people for white people: 9.6% and. 5% of qualified clinical psychologists in the UK are Black, Asian or Minority Ethnic, despite these groups forming an estimated 18% of the population.
But some practitioners are finding found ways to address the bias in their fields.
In Manchester, a new therapy approach is starting to address inequalities that face people of colour with a mental health diagnosis.
Prof Dawn Edge is leading a project on Culturally-Adapted Family Intervention (CAFI) at the University of Manchester. Created for Black African and Caribbean people with schizophrenia or experience of psychosis, the approach adapts family therapy to improve outcomes for non-white participants.
It’s designed specifically for that cohort because in the UK, people from Caribbean heritage have a relative risk of schizophrenia seven times greater than white people (for people with African heritage, it’s four to five times greater.)
“One of the things I found quite distressing was how many of the people who took part in the feasibility study became unwell when they were in school/university,” Prof Edge says. “That was a huge point of transition in people's lives. Some of those people have never gone on to complete their studies, go into employment, or have a family: all of these losses, because they developed psychosis and didn't get the treatment that they really needed. Now, for relatively a small amount of investment, we're talking about creating significant effects in terms of people's ability to function.“
Black people are also more likely to enter healthcare systems through what are euphemistically called ‘negative care pathways’ – namely, through the police or sectioning – and once ‘referred’, are more likely to experience coercive care such as seclusion, control and restraint. People with Black or mixed heritage are also less likely to be offered therapy.
“One of the main reasons why we're doing this work is because of a lack of access to psychological therapy for people, and generally for minoritised communities – particularly when you consider that over-representation in services is really telling,” Prof Edge explains. “Family therapy is recommended by the National Institute for Health and Care Excellence [Nice] for service users in regular contact with their families. But generally speaking, family therapy is poorly implemented in the NHS –and uptake is especially low in people from African, Caribbean and other minority groups.
“That may be in part because Nice recommends family intervention for service users in regular contact with their families. So if you're not living in the same country or same part of the country as your family, or if your family is lost to you, for example because you've fled conflict, then that's unlikely that you'll be able to take part.”
A small feasibility study was set up with adaptations, such as enabling service users to appoint ‘family support members’ (such as a faith leader, care co-ordinator or youth worker) in lieu of family. More than half of participants requested a family support member.
The feasibility study found that of the 26 family units that took part, 24 completed the 10-session course – a remarkably high completion rate. Many participants reported being able to return to work or education, or start volunteering at the end of the course. Feedback from service users, carers and therapists all agreed CAFI should be made available on the NHS. A national randomised controlled trial is now in progress.
‘Colourblind services are complete rubbish’
Like CAFI, Black Minds Matter (BMM)’s objective is to address inequalities in the system as it is. Set up in 2020, its remit was to fund a 12-week course of therapy for Black people, by Black people. Funding was raised through donations (£1.23m in 2021/22 alone), most successfully on social media. Their help was in high demand: within a month of set-up, around 2,600 people had applied for help. Some 500 people began therapy by the end of that year, and BMM UK is now celebrating having cleared its waiting list.
“From our charity’s point of view, it means everything to us,” says Danielle Bridge, BMM’s CEO. “That in and of itself is a really big deal. Clearing the waitlist is a result of being completely overwhelmed in the beginning of the charity's inception, because of the unprecedented response to saying that this was available. We reached capacity pretty quickly, and had to spend a long time matching clients to therapists.”
Clients reported high levels of satisfaction. “I have had therapy before, and many things did not work due to cultural differences,” one woman, 35, told BMM. “It was refreshing working with a Black therapist who understood who I was as a person without having to explain myself. This saved much time as we started working on my presenting issues. This has made the process of therapy smooth and changed my life. I am forever grateful to BMMUK.”
“Being able to speak out loud my hard truths in front of a Black therapist who was open and kind was what I needed the most from therapy,” a male client, 38, reported. “I would recommend others to find safety in such an environment and give themselves the best chance to come out of therapy with a shifted mindset about their issues – or at least to find a starting point for healing in whatever form that may be for you.”
The charity is now in a period of reflection where staff are revisiting mission and vision, who they are and by BMM UK exists. For Bridge, the main finding is patently clear.
“The service is categorically needed,” she says. “We were inundated with public interest, particularly Black and brown people wanting to access therapy, and we're going to need more therapists to be able to help meet the demand.”
Bridge avoids conversations about the factors behind the importance of good therapy for Black and brown clients, which are by now well-evidenced.
It’s much more pressing, she explains, to address the failure of the therapy profession to meet that need – for example, the ways in which therapists’ lack of shared culture, lived experience and empathy delays or even derails treatment.
“What drove people to BMM in the first place is the recognition that some people have reached out for therapy before, and it's been a very difficult and somewhat disappointing experience for them because of issues they've had in those spaces,” she says. “Having a therapist of either Caribbean or African diaspora background means that time spent is more in tune with recovery. We already know that there are massive advantages of having a therapist that understands the things that you've been through: lived experience is huge.”
BMM UK’s unique provision has an intersectional basis, Bridge explains: “This is not a segregation position. It is an understanding of certain services needing to be led by the people that it is set up to serve.” In the same way that LGBTQIA+ or men’s services need representative leadership, so BMM UK’s success has come down to a profound understanding of its brief.
“I want to try and get BMM a seat at the table where decisions are being made, to take our inception into places as an example and say, 'Look, this is what happens when you have really clear objectives about helping people',” Bridge says. “This whole ‘colourblind’, 'every service is fit for everybody' message is complete rubbish. We know this now. Community and statutory organisations, and social services, need to take these things into consideration in order to be effective to serve the communities they are set out for.”
From racist tropes to specialised therapy
For leading thinkers in this field, mental healthcare has a long history racist history that today’s clinicians need to set right.
Micha Frazer-Carroll’s new book Mad World: The Politics of Mental Health dedicates two chapters to the ways in which minorities have been pathologised and mistreated in mental healthcare. She recounts the c19th diagnosis ‘drapetomania’ for Black people who escaped from slavery and the c20th doctors who blamed Black patients diagnosed with ‘dementia praecox’ for their ‘degeneracy’, ‘primitiveness’ and the ‘inferior durability’ of their brain cells. In the 1960s, psychiatrists diagnosed Black people in the civil rights movement with ‘protest psychosis’.
Around the same time, Frazer-Carroll writes, the psychiatrist Franz Fanon de-pathologised the suffering of Black and brown people under colonialism. She also notes his rejection of the individualistic approach in psychiatry, and the way this approach enables ‘syndromes’ that depoliticise trauma. For example, she cites the fact that the rates of higher schizophrenia diagnoses in Black people in the UK haven’t been replicated in the Caribbean. Another example: a proposal from 2001 that group survivors of Canada’s residential school system be diagnosed with ‘residential school syndrome’; the system was officially recognised last year as genocide.
Today, in both the NHS and private practice, many therapists are widening the worlds of mental healthcare and therapy to make room for the clients who need it.
In the last five years, a new NHS role, the ‘Clinical Associate in Psychology’, was developed to improve access to psychology careers through Masters-level apprenticeships, which may in turn make psychology a more representative field. In the class of 2021, 11 out of 24 Clinical Associates were from minorities.
Clinical Associates at East London Foundation Trust were able to start working in partnership community organisations including the Bangladeshi Mental Health Forum (BMHF) in order to build partnerships and improve outcomes. The Trust won HSJ awards for their work on the initiative this and last year.
In therapy and counselling, Black African and Asian Therapists’ Network (BAATN) is primarily known for providing a directory of therapists of colour. But it has also used the considerable experience of its therapists over the last 20 years to support and platform writers in the field, including Dr Isha Mckenzie-Mavinga.
Her work to define concepts such as 'ancestral baggage', 'the Black empathic approach' and 'recognition trauma' were part of the development of transcultural therapy in the UK. Together with other BAATN members Kris Black, Karen Carberry and Eugene Ellis, Dr Mckenzie-Mavinga recently produced a handbook on anti-racist approaches, Therapy in Colour. BAATN has just launched an anti-racism training for therapists, starting in September.
Amongst Black and Asian therapists, other communities are making strides in spiritually-informed counselling. Back in 2013, counsellors and therapists set up the Muslim Counselling Network (MCAPN) so, like with BAATN, clients could get directly in touch with Muslim practitioners, and so Muslim therapists could also find Muslim supervisors.
Five years later, Islamically-Integrated Psychotherapy laid out a specific framework for supporting Muslim clients and therapists to work together in context, and Routledge also published Islamic Psychoanalysis and Psychoanalytic Islam, a groundbreaking collection of work by analysts, therapists and scholars on the relationship between the two subjects and their relevance to events like the Arab Spring.
And in the US, psychoanalysts are shining a light on racism at the heart of their profession. In 2014, dozens of Black psychoanalysts in New York shared their experience of analysis, training and practice for the hour-long documentary Black Psychoanalysts Speak. They describe the outsider status Black people are stuck with, on and off the couch, facing microaggressions in analysis, and the essential contribution of Black experience to psychoanalytic concepts including projection, transference and Othering.
In 2019, Fanny Brewster’s book The Racial Complex: A Jungian Perspective on Culture and Race addressed the explicit racism in Carl Jung’s foundational writing on psychoanalysis by revisiting core Jungian concepts such as shadow, as well as breaking new ground on America’s Black and white cultural complexes. She shared insights with thousands of listeners on the This Jungian Life podcast in the same year.
In 2023, some therapists warn that professional initiatives threaten the existing workforce of colour. Leading therapists and counsellors such as Dr Dwight Turner have warned that a new review into the way both professions are regulated (the BACP’s Scope of Practice and Education) will marginalise people of colour in the workforce.
Meanwhile, a new survey by Counsellors Together found the cost of living crisis had exacerbated existing inequalities amongst clients, therapists and trainees: clients switching to shorter therapy or bi-monthly sessions, and a higher level of debt for trainees and therapists.
“The past and present of mental health has been dictated by capital, alienation, racism, colonialism, gendered oppression, psychiatric abuse, incarceration, gatekeeping and the enforcement of particular ways of knowing,” Frazer-Caroll concludes in her book. “The future must be something else.”
- CAFI is seeking service users and therapists. Service users (14+) with a schizophrenia/psychosis diagnosis or in early intervention services, and with at least a grandparent from the Caribbean or sub-Saharan Africa are welcome at pilots in Manchester, Birmingham, London, Southampton and Bristol. Qualified therapists can be located anywhere.