On Racism in IAPT: Part 2

Introduction

The reaction to Part 1 of my article on Racism in IAPT was absolutely breath-taking. Over 2000 views in just two days – I didn’t expect to get more than a couple of hundred! Again, MASSIVE thanks to those of you who reached out to share your experiences of racism in IAPT. Part 1 would not have been nearly as powerful without you – I hope you felt included in our message and invigorated for having your stories out there for all to bear witness to. I can only hope that Part 2 is the practical, comprehensive tool-box you’ve all been hoping for. I’ve tried to tailor these “Top Tips” to the IAPT context, to ensure they feel relevant and realistic to clinicians and managers alike. 

We hope you found Part 1, on acknowledging racism within IAPT services, eye-opening and/or painful and/or cathartic. If you haven’t read that yet, click here. 

If you have read Part 1, and felt miserable for it… Yeah, join the club. We may have taken a few steps forward in recent months,  but we clearly have miles to go to achieve the levels of respect that Black, Asian and ethnic minority staff working in IAPT deserve. And if that’s the way we treat our staff, then surely that raises concerns as to how service-users experience our services? It doesn’t bear thinking about. 

Today, we consider how to change things for the better: striving for respect and acceptance, not just “tolerance”. I have to believe that this is a possibility, else what are we all doing here? Let’s be clear, racism is not a “BAME” problem, it isn’t a Black and Brown problem: racism is all of our problems and all of our responsibilities (most of all White British people, but that’s a whole ‘nother conversation). We all need to wade in, get our hands dirty, and be ready for the long-haul. This is uncomfortable work, but the pay-off will be priceless.

In the wake of the Black Lives Matter movement gaining momentum, there have been many workshops and reflective spaces created to consider how to work towards becoming an anti-racist psychological therapist. Not only that, but several BAME leads in IAPT have joined forces to discuss past and future endeavours. After all, IAPT services remain some of the most diverse within Psychology in the UK: many of us have already been doing good work. Still more have excellent ideas to shine a light on our short-comings and do better altogether. Why reinvent the wheel? 

It also feels important to acknowledge that CBT and many other therapies we learn and practice are Western-centric and individualistic in nature. As such, it seems rather unsurprising that they may not land exactly how we might want or expect them to. We should begin to consider the impact of telling people (even if not in so many words) that their way of meaning making, understanding themselves or their trauma, the way that they view their communities and responsibilities are somehow “wrong” and contributing to their mental health difficulties. 

We should reflect: are we white-washing people’s self-perception (“unhelpful thinking styles” come to mind)? Are we generalising our theories to communities who just don’t see the world the same way, which is absolutely fine? Is this a form of post-colonialism? When we ascribe the label “not psychologically minded” to (majority Black and Asian) service-users who struggle to make sense of our model, are we not just excluding them on the basis of a different understanding of the psyche, not to mention stigmatising them? How can we hope to do better, when our core modalities were created with only one type of patient in mind? I definitely don’t have the answer, but I think it is important to ask these questions. I hope it will allow us to stop pointing the finger and look in the mirror instead.

Top Tips for Authentic Allyship within IAPT

Reflect

You’ve already started on a journey of recognising just how much racism already runs through IAPT.

Having more diverse teams is a good start, although we clearly need to do more in this respect, but it honestly counts for nothing if our colleagues are experiencing racist jibes, comments and/or discrimination. It doesn’t matter what the intent behind a comment is: racism is relentless, and it is exhausting. This is our reality, but it is not our problem: it is all of our problems. Pay attention, please.

Educate yourself

An educational resource on racism and anti-racism created for my IAPT service, by yours truly. Please take some time and actually read, listen, watch and reflect.

Read into Race and Psychology

–         IAPT BAME Positive Practice Guide

–          Addressing issues of race, ethnicity and culture in CBT to support therapists and service managers to deliver culturally competent therapy and reduce inequalities in mental health provision for BAME service users – Naz, Gregory & Bahu, 2019

–          Developments in Social GRRRAAACCEEESSS: visible–invisible and voiced–unvoiced – John Burnham, 2011

–         Digging deeper: population-level racial disparities, exposure to police victimisation and psychological trauma – Ross, 2017

–          Benign Bigotry: The Psychology of Subtle Prejudice – Kristin Anderson (free until 12th July)

–          Consider Dr Rashad’s excellent Twitter thread, on naming and normalising race, race-based trauma and White privilege in the therapy room, and the impact of *not* doing so

– Read Sheena’s thread on the ways in which her therapists and colleagues never truly considered cultural differences in formulation

–          Fellow White Therapists, We Need to Talk about Our Microaggressions Toward Clients Immediately – Annette Miller

Take action

Improving clinical practice

• Bring race into case management and clinical skills supervision. Remember, ethnicity and identity have dictated which diagnoses we label people with. Let’s consider the role that our biases play all the way from assessment through to treatment and recovery (or lack thereof).
  
  Consider how to address race and difference with service-users (the elephant is in the room, whether you choose to name it or not). Consider how best to use your natural empathy and curiosity to broach this topic. Consider who you are doing this for: for yourself, to assuage your own discomfort? For the service-user, to give them permission to talk about these issues if they feel relevant? 

• Ask for CPD – no, not just “unconscious bias” training. If you’ve read this far, you will hopefully recognise that we are not just dealing with a background issue that just might colour some of your interactions.
  
  Ask your leads to pay a Black or Asian expert on race and anti-racism to come and help you and your colleagues explore the intersections of your identity, your belief systems, and consider how to do better each and every day.

Supporting staff

• Set up a minoritised staff working group, in order to provide a safe space to consider the impact of recent events (and several lifetimes’ worth of oppression), as well as to allow room to think creatively of solutions.

  We’d recommend working closely with your management team to allow for some guarantee that suggestions emerging from this group will be considered fully. 

It might be worthwhile including White allies every so often, so they can bear witness to these important conversations. Or, create a mixed reflective group to facilitate discussions around bias and anti-racism.

• When a member of staff calls you out for misspeaking, being thoughtless, not doing enough – please don’t react defensively. We know (or at least hope) that you’ve been trying. We are not denying that, we are merely voicing distress and trying to point out an area for improvement. 

When you tell us “that’s already been done, haven’t you seen X, Y and Z initiative”, suggest a “quick fix” that will only solve that specific issue, or make excuses, you are shutting down conversation and an opportunity for growth.

We see you, when you bristle and react. You lose a part of our trust every single time. At some point, we will give up, burn out and/or leave.

• Set racism and anti-racism initiatives as a standing item in Team Meetings: this is not an issue that can be dealt with all at once. Many of us have been trying to change things forever, but we need your help. 

• Safeguard time for staff to take part in Trust-wide initiatives such as BAME Networks, reverse mentoring schemes, leadership programmes… These discussions need to be heard at the highest levels and this can only happen through improving opportunities for growth. 

• Commission audits and research projects to find out more about the impact of service-user ethnicity on clinical engagement and recovery. Run focus groups for ex-service-users to make sense of what worked well and what didn’t.

  For instance, look into every Black and Asian client who has used the service in the past 2-3 years, and check:

  • The number of referrals for this group of people
  • The number that make it through to initial assessment
  • The numbers taken on at Step 2 and 3
  • Average waiting times
  • Drop-out and recovery rates

• So you have a “BAME Lead”? Great.

  First off, consider banishing the term “BAME” (feel free to Google to find out why it’s no longer deemed helpful).

  Secondly, have you really protected time for them to do their role? Is an afternoon a month really going to cut it? Are you ensuring their clinical contacts are kept manageable so they can dedicate themselves to this rather significant endeavour?

  Have you considered that this might be a responsibility to be shared between the admin team, clinicians and managers, in order to achieve any kind of meaningful change?

 

Recruitment and retention

• Question the state of Black, Asian and other ethnic minority staff recruitment and retention:
  Does your service reflect your local community? Are there ways that you can do better, for instance advertising further afield?

  Is your management team majority-White? Why is that? Is it really because none of your minoritised staff were “qualified”? Do they even get promoted at the same rate? 

Are your Black and Asian staff leaving your service faster than your White staff? Are you auditing exit interviews? Could you improve upon your exit interview set up to ensure your staff tell the truth about why they’re leaving?

Do not assume these questions aren’t relevant to your service: actually check. 

• The following demographic stats should be made transparently available and regularly reviewed at all levels for each individual position:

• • % break down of which ethnicities apply for jobs
  • % break down of which ethnicities are shortlisted for interview
  • % break down of which ethnicities are offered

A fair system would show (at least) a similar ratio from application to appointment. 

• There is a common phrase given to those from more diverse backgrounds seeking promotion: “You aren’t ready for the role’. I would implore recruiting managers to consider which of their staff they tend to gravitate towards, when considering who to groom for a particular role (we all know it happens). Please reflect on whether all candidates that step up/are promoted into new positions already excel at all of their new duties, or whether some are afforded the time to grow in the role and make mistakes. 

Such opportunities are seldom given to people from minoritised backgrounds – we basically have to be doing the job perfectly already… And even then we are sometimes pipped to the post.

• “Bring a Band 5 to work day”: it is helpful for those from diverse backgrounds to have more exposure to what happens at higher levels, in order to combat the Snowy White Peak effect. This could include being given opportunities to observe parts of CIG meetings or shadow/support band 8A duties from time to time while working at bands 5-7.

This is not to say that people from minoritised groups should be forced to take these opportunities and penalised if they don’t; it is about creating an environment which gives them access to those opportunities, should they want them.

• Ensure you have one Black, Asian or other ethnic minority member of staff on every interview panel, and listen to them. Consider whether your inherent bias is creating prejudice against certain candidates – not hiring someone on the basis of their accent is not unheard of!

  Remember, everyone’s a little bit racist. We all hold some form of prejudice. We grew up in a world that conditioned us to think that way. Combat that. 

• Also, please include a question about attitudes to diversity in every interview. Not your bog-standard “what does ED&I mean to you?” but perhaps “Are there any groups of people you would feel uncomfortable working with?” or “What would you do if you heard a colleague say something prejudiced against a minority group?”. 

You might think it’s easy to prepare a perfect answer to these questions, but I guarantee you will know whether the applicant means what they say. This is utterly relevant to our jobs – unless you’re happy to work with a bigot who doesn’t uphold NHS values, that is.

Connecting with communities

• Consider holding focus groups with ex-service-users, community leaders and laypeople, to acknowledge past missteps and consider how to engage in a more sensitive, thoughtful way. We might have a really poor reputation in the community. We won’t know unless we ask, and actually want to hear the answer.

  It’s likely that these meetings might feel hostile to start with, but to be a true ally, there needs to be an understanding of where our services have gone wrong in the past and a desire to persist until there is a breakthrough. These meetings should include suggestions of concrete improvements (including funding allocation to these long-term plans), how these will be measured and by when. 

• Go into local colleges, places of worship, community centres: we need to figure out how best to make our services feel safe, trustworthy and relevant to our local communities.

  If our access rates are low, then we need to ask ourselves what we are doing wrong, and not push the blame back to those communities which have been mistreated by mental health professionals for generations.

  Consider people’s relationship to help (Reder & Fredman, 1996) – what are their experiences with similar services? How can we take those into account in our policies? How can we break down stigma barriers? How can we diversify and educate our workforce so that the assumption that all therapists are White (and thus won’t understand) becomes untrue?

• Think about how to authentically integrate into communities who may fear this is just another way to boost access figures. How can we (clinicians, managers, commissioners) make clear that we truly care about minoritised groups? Do we truly care about minoritised groups?

What else?

• Shameless plug: send this article to your team. Then, start having conversations.

  Listen to your Black, Asian and other ethnic minority colleagues (in this moment, allow your Black colleagues to take centre-stage if they feel comfortable to). Do not second guess them, do not tell them all the ways in which you’ve already dealt with this issue, do not ask them if they’re sure that’s what happened. Just listen. And take note.

Equally, don’t wait for your Black, Asian and other ethnic minority colleagues to get the ball rolling. We’re tired.

• Speak up. Please, don’t leave it to your minoritised colleagues to report harmful language, beliefs or behaviour. We stand to be labelled trouble-makers, end up with disciplinaries, don’t get our contracts renewed.
• If you know that something is wrong, then please, reach out to the offender and have a conversation. If they aren’t willing to listen or admit wrongdoing, then report them to your supervisor or manager. Don’t let the Karens of this world keep ascending the ranks – because they will. And they will cause harm.

Last but not least… Take a minute to acknowledge the time you have taken to read this article and its predecessor. Thank yourself for taking the time to grow, learn and be better. Take a deep breath – and don’t stop now.