When Sana, then a student in London hailing from Coventry, was 20 years old, she was referred to a psychotherapist. Her father had died and, miles away from home, she had begun to spiral into a depression. She became withdrawn and would lock herself away in her bedroom. Eventually, her friends persuaded her to seek help.
“It had got to the point where I was basically paralysed and I needed some kind of escape,” she recalls. “There was no other way out … I forced myself to go to the doctor.”
Sana was quickly assigned a therapist. It was the first therapist Sana had seen and she did not know what to expect. “My therapist was white, and I’m assuming hadn’t had much exposure to minority people because of the way that she spoke to me.”
That is because at the second session, “out of the blue”, the therapist started to question Sana about forced marriage. Sana had not mentioned anything about marriage, but she had mentioned her Pakistani heritage.
“I said I’m here for depression and anxiety,” she says. “My dad passed away, I was there for grief therapy, and I was quite clearly distressed about that particular issue.”
Sana describes how the therapist seized upon one detail – her Pakistani heritage – to make the inappropriate suggestion of why she might really be upset. “She was so unaware of how what she was asking would make me feel. It felt like she was putting me into a box.”
Experiencing this while she was at her most vulnerable made her feel worse. “I thought, if this professional can’t help me then I’m a lost cause.”
Nevertheless, Sana continued to attend sessions: “I didn’t feel I could say could say anything because I was given the sessions through the NHS. I didn’t want to be ungrateful.
“But I knew I couldn’t open up to this woman. I was holding back every time she’d try to get deeper. I think she sensed it because after a few sessions she said: ‘I don’t think we’re getting very far. I think you’d be better suited to somebody else.’”
Sana was assigned to a new therapist to complete the rest of her treatment.
Those from a black and minority ethnic (BME) community are at greater risk of developing mental health conditions than their white counterparts. There is a growing body of research to suggest that regular exposure to racism increases the chances of developing psychosis and depression, while other mental health risk factors such as poverty, higher unemployment and lower educational outcomes tend to have an impact on BME Brits.
Despite this need, an independent review of the Mental Health Act, which was submitted to the government in 2018, found that “profound inequalities” exist for BME patients accessing mental health services. The report focused primarily on the overrepresentation of BME in-patients in psychiatric units: black British people are four times more likely to be sectioned than white patients. BME patients are also more likely to be given medication rather than being offered talking therapies (eg counselling and psychotherapy).
These factors, alongside the lack of diversity in the mental health workforce, were identified as contributing to widespread distrust in the system, which may be preventing BME patients from accessing help at an earlier, more treatable stage.
Specific attitudes toward mental health may also be a factor. In south Asian communities, mental illness can carry a taboo, with some believing that it could affect marriage prospects, bring shame upon a family or that the causes and cures of illness can be linked to religion.
“There’s a long history of oppression towards people of colour in psychiatry,” says Eugene Ellis, the founder of the Black, African and Asian Therapy Network (BAATN). “And [BME patients] may see all of it – psychotherapy, counselling – as the same.”
But the problems for BME patients are not limited to psychiatry. In 2013, the mental health charity Mind conducted a report for the coalition government on improving access to talking therapies. With BME patients, their findings were shocking: only 10% of those surveyed felt that their talking therapy service adequately took into consideration their cultural background, with a third of the respondents believing that the service was not fit for BME people.
However, surveyed professionals rated themselves more highly, with 75% of therapists saying their service did meet the cultural needs of BME patients. It is this difference that forms the loudest complaint from BME patients – that is, therapists don’t “get it”. BME patients complain about their therapists gaslighting them if they talk about racism they have experienced, with some even becoming defensive; others point to racial stereotyping and a lack of understanding about cultural nuances.
I have some personal experience with this. Years ago, I saw a therapist who I felt I was making progress with. We had spent time making sense of difficult past relationships, some of which had at points become abusive. Then one day, she advised me to cut off the problematic family members. This, I tried to explain, was not so simple for a woman of south Asian heritage where family units operate differently; if I were to cut off these members it would have consequences and I did not think I could cope with the additional drama.
Plus, I didn’t agree with the assessment. I didn’t want to remove my family – many of whom had suffered their own traumas – I simply wanted to move past what had happened, and ensure I made healthier choices in future.
But each week, she would ask me if I had yet severed the ties. I felt ashamed when I said I hadn’t, as though I was a disappointment to her. It made our sessions tense and unproductive, and was an experience that put me off therapy for many years.
It is not a given that a therapist from an ethnic minority background will understand a BME patient in exactly the way they require. But in the same way a woman may feel more comfortable speaking to another woman when discussing experiences relating to their sex, a person of colour may feel safer speaking to someone with similar racialised experiences. A quick solution therefore might be for BME patients to be treated by therapists of colour.
However, this is not always possible. First there is the issue of geography, with patients living outside cities having fewer choices. Increasing the number of BME therapists may help this but, according to Ellis, there seems to be a higher dropout rate in therapy courses for BME candidates, who too can become frustrated by a lack of understanding about race from largely white therapy training providers.
This is something Ellis has noticed in his work at BAATN, which was set up as a place for patients to quickly locate a BME therapist, before growing to become a professional hub for therapists of colour offering events, training and membership.
“In psychotherapy as part of your training, you’re invited to speak about yourself because you need to know yourself if you’re going to help others,” says Ellis. “A large part of that will be [the therapist of colour’s] racial identity.
“But people don’t know how to talk about race, they feel uncomfortable, the facilitators don’t say anything, until eventually the comments come – ‘Why do you keep talking about it?’ or ‘Get over it.’”
In response to this, BAATN has set up its own mentoring programme to give trainees a space to be heard and to speak more effectively in their training programmes.
Class also plays a large factor. “Everything in therapy – the way that people talk, their language and their expectations – is organised around middle-class values,” says Ellis. People will have some experience of this approach if they have been to university, but it can be difficult for those who have not. It is interesting to note that people are more likely to train as therapists if they have received therapy previously, and are more likely to go to therapy if someone they know has. This is much more common in university-educated, middle-class circles.
But the hurdles continue even after training, as the system incentivises therapists to treat private patients who tend to be white and middle class.
“If you wanted to work within your community, it’s more of a challenge,” says Ellis. “You’ll need to work in the NHS where you’re likely to meet that same racism again. So a lot of people just get worn out and leave.”
Ellis believes that all therapists – regardless of their own race – need to undergo some kind of training to help them treat BME patients, and to help therapists overcome their discomfort at talking about race. “Because it doesn’t really matter what kind of identity you are as a therapist,” says Ellis, pointing out that specialist counsellors in bereavement or sexual abuse don’t necessarily have had to experience those things personally. Rather, they need space in training to get to grips with the issues. But “the profession just doesn’t train counsellors to [deal with race] as standard”.
The type of therapy may also have a bearing on outcomes for BME patients. Cognitive behavioural therapy (CBT) has become the dominant form of therapy offered by the NHS. CBT focuses on present moments rather than past experiences and is designed to alter negative thought patterns; it is a far cry from the stereotypical therapy setup of a patient on a chaise longue, spending years poring over childhood. Instead, CBT is a task-oriented, structured programme designed to quickly deliver results, often in as little as 10 sessions.
To its critics, CBT has become so common because it is inexpensive to administer and focused on getting people back to work. “You don’t need a lot of training to give someone a CBT programme,” says Ellis. “So staff [delivering it] can be paid fairly cheaply.”
But at the heart of its approach is the notion that, whatever distress the patient is feeling, it is their thinking that needs to be changed. This approach may add to their trauma, particularly when therapists are dealing with communities that are likely to be expressing distress due to very real political and social issues.
In her essay, the psychologist Guilaine Kinouani criticises CBT for its silent assumptions, including “the division between the world (the objective) and us (our subjective reactions). The need for objective evidence to support our beliefs and, related to that, the requirement to doubt and reject our subjective reality and lived experience, if it cannot be objectively backed up.
“It is one thing to encourage people to seek ‘objective evidence’ to help disprove the belief that everyone hates them, but quite another to ask people of colour to back up their belief that they are experiencing racism.”
Kinouani notes that this approach is the embodiment of western, rationalist thinking, but that there are many other worldviews that do not adhere to this. And for Ellis, this philosophical difference can have real impact on patients.
Ellis describes the western approach to thinking as linear. “It says, ‘This comes first and then that comes next,’ so we can logically rationalise and get to an answer at the other end.”
But many people do not think in this linear way. Instead, they may “think of one thing, then something else in a more circular way. Just open to whatever’s happening and then putting something together based on various bits they might be experiencing.”
Ellis notes that the linear style of thinking is hammered home in schools and universities, so if a patient is schooled in the UK (and the further they go, the more experience they will have with this approach), regardless of race they can still benefit from therapies based on it. But for people educated outside the UK, or outside the west entirely, CBT may simply not work as an approach. Moreover, due to cuts to mental health services during austerity, funding for non-CBT-focused therapies, be they music or art therapies, have been slashed. Could this go some way to explain why BME patients who do manage to access talking therapies through the NHS are still less likely to regain their health?
Despite the problems, there are many, many BME therapy success stories. Mandi was working in the Welsh tech sector when she started seeing a counsellor. “There weren’t many BME people in the general population, never mind the therapy profession,” she recalls. “I had the space in that therapy relationship to explore all that I needed to … any cultural nuances I needed to explain, I could.
“My positive experience makes me hopeful that more in the profession will exercise the same level of professionalism and kindness to help break down cultural barriers.”
For those who don’t find the right therapist the first time, recovery is still possible. Sana completed her sessions with her second therapist without issue. “She was much more focused on treating me for grief, which can happen to anyone.”
But it is with her latest therapist – whom she has been seeing for well over a year – that she has made the most progress. “He is a white man. And he started off by asking me about my previous therapist – what I liked and did not like – so I told him about the first lady and the forced marriage thing. And he thought that was ridiculous and he made that very clear.
“I’ve not felt judged by him. If he doesn’t understand something he asks me questions inquisitively, and is understanding. He is just so good. Because he listens and he never makes assumptions.”
