Race, racism and mental health - part 1: Interpersonal versus institutional racism

As part of our Black History Month coverage, Dr Heather Bolton, Head of Psychology at Unmind, caught up with clinical psychologist, Dr Fabienne Palmer, to talk about race, racism and mental health. The first post in this three-part series explores the complexities of the topic, interpersonal versus institutional racism, and why we need to challenge preconceptions to build a more equal society.

Dr Heather: Let’s start by reflecting on the complexities of the relationship between race, racism, and mental health. How would you characterise that relationship?

Dr Fabienne: Different people are going to have different experiences and I'm mindful that I can’t capture the voice of everyone. First of all, let’s think about the difference between interpersonal racism and structural or institutional racism.

Interpersonal racism is the experience that people have with other people. Direct experiences of somebody being verbally abusive or physically abusive, whether it's as explicit as that or whether it's a micro-aggression that people might experience on a more day-to-day level.

That’s going to be very different from the more structural and institutional racism that people might feel and be really aware of. Institutional racism may affect people directly through policies and through various practices which limit them in their day-to-day lives, really impact their outcomes, or their futures, or their experiences in different places. It's written into a culture within an organisation or within society, it's very hard to challenge or to even really articulate what that feels like.

It’s important to separate out those two aspects of racism. On a very basic level, racism can communicate to people that they are not worthy, that they are lesser than, that they are in a position where they can expect to be treated differently based on something as ridiculous as skin colour, facial features, hair type, or other characteristics. It’s telling them that there's something innate, inbuilt, and biologically flawed about them. That then means they’re deserving of lesser treatment or not having a good quality of life.

It's very hard to challenge when there aren’t really systems that allow you to challenge it effectively. People end up feeling very distressed and traumatised by all kinds of experiences. Things that, on the face of it, might seem small, like somebody saying something about someone's hair. These can form big workplace discussions.

There's so much history embroiled in those experiences that even just trying to make sense of or articulate that frustration can leave you feeling like it's all in your head. You can feel like you're overreacting, being hyper-vigilant, just trying to make sense of it. You’re asking questions like, “Is this person saying something to be rude?”, “Are they being hurtful?” or “Are they being ignorant?”. There are lots of things in somebody's day-to-day experiences that can make them feel on edge, make them feel worse than their counterparts.

Over a longer period of time, that will lead to things like low self-esteem. It will lead to things like people feeling very anxious. It will lead to things like trauma. 

In terms of creating a space for mental wellbeing and positive outcomes, it's difficult to imagine how somebody carrying all of those different feelings every single day, constantly having to weigh up these things in their mind at every interaction, will be able to inherently have a space of wellness and strength that they can pull on all the time. 

Dr Heather: You’ve touched on some really important things here, and the idea that someone might be treated differently due to something as arbitrary as their skin colour, it seems almost unfathomable, yet we know it’s happening. In order to be able to challenge racism, we need to be able to understand how it can permeate different aspects of a person’s life, and it seems like we still have a long way to go as a society.

It’s helpful to make that distinction between interpersonal and institutional racism, as well as highlighting the impact that even very subtle day-to-day experiences can have on the way people feel about themselves and how safe they feel in the world.

When you think about that, about the absolute disadvantage that being in a minority group can sometimes entail, it’s not surprising that it can have a detrimental impact on mental health. When it comes to mental health, we know that minority groups can be disproportionately affected – an unfair fact, and one that perhaps we don't yet fully understand.

Dr Fabienne: What I found when I was doing my [doctoral] research, is that there's something helpful about even the terminology that helps to identify that there's a difference between the white majority and then those from Black, Asian, and minority ethnicity groups. The label [BAME], which covers so many different people, was developed initially as a political stance, a way of aligning non-white British people and helping those differences to be highlighted.

What I think it's done is mask the different experiences that people from different backgrounds end up having. That then means the resultant impact on their emotional wellbeing and mental health is going to be very different too. There’s a lot of focus on attending to the language at the moment. People are wanting to almost overthrow that term. There is a movement towards finding another way of talking about difference, inclusion, diversity, and race.

The reason that's relevant for research is the lack of clarity in terms of language and labels used in the literature, which makes it difficult to identify the very nuanced and different experiences faced by people from different minority ethnicity groups. Who are we talking about when we group so many people together?

In my research, I found that there's been a real focus on disorders or diagnoses such as psychosis, severe depression, or severe anxiety among people from Black African and Black Caribbean backgrounds. The existing research also seems to focus on people that are within the mental health system, while not really capturing the experiences of those who don't access mental health services, who effectively go under the radar.

There's a bigger question of how do we even know what people from minority ethnic groups experience, in terms of distress or diagnoses, as they go about their day-to-day lives? We can guess based on some of the things I was saying earlier. We can guess that there's probably high rates of anxiety, depression, low self-esteem, and trauma.

Then we're also using a framework that’s Eurocentric – it’s based on the understanding of mental health within the medical framework. Some of these labels won't even really feel applicable, nor do they even touch the sides, capture the depth nor complexity of people's experiences.

Sometimes, it can be a way of de-politicising the situations that people find themselves in because of things like structural racism. It's almost like it individualises and puts a lot of pressure on people themselves to get out of situations, out of their distress, out of their trauma, when actually we're in a traumagenic society.

Essentially, I feel it's quite difficult to say even what the most common mental health difficulties are for people from minority ethnicity groups because we don't have research that accurately captures that. What the research does suggest is that there are high rates of psychosis, depression, and more severe anxiety in minority groups than there are compared to their white counterparts.

Dr Heather: So, there’s really a lot we still need to understand as a profession. We need to make sure we’re not missing important nuances and we need to be prepared to challenge any pre-existing assumptions.

It’s clear that talking about ethnic minorities in terms of being non-white masks huge differences, and even when people think they’re being helpful, it’s likely that they’re glossing over important differences. And there’s still a lot we just don’t know because, as you highlight, even the research that’s intended to explore this topic isn’t always involving the right people or asking the right questions.

In part two of this series, Dr Heather and Dr Fabienne will explore the prejudices and biases to access to mental health care, and how we can forge equality in the area. 

In the meantime, check out our Black History Month post on how race, racism and mental health intersect among Black people living in the UK.