Here is the next interview from in our BME Women, White Uni series. Last year, Shruti Iyer went to interview Dr Shubulade Smith, Consultant Psychiatrist and Clinical Senior Lecturer at the Institute of Psychiatry, Psychology and Neuroscience at King’s.
SS: Hi, Shruti.
SI: So, tell us something about your work?
SS: I’m a Consultant Psychiatrist and Clinical Senior Lecturer at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), as we are as of a few weeks ago. I also run a Clinical Service at the South London and the Maudsley NHS Foundation Trust (SLAM). I work in the Department of Forensic and Neurodevelopmental Science at the IoPPN, and run the Forensic Psychiatric Intensive Care Unit which is also the main admissions unit for the Forensic Service of SLAM. And that’s the main psychiatric hospital that’s affiliated to King’s. So I have various roles, and my main job at the Institute is that I run an MSc in Clinical Forensic Psychiatry, and I also do bits of research. My research interests are mainly around physical health in severe illness, so things like schizophrenia, psychosis, bipolar illness, and also trying to help improve and reduce violence rates in severe mental illness. I also have a research interest in the mental health of Black and Minority Ethnic people, and also have done some work, book chapters, and reviews around women with mental health problems. And in my clinical work, I run the Forensic Psychiatric Intensive Care Unit, it’s… quite full-on. Quite a busy ward. And I look at people who are acutely disturbed, and or violent, and or who have offended quite seriously against other people. So they’re very unusual, actually. Most people with severe mental illness don’t hurt anybody else. They usually – the biggest risk that they pose is to themselves. But I look at that small minority of people who have, unfortunately, behaved in violent or aggressive ways towards others and what we try and do is help them in various ways. It’s a very holistic approach, we use some medication but also psychological therapy, a lot of occupational therapy, to try and get people well. When they come in they’re usually very acutely unwell. They do get better, and then it’s also about keeping them well. But for the most part, they’ve all had really horrendous backgrounds. So what makes them risky and violent and dangerous is usually not their illnesses, it’s more to do with them with them having awful, disruptive, traumatic experiences growing up. So they’ve become people who’ve learned to use violence as a coping mechanism. And they’ve often got into drugs when they were quite young, which has increased the risk of getting involved in criminality and violent behaviour.
SI: That’s really cool. I’m doing a criminology class right now, and I’m just interested – because obviously, we know that Britain is incarcerating more people, often disproportionately black men. So a bit of a digression, but what do you think is the correlation is between mental illness, race, and what that has to do with incapacitating measures taken by the state, i.e., just putting everyone in prison?
SS: Yeah, yeah.
SI: And is there a difference in care provision given to black people who happen to be mentally unwell?
SS: That’s a big question! And a lot of questions. I think probably the first thing to say is that it’s not a simple process. Certainly, when I came to psychiatry, there were a lot of black people and in particular, black men, who were in mental health institution. And I thought, “this is simply about racism, clearly.” When you go into the units and you meet people – and I’ve been doing psychiatry now for 22 years – you find that, “actually, this guy is really ill.” He is really ill. And what you realise over time is that a lot of the problem here is that this person has been ill for a long time but they haven’t been treated earlier. Over time, research has been done and found that, guess what, there are higher rates of black people, particularly black men, coming into the services at a much later stage.
SI: Yeah, they kind of slip through that net, maybe.
SS: Well, it’s not only slipping through the net. Because that implies that there’s a net to be slipped through. But I think there’s something about – so black people don’t access the opportunities and the services that are available to them that other people would do. Black men in particular. Especially when it comes to health – all types of health, physical and mental. Black men aren’t as likely to present, full stop.
SI: We talked about this with Dr. Hatch as well, but do you think that has to do with the anticipation of racism? That they’re socialised into anticipating discrimination?
SS: Yeah, no, it’s interesting. I actually think it’s deeper than that. I think it’s not simply about thinking that people are going to be racist. I don’t even think it gets that far. I think, it’s literally just thinking that “this isn’t for me.” This is something that isn’t available for me. It has to do with people feeling that they don’t quite belong. They’re not quite citizen. And that’s a very unconscious, a very subconscious thing. So if you don’t feel that – it’s a bit like being on holiday somewhere. And not feeling – more than being on holiday somewhere. You’re on a holiday, but you’re on a prolonged holiday. Say you’re somewhere for four weeks. And in that time, you’ve got over the usual two-week, you know, just my little beach holiday thing. And you are more involved in the society of the place. But because you don’t feel like you’re part of the local populace, the rules don’t apply to you in the same way. You might know what they are, but in fact, everyone else lets you off too. So they won’t expect that you’ll know all the customs and everything else in the same way. So you don’t quite feel like you belong. People are friendly enough to you, but you don’t feel like all the things apply to you. And I think there’s something of that for all black people. All people who aren’t the majority, indigenous white population may well feel that. And I suspect that even – and I grew up in Britain. And I think about how things have changed over my lifetime. And how my children feel much more a sense of belonging than I would ever have felt actually. It doesn’t occur to them that they might be anything else other than British. Whereas I grew up and still considered myself to be – and people say, “where are you from?” and I say I’m Nigerian-descent. And that’s a bit of a fudge in some way. It doesn’t tell you anything about where I’m from. And I belong to this group of people who were born in Britain, whose parents are West African, who’ve been to West Africa a bit, and always felt that they might one day go back, but actually didn’t, and stayed here. And so, although, really, my accent and my customs are very British, I wouldn’t necessarily consider myself as British.
SI: Yeah. I think there’s always something other.
SI: I thought it was really profound when you said “not quite citizen.” That really encapsulates it for me.
SS: Yeah, I think that’s really important. Because if you’re not quite citizen, it not only means that you don’t feel that you can access these things legitimately. It also means that you don’t necessarily feel like you can get involved in all the other things that enhance the community. A good example is say, bone marrow or kidney transplantations. Black people, ageing people, often have major problems with kidneys because of diabetes and hypertension. Which are diseases that affect black and ageing people more commonly. But if you look at the kidney transplant list, the percentage of people who are black or ageing is really, really low. But the percentage of people who require the transplant is really high. And many people who are black as they get older will know somebody who’s on dialysis. But you can ask these people, and it probably wouldn’t have even occurred to them that they could put their name down on the list for transplantation. Coming away from the cultural thing of giving organs. But at the same time, there’s also something about it’s not something that’s available to you.
SI: That you would partake in. Yeah.
SS: And that, I think, is interesting. It’s a very British thing – an Anglo-British thing – to put your name down on the donor list and to help out with charity, to do runs, things like that ––
SS: –– it’s not necessarily something black people would think that they could do. I remember growing up, and I consider myself lucky that I used to go to Nigeria quite a bit. But I remember growing up and my neighbours at the time, they were West Indian. And I’d come back from Nigeria, the summer I was 11, and my friend from next door said, “how’d you get there?” And I said, “oh, we got on the plane.” And they said, “what airlines was it, British Airways?” And I said, “no, no, it was a Nigerian airlines.” And they said, “oh! Who flew the plane?” And I said, the pilot. And they said “no, no, like a British pilot?” And I said, “what do you mean? No, it was a Nigerian pilot, a black guy.” And she just couldn’t believe it. The idea that a pilot could be a black man, she just couldn’t believe it. She went and told her mum!
SS: So the reason I said I consider myself lucky is because we grew up in the same area. And where we grew up was a relatively poor bit of Manchester, though I didn’t realise it at the time. And I suspect that if it wasn’t for me going to Nigeria and seeing people doing all the jobs that everyone does – being doctors, lawyers, flying planes, being pilots, things like that. Just like my friend next door, I wouldn’t have thought that it was possible. She just thought that black people could be bus drivers. Her mum was a nurse, her dad was a labourer, handyman type of person. She didn’t know it was possible. And that’s actually more to do with the class system and the people she was around. But there’s lots of people like that. And I remember growing up, and I was in an art gallery. Probably the Tate, actually. Swanning around the Tate! And I saw another black guy there. And I saw him, and he saw me. And at some point our paths crossed. And he said something like, “I can’t believe you’re here!” But what he was saying was, this was about twenty odd years ago. But I understood what he was saying. Which was, isn’t it amazing that black people can come to an art gallery.
SI: Ahhh. Yeah, definitely that sense of –––
SS: That sense of limiting yourself. And I’m not saying that happens all the time, and it happens much less. But it does happen to a certain extent. And I think that now, what allows people to be out of that, to feel that they can be citizen just as much as anyone else, is because there is less racism. There’s a lot less than there used to be. Well, everyone’s prejudiced. We have it inside. But it’s not as acceptable anymore the way it was when I grew up. It’s unacceptable. If I walk down the street now, and someone started making monkey noises at me like they did when I was little; then someone else on the street, and not a black person, for sure, someone else on the street, certainly in London anyway, would say, “what the hell! I don’t like that at all, I don’t feel comfortable with it.” Someone else would tell them off, tell them it wasn’t acceptable. Which is not how it was when I was younger. Things are better in that respect. And also, it’s not okay if you’re somewhere like London which is quite multicultural, for your institution to be completely white. That’s odd. One of the things that’s odd about the Institute is that if you walk down the corridor of the Maudsley which is linked to the Institute, you’ll see lots of black people. In the wards, yes. But also amongst the staff. Lots of nurses, doctors – well, not lots of doctors, but at least some of the doctors – some of the senior managers and managers. Lots of representation. Not so at the Institute, to be perfectly honest with you. It’s strikingly different.
SI: So this is the Institute of Psychiatry?
SS: This is the Institute of Psychiatry. It is strikingly different in that it’s a much more white place. It’s funny because people are doing – it’s two sides of the same coin. Everyone’s interested in mental health and trying to improve it. On this side there are lots of people working who are black, and the other side is –
SI: And this side is ––?
SS: The Institute of Psychiatry, which is much whiter. The clinical side, the Maudsley, has much more representation. And I think probably that’s something to do again with people feeling that, I don’t know if I can be an academic.
SI: Yeah. I definitely feel like we’ve hit upon this throughout the course of the conversations that we’ve been having. There is a huge drop-out with black students going into academia, and attainment at university.
SS: There’s also something which I’ve felt. So sometimes I meet people, and tell them what I do, and they say, “wow, you’ve done really well!” And I say, thank you. But I also think, yeah, but I haven’t done quite as well as I think I ought to have done for my level of intellect. The difficulty is that I’m quite a capable individual, obviously. If you end up a doctor or a consultant, you’re relatively capable. And I think that means that people think that I therefore don’t need anything. People say, “oh, she’s doing really well, she knows what she’s doing.” I think if I were a white male, all the way through, there would have been someone saying, “oh you should think about doing this.” I would have got a lot more guidance. And I can understand that people feel it’s easier to guide someone that they feel more familiar with. And I won’t say I didn’t get any guidance, I was lucky and did get some. But there aren’t any transparent support systems. And if you’re doing okay, people felt certainly for me that they didn’t need to support me in any way. Yet I would see my male counterparts being offered this, offered that. Come and meet this person, etc. People didn’t think I needed that. Two things: people didn’t think I needed it, I was doing okay. But that was their version of what me being okay was. Does that make sense?
SS: So in some ways, although I did say before about black people limiting ourselves, there is something about other people’s expectations of you as an individual are actually lower than they might be otherwise. So you are also limited by other people’s expectations. So I might say, “well, I might quite like to be in an academic position, and I want you to support me to do that. What are you going to do to help me?” I am now an appraiser of other people, and I supervise them. And I know what I do for them, and I think, well, I never had any of that. Not that I resent it necessarily, but I only recognise now that I’m in a position of ––
SI: Being able to do that for other people.
SS: Yeah, to supervise, mentor, etc. And it’s often – information you can get from the Internet that you couldn’t before. But there are things that you can do, little things, that you get told at the lunch table that would never be told anywhere else. It’s not that people are hiding information. Just that it doesn’t come out there because they wouldn’t think of saying it in a different forum as it’s informal, but turns out, it could be the biggest, most important opportunity. And also, people pigeonhole you. So people would say, “Lade’s in a good condition.” They wouldn’t think of me to say, “Lade’s got an interest in getting that kind of funding.” And they’ll get someone else to do it, because they know somebody else doing it because they mentor them. Does that make sense?
SI: Yeah. So racism in academia isn’t so much the overt, “we’re not going to let you in” that it was in the past. But kind of more subtle stuff that’s unconscious. The stuff that you might not even realise is happening.
SS: Yeah. Yeah. And it’s funny because it’s hard to call it racism. Because these are people who are kindly and helpful ––
SI: –- and you don’t want to use that word –
SS: Because they’ll say, “well I’m not a racist!” And actually, they’re not a racist.
SI: But it’s the unconscious stuff that we grow up with.
SS: It’s very unconscious. This thing about people finding it a bit difficult. I wonder what it must be to be a white male who’s worked really really hard and done really really well, become Professor and Head of his department and whatever. And if you see some black person, black female in particular, coming along and doing the same thing, maybe even doing it better, how does that feel? Does it undermine you? Or do you feel “great, I’ve been part of that and I can nurture them”? Do you see what I mean? And I wonder sometimes about whether there is a very unconscious thing going on. About hierarchies, and it not feeling “quite right.” You know. Like, “this person’s all right but they’re not that brilliant”!
SI: Yeah! I think also it becomes about your race and your gender.
SS: Yeah. I always think of George W Bush and Barack Obama. Look at George Bush – a guy who had major alcohol problems (yeah, he got over them), not massively clever, really quite lazy, often took holidays, made some really poor decisions ––
SI: To say the least!
SS: –– he wasn’t incredibly debonair, he wasn’t incredibly engaging as a speaker. In order for Barack Obama to be President, he had to be tall, handsome, incredibly clever, brilliant at what he does, fantastic orator. You know, he had to be so much better as a person! To get to the same position. Do you understand what I mean?
SI: Yeah, yeah, completely! The standards that are expected of us to prove ourselves are so much higher. It’s not just people underestimating you, but you have to surpass their expectations by miles and miles. There’s a comedy, is it Chris Rock? He says something about living in one of the most expensive places in New Jersey, but his neighbours are white dentists that can afford the same neighbourhood. And he says, “man, if I were white, I’d be living next to the White House!” I think that’s really telling. That has massive implications for spatial segregation within cities – which areas tend to be black and minority ethnic, and which areas tend to earmarked as unsafe or dangerous.
SS: Absolutely right. So positive things are that things are definitely better. Things are better. Things are improving. There is something else I may not have touched on, though this is definitely changing – as time has gone on, some of the worst racism I’ve encountered has actually been from other black people. And there is that thing of, it’s also almost like Little Britain, you know, “I am the only gay in the village!” I’m the only black person here, what are you doing here?! And people – it makes you special if you’re the only black person there until someone else comes along.
SI: Yeah. I think these are conversations our communities definitely need to have, because I feel that I’ve experienced this as an Indian woman and possibly have been that way to other Indian women, though I hope not. I think that these are conversations we need to be having that we’re not having because when we start talking about how my community has internalised racism or if I am racist to another Indian woman, white people will listen to that and say, “my racism isn’t a problem, because they’re racist to each other!”
SS: Yeah! That is what people say, it’s amazing!
SI: So, it’s hard. Because you want to have this conversation within our communities, but then you also don’t want that narrative to be used by white people to excuse their racism.
SS: Exactly, exactly. I know, I know. And that’s a real shame, actually, because people do do that. And it’s like, you really don’t understand that this is about power and about the way in which people have been culturally institutionalised to have a low self-esteem. And if you’re in that position – it’s literally like a pile of bodies. And you want to climb to the top of the pile of bodies.
SI: Such a morbid way of putting it.
SS: But it is, it is like that. I also remember seeing a patient, an out-patient, and she’s doing really well actually. And she came with her mum one day, her mum’s from an older generation, a black woman. And her mum said, “she’s not happy. It’s just that you know, she feels that she’s not getting everything she should be getting. She wants a different doctor.” And I said, “okay, which doctor?” And she says, “well, maybe she’d like a male.” Well, okay, okay, I’ll refer you to my colleague. Her issue though, was really that she thought that she can’t be getting good service if it’s a black female doctor.
SS: Yeah. It really – that was really like, “okay, fine.”
SI: I think it’s telling, the race of the patient. Because I certainly feel more comfortable when I’m treated by a BME female doctor. I feel that way when I’m around BME female professors. Definitely much more a connection, and the ability to talk about race, and “make it about race and gender.” If I was around a white male, it’s not that they would shut that down but –
SS: Yeah, yeah, they’d get more anxious about it, wouldn’t they?
SI: It’s like you’re introducing something that’s inconvenient. But maybe if I wasn’t aware of my race and gender in the way that I am, maybe I’d want a white male doctor too. Because of the images that we’re constantly fed, about competence and efficiency being a white man. So. I think that my awareness now makes me feel more solidarity with women of colour than before. I’m interested though, in what you think King’s is doing about race and gender? And if you think the levels of representation that you’re seeing are adequate – amongst your students and amongst staff?
SS: What are King’s doing… well, there is a BME Race and Equality group. It’s difficult because recently I’ve been bombarded with lots of emails.
SS: So it feels like, “oh look, they are doing something!” And it’s good that it’s being mentioned. I’ll be completely honest with you – until a few years ago, I’d say that it was a completely colourblind place. In a rather old-fashioned way.
SI: How many years have you been at King’s?
SS: Well, I trained at the Maudsley in 1992. And what used to happen was that you worked at the Maudsley but you were always at the Institute. The two places were like this [clasps hands together] So you had your academic training at the Institute, so it was always linked that way. Then I did my research degree at the Institute and my clinical work as an honorary at the Maudsley. Then I got my consultant post, and then I worked at the Maudsley and had an honorary position at the Institute but I didn’t do much Institute stuff. And then I got a substantive post at the Institute, which is the forensic job I have now, and then did some honorary work at the Maudsley, but then I –– got a substantive post at SLAM and a couple of sessions at the Institute. So, well. It’s been a long time.
SI: So it’s been twelve years ––?
SS: No, no! Twenty two years.
SI: Wow. I thought you said 2002.
SS: I’ve had an affiliation with the Institute – though the Institute wasn’t subsumed under King’s until 2002 or 4, I think. But I actually trained at Guy’s Hospital. Which has also now been subsumed under King’s.
SI: So what do you have to say about the levels of representation of BME women and what King’s is doing?
SS: Recently, much more initiative. There aren’t that many black women academics full stop, and that hasn’t changed significantly, really, in all the years. I’ve seen people come and go very quickly. And I think particularly for students, it was quite hard for them to come along. There’s something about being at the Institute anyway. It’s a place of clever people. And it was a real – it used to be a real ivory tower, the Institute and the Maudsley. Often Oxbridge graduates and everything. You had to really have a sense of your own self-worth to say, “yes, I am clever enough to be here.” People always ask themselves that question. And I have seen a couple of people come, being clever kids, and finding it kind of overwhelming. Coming back to not feeling supported in that environment.
SI: But also, you’ve got a culture that won’t let you value yourself and have that sense of self-worth, so why would you believe that you belong?
SS: Yeah. And then, so these people, unfortunately, didn’t stay. But they tended to be people who were doing an MSc or that kind of thing, and then disappeared. The thing I also was struck by – at least in psychiatry, there are black people, medics who are black or Asian. But in psychology, psychology is just a place of white people. White women, actually, psychology. [laughs] So deep inside, there are very few black people. And that’s been a problem for years in psychology. And I was involved in this thing called the Schizophrenia Commission, we wrote a big report about the state of mental health services for people with psychosis. It made quite a big splash. And I wrote the bit about black people and mental health. The fact that there – although representation was improving in the staff groups, the one staff group where it hadn’t changed at all was psychology. What’s interesting, and what we talked about before, is that black men who have the worst outcomes in terms of mental health, don’t present till far too late down the line. Till they’re running around and the police pick them up, their families end up sending them in via the police instead of taking them to the GP. And they’ve usually been ill for a year or two before you see them at all. And maybe if someone had picked up that things weren’t quite so good and took them to a psychologist or a counsellor, maybe some of this could have been averted. But of course, if you’re a black male, and you walk in and there’s a tiny little skinny [laugh] white girl sitting there ––
SI: Yeah, our cultural images ––
SS: –– that encounter could be one where she’s scared of you because you’re so big, you know. Where to start.
SI: Also because, often, mental illness in men manifests in violence. So if black men are pathologised as being violent, it’s difficult to see that as something that might need to be fixed.
SS: Yeah, that’s interesting. I’m not completely sure that mental illness often presents as violence. It doesn’t, really. When men are not feeling right, they abuse substances. They abuse drugs and alcohol. And they’re disinhibitors, and they’re mediators to violence. So there is an increased risk, definitely, “it’s Friday night, there’ll be fights tonight!”
SS: The drugs and alcohol mediate the risk. And then there’s the separate group, like the guys I look after, who’ve just had horrendous upbringings. It’s funny actually, in my ward, there’s not a lot of black people. They’re from all over. Afghans, Iranian. Any country there’s been a conflict.
SI: I also wanted to ask, because you’ve been at King’s for a long time but were also a student – do you think it’s important to have BME women represented around you as role models? Because that’s kind of what our campaign is about, celebrating the histories of the black women who are and have been at King’s, but also it’s about trying to get our faces up there.
SS: It would have made it a lot easier for me, I think. It depends on who the person is, and whether they were nurturing and happy to nurture other people. Would it have made it easier for me? I hope so. I don’t know! Because there weren’t any. I don’t know. I do know though that knowing that it was possible to be a black person who was a doctor was very important. But I didn’t know that from my experiences in Britain. I knew that from my experiences in Nigeria. Do you understand?
SI: Yeah, I get it. Because you didn’t see it here, so you wouldn’t have known.
SS: No. And also, the images here were that that sort of thing didn’t happen. And also, obviously, I had parents who were keen on my education so I was supported in that. And also, I was clever! I was a clever kid! And what’s quite good – I was lucky, because even though the school I went to was a predominantly white school, it was widely acknowledged that I was a clever kid. As opposed to people saying I couldn’t be clever because I was black. Which I think, did happen to some people that I met.
SI: So the things that you get told as a child have a big impact on what you go on to do.
SS: They do, they do. And I was repeatedly told that I was clever. So I knew I was clever. And that helped. But, interestingly, there were still things like I couldn’t have certain parts in the school play because I was black. But I thought that too though!
SI: And also, how did you get interested in issues around race and gender? Because you obviously had your lived experiences, but around mental health?
SS: I think in terms of mental health, it was only as a medical student, discovering that there were so many black people in mental institutions. Thinking, “this can’t be right! This has just simply got to be racism!” surely. And then going into it more. Especially because I kept thinking, “I’ve met loads of black people who aren’t mentally ill! This has just got to be rubbish.”
SS: Obviously, a very childish way of looking at things. And then I did naively think that when I started to do psychiatry I would find that actually they were fine and, you know, that’s not true. It really isn’t true. I still meet lots of people who think that now. And I think “mmmm, nah, you haven’t met a lot of the patients I see actually.” Frankly, we have so few beds now. If you don’t have to be in hospital, we will chuck you out. We’re not looking for black men to put in hospital. You know? There’s all sorts of things. My patients who are black, they’ve often had relatively difficult upbringings. A traumatic aspect of that. Harsh parenting, sometimes. Frankly, sometimes, abusive parenting. And all too often they started smoking cannabis from too young an age. And if you start smoking cannabis when you are in your early to mid teens, and you smoke it regularly, then you are more likely to develop psychosis by the time you’re in your mid-twenties. And that’s that, full stop. And that’s been proven now, and for some people, there’s a cultural acceptance of smoking cannabis. And not one person on my ward doesn’t abuse cannabis and other drugs. That’s what makes them my patients.
SI: Wow. This is really interesting, I’m learning so much! I guess that’s quite telling as well, of the expectations that you have, “it has to just be racism” ––
SS: –– yeah, not so simple as that. The racism that does exist comes in the expectations that you have, and the expectations that you have of your patients. And once you get to a certain stage of your patient career, people may not expect too much from you. That’s not necessarily a bad thing, because once you’ve got to that stage, you can’t expect them to get right back on their feet. But perhaps we have lower expectations of people than we ought to. And I suspect that there’s a little bit of – the person’s ethnicity is mixed up in there somewhere.
SI: Well, okay, it’s almost 7! So last question – if you had to give one piece of advice to people listening, what do you have to say?
SS: I’d say… don’t simply believe in yourself. People say, “believe in yourself, you’ll be fine!” Don’t do that, because it’s not enough. Believe that you can do much more than either you or other people think you can do. Instead of just aiming to be okay at something, aim to be good at something, and don’t let anyone tell you that you can’t do it.
SI: Thank you, it was really good to speak to you.
If you’d like to attend the conference on Saturday, there are only a very limited amount of tickets left, so pick them up here!