Equality and Diversity Impact Assessment
Introduction
The Information Systems, Referral Criteria and Patient Pathways Group has been set up
by the Mental Health Division to carry out scoping work around setting a Psychological
Therapies access target. As part of this work, the group aims to assess the impact that
setting an access target for psychological therapies could have on equality target groups.
Risk and resilience factors for mental health problems are differentially distributed and
influenced by aspects of social identity including gender, ethnicity, sexual orientation and
age, and the experience of disability (Myers, McCollam & Woodhouse, 2005). This report
explores the cultural factors and inequalities that come to bear and create potential
barriers for people accessing psychological therapies.
First this paper considers barriers that could arise from the philosophical underpinning to
psychological therapy, case identification, the development of the therapeutic relationship,
and the therapies themselves. It will them explore the potential barriers to accessing
services for minority groups.
Philosophical underpinning to health and therapy
Many Western health models of care and therapies are underpinned by Western
philosophies such as; phenomenology, existentialism, and hermeneutics. There are
differences in the fundamental philosophical principles between Western and collectivist
societies. In western societies, people become who they are because of what they do,
whereas within collectivist societies, people consider this to be closely linked to what they
are born with. Most Western health models of care and psychotherapies stem from the
context of ‘mind-body’ separation, which is an idea that is alien in many other cultures.
Constructs of illness
Different cultures can ‘construct’ illness and well being in different ways. It is likely that
different cultural groups will perceive their problems to be physical or spiritual, and less
likely that they will perceive them to be as a result of a mental health problem. Many
people do not recognise their symptoms as pertaining to particular disorder, such as
depression, but focus on the somatic complaints that are part of the illness e.g.
gastrointestinal problems, fatigability, headaches, pain and sleep problems (Unstan &
Sartorius, 1995). This can lead to somatisation and somatoform being common responses
to distress. This can be particularly likely for people who have lived in countries where
serious and life-threatening diseases can present with vague symptoms. This ‘physical’
construct of illness can also lead to expectations that medication is the main solution and
will be prescribed. Therefore people may be unfamiliar with the psychological concepts
that underpin psychological therapies. Languages of collectivist cultures may not have
separate words for particular aspects of psychological therapy; such as a person’s
thoughts and emotions. Emotions may be expressed more in terms of relationships to
family, group or the community.
NHS Education Scotland, Psychological Intervention team, Draft 3, Updated 21st September 2010
Evidence based health care
Western health care adopts rigorous scientific approaches in determining the
psychological therapies that should be available to people. However, evidence for
psychological therapies has been predominantly gathered in Western societies (dominantculture therapists on dominant-culture patients) and may not be as relevant to different
cultures (Benson & Thistlethwaite, 2008). This has implications for therapists working
across cultural boundaries. Therapists are urged to be cautious in extrapolating the
outcomes of studies to situations involving the receipt of treatment of people from different
cultures, or the delivery of treatment from international health professionals.
It is also worthy of note that some collectivist societies value connection, spirituality, music,
intuition, body language, art, facial expression, emotions, dreams and images, most of
which are areas within psychotherapy that do not have a significant evidence base.
Barriers to the development of the therapeutic relationship
It has been proposed that the benefits of psychotherapy may be more about the common
factors involved in therapy, such as the therapeutic alliance, active listening by the
therapist, the trust between patient and practitioner and the adherence of the patient to an
agreed management plan (Wampold, 2001). Therefore communication is critical to
success within psychological therapies. Trust is critical to the development of a therapeutic
relationship. Language and cultural barriers may hinder the development of trust and the
therapeutic relationship. The communication of empathy from therapist to patient will often
rely on modulation of the voice, eye contact, or other subtle means that may be lost across
cultures.
Typically within psychological therapies, the therapist is expected to work collaboratively
with the person seeking help, and explore and tackle their problems. The belief in this
process, by both the therapist and client, is considered to have impact on therapeutic
outcomes. People enter a therapeutic relationship with the ‘hope and expectation that their
problems will improve. In addition to this, many cultures have explicit or implicit taboos
about relationships and their confidentiality – people are less likely to talk about trauma if
there is a cultural gap causing them to fear being misunderstood or judged because of
their experiences e.g. Chinese and Cantonese population.
The therapy itself as a barrier
There are several specific issues that have been raised about the delivery of psychological
therapies. Cognitive Behavioural Therapy (CBT) is recommended by many clinical
guidelines and good practice statements. It is based on assessing the inter-relationship
between the environment and the person; focusing on thoughts, feelings, physical
symptoms and behaviour. However, ‘cognition’ is a culturally based phenomenon and
some people may be uncomfortable separating their thoughts and feelings. They may also
find the concept of challenging unhelpful thoughts a difficult one to grasp. Some people
may not accept that the mind has the ‘power’ to make a difference to the circumstances a
person is in. Equally, what is deemed to be ‘normal’ or appropriate behaviour is also a
culturally mediated phenomenon. Differences can be observed within groups in similar
societies. Further to this, a lack of confidence in cultural knowledge and understanding
NHS Education Scotland, Psychological Intervention team, Draft 3, Updated 21st September 2010
may result in some therapists lacking conviction in their ability to help people find solutions
to problems that are outside their personal experience.
Within psychodynamic psychotherapy it has been suggested that processes that are
integral to the therapy experience may be affected by cultural differences. People being
treated by a health professional of a dominant culture may develop a transference based
on the cultural divide generated by conflict between two cultures (Benson & Thistlethwaite,
2008).
In contrast to this, people who are gradually moving away from their original cultural
expectations may prefer to access a therapist from a different culture as it may help them
feel relaxed about their transition.
Case identification as a barrier
Rusch, Angermeyer & Corrigan (2005) report that people progress through several stages
before seeking treatment; experiencing symptoms, evaluating the severity and
consequences of symptoms, assessing whether treatment is required, assessing the
feasibility of and options for treatment, deciding whether to seek treatment and accessing
care. Barriers can appear at any of these stages, especially if the patient’s own
understanding of psychological symptomatology is limited or is perceived to be culturally
unacceptable.
Commander et al (1997) suggest that ‘Asian’ (which includes Indian, Bangladeshi and
Pakistani) people, are more likely to present to their GP with physical manifestations of
their mental health problems, and do so more frequently than White people. However
research (Wilson & McCarthy, 1994; Williams & Hunt, 1997) has also shown that despite
this increased GP contact and even when a psychological problem is present GPs are less
likely to detect depression and more likely to diagnose ‘Asians’ with a physical disorder.
Case identification tools have been developed and validated on White populations (Husain
et al, 2007). Cultural specific instruments are being developed (Singh et al, 1974; Abas,
1996) but have not been found to have high specificity (National Collaborating Centre for
Mental Health, 2009) when compared with other measures. Within this review, the
measures that were included had to be based on a Gold standard diagnosis defined as
DSM-IV or ICP-10 diagnosis of depression.
Gender
Men and women are exposed to different risks to mental health and well-being that are
linked to socio-economic status, social (and reproductive roles), discrimination, violence
and abuse. The incidence and prevalence of depression and anxiety is higher among
women than men (Melzer et al, 2001). This same pattern is consistent across ethnic
groups (Nazroo, 1997; Melzer et al, 2001; Melzer et al, 2004), yet the opposite is true of
people with psychosis. Men have higher levels of suicide than women (DH, 2001; WHO,
2003; Samaritans, 2003), have higher levels of substance misuse (Singleton et al, 2001;
Scottish Executive, 2003) and are more likely to engage in violent behaviour (Myers,
McCollam & Woodhouse, 2005). There are also differences in help-seeking behaviours
between men and women, men for example who experience trauma are less likely to seek
help than women due to ‘macho culture’(Good, Dell & Mintz, 1989; Moynihan, 1998;
NHS Education Scotland, Psychological Intervention team, Draft 3, Updated 21st September 2010
Busfield, 1996; Rogers and Pilgrim, 2003; Real, 1997; Royal College of Psychiatrists,
1998; Saladin et al., 2009). It is possible that service structures could be perversely
gender-sensitive e.g. women accessing anxiety management while men have difficulty
accessing anger management. It is essential that access to psychological services is
gender-sensitive.
Age
Depression is a commonly occurring problem in persons who are elderly and has been
found to significantly decrease quality of life in older adults (Blazer, 2003), yet there are
limited referrals for psychological therapies for this group. Even when mental health
problems are identified, diagnosis does not necessarily result in referral for psychological
therapies. GPs often don’t refer, they don’t know what’s available and how effective it can
be (Robson and Higgon, 2010). They view depression as an inevitable part of ageing and
thus less deserving of treatment, or assume older adults are not interested in
psychological therapies because of the stigma associated with mental illness (Laidlaw,
2003).
Predicted rates for depression are 13.5% (Blazer, 2003) and anxiety has been claimed to
be more prevalent in older adults (Brenes et al, 2003). Despite this, in Glasgow an audit of
mental health referral to primary care mental health revealed that only 3.2% of the referrals
were for older adults, although older adults form 16% of the population (Broomfield &
Birch, 2009). The first wave of Increasing Access to Psychological Therapy (IAPT) sites
have shown that attrition rates decrease when home visits are used for assessment: and
report 91% attendance (Boot & Hulmes, 2010). It is also possible that features of adult
services can discriminate against older adults e.g. referral ‘opt-in’ arrangements. There are
also practical barriers, a women over 60 is four times more likely than a man to fear going
out at night (Palmer et al, 2003)
Socioeconomic deprivation
Studies indicate an association between experience of common mental health problems
(CMHP) and a range of socio-economic status (Gordon et al, 2000; Ellaway, 2003; Melzer
et al, 2004). Structural inequality can lead to people feeling distressed and hopeless, and
to ‘unfairness being construed as in some way of their own making’ (Myers, McCollam &
Woodhouse, 2005, p21) which in turn present barriers in making attempts to access
services. There is also a suggestion that pressure from families and peers with negative
attitudes towards psychological therapies encourage support from those who know them,
rather than talking to a stranger.
Grant, McMeekin, Jamieson et al. (in press) specifically explored attrition rates in people
accessing either individual Cognitive Behavioural Therapy (CBT) or Person Centred
Counseling (PCT) and the impact of deprivation. Using the Scottish Index of Multiple
Deprivation (SIMD), where 1 represents the most affluent and 10 the most deprived
households (Scottish Government, 2009), they found that 40 % of referrals received for
individual therapy were from the most deprived communities. Of this group, 60% opted in
to either CBT or PCT, and then 23% failed to attend their first appointment. This is in
contrast with less than 5% of referral being received from the most affluent communities,
of which 70% opt-in, and then 63% fail to attend their first appointment. They concluded
that individuals from deprived areas (those with a higher SIMD score) were more likely to
NHS Education Scotland, Psychological Intervention team, Draft 3, Updated 21st September 2010
fail to opt-in to the services but there was no evidence that they were more likely to fail to
attend their first appointment or drop-out during therapy than those from affluent areas.
Following on from this, White, Ross, Richards et al. (submitted) present a service
evaluation of ‘call back’, designed to increase access to low-intensity services and found
that of the calls received requesting a ‘call back from a qualified therapist, 35% were from
the most deprived communities and less than 5% were from the most affluent
communities.
Ethnicity
There is evidence that the prevalence of mental health within ethnic minority populations is
higher than within the general public. Ethnic minority groups can also experience risk
factors similar to the general population, plus they experience victimisation and racial
discrimination. They can also be subject to potential racism experienced through contact
with mental health services. Some groups report feeling misunderstood by the mental
health system because they are feared, stereotyped or ignored. Asylum seekers and
refugees may experience post-traumatic stress as a result of the trauma in leaving their
homeland, or experience poor mental health as a result of racial harassment.
Common barriers to mental health services include; language, stereotyping, lack of
awareness of different understandings of mental illness, cultural insensitivity including
toward religious or cultural beliefs, colour-blind approach, direct or indirect racism.
Consideration should be given to mental health / illness means in different communities,
and what the specific experience of stigma and discrimination is to each individual.
Reporting on the Newham IAPT demonstration site, Clarke et al. (2009) found the
population consisted of 49% from Black and Minority Ethnic (BME) communities, with 13%
not speaking English. One in five of the people seen in Newham referred themselves to
the service. When compared to GP referrals, self-referral patients were at least as ill,
tended to have had their problems for longer, and more closely matched the ethnic mix of
the local population. Therefore it would appear that the access arrangements to services
(referral by GP, or opt-in systems) could be off-putting for both socio-economically
deprived and BME populations
Sexual orientation
International research and Scotland - specific studies (Coia et al, 2002; John & Patrick,
1999; Hutchison et al, 2003).) all indicate higher levels of depression and anxiety, selfharming and suicidal thoughts, eating disorder, substance misuse among lesbian, gay,
bisexual and transgender people (LGBT). Many of the risk factors are related to the
experience of: economic and social discrimination; abuse, bullying, harassment and
violence; and social isolation (Myers, McCollam & Woodhouse, 2005). Factors that affect
access to mental health services include;


reluctance by LGBT people to disclose their sexual orientation to health care
professionals because of a fear of discrimination or negative response
the lived experience of discrimination and negative reaction following disclosure,
including breaches of confidentiality.
NHS Education Scotland, Psychological Intervention team, Draft 3, Updated 21st September 2010
Lumsdaine (2002) recommends that attention is shifted from seeing LGBT people as ‘at
risk groups’ to recognising the risk conditions which generate health inequalities. Services
need to be ‘culturally competent’ mental health service.
Disability
People with physical disabilities experience multiple sources of discrimination and
disadvantage (Molloy, Knight & Woodfield, 2003; Pierce, 2003; Breslin, 2003). Morris
(2004) reports that people with physical impairments and mental health support needs
often have difficulty accessing mental health services because of their:



physical impairment
difficulty using physical health services because of the inadequate recognition of
their mental health needs
negative attitudes amongst staff towards mental health services.
People with specific perceptual or sensory disability (deaf / blind) may also have difficulty
articulating responses to meet the needs of the therapist (Titus et al., 2008; Titus, 2010;
Kendall & Rosenheck, 2008; Hayman et al., 2007; Wallhagen et al., 2001). The same
issues are apparent for those with intellectual and developmental disabilities (Burgard et
al, 2000; Cooper et al, 2007; Hatton, 2002). Cognitive impairment linked to alcohol abuse
or severe and enduring psychosis can contribute to lack of attendance at organised
psychological interventions. Deficits in memory and conceptual disorganisation may also
affect attendance (Aharonovich et al., 2003; Grohman et al., 2006; Rogers & Robbins,
2001; Vocci, 2008).
People who are visually impaired and experience e.g. Alcohol and Other Drug Abuse
(AODA) disabilities do not fit into a single, specialised service delivery system. AODA
counsellors are usually unfamiliar with visual impairments and lack the knowledge and
skills to provide services to people who are blind or visually impaired (Koch, 2002). This
same issue has been highlighted in care of the elderly suffering from both sensory loss
and depression (Chou, 2008; Capella-McDonnall, 2005). Lack of cross-training and formal
education about each disability and the effects of co-existing disabilities result in
consumers failing to benefit from interaction with either system. Service providers must
therefore consider means through which they can address the needs of complex cases.
Mental health problems
People with mental health problems experience disadvantage through poverty and
unemployment, housing and homelessness, further education, physical health, suicide,
stigma and prejudice (Melzer et al, 2002; Rogers & Pilgrim, 2003). Risk factors include
socio-ecomomic disadvantage, discrimination and stigma (with housing and provision of
goods) and physical ill-health. Rogers and Pilgrim (2003) have reported on the inequalities
created by service provision which they state has three dimensions:



equity of access to services
negative or stigmatising experience of mental health service provision
longer term impact for individuals.
NHS Education Scotland, Psychological Intervention team, Draft 3, Updated 21st September 2010
Anecdotal evidence from Community Psychiatric Nurses explaining poor uptake in
psychological therapies amongst people with severe and enduring mental health problems
that would fall within the description of lower socio-economic groups – especially amongst
the rural population- describe the cost of travelling to centres for treatment as the main
contributory factor for non attendance. Myers, McCollam & Woodhouse (2005) argue for a
social justice culture to be part of the ‘warp and weft’ of the service system. This could
involve asking key questions about employment and fulfilling a key role in maximising the
opportunity gap for people with mental health problems.
Past and current literature fails to focus on the difficulties linked to clinicians working within
the mental health services addressing their own mental health needs and accessing
services, yet this is a growing problem evident in many services.
Literacy
A report by the National Audit Office (2004) indicated that twenty-six million people of
working age have levels of literacy and numeracy below those expected of school leavers.
They are spread across all ages, with no significant variation between men and women or
different English speaking ethnic groups. Many who did not learn those skills at school are
reluctant to start or persevere with learning as adults. People with the lowest levels of skills
– those expected of a 9-11 year old or below- can experience practical difficulties in their
everyday lives. They may be able to read and understand signs, notice or labels. Many
work in low skilled employment, are unemployed, or on benefits. Some are offenders in
prison or being supervised in the community. As a consequence of literacy problems,
accessing services, engagement in therapeutic activity that requires the use of written
homework, reflective accounts or staying well plans may be problematic and lead to
exclusion. Limited literacy is recognised as a barrier to effective services (Currier 2001)
and to appropriate service utilisation (Baker 1998).
Recommendations
Key legislation is in place to provide a framework to tackle discrimination, including
Equal Pay Act 1970, Sex Discrimination Act 1975, Sex Discrimination Act (gender
reassignment regulations 1999, Race Relations Act 1976 (Amendment 2000 &
Amendment Regulations 2003), Disability Discrimination Act 1995, Employment Equality
(Sexual Orientation) Regulations 2003, Employment Equality (Religion or Belief)
Regulations 2003.1

At the population level
Programmes that increase awareness of equality and diversity issues and drive the
creation of a culturally sensitive health service will help improve the access of many
groups to psychological therapy services.
1
For more information on the legislation framework please see Equal Minds available at
http://www.scotland.gov.uk/Publications/2005/11/04145113/51135
NHS Education Scotland, Psychological Intervention team, Draft 3, Updated 21st September 2010

At the service level
Develop cultural competence in staff, increasing their confidence in working with diverse
populations and monitor the development of culturally sensitive outcome measures.

At the individual level
Clinicians delivering psychological therapies have expertise in adapting and modifying
their approach and techniques to engage people in the therapeutic process. When working
across cultures there is a greater need to be aware of their own innate ethnocentrism.
Therapies are more likely to be effective and cross the cultural divide if they are based on
a curiosity and respect for the different beliefs of that culture (Benson & Thistlethwaite,
2008). Supervision structures are critical to ensure health professionals develop good
insight into their own ethnocentrisms, receive good support, are flexible and honest with
the person seeking help, and develop confidence in adapting their particular therapeutic
modalities to meet people’s needs.
Anne Joice, Programme Director – Psychological Intervention Team
Helen Walker, Education Project Manager - Psychological Intervention Team
September 2010
NHS Education Scotland, Psychological Intervention team, Draft 3, Updated 21st September 2010
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NHS Education Scotland, Psychological Intervention team, Draft 3, Updated 21st September 2010