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. 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