Minority groups and access to psychotherapy

Definition: A group within a community which has different national or cultural traditions from the main population

Populations in western industrialized countries become increasingly multi-ethnic as a result of the internationalization of the market place and the successive opening of borders

Although migration is the norm and health care a natural right of every individual, ethnic minority patients seem to be confronted with barriers when using health services

Language and culture are by no means the only factors that may act as a barrier. There seems to be a general agreement on the primary reasons to seek psychotherapy. Participants reported

that schizophrenia, depression, and suicidal ideation suggested the need for psychological intervention. The identification of these disorders suggests that seeking therapy is associated with serious mental illness

Potential barriers at patient level

Some Jewish and South Asian groups felt it was their responsibility to deal with mental health problems within the family and saw acknowledging a mental health problem as a sign of personal and familial failure.

Some ethnic minority groups will not acknowledge a mental health problem because they experience their symptoms physically and so are more likely to be viewed by services as hypochondriac.

Negative and out-dated stereotypes of what a mental health problem is like mean that some people do not consider their symptoms a mental health problem because they do not correspond to that image.

Gossip, social rejection and negative community reactions to people with mental health problems meant that many people from ethnic minority groups do not feel comfortable considering themselves to have a mental health problem. Lack of understanding and fears about who you can trust were common. Ultimately this points to severe ignorance in the general public about mental health.

A range of groups wanted community education about mental health, and for this to start with children in schools. Two important projects are due to commence in Redbridge schools but neither will work with young people themselves.

Many people identified spirituality or religion as critical to their recovery but the NELFT provision of chaplaincy is extremely limited. Faith leaders were identified as key partners who needed to be worked with for better community signposting and referral to services. There are also common religious interpretations of mental health problems which can sometimes be very negative and can be remedied by greater community awareness about services and support available

(Keynejad, 2014)

‘Asking for help means that you have failed’: There is a strong sense from South Asian and Jewish people that family mental health problems are kept secret. They cause embarrassment and families will worry what other people will think and say. People from South Asian, Jewish and Catholic communities all talked about how admitting to having a mental health problem and asking for help means admitting a failure to deal with a problem yourself or within the family unit

One South Asian woman using mental health services commented that being with people who were afraid of mental health problems made her feel like they must be right. It is clear that the current community levels of fear and stigma surrounding mental ill-health will impact negatively on the self-esteem and recovery of people coping with mental health problems

Mental health problems are experienced as physical health problems Research suggests that some people may experience what those in the West call a ‘mental health problem’ through physical symptoms, ‘somatising’ their emotional experiences (Rack, 1982).

One example is the ‘sinking heart’ discussed among Punjabi people (Krause, 1989) which we in the West approximate to depression. Some ethnic minorities may not acknowledge that mental health problems of any kind affect their community because they perceive mental health in physical terms.

This has been observed in Redbridge by the Accident and Emergency Psychiatric Liaison service: We have noticed that the Asian community can try to physicalize it. Some can seem to be hypochondriacs, coming to A&E for many minor physical complaints. They can present with a physical presentation, then the physical doctor may refer to us… An Algerian man collapsed with chest pain and he was being bullied at work and was clinically depressed; he was physicalizing.

Negative stereotypes Very negative and quite out-dated stereotypes of people with mental health problems were commonly discussed by South Asian people I spoke to: Someone who can’t cope with things themselves.

They don’t have the right faculties, not able to think properly, not able to do day to day functioning properly. Need to be looked after, can’t be left alone. I don’t think of milder problems when I think of mental health. It was mentioned that learning disability and mental health were confused or considered to be the same thing by some people, which echoes the findings of studies conducted in the United States in the 1980’s (Caruso & Hodapp, 1988). This again implicates low levels of community mental health knowledge.

Gossip People from ethnic minorities who had mental health problems frequently reported very negative reactions from people in their community. Those who had not told anyone outside their family were often very afraid of being gossiped about.

The close knit nature of South Asian communities in particular creates genuine fear that if one person finds out about their mental health problem it will soon be known by everyone. Again, the theme that mental health problems are a personal failing rather than something out of one’s control was recurring.

This notion that people who have families and homes could not have a mental health problem illustrates a grave need for community education to improve understanding about the pervasive nature of mental health problems and the range of severity. In addition, People may worry about its effect on the family’s marriage prospects. Even dementia may not be mentioned to neighbours because they will think it runs in the family and that will affect marriage.

It is important to acknowledge that these negative experiences of stigma are in no way exclusive to ethnic minority groups. Several White British people using a mental health day centre mentioned how difficult it is to talk to their communities about mental health and that they will always choose to speak to fellow service users instead.

(Thompson et al, 2004, Scheppers et al, 2006)

Lack of understanding There was universal agreement among those that I spoke to that there is insufficient education about mental health for the community. Many people suggested that mental health needs to form part of Personal, Social and Health Education programmes in schools. A group of young men also suggested that there should be education provided at university level since this is a time when a young person’s life really begins to change, and that students would then pass on the knowledge to their younger siblings. In fact, universities tend to provide extensive pastoral care and mental health support to those who need it, which far exceeds provision in schools.

Perception of psychologists among African subjects: Variations in views were encountered as discussions of psychology and psychologists ensued. Psychologists were described as older White males, who were unsympathetic, uncaring, and unavailable.

A common characterization was that psychologists were “impersonal.” Psychologists were described as elitist and too far removed from the community to be of assistance to most African Americans. Those participants with prior therapy experience gave the most realistic descriptions of psychologists; however, this did not always result in a positive image

Mistrust: The issue of trust generated the greatest debate among participants. Participants with no psychotherapy experience and little knowledge of the profession reported that although psychotherapy might be beneficial, most therapists lacked an adequate knowledge of African American life and struggles to accept or understand them. Participants discussed the stereotypes of African Americans in the larger society and challenged the ability of psychologists to remain unbiased.

(Thompson et al, 2004)

Local language skills: Lack of local language skills can act as a barrier. It is one of the major factors that prohibit the use of health services because it jeopardizes effective communication between ethnic minority patients and health care personnel.

In view of the fact that most messages and instructions are communicated in the local tongue, people may feel embarrassed to seek out services. Conversely they may feel hindered because of their own ineptness at expressing their feelings due to language difficulties and reading ineptitudes.

The inability to communicate in what is not their mother tongue inevitably leads to discrimination; due to the lack of a common language they struggle to express their inner feelings, to ask questions or to represent themselves or their families.

Values concerning health and illness. Differences in health beliefs between the patient and the provider i.e. the explanatory model of health, illness and healing methods, can act as a barrier to the detriment of the ethnic minority patients. Ethnic minority patients may have one of the following sets of belief patterns.

(i) The belief that western concepts should be holistically defined; a holistic view integrates the body, mind and soul. (ii) The belief that personal problems and illness are caused by external factors such as family relationships and less by

internal influences such as damaging childhood experiences. (iii) The belief that external causes can be natural or supernatural by nature. Natural in this context means a so-called ‘Act Of

God’ (e.g. the ‘tsunami’). By supernatural is meant karma (consequences of good or wrong doings in another life), magic, sorcery and voodoo.

(iv) The belief that the concept of (mental) health should include religious/spiritual dimensions as well as bodily dimensions and that mental illness and psychiatric hospital admission is to be avoided (taboo).

(Thompson et al, 2004)