# data[].attributes.attachment_link.title
Cultural diversity core concepts PM PowerPoint slides

# data[].attributes.headline
‘Not a cure, but helpful’ – exploring the suitability of evidence-based psychological interventions to the needs of Black, Asian and Minority Ethnic (BAME) communities

# data[].attributes.subject
‘Not a cure, but helpful’ – exploring the suitability of evidence-based psychological interventions to the needs of Black, Asian and Minority Ethnic (BAME) communities

# data[].attributes.attachment_link.readable_text
Introduction

The Office for National Statistics ( 2021) reported that there are over 67.1 million people living in England and Wales, of which approximately 15.2% identify as Black, Asian and Minority Ethnic (BAME) backgrounds. Despite the growth in ethnic minority populations, evidence suggests that there are disproportionate inequalities in mental health care and treatment (e.g. Fernando, Reference Fernando2012; Good and Hannah, Reference Good and Hannah2015; Harwood et al., Reference Harwood, Rhead, Chui, Bakolis, Connor, Gazard and Hatch2021). The Improving Access to Psychological Therapies (IAPT) programme was launched in 2007 to tackle the impact common mental health disorders were having on individuals, the economy and society by increasing access to psychological therapies (Clark, Reference Clark2011; Clark, Reference Clark2018). A stepped-care approach was implemented which included low-intensity and high-intensity evidence-based psychological interventions such as guided self-help and cognitive behavioural therapy (CBT).

Psychotherapy is a product of the West, and tends to adopt the values, beliefs and principles of the dominant individualistic culture (Frese et al., Reference Frese, Stanley, Kress and Vogel-Scibilia2001; Laungani, Reference Laungani2007). Clinical trials examining the efficacy of evidence-based psychological interventions tend to include a homogenous set of participants (e.g. White, middle-class); therefore, when interventions are applied to 'real-world' clinical settings, seldom do they produce consistent findings (Gordis, Reference Gordis2014; Pawson and Tilley, Reference Pawson and Tilley1997). These disparities become more salient in ethnic minority clinical populations served by IAPT services who show poorer recovery outcomes when compared with their White British counterparts (e.g. Baker, Reference Baker2018; Harwood et al., Reference Harwood, Rhead, Chui, Bakolis, Connor, Gazard and Hatch2021; Moller et al., Reference Moller, Ryans, Rollings and Barkham2019). Recovery is defined as the subjective experience of having gained control over one's life, in which hope, achievement and social connectedness are some of the direct benefits (Ryan and Pritchard, Reference Ryan and Pritchard2004). IAPT services grounds itself in producing numerical outcome data to quantify and evidence service success. Whilst empirically supported outcomes are useful for monitoring and planning, they often ignore the recovery narrative which is important to understand what works well, for who, and when (Christodoulou et al., Reference Christodoulou, Fortune, Arslan and Canan2018; Williams, Reference Williams2015).

Theoretical approaches such as individualism-collectivism (Hofstede, Reference Hofstede1980; Hofstede, Reference Hofstede2011; Triandis, Reference Triandis1995) and the self-construal theory (Markus and Kitayama, Reference Markus and Kitayama1991) allude to cultural differences between those living in the West and those who originate from collectivist societies. Namely, the desire for individuals from collectivist societies to preserve cultural norms, values and traditions in order to maintain harmony and group cohesiveness (e.g. with family members, clans, tribes) over self-serving needs (Hofstede, Reference Hofstede2011; Markus and Kitayama, Reference Markus and Kitayama1991; Tse and Ng, Reference Tse and Ng2014). These characteristics often clash with Western notions of therapy that insist on self-sufficiency, independence and autonomy (Al-Krenawi and Graham, Reference Al-Krenawi and Graham2000; Christopher, Reference Christopher2001; Fernando, Reference Fernando2012). These cultural conflicts can intensify for those brought up in the West as they tend to hold bi-cultural identities, thus increasing dissonance between cultural expectations and Western therapeutic practices (e.g. Allen and Bagozzi, Reference Allen and Bagozzi2001; Gushue and Constantine, Reference Gushue and Constantine2003).

A qualitative meta-analysis exploring 'hard-to-reach' communities in the UK reported that factors such as expressions of mental illness, differing world-views, barriers to accessing mental health services, and psychological interventions not accounting for patient cultural needs disrupts therapeutic uptake and engagement (Lamb et al., Reference Lamb, Bower, Rogers, Dowrick and Gask2012). Ethnic minority caregivers echoed these concerns (Miller et al., Reference Miller, Bosun-Arjie and Ekpenyong2021) which together can increase scepticism about the credibility of psychotherapy and mental healthcare (Prajapati and Liebling, Reference Prajapati and Liebling2021; Sue, Reference Sue2006). Beck and Naz ( Reference Beck and Naz2019) highlight a number of fundamental issues that hinder therapeutic success in BAME communities who access IAPT services. This includes services not being able to facilitate or recognise distress across cultures, patient therapeutic fears, and poor treatment outcomes due to inadequate cultural adaptations. Whilst IAPT services aim to consider patient cultural needs, they seldom incorporate cultural specific factors such as patient idioms of distress, values or practices (Beck, Reference Beck2016; Naz et al., Reference Naz, Gregory and Bahu2019).

Research exploring the recovery narrative of BAME service users has been scarce. In one study, Christodoulou and colleagues ( Reference Christodoulou, Fortune, Arslan and Canan2018) explored the experiences of Turkish-speaking service users offered guided self-help at an IAPT service in London. Results showed that the therapeutic expectations caused service users confusion and anxiety. In addition, service users had differing cultural experiences of distress, ambivalent help-seeking attitudes, limited self-efficacy, and problems with continuity. Often therapy sessions were too short to make real progress, which in turn, impeded the recovery process. In another study, Omylinska-Thurston and colleagues ( Reference Omylinska-Thurston, McMeekin, Walton and Proctor2019) found that CBT did not meet the needs of service users. Participants reported difficulties in grasping CBT concepts, had negative perceptions of therapists, and found IAPT processes unhelpful. However, the population sample was majority White British, thus authors recommended further exploration in ethnic minority populations.

Given the inadequate recruitment of BAME groups in clinical trials and poorer treatment outcomes, this study aims to explore whether evidence-based psychological interventions offered by IAPT services are suitable to the needs of BAME communities. Exploring such needs are crucial for clinical practice, especially since ethnic minority communities can feel misunderstood or even mistreated by mental health service providers (Bristow et al., Reference Bristow, Edwards, Funnel, Fisher, Gask, Dowrick and Chew Graham2011; Mclean et al., Reference Mclean, Campbell and Cornish2003; Naz et al., Reference Naz, Gregory and Bahu2019) leading to increased therapeutic disengagement (Baker, Reference Baker2018; Harwood et al., Reference Harwood, Rhead, Chui, Bakolis, Connor, Gazard and Hatch2021).

Method

Participants

Participants were recruited using purposive sampling via social media and word-of-mouth (Bricki and Green, Reference Bricki and Green2002). Participants were not seeking or receiving treatment at the time of the study. The experiences are reflective of the course of treatment(s) participants received from an IAPT service. Participant demographics have been highlighted in Table 1. The mean age was 37.33 years ( SD= 5.74). The majority of participants were female. Most service users identified as Pakistani, followed by Arab, Bangladeshi, Chinese, and other ethnic groups. The most common religious orientation was Muslim. The majority of participants were referred to IAPT service by their general practitioner (GP). The most common therapy received was CBT, followed by counselling and group CBT. Out of nine participants, three reported that they had recovered from therapy.

Design and procedure

Qualitative research methods were chosen as this allows for in-depth exploration of service user experiences and recovery narratives (Williams, Reference Williams2015). Participants interested in the study were emailed the information sheet and consent form detailing the purpose of the study. Once agreed to participate, the author arranged for the interview to take place online (e.g., Zoom) or via telephone due to the study taking place during the global COVID-19 pandemic. The author developed the topic guide by careful consideration of existing literature, discussion with practitioners, and by brainstorming ideas that would enrich understanding of service user experiences and needs. The interview schedule consisted of 12 open-ended questions, including prompts where needed, to allow participants to discuss their lived experiences (Braun and Clarke, Reference Braun and Clarke2013). Topics relating to referral pathways, therapeutic engagement, therapists cultural competency and therapeutic effectiveness were considered core areas of interest (Beck and Naz, Reference Beck and Naz2019; Good and Hannah, Reference Good and Hannah2015). Questions included ' How well do you feel the therapy was tailored to your needs?' and ' How well was your therapist able to understand your cultural background, values, and beliefs?'. The author was conscious of personal biases as someone from a BAME background, so took precautions to ask neutral questions that were not led by personal subjective experiences or knowledge (Pope & Mays, Reference Pope and Mays2006). The author carried out all the interviews as part of her doctoral research. The interview process was interactive whereby the author weaved in and out of the topic guide to allow participants the opportunity to talk about what was important and meaningful to them. Interviews were audio-recorded and lasted between 30 minutes and 1 hour. All participants were debriefed verbally and sent a debrief sheet after the interview took place. Audio files were transcribed verbatim and anonymised. Participation was entirely voluntary and no payment or incentive was offered.

Analysis

Reflexive thematic analysis (RTA) was chosen as it is a flexible approach that does not confine to particular theoretical frameworks, philosophical positions, or ideologies (Braun and Clarke, Reference Braun and Clarke2013; Braun and Clarke, Reference Braun and Clarke2021a). RTA was considered the most useful analytical approach to explore service user perspectives by generating meaningful insights into their lived experiences (Braun and Clarke, Reference Braun and Clarke2006; Clarke and Braun, Reference Clarke and Braun2013). RTA involves reflexive engagement with the data, guided by a six-phase process to produce a robust pattern-based analysis (Braun and Clarke, Reference Braun and Clarke2006; Braun and Clarke, Reference Braun and Clarke2019). During the data familiarisation stage, the author immersed herself in the data by conducting the interviews, making notes, and thorough engagement with the transcripts. Notes about initial analytical observations and insights included participant feelings, discourse, and understanding of their world. The author also considered her positionality as someone from a BAME background and reflected on her assumptions, biases and subjective knowledge by keeping a reflexive diary. Next, the author coded the transcripts by using the 'comments' function in Microsoft Excel to create side margins to highlight the relevant extracts and codes (Byrne, Reference Byrne2021). To generate initial themes, topic areas were clustered according to their shared meaning. This included a number of themes and subthemes that were generated in the data and aligned to the research question (see Supplementary material for codebook extract). The author recursively developed and reviewed themes to ensure that they addressed the research question (Braun and Clarke, Reference Braun and Clarke2013). To refine, define and name themes, the author went back and forth between the data to ensure that the data tells a 'story' that does not drift off topic (Braun and Clarke, Reference Braun and Clarke2019). To note, the author recognises the added benefits of multiple coders and research triangulation (Nowell et al., Reference Nowell, Norris, White and Moules2017); however, inter-rater reliability is considered ' illogical, incoherent and ultimately meaningless' in RTA as it impossible to avoid researcher bias and subjectivity of how the data is conceptualised and understood (Braun and Clarke, Reference Braun and Clarke2021a). Thus, the credibility of single coder analysis is not entirely diminished. Nonetheless, to minimise such concerns, the author shared findings with the doctoral research supervisory team and a clinical expert to review the credibility of the analysis. Following feedback, themes were further refined and defined. The thematic map is shown in Fig. 1. Finally, the report was written up to offer a narrative account of whether evidence-based psychological interventions meet the needs of BAME service users accessing IAPT services.

Results

Three over-arching themes were generated: (1) recognising cultural dissonance within therapy, (2) developing cultural competency, and (3) the road to recovery (see Fig. 1). Pseudonyms are used to preserve participant anonymity.

Recognising cultural dissonance within therapy

The first theme highlights the importance of recognising cultural dissonance within therapy and considers service user therapeutic expectations, therapeutic guilt, and conflicting cultural identities.

Therapeutic expectations: 'How will I talk this problem away?'

The first subtheme considers service user experiences of accessing IAPT services and receiving therapy. Several service users felt apprehensive about therapy, often due to the lack of knowledge about mental health disorders, the purpose of therapy, and what to expect from IAPT services. Service users opened up about feeling ' anxious', ' afraid', ' uncomfortable' and ' nervous' about attending their first therapy session. Often this was the first therapeutic encounter they had with mental health services and was a ' big change' from the traditional route of seeking help from their GP. Service users talked about having ' no idea' what they were signing up for. This resulted in a few service users dropping out of IAPT services because they were unable to explain the purpose of therapy to their families. For example, Zara (SU7) questioned ' how will I talk this problem away? ' given the inherent reliance on the medical model within her culture.

Service users talked about disorders such as depression, anxiety and post-traumatic stress disorder being absent from their culture, which meant it was difficult to translate them ' back into the community or the mother tongue'. Service users often lived in multi-generational households, which meant they found it difficult to explain their mental distress and therapeutic needs to older family members, who reinforced that they had ' no problem '. For example, Bushra (SU6) talked about how mental distress was normalised as everyday problems and deterred her from seeking therapy:

' You know, in my culture... these things, depression and anxiety, they don't exist. Now they exist, but when I got it, it didn't exist. It was like there's nothing wrong with you, just shake it off... '

Therapeutic guilt: 'You're going against the way that you're taught...'

This subtheme describes the therapeutic guilt service users experienced by engaging with therapy. Service users experienced dissonance between their cultural, familial and religious obligations and Western therapeutic expectations. This led to feelings of shame, guilt and entrapment. Service users often found therapy culturally insensitive and felt that White therapists in particular did not understand that they were bound by certain ' cultural expectations and values '. Some service users talked about the negative consequences advice from therapists would have had on their lives. For example, Qadira (SU9) dropped out of therapy because she felt that her therapist did not understand that she was unable to disclose her personal issues to her family as it would have caused shame and embarrassment:

' I think some of the advice that she was giving me... is just not possible for me to do in general as part of religious cultural limitations for me... I possibly would have lost my family, my parents, my siblings. I don't think she realised that that side of it.'

For others such as Annie (SU4), being asked to involve her family in the recovery process led to immense guilt for not being able to deal with her own ' problems '. Annie's Chinese upbringing taught her to be resilient, and she felt that by revealing her concerns to her family would have been negative:

' Yeah, we feel guilty that you're going against the way that you're taught to deal with your problems and a lot of that comes from how you're raised and how your upbringing was, I think.'

Service users also talked about therapists not understanding the gravity of their religious teachings and obligations. Some service users felt ashamed that they had to seek therapy as they were taught that it was ' forbidden' to have negative thinking patterns. For example, Kalsoom (SU5) was often told by her family that if she had ' tawakkul ' [faith] in God she would not have depression:

' It's almost like, well, if you believe in God, you shouldn't have depression. That was the information that was fed to us growing up... '

Conflicting cultural identities: 'I have a massive identity crisis'

This subtheme describes the cultural clash between Western therapeutic practices and service users' cultural identity. Some service users felt that by challenging their thoughts and behaviours, they were having to compromise their own identity. For example, Annie (SU4) felt that Western concepts such as ' self-compassion' went against the way she was ' taught to deal with your problems ':

'... I guess I was getting really hesitant, but one of the things I said was it feels like I'm changing who I am by challenging these thoughts. I think to some extent I have a massive identity crisis... I'm incredibly hardworking and my parents have always believed in, like working really hard... I think that is partly a cultural thing. ... But I think one thing that she tried to get to was self-compassion and I found that really hard because it almost felt like slacking off. '

Some service users talked about the different ' personalities' and ' masks ' they had to adopt and interchange due to varying cultural expectations. Most service users were British born, and had to juggle familial expectations to abide and serve elders (e.g. parents and older siblings) and the western notions of being independent and autonomous. Service users such as Khalid (SU1) felt that White therapists in particularly had limited understanding about these challenges:

' Because even though they don't understand this at the moment, I have two masks on, one for when I leave the house, basically confident, strong, leader, not discriminated against. The other is for dealing with my issues... It was a good therapist, but he didn't understand the cultural barriers... I would say that there was partial cultural values, partial UK values and emotions in one. But he couldn't understand the concept that I had three different psychological personalities - one for home, one for work, and one for with friends.'

Developing cultural competency

The second theme considers the importance of developing cultural competency by building therapeutic trust and exploring patient culture within therapy.

Building therapeutic trust: 'I don't think she understood the middle ground...'

This subtheme describes concerns relating to confidentiality, cultural misinterpretations, and lack of trust in mental health services and professionals. Despite understanding that therapists were ' bound by confidentiality', service users felt that a key component of therapy was to build a ' safe space' where they could ' trust' the therapist. Given the sensitivity of their personal issues, service users worried that if anything was to ' come out' it would not be a ' positive thing' for them. Service users often opted for one-to-one therapy over group therapy formats for fear of being recognised by community members. Service users desired ' privacy' and wanted to discuss ' sensitive' and ' private ' matters with the therapist alone. Khalsoom (SU5) discussed that this resulted in her dropping out of group therapy and re-referring for one-to-one sessions:

' I have to go back to my GP and be like, I can't do this, but [they] keep sending me to group therapy. It's not something that I can do. And it actually made my panic attack condition worse, my mental health worse. '

Service users also talked about the cultural misinterpretations by White therapists which led to them not wanting to continue with therapy or trust that their concerns would be fully understood. For example, Khalid (SU1) reported that his therapist misunderstood his cultural expressions as ' angry' and ' aggressive ' which instantly instilled barriers within the session. Others such as Aisha (SU3) reported that her therapist's mannerisms, expressions and assumptions about her hijab [Muslim headscarf] were offensive and led to her dropping out of therapy:

' Yes, I wear a hijab. She spent like maybe two minutes looking at that and then very dismissively, you know, look at me, kind of like a really sorry way and really, like, squinting her eyes and nose... looking at my hijab. ...Instead of saying, tell me about yourself... it was like to tell me, why do you wear this? ... Then she obviously pointed towards my hijab and she said that, well, OK, is it is it like your dad or brother? ... And I was like, no, it's completely my choice. And she wouldn't accept it, that I would make that choice for myself.'

Some service users felt that due to Western thinking, White therapists misinterpreted everyday cultural barriers as ' extreme ' incidents. For example, Qadira (SU9) reported that her therapist did not quite understand everyday cultural norms and misjudged them to be life threatening:

' ... I do remember mentioning it [family pressures], but then I think she took the opposite extreme... I think it was more like honour killing. And I mean, it's nothing like that. I don't think she understood the middle ground, the family, where they just stop talking to you.'

Exploring patient culture within therapy: 'I wish that he'd made a little bit more effort...'

This subtheme considers the importance of exploring service user culture within therapy. Service users felt that ' social traumas' and everyday inequalities contributed to their mental distress so would have ' valued' therapists asking them about their ' culture', ' beliefs' and ' background'. Most service users felt that White therapists in particular were ' scared' to ask questions and ' couldn't easily relate because there were cultural differences '. For example, Annie (SU4) felt that exploration of her cultural values would have enhanced her therapeutic experience:

' I wish that he'd made a little bit more effort about what I value. That would have helped shape the programme as well, and help shape some of the tasks... but there wasn't very much conversation about it and how much my symptoms are impacting my day to day behaviour routine and say why that made some of the past more difficult.'

Service users appreciated therapists who were culturally sensitive and curious. A couple of service users preferred a therapist from a different religious and cultural background for fear of being ' criticised' or ' judged '. For example, Khalsoom (SU5) valued her White therapist taking the time to find out more about her culture. This made her feel extremely comfortable in the sessions and allowed her to open up about her concerns, which she struggled to do so in the past:

' I feel like it was because the lady I went to see wasn't of the same background as me, so she was really interested... and, you know, from that she picked up that I was talking about my culture and my cultural practices. But she was really engaged in that and I felt that really helped me open up because she actively tried to get to know me.'

However, some service users preferred having a therapist who shared the same cultural background, although they felt this was not crucial to their care needs. Service users found it ' easier' to talk to therapists from similar cultures because they did not overtly have to explain factors such as their upbringing, religious obligations, familial and cultural pressures and barriers. For example, Bushra (SU6) felt that her BAME therapist ' just got it ' and made her feel at ease during the therapy session:

' Like, if someone doesn't understand that [culture], they ask you question, why was this like this? She has a similar background of how I was brought up and, you know, the family rules and everything. But she kind of understood that as well. So it was quite, you know, nice.'

Cultural competency training was deemed important to understand cultural complexities. Service users felt that ' White, middle class' therapists ' seem to be getting no training around cultural competency and how to apply it to different cultures'. Service users felt that ' representation' was important and wondered if ' additional courses' were needed to enhance cultural competency. A couple of service users described the lack of training as ' systemic discrimination' and a ' pyramid scheme' that favoured White therapists in clinical roles and offered ' cheap labour' by using inexperienced psychological wellbeing practitioners (PWPs) over those who ' cared ' about the profession. Aisha (SU3) was particularly vocal about this matter:

' This is actually robbing the system from people who actually care about the profession, people who actually care about somebody. ... A degree got you into, you know, IAPT.'

The road to recovery

The final theme highlights the road to recovery by considering challenges with therapeutic engagement and service user evaluations of therapeutic effectiveness.

Challenges with therapeutic engagement: 'I don't know if it was tailored at all?'

This subtheme considers the challenges encountered during therapy and the implications that this had on service user therapeutic engagement. Service users felt that regularity (e.g. same therapist throughout course of treatment), option to choose type of therapy, and ' fostering an environment where people can actually talk about things' would have improved their experience. Most service users had disengaged from the service at least once, but did take up therapy when conditions got worse. The majority of service users reported that therapy was not ' tailored' to their needs and they were just ' going through the motions'. For example, Khalid (SU1) was particularly unhappy about therapy and felt that his therapist saw him as a ' number' rather than a ' person ' in order to meet targets:

' It was not tailored to me as an individual, irrespective of culture. So the culture didn't even come into it... They see you as part of their targets, and they see you as a number to get you in and out to hit the target.'

There was a distinct difference between service users who received counselling or CBT. Service users who received CBT generally found it ' prescriptive' and a ' rigid set of tasks' where therapists went through the ' process' and completed ' forms and questionnaires'. Service users felt that therapy was ' superficial' and therapists were too focused on trying to ' fix ' their problem rather than getting to know their personal history. For example, Annie (SU4) recalled her therapeutic experience:

' I just felt like he was like trying to stick me into a programme. I didn't necessarily feel like that programme was right at the end of the day. And I guess it felt like frigid... it's very much like bring your problem, let's solve your problem.'

Service users reflected on homework tasks offered as part of CBT. They found homework ' unhelpful' and ' silly' and felt that therapists were following set ' programmes' without ' modifying ' tasks to their individual needs. For example, Annie (SU4) reported:

' I don't know if it was tailored at all? You like come to a session and have homework printed out without meeting me. How do you know what homework you're going to give me if we didn't have the session? '

Others felt that the ' cultural connotations ' attached to doing certain homework tasks were not considered by therapists. Khalsoom (SU5) felt that her therapist was dismissive of her cultural and familial boundaries:

' A lot of parts, I was doing in private, so my family had no idea at all I was doing them... yeah, so it didn't really look at my cultural side of things. They were just like, well, you need to work on these, you know, you need to be able to speak to your family... and it wasn't something I was comfortable doing. So I think that would be more of a negative than a positive.'

However, some service users understood the importance of homework and the benefit it would have on their recovery process. For example, Khadija (SU2) talked about her initial apprehensions, but soon realised that to achieve wellness, she had to take control of her own situation:

'... If you walk up to the session and think someone's going to fix you, you're not a machine. So I really have a lot of time for people who actually get on with doing the work. And I think that's what makes a very big difference.'

Service users who received counselling valued being able to ' just talk' given the inherent stigma attached to mental health problems in their culture. Qadira (SU9) preferred just being able to ' let everything out' and felt that ' if it was more interactive or anything like that, I probably wouldn't have not attended'. However, for Zara (SU7), more practical ' advice ' on how to manage her situation would have been beneficial. This resulted in her dropping out of therapy after one session:

' But I prefer to get some maybe advice, like something that might make me be better... I'm just like free from the things I needed to say. But I'm the same, I have the same problem.'

Evaluating therapeutic effectiveness: 'Not a cure, but helpful'

This subtheme describes service user evaluations of their recovery process and psychological therapies. Most service users described therapy as ' hit and miss' and could see the benefits of ' just talking' or using certain ' techniques' to ' get back into society'. Whilst service users found therapy useful, they questioned the long-term benefits of therapy and felt that it did not help them recover from their mental distress. Service users reported that they had ' the same problem' and did not feel ' 100 percent' following a course of treatment. A couple of service users said they were ' looking for a cure ', but this was not achieved through therapy. For example, Bushra (SU6) reflected on her therapeutic experience:

'... I don't think they can fix you. I think, you know, people need therapy. They need it in their lifetime again and again. I think, you know, to kind of get back into that kind of habit that they kind of teach you.'

Service users felt that a course of therapy was ' just too short' and would have preferred more sessions to help them overcome their issues. They understood service demands, but felt that it was a ' waste of time' if people were not recovering from their disorder or seeing the full ' benefit' of therapy. Most service users felt that therapy was ' momentary ' and did not help resolve past traumas, issues or concerns. Aisha (SU3) was particularly vocal about this:

'... You know, they need to focus on the past and the present for you to move forward. You are constantly stuck in today throughout the therapy ... I just like I'm seeking this to resolve past issues and how I ended up here and how to move forward from here, and none of that was addressed ever.'

Most service users said that they would recommend therapy to others and felt that everyone who needed it should ' try it at least once'. For example, Bushra (SU6) felt that her therapeutic experience challenged her preconceptions of therapy and helped her move forward in the road to recovery. She felt that therapy was ' not a cure, but helpful' and recommended IAPT services to ' break down barriers' and ' misconceptions ' of therapy to others:

'... If someone said to me go for therapy, I would laugh at them, and say what's talking going to do? You can talk to your family, your friends, you can talk to anybody. But I do think it does help because they're like professionals. They know what to say... I would recommend therapy, I think therapy does help.'

Discussion

The aim of this study was to explore whether evidence-based psychological interventions offered by IAPT services are suitable to the needs of BAME communities. Three themes were generated: (1) recognising cultural dissonance within therapy, (2) developing cultural competency, and (3) the road to recovery. Overall, service users felt that therapy was not a cure, but found it helpful. Critical areas of concern are discussed and recommendations are made to improve the therapeutic experiences and outcomes for BAME communities.

Recognising cultural dissonance within therapy

Recognising dissonance between cultural norms, values and expectations with Western concepts of mental health and therapy was deemed important. Western terminology for common mental health disorders was often unrecognised by family members or the wider community which prolonged access to care (e.g. Aggarwal et al., Reference Aggarwal, Pieh, Dixon, Guarnaccia, Alegria and Lewis-Fernandez2016; Mohamed and Lowenthal, Reference Mohamed and Loewenthal2009; Prajapati and Liebling, Reference Prajapati and Liebling2021). Once services were accessed, service users were apprehensive about what to expect from therapy. The innate desire to put others first was synonymous to that observed in collectivist societies (Hofstede, Reference Hofstede1980; Hofstede, Reference Hofstede2011; Triandis, Reference Triandis1995) which led to feelings of guilt for seeking and engaging in therapy (Miller et al., Reference Miller, Bosun-Arjie and Ekpenyong2021). It was clear that psychoeducation was imperative, not only at an individual level, but for the wider community. Psychoeducation can help improve mental health outcomes for BAME communities (Jacob et al., Reference Jacob, Bhugra and Mann2002; Horrell et al., Reference Horrell, Goldsmith, Tylee, Schmidt, Murphy, Bonin and Brown2014), and thus a progressive model, which incorporates psychoeducation as a priori to therapy could enhance therapeutic engagement and outcomes (Boyd et al., Reference Boyd, Baker and Reilly2019). Moreover, to normalise mental health care, more community outreach is needed to make services more accessible and equitable for ethnic minority communities (Beck et al., Reference Beck, Naz, Brooks and Jankowska2019; Jacobs and Pentaris, Reference Jacobs and Pentaris2021; Lawton et al., Reference Lawton, McRae and Gordon2021; Memon et al., Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and de Visser2016).

Given the interdependent nature of the self (Markus and Kityama, Reference Markus and Kitayama1991), Western therapeutic notions of independence and self-sufficiency conflicted with cultural and familial norms and expectations (Jacobs and Pentaris, Reference Jacobs and Pentaris2021; Loewenthal et al., Reference Loewenthal, Mohamed, Mukhopadhyay, Ganesh and Thomas2012; Mantovani et al., Reference Mantovani, Pizzolati and Edge2017). Most service users were British born and tended to hold bi-cultural identities that enabled them to interchange between individualistic-collectivist patterns for living (e.g. Allen and Bagozzi, Reference Allen and Bagozzi2001; Gushue and Constantine, Reference Gushue and Constantine2003). This was termed as wearing ' masks' or having different ' personalities'. However, some service users felt that White therapists in particular did not understand the cultural clash and cultural boundaries during therapy which led to them dropping out (Bhullar et al., Reference Bhullar, Schutte and Malouff2012; Hong and Woody, Reference Hong and Woody2007; Mofrad and Webster, Reference Mofrad and Webster2012). Given the evolving nature of cultures and increasing globalisation, theoretical models and concepts should not be seen as gospel, but rather as guiding frameworks to help understand cultural differences (Cohen et al., Reference Cohen, Wu and Miller2016; Triandis, Reference Triandis1995). Practitioners should tailor therapy to the individual needs of service users by considering their cultural identities, experiences, requirements, and expectations from therapy.

Developing cultural competency

Developing cultural competency is important for therapeutic success (e.g. Castillo and Guo, Reference Castillo and Guo2011; Fernando, Reference Fernando2010; Miller et al., Reference Miller, Bosun-Arjie and Ekpenyong2021; Sue, Reference Sue1991; Sue, Reference Sue2001). However, service users felt that it was first important to build trust within the therapeutic relationship. The inherent stigma attached to mental health disorders was apparent which led to service users worrying about confidentiality and their personal issues being let out into the community (e.g. Bristow et al., Reference Bristow, Edwards, Funnel, Fisher, Gask, Dowrick and Chew Graham2011; Clement et al., Reference Clement, Schauman, Graham, Maggioni, Evans-Lacko, Bezborodovs, Morgan, Rusch, Brown and Thornicroft2015; Jacobs and Pentaris, Reference Jacobs and Pentaris2021). As a result, group therapy was the least preferred option. Service users valued therapists who asked them about their culture, beliefs and background, as this helped them to understand their circumstances better. Whilst therapists from similar cultural backgrounds were favoured, this was not deemed important for recovery (Naz et al., Reference Naz, Gregory and Bahu2019; Sue, Reference Sue1991). Some service users preferred the option for a therapist from a different cultural and religious background for fear of being judged (Prajapati and Liebling, Reference Prajapati and Liebling2021). Therefore, IAPT services should consider patient choice when allocating therapists.

Given the inherent individualistic values systems of the West, service users felt that cultural competency training was particularly important for White therapists as they were the least likely to understand patient socio-cultural needs and requirements (Al-Krenawi and Graham, Reference Al-Krenawi and Graham2000; Fernando, Reference Fernando2012; Loewenthal, Reference Loewenthal2018). Service users talked about White therapists misjudging their tone of voice, religious garments and cultural norms which built up barriers within therapy. Research shows that cultural misinterpretations can have detrimental consequences for the individual and heighten the 'circle of fear' in mental health services (Prajapati and Liebling, Reference Prajapati and Liebling2021; Sainsbury Centre for Mental Health, 2007). Therefore, IAPT services should regularly evaluate and enhance cultural competency training needs for its workforce so that they can better serve BAME communities (Bassey and Melluish, Reference Bassey and Melluish2012; Beck et al., Reference Beck, Naz, Brooks and Jankowska2019).

The road to recovery

Service users discussed the challenges with therapeutic engagement and evaluated therapeutic effectiveness. Service users worried that therapy sessions were too short, not personalised, and therapists were more concerned about meeting targets at the expense of their needs. Given increased service demands, the 'McDonaldization' of IAPT services has been under scrutiny with concerns over the quality of care for patients (Bassey and Melluish, Reference Bassey and Melluish2012; Binnie, Reference Binnie2015). Service users recognised that therapy was not a short-term fix and would have valued longer sessions to feel the full benefit of therapy (Christodoulou et al., Reference Christodoulou, Fortune, Arslan and Canan2018). Most service users reported that they did not recover following a course of treatment, but found therapy helpful and would recommend it to others. Given the high attrition rates in BAME communities (Baker, Reference Baker2018; Harwood et al., Reference Harwood, Rhead, Chui, Bakolis, Connor, Gazard and Hatch2021), IAPT services should consider culturally sensitive and culturally responsive services to meet the needs of service users (Beck et al., Reference Beck, Naz, Brooks and Jankowska2019; Beck and Naz, Reference Beck and Naz2019).

CBT was the most common therapy offered, but service users questioned its authenticity. In line with previous research, patients found CBT prescriptive, rigid, and not tailored to their specific needs (Omylinska-Thurston et al., Reference Omylinska-Thurston, McMeekin, Walton and Proctor2019). Some service users found CBT situational and too focused on the present without consideration of past traumas. The need for therapists to consider the patient as a whole, which includes their cultural, religious, spiritual and social needs is imperative to boost the recovery process (Fenn and Byrne, Reference Fenn and Byrne2013; Prajapati and Liebling, Reference Prajapati and Liebling2021). Similarly, service users felt that therapists did not consider their cultural boundaries and implications when setting homework tasks (Miller et al., Reference Miller, Bosun-Arjie and Ekpenyong2021; Prajapati and Liebling, Reference Prajapati and Liebling2021). Often, it was not easy for service users to disclose personal problems to their families or carry out tasks rooted in Western rhetoric (e.g. being independent and self-sufficient). Despite reservations, some service users understood the benefits of homework should they want to take control of their situation and improve their mental wellbeing. Those who received counselling valued being able to talk to someone about their concerns as this was uncommon within their communities (Cardemil and Battle, Reference Cardemil and Battle2003). However, some service users felt that more practical advice was needed to help improve their lives. To minimise disengagement from therapy, IAPT services should consider patient choice of treatment options through informed and collaborative discussions (Marshall et al., Reference Marshall, Quinn, Child, Shenton, Pooler, Forber and Byng2016).

Limitations

Despite data saturation being achieved after seven interviews (Braun and Clarke, Reference Braun and Clarke2021b), the sample size ( n=9) was small and does not offer a comprehensive account of service users from different ethnic minority backgrounds, genders and age groups. This was due to the study taking place during the global pandemic which minimised recruitment options and availability (e.g. via IAPT services). Future research should consider such variations in order to capture the experiences of broader clinical populations (Jacobs and Pentaris, Reference Jacobs and Pentaris2021; Mohamed and Lowenthal, Reference Mohamed and Loewenthal2009). Moreover, given that this study was a reflective account of service users' past experiences, there is possibility of recall bias due to the length of time between receiving therapy and the interview (Althubaiti, Reference Althubaiti2016). To minimise this, future research should consider exploring service user experiences during a course of therapy to understand what works well and how services can be improved.

Conclusion

Exploring the recovery narrative of service users from BAME communities is imperative. The cultural clash between Western notions of therapy and service user cultural and familial expectations was evident. To better understand and serve the needs of ethnic minority populations, IAPT services need to increase cultural competency training for its workforce. Whilst most service users did not fully recover, they found therapy useful and would recommend it to others. It appears that there is a long way to go, yet not unachievable. Future research should consider inclusion of more diverse individuals to capture a broader narrative of service user experiences and needs. Moreover, research should seek to explore whether IAPT practitioners are culturally competent to deal with the needs of BAME communities and identify training needs. Given the limited knowledge about mental healthcare, IAPT services should consider more community engagement by increasing psychoeducation as a priori to therapy.

Key practice points

(1) To provide mental health professionals with theoretical models and concepts that may assist with understanding therapeutic differences across cultures.

(2) To assist mental health professionals to reflect on their own cultural competency training needs and consider how to better serve BAME communities.

(3) To encourage IAPT services and commissioning bodies to promote psychoeducation as a priori to therapy for both service users and the wider ethnic minority communities.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Acknowledgements

This study was conducted as part of a fully funded doctoral research programme at Birmingham City University. The author would like to acknowledge and thank the supervisory team for their guidance during the course of studies and Dr Kate Cooper (University of Bath) for her expertise during the review of the study themes.

Author contributions

Afsana Faheem: Conceptualization (lead), Data curation (lead), Formal analysis (lead), Investigation (lead), Methodology (lead), Project administration (lead), Resources (lead), Validation (lead), Writing - original draft (lead), Writing - review & editing (lead).

Financial support

This study was part of the author's fully funded PhD at Birmingham City University. No other grant from any funding agency, commercial or not-for-profit sectors was received.

Conflicts of interest

The author declares none.

Ethical standards

Ethical considerations were reviewed in line with the British Psychological Society (BPS) code of conduct and those drawn from the British Association for Counselling and Psychotherapy (BABCP) Ethical Framework to inform best research practice. This study received approval from Birmingham City University Research Ethic Committee by an independent panel consisting of a team of academics in April 2017 (Ethics Code: 060/17 Cat A). The study was a service evaluation and did not require approval from the Health Research Authority (HRA). All participants provided signed informed consent and agreed for the results to be published.

# data[].attributes.attachment_link.title
'Not a cure, but helpful' - exploring the suitability of evidence-based psychological interventions to the needs of Black, Asian and Minority Ethnic (BAME) communities | the Cognitive Behaviour Therapist | Cambridge Core

# data[].attributes.attachment_link.description
'Not a cure, but helpful' - exploring the suitability of evidence-based psychological interventions to the needs of Black, Asian and Minority Ethnic (BAME) communities - Volume 16

# data[].attributes.headline
Frontline yet at the back of the queue – improving access and adaptations to CBT for Black African and Caribbean communities

# data[].attributes.subject
Frontline yet at the back of the queue – improving access and adaptations to CBT for Black African and Caribbean communities

# data[].attributes.attachment_link.readable_text
Context

Historical context

Western mental health systems have historically exhibited racial bias. In January 2021, the American Psychiatric Association (APA) issued a formal apology to Black, Indigenous and people of colour, for its support of structural racism in psychiatry (American Psychiatric Association, 2021). With APA's roots of racism dating back to the 1700s, mental health diagnosis and treatment aligned with the era's racist social-political policies (American Psychiatric Association, 2021). This is evidenced in selective diagnostic criteria for mental illnesses to justify oppressive practices (Fernando, Reference Fernando2017). During this period, APA upheld racist beliefs regarding blacks being primitive and hostile, which had devastating consequences for their mental health 'care'. Black patients were segregated from whites and enslaved blacks used as payment for psychological treatment of whites. Interpretive comparative biological differences between whites and blacks have been used to uphold beliefs about inferiority of blacks, where the false rhetoric of Eugenics implied that blacks had smaller brains and were psychologically adolescent (Medlock et al., Reference Medlock, Weissman, Wong and Carlo2016).

For example, the 'Runaway slave syndrome': drapetomania was a formal diagnosis provided by white psychiatrists to justify abuse inflicted on slaves who attempted to escape from abusive slave masters (Colman, Reference Colman2015). Severe beatings and toe amputations were medically prescribed to treat the 'mania': impulse to run away (Lipsedge and Littlewood, Reference Lipsedge and Littlewood2005). This was pathologised through beliefs that blacks lacked cognitive ability to desire or seek freedom and benefited from enslavement (Ruane, Reference Ruane2019). Rush proposed that black skin on black people was due to a form of leprosy, negritude (Hogarth, Reference Hogarth2019). Pro-slavery advocates were in agreement, although not all physicians were of this opinion (Dumas, Reference Dumas2016; Myers, Reference Myers2014). This evidences how scientific racism attempts to pathologise hypothesised constructions of race, which infer inferiority of racialised people and white superiority (Hogarth, Reference Hogarth2017).

Although there has been some progress from slavery to the modern day, to some extent health advantages have become accepted as intrinsic to ethnicity (Byrne et al., Reference Byrne, Alexander, Khan, Nazroo and Shankley2020; Darlington et al., Reference Darlington, Norman, Ballas and Exeter2015; Fanon, Reference Fanon1952; Medlock et al., Reference Medlock, Weissman, Wong and Carlo2016). Blacks are at increased risk of common mental disorder (CMD), yet more likely to receive pharmacological treatment and detention than psychological therapy. This suggests some bias in expectations/beliefs that this can be addressed, stemming from perceptions of cultural or genetic weakness as opposed to disadvantages due to socioeconomic inequalities, and ethnic discrimination (Byrne et al., Reference Byrne, Alexander, Khan, Nazroo and Shankley2020; Mason, Reference Mason2003).

Race as a social construct is designed to maintain oppression and dominance of people considered inferior, with white considered the gold standard (Witzig, Reference Witzig1996; Zevallos, Reference Zevallos2017). The dominance and assumed superiority of the social construct of Whiteness is illustrated through history (Frankenberg, Reference Frankenberg1993). Whiteness refers to invisible privileges and power which, via various ideological and cultural practices, systematically maintain structural, racialised and intersectional hierarchies and the oppression of people of colour (Carr, Reference Carr2017).

The Slavery Abolition Act was passed in British parliament in 1833, which allegedly freed slaves across most British owned colonies. The legacy of slavery was not eradicated with centuries of oppressive economic and social practices. This presents implications for intergenerational trauma within the BME population (Fernando, Reference Fernando2017). From 1833 up until 2015, slave traders were in receipt of compensation (up to 17 billion pounds) for loss of earnings; slaves were considered business assets (Olusoga, Reference Olusoga2018). Compensation records evidence that ancestors of David Cameron and George Orwell were among the beneficiaries (Jones, Reference Jones2013). There is evidence of the presence of African Romans in Britain, dating back to the third century (Olusoga, Reference Olusoga2016). Moreover, the famous Windrush marked the arrival of tens of thousands of individuals from the Caribbean in the late 1940s. Our government's campaign for workers from Commonwealth countries saw increased immigration from 1948 to 1970. The British Nationality Act (1948) gave citizens of UK Colonies the right of settlement in the UK (Jones, Reference Jones1948), with working age adults and many children arriving, joining parents or grandparents in the UK, without their own passports.

Today systems and structures for marginalised groups can be oppressive. Understanding systemic forms of racialisation supports continued growth in equity of access and experience (McKenzie-Mavinga, Reference McKenzie-Mavinga2009). Improved alliance can be developed when CBT therapists understand and acknowledge the historical context of the treatment of black people in various contexts which include health and mental health.

Current societal context

The socio-political landscape can impact the mental health needs of a population, and this is evident in the current COVID-19 pandemic. The devastating impact of discrimination was a correlating factor for higher risk of COVID-19 in BME people (Elwell-Sutton et al., Reference Elwell-Sutton, Deeny and Stafford2020). The service of those on the frontline of health services is impeded by inequalities, which were an issue prior to COVID-19 (Kings Fund, 2020; Royal College of Psychiatrists, 2020). The phrase institutional racism was initially coined by Carmichael et al. ( Reference Carmichael, Ture and Hamilton1992), referenced also in the Stephen Lawrence MacPherson report (MacPherson, Reference MacPherson1999). This can be described as routine processes and procedures that translate into actions that negatively shape experiences of racialised groups within institutions (Nazroo et al., Reference Nazroo, Bhui and Rhodes2020). Disproportionality in BAME COVID-19-related deaths have highlighted these disparities.

Furthermore, both Brexit and the Windrush scandal have emphasised the effects of the 'hostile environment policy'. In 2018, the Home Office was exposed as failing to keep records of the legal status of British Caribbeans, and this led to mass evictions and deportation (BBC News, 2020; Gayle et al., Reference Gayle, Taylor and Gentleman2020). This was met with public protests and pushback which resulted in a commitment to support and compensate those who have been affected (Quille, Reference Quille2018). The commitment has not been upheld.

Public health experts have considered several explanations for the unequal disease burden for the UK BAME population. Razai and colleagues provided explanatory factors as socio-economic, underlying co-morbidity, cultural and epigenetic vulnerability, and occupational inequities (Razai et al., Reference Razai, Kankam, Majeed, Esmail and Williams2021). Williams concluded that racism and poverty could cause biological weathering and increase risk of chronic disease; he noted the implications for BME communities in poorer paid frontline, essential worker roles, statistically more likely to live in crowded accommodation and in deprived areas (Williams, Reference Williams2020a). The ecological analysis of Nazroo and Becares of COVID-19-related mortality rates and ethnic composition of the population accounted for age, population density, area deprivation and pollution; their findings concluded that entrenched systemic and institutional racism were root causes in higher prevalence of BAME COVID-related deaths (Nazroo and Becares, Reference Nazroo and Becares2020).

These data expose the effects of structural inequalities with the potential for increased prevalence of traumatised and disenfranchised BME communities. As CBT therapists we need to consider societal context in the provision of culturally congruent clinical practice.

Current mental health service context

The Adult Psychiatric Morbidity Survey (McManus et al., Reference McManus, Bebbington, Jenkins and Brugha2016) indicated that BME communities are less likely to voluntarily seek support for mental health problems. Individuals from a BME background are four times more likely to be detained under the Mental Health Act and diagnosed with severe and enduring mental illness, compared with the white population (Barnett et al., Reference Barnett, Mackay, Matthews, Gate, Greenwood, Ariyo and Smith2019). BME groups are broadly perceived as hard to reach and engage with, within the mental health system. A weakness with this argument is that institutional barriers affecting attrition and access for this group are not considered (Joint Commissioning Panel on Mental Health, 2014; Naz et al., Reference Naz, Gregory and Bahu2019; Nazroo et al., Reference Nazroo, Bhui and Rhodes2020).

Memon and colleagues' qualitative study (Memon et al., Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and de Visser2016), identified barriers to BME access of mental health provision, which included lack of cultural humility, discrimination and mistrust.

Psycho-social factors affect mental health, whether individuals are asylum seekers who have no recourse to public funds, or second or third generation BME communities. In the literature BME refugees are pre-disposed to common mental disorders through exposure to trauma through pre-displacement, displacement, and post-displacement processes (Schlaudt et al., Reference Schlaudt, Bosson, Williams, German, Hooper, Frazier and Ramirez2020). The South East London Community Health Study (SELCoH) using diverse population samples evidence links between discrimination, ethnicity and migration status (Hatch et al., Reference Hatch, Gazard, Williams, Frissa, Goodwin and Hotopf2016). Hatch and colleagues noted this causality for mental illness within BME populations, with indications that the Caribbean population were at highest risk (Hatch et al., Reference Hatch, Frissa, Verdecchia, Stewart, Fear, Reichenberg and Hotopf2011; Singh, Reference Singh2019). A significant percentage of BME individuals are within low-income families where lack of information, opportunity and support networks will influence life choices and equity of access (Equality and Human Rights Commission, 2018).

Service users who experience themselves as the 'stigmatised other' tend to conceal their illness and experience a deleterious effect on the process of their recovery (Wong et al., Reference Wong, Collins, Cerully, Seelam and Roth2017). For some service users, related to the perception of social stigma is low self-esteem, poor employment prospects, lack of money and altered behaviour from others (Corrigan et al., Reference Corrigan, Bink, Fokuo and Schmidt2015). Cross-cultural studies have identified social stigma against mental illness in Eastern Asian societies; for example, Japan has a tendency to delay accessing services (Zhang et al., Reference Zhang, Sun, Jatchavala, Koh, Chia, Bose and Ho2020). Service users' self-concept and sense of social identity may be influenced by broader social factors. This may impede rejection of unhelpful labels, denoting negative stereotype, whilst acknowledging their own mental distress (Stuart, Reference Stuart2016).

In order to address low rates of engagement and improve outcomes, service providers need to develop a good understanding of why there is the discrepancy for this population (Whittington and Grey, 2013). It is not enough to identify the existence of inequality for BME populations. This has been illustrated through literature over many years, with common themes consistently conveyed, yet little visible change following on from government strategies as indicated by the data in the Race Disparity Audit (Audit, Reference Audit2018) and Equality and Human Rights Commission ( 2018). There is a necessity to move forward and address the differing barriers (Memon et al., Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and de Visser2016).

Over-representation in secondary care

In the last two decades numerous papers have examined the race disparities between under-representation of BAME communities in primary care and the over-representation in secondary adult mental health and forensic services. The Lammy Review (Lammy, Reference Lammy2017) estimated the cost of £309 million for over-representation in the Criminal Justice Courts. The Joint Commissioning Panel on Mental Health ( 2014) approximated the cost of race inequalities within in-patient and community mental health services at over £100 million. This was attributed to high BME prevalence and re-admissions on both psychiatric intensive care units (PICU) and medium secure care units. Therefore, the comparative individual service-user costs for BME were 58% higher than white service users.

The report provides commissioners with useful guidance in tackling this. However, formal frameworks to resolve longstanding inequalities have not been nationally disseminated within IAPT. Despite specific recommendations for funding via Payments by Results (PBR) to be based on improved access for BAME populations in 2018, this was not implemented widely (NHS England, 2018).

BME people born in the UK are diagnosed with psychosis at a rate nine times higher than white British people (Kirkbride et al., Reference Kirkbride, Coid, Morgan, Fearon, Dazzan, Yang and Jones2010). This occurrence is related to social (isolation, alienation) and environmental factors rather than having a biological basis (Tortelli et al., Reference Tortelli, Errazuriz, Croudace, Morgan, Murray, Jones, Szoke and Kirkbride2015). Perkins and Repper ( Reference Perkins and Repper2020) argued that black people were more likely to be detained involuntarily under the Mental Health Act (1983) than other ethnic groups. Understandably, coercion fuels a perception that one will be intentionally harmed by others and may lead service users to mistrust health care providers so that working collaboratively to engage them in psychological therapies becomes an almost impossible task (Mercer et al., Reference Mercer, Evans, Turton and Beck2019). Clearly there is a need to promote cultural awareness within organisations to prevent people from minority ethnic groups being caught in a cycle of relapse and readmission under the provisions of the Mental Health Act (1983).

According to Gordon ( Reference Gordon2007), black service user and carer participants described the careful consideration of cultural diversity as essential to the provision of an acceptable service. When they perceived poor communication, with a lack of information sharing between carers and the mental health team, they found those factors affected their engagement. According to black service user participants, when there was a high perceived 'clash of interests' between mental health professionals and carers in relation to differences in culturally diverse beliefs and values, this was a barrier to accessing psychological therapies. Mental health professionals and service users in the study spoke about the importance of examining the process of engagement with carers. A service was considered 'hostile' when cultural sensitivity was low, and when it did not engage carers in a culturally congruent manner. In contrast, where there was a demonstration of adequate efforts to value cultural diversity, minoritised ethnic groups reported they would be more likely to engage.

Under-representation in primary care mental health

The Adult Psychiatric Morbidity Survey (2014) survey found that 14.5% of white British aged 16 and over were receiving treatment for mental health compared with only 6.5% of BME. Data presented within the briefing paper by Carl Baker on Mental Health Statistics for England (Baker, Reference Baker2020) appears to support this view of lower treatment rate. The paper highlighted that 23% BME reported a common mental disorder compared with 17% white British. Yet they are not represented in primary care and are over-represented in psychiatric care (Mercer et al., Reference Mercer, Evans, Turton and Beck2019). In IAPT BME have high attrition rates and lower percentage of referrals, with 86% of self-reported referrals made to IAPT from white British backgrounds. Although there is no evidence that increasing BME access in IAPT will address over-representation in secure settings, studies indicate that social disadvantage and linguistic distance can create pre-disposition to psychosis (Jongsma et al., Reference Jongsma, Gayer-Anderson, Tarricone, Velthorst, van der Ven, Quattrone and Lasalvia2020). This is an area for further research; poor mental health correlates with less access to opportunity in education, community and employment (Haque et al., Reference Haque, Becares and Treloar2020).

The English IAPT is a country-wide initiative delivering psychological therapies recommended by the National Institute for Health and Care Excellence (NICE) for mild, moderate and severe common mental disorders (CMDs) in primary care (Clark, Reference Clark2011; Clark, Reference Clark2018). Although CBT is the primary treatment offered, therapy is not limited to CBT. Therapy is accessible using a stepped care model, based on severity of symptoms. IAPT pioneers ongoing transparency in recording of mental health outcomes and demographics of service users, which includes data on ethnicity (Clark et al., Reference Clark, Canvin, Green, Layard, Pilling and Janecka2018). However, equitable access by ethnic populations is not currently set as a key performance indicator by the NHS.

IAPT has been demonstratively responsive to remote working and should commit further to learning and implementation of adaptations for increased access. IAPT is strategically placed to contribute to the working solutions in improving access and engagement for the BME population, which may be further compromised due to experiences relating to COVID-19 and accumulative racial injustices (Royal College of Psychiatry, 2020; Murray, Reference Murray2020).

National ethnic differences in access and recovery rates

NHS England ( 2020 b) have national data on numbers accessing services but not rates relating to ethnicity and the population within areas. Data on access by ethnicity are examined by some individual services and we will report on that in the next section.

The IAPT recovery rate of 50% was met by the white population averaging at 52.4%, compared with black British Caribbean and black British African 49.4 and 48.3%, respectively. However, there are substantial discrepancies between the rates of white British and BME communities in accessing IAPT. Invariably distinctions differentiating ethnic groups are not always recorded or lack specificity (Loewenthal et al., Reference Loewenthal, Mohamed, Mukhopadhyay, Ganesh and Thomas2012). This indicates that BME retention, and numbers accessing and recovered at completion of treatment may be proportionately lower.

The individual context: CBT therapist and patient

The British Association for Behavioural and Cognitive Psychotherapies (BABCP) does not explicitly refer to cultural competence within their Standards of Conduct Performance and Ethics (BABCP, 2018), although several health professional associations reference this (Haarhoff et al., Reference Haarhoff, Thwaites and Haarhoff2016).

An excerpt from their current standards is limited to: 'You must not allow your views about a service user's sex, age, colour, race, disability, sexuality, social or economic status, lifestyle, culture, religion or beliefs to affect the way you treat them or the advice you give. You must treat service users with respect and dignity. If you are providing are, you must work in partnership with your service users and involve them in their care as appropriate.' (p. 6).

A recent BABCP Diversity and Inclusion audit made recommendations for inclusive policy, procedure, campaigns and research including cultural competence training as accreditation criteria for CBT therapists, which would benefit the BME community (Murray, Reference Murray2020). It is of note that BABCP's revision of training standards are currently at consultation stages.

Understanding microaggressions in CBT

The therapeutic alliance has been heralded as a key component for successful psychotherapy where emphasis is placed on the merits of unconditional positive regard (Okamoto et al., Reference Okamoto, Dattilio, Dobson and Kazantzis2019; Rogers, Reference Rogers1957). The therapeutic alliance can impact access and retention of service users in mental health provision (Hartley et al., Reference Hartley, Raphael, Lovell and Berry2020). Implicit or explicit bias and microaggressions may threaten this (Sue et al., Reference Sue, Capodilupo, Torino, Bucceri, Holder, Nadal and Esquilin2007). Microaggressions are intentional or unintentional racial slights or derogatory comments, and as therapists we need to be aware of our own assumptions, prejudices and stereotypes. The absence of this risks repetition and reinforcement of daily discrimination experiences for BME service users in the therapy room (Lago, Reference Lago2011).

A review by Sue ( Reference Sue2010a,b) provided a taxonomy of aversive racism. These were identified as microassault, microinsult and microinvalidation, as illustrated and explained in Fig. 1 (Sue et al., Reference Sue, Capodilupo, Torino, Bucceri, Holder, Nadal and Esquilin2007; Sue, Reference Sue2010 a,b).

In summary, microassault and microinvalidations are deemed unconscious (and thus unintentional) and microinsult as conscious. Microinsults are characterised primarily by a verbal or non-verbal attack meant to hurt the intended victim through name-calling, avoidant behaviour, or purposeful discriminatory actions. Terms intended to belittle and lead to questioning of one's identity effects motivation, causes low self-esteem and internalised prejudice (Saleem et al., Reference Saleem, Anderson and Williams2020).

It is important to consider power dynamics between BME therapists and white patients, in addition to white therapists with BME service users and BME staff with white staff (Constantine and Sue, Reference Constantine and Sue2007). White therapists as members of the larger society may not be immune from inheriting the racial biases of their forebears (Burkard and Knox, Reference Burkard and Knox2004). A systematic review has evidenced how racism, prejudice and stereotype can impact on BME service user psychological safety (FitzGerald and Hurst, Reference FitzGerald and Hurst2017).

Several papers have defined and conceptualised the impact of microaggressions (MA) on BME and BAME service users (Saleem et al., Reference Saleem, Anderson and Williams2020; Solorzano et al., Reference Solorzano, Ceja and Yosso2000; Sue et al., Reference Sue, Capodilupo, Torino, Bucceri, Holder, Nadal and Esquilin2007; Williams and Halstead, Reference Williams and Halstead2019; Williams, 2020; Williams et al., Reference Williams, Rouleau, La Torre and Sharif2020). Kanter and colleagues' randomised controlled trial indicated that therapists had difficulties acknowledging microaggressions or may be defensive; however, defiance may imply bias and in practice may pose demonstrative detrimental effects on emotional rapport and empathy (Kanter et al., Reference Kanter, Rosen, Manbeck, Branstetter, Kuczynski, Corey, Maitland and Williams2020). The trial evidenced how workshops on cultural competence mindfulness in inter-racial interaction improved white therapists' emotional rapport and responsiveness towards BAME patients (Kanter et al., Reference Kanter, Rosen, Manbeck, Branstetter, Kuczynski, Corey, Maitland and Williams2020). Williams and colleagues' Racial Harmony study evidenced ways of reducing microaggressions and improving inter-racial connections (Williams et al., Reference Williams, Rouleau, La Torre and Sharif2020). Both Beck ( Reference Beck2016) and Carter ( Reference Carter1995) have suggested that transcultural therapy is more successful when white therapists are comfortable with difference and discussions on discrimination. We reference specific clinical examples in the next section of this paper.

The individual context: CBT therapists and service users

Beck ( Reference Beck2019; p. 2) noted that many CBT therapists 'may steer away from discussions on race' and the impact of racism on the service users' mental health. A 2016 qualitative study found that BME service users felt that therapists may not understand their presenting problem within their psycho-social context (Memon et al., Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and de Visser2016). The last few decades have seen recognition, identification and understanding of microaggressions within therapeutic settings. Therapists from all backgrounds need to bring this to their consciousness within their work. Table 1 illustrates examples that help explore subtle nuanced behaviour that can cause harm in relationships between both BME and white therapists and white therapists and BME service users. Whist we cannot assume that there would not be potential for therapeutic ruptures between people from similar backgrounds, this depicts specific examples and implications of bias and prejudice.

Intended or not, in whatever form verbal indignities, unintentional physical responses of fear or disgust may occur, these frequent racialised slights serve only as a reinforcement that BME people do not belong, perpetuating negative stereotypes (Forrest-Bank, Reference Forrest-Bank2016). These examples are not there to shame or degrade, rather to educate and aid healthy discussion in safe spaces to explore issues within the therapeutic setting. There is much to learn about inclusive working and no one group, or person, has the monopoly on cultural competence (a concept difficult to measure; in relation to attainment, this is indeed a lifelong pursuit for us all). A recent literature review of related terms by Curtis et al. ( Reference Curtis, Jones, Tipene-Leach, Walker, Loring, Paine and Reid2019) found definitions of cultural safety more helpful: 'a focus for the delivery of quality care through changes in thinking about power relationships and patients' rights'. This suggests that challenging our own culture and cultural systems engenders cultural protection (Curtis et al., Reference Curtis, Jones, Tipene-Leach, Walker, Loring, Paine and Reid2019; p.12). We are in this together, no one person is immune to prejudice on a range of dimensions. These frameworks on issues of race may transfer to consideration of discrimination on other intersectional domains. As CBT therapists we all need to navigate towards more inclusive practice.

Barriers to implementation of formal frameworks for equitable access to psychological therapies

It has taken a global pandemic for calls for better funding and research for mental health (Holmes et al., Reference Holmes, O'Connor, Perry, Tracey, Wessely, Arseneault, Ballard, Christensen, Silver, Everall, Ford and Bullmore2020). Prevalence of common mental disorder within BME communities, linked to inequalities, is not a new phenomenon (Joseph Rowntree Foundation, 2016). The absence of key performance indicators (KPI) on diversity and inclusion, within IAPT services, suggests that addressing inequities in access are not IAPT core business. Funding to implement the pioneering BAME PPG guide (2019) has not materialised.

There is a need for local commissioning bodies to support a standardised formal framework, with related KPIs, otherwise services may struggle to implement the audit tool. At a recent Public Health England webinar, Williams gave examples of communities of opportunity (Williams, 2020). This included provision of care that addresses the societal context. As CBT therapists, supervisors and clinical leads, our work is greatly assisted by partnership working with both statutory and non-statutory organisations (Beck and Naz, Reference Beck and Naz2019; Fountain et al., Reference Fountain, Patel and Buffin2007).

Formal frameworks for integrated BME access

The model of Beck and Naz ( Reference Beck and Naz2019) illustrates unmet need in the community and steps to address this. The bottom-up pyramid (see Fig. 2) displays a baseline of unmet need, with the peak representing recovery. It demonstrates barriers that BAME populations encounter at each level of the pyramid (Beck and Naz, Reference Beck and Naz2019).

The diagram highlights the barriers to successful treatment from community to recovery stages. The narrowing of the pyramid is a visual representation of reduction in numbers before and after the assessment and treatment phase. The research of Beck and Naz ( Reference Beck and Naz2019) indicated that poor conceptualisation impacted on drop-out rates, where there is an absence of formulation of racialised contexts. Several papers support the need for this, which we discuss below (Beck, Reference Beck2019; Williams et al., Reference Williams, Metzger, Leins and DeLapp2018).

Their findings highlight how retention of service users can be improved from referral through to completion of treatment, by co-location of therapists (Fountain et al., Reference Fountain, Patel and Buffin2007). To address unmet need access, attrition and recovery rates, we suggest co-location of CBT therapists within representative community groups. The presence of an IAPT therapist in these settings can evidence the value IAPT services place on the community. Statutory services within the community destigmatise mental health provision. With opportunities for reciprocal learning (Fountain et al., Reference Fountain, Patel and Buffin2007) this may support IAPT services' ability to recognise, appropriately assess and treat CMDs across cultures. This infrastructure supports the development of representative research within these communities, which IAPT services are well positioned to support (Hakim et al., Reference Hakim, Thompson and Coleman-Oluwabusola2019).

Where therapists may lack the necessary skills to engage and successfully treat BME service users, mandatory training on cultural safety, cultural humility and white privilege may support this (Naz et al., Reference Naz, Gregory and Bahu2019). This also poses implications for diversity training in CBT training programmes, of which we do not have the scope to review within this article. Although CBT models are idiosyncratic in nature, the CBT evidence base may not always be generalisable to BME or BAME populations. This is due to majority white homogeneity in research samples. Culturally congruent approaches need to be implemented and embedded within assessment and treatment formulation (Beck, Reference Beck2019). IAPT may consider collaborative research and learning from experts in Afrocentric psychology approaches, to build a representative evidence base (Majors et al., Reference Majors, Carberry and Ransaw2020). A growing body of literature endorses service change and outreach work, evidencing improved access, experience and outcomes for BAME communities (Kada, Reference Kada2019; Naz and Beck, Reference Beck2019). The structure of CBT services has a role to play in assisting CBT therapists to address these needs.

Southwark demographics

Southwark is a richly diverse inner London Borough. Both deprivation and affluence are represented in neighbourhood wards. Just over half (54%) of Southwark's population is of white ethnicity, a quarter (25%) BME and a third of Asian (11%) or other (10%) ethnicities. This differs from the rest of London where a considerably smaller proportion (13%) identify as black, and a considerably larger proportion identify as Asian (21%). The ethnic diversity of the borough varies markedly across age groups and the population under 20 is much more diverse than other age groups, with a similar proportion of young people from white and black ethnic backgrounds (Council, 2019).

Talking Therapies Southwark review

The review (using the audit tool) identified robust screening policies and procedures where ethnicity is recorded of nearly 97% of open cases on the Southwark IAPT data set, allowing for a small percentage of service users who choose to not disclose their ethnicity. It was identified that providing a rationale for monitoring may support disclosure of ethnicity. Although data on ethnicity of referrals that do not reach screening stage are not captured, this implies the need to refine processes to obtain ethnicity recording on referral forms.

Reports demonstrate mapping of ethnicity of the population. Local authority Joint Strategic Needs Assessment (JSNA) data are consulted as they provide detailed analysis of local demographics, which was compared with TTS data.

The review confirmed that BME service users have a lower recovery rate than white British service users. The mean recovery rate for BME population was 48%. The Bangladesh community has the only lower recovery rate compared with other ethnicities. Access rates are illustrated in Table 2.

With 25% of the Southwark population from BME backgrounds, this equates to 78,500 people of the total population of 314,200. 2955 referrals were made to Southwark IAPT for the 3rd quarter IAPT data set 2019/20, 630 of those were BME: 285 African, 180 Caribbean and 75 of mixed heritage, either White British and African or White British and Caribbean, with 90 any other Black background. This equates to 21% of total referrals (JSNA, 2018/19). What is significant is the difference in number of BME accessing services to number completing treatment and recovering; only 145 of 630 referrals completed treatment, less than 20%. Recovery rates for Caribbean were 41%, African 37% and 52% of any other black background. This evidences that at least 80% of BME people drop out of therapy between referral, assessment and into treatment stages.

The most recent IAPT dataset confirmed that TTS do not currently have people accessing the service and completing treatment who fully reflect the population served. Action to remedy this is evidenced by the BAME Initiative working group, QI project targeted at BME communities, engagement with our South London and Maudsley (SLaM) Trust wide IAG (Independent Advisory Group) meetings, and development of an online Race Identity & Me group. Table 3 displays the results of the BAME PPG audit tool for TTS.

Some materials in representative languages have been sourced from the Royal College of Psychiatry. Southwark work closely with the Multi-Ethnic Counselling service to provide service users the option of support in their first language, in addition to provision of interpreters where required within the service, although training has been delivered on depression and anxiety across cultures to CBT therapists within the SLaM trust within the last two years. This needs to be mandatory and delivered annually. TTS arranged further training which included cognitive behavioural therapists, counsellors, clinical psychologists, dynamic interpersonal therapists (DIT), eye movement desensitisation (EMDR) therapists, interpersonal therapists, and psychological wellbeing practitioners (PWPs).

The present context provides opportunities for virtual co-location, co-production and delivery. TTS therapists are usually co-located in GP services and Childrens' Centres. Mummies Republic (MR) is an example of integrated community provision of psychological therapies. It is a partnership with the South London Mission church in Bermondsey, providing support for BAME mothers, many with no recourse to public funds and seeking asylum, hence being less likely to access traditional mental health provision, despite increased vulnerability to forms of abuse. Moving forward, services may need to consider development and delivery of digital therapies in partnership with community groups in the current absence of physical co-location, with potential virtual co-location and consultation with community groups, and co-production of materials with therapists and community representatives.

In TTS overall, there is good BAME representation in the workforce and the team broadly reflect the population served. BAME staff have equal access as white staff to continued professional development (CPD). The BAME network circulates information on the Workforce Race Equality Standards (WRES) courses for BAME staff (Chatwood, Reference Chatwood2015). There is BAME representation in the workforce at senior level with three out of eight in the leadership team being from BAME backgrounds, although there is more BAME representation at administrative and PWP levels than within Step 3 therapists. We need to consider broader implications for anti-racist practice in recruitment processes and clinical training. There is potential for conformity and confirmation bias (the tendency of people to favour information that confirms their existing beliefs or hypotheses) affecting employment diversity, through senior staff pre-conceived ideas about different social groups which may introduce discrimination (unconscious or otherwise) and impact the recruitment process (Agarwal, Reference Agarwal2018).

If there are less BAME voices in senior positions, diversity of thought in decision making processes may be lacking and there is a distinct lack of power to implement inclusive practices. This is an example of systemic racism. SLaM NHS trust are committed to addressing this. The Psychology and Psychotherapy (P&P) Race Equity working group aims to support projects that involve collaborative working with local community organisations and create an infrastructure for embedding anti-racist practice within the P&P workforce. The group has asked to pool resources with the Patient Carer Race Equality Framework (PCREF) and the Trust BAME Network to ensure that its ambitions are continually informed by the needs and ideas of network members, patients, carers, and the community. Provision of resource and infrastructure from the Chief Executive Officer is imperative to ensure implementation. This would also evidence the commitment SLaM have made to reduce ethnic inequalities in mental health (NHS England, 2020c; Synergi Collaborative Centre, 2020).

Services could consider localised agreements on audit-review frequency, dependent on demonstrative progress towards the BAME PPG required standards. We suggest a traffic light system as a measure, where points allocated to each standard are collated and ranked from red (not met) to amber (working towards) and green (met), for clear identification of gaps to support agreed action plans.

# data[].attributes.attachment_link.title
Frontline yet at the back of the queue - improving access and adaptations to CBT for Black African and Caribbean communities | the Cognitive Behaviour Therapist | Cambridge Core

# data[].attributes.attachment_link.description
Frontline yet at the back of the queue - improving access and adaptations to CBT for Black African and Caribbean communities - Volume 14

# data[].attributes.headline
Cultural competence in the experiences of IAPT therapists newly trained to deliver cognitive-behavioural therapy: A template analysis focus study

# data[].attributes.subject
Cultural competence in the experiences of IAPT therapists newly trained to deliver cognitive-behavioural therapy: A template analysis focus study

# data[].attributes.headline
The association of migration and ethnicity with use of the Improving Access to Psychological Treatment (IAPT) programme: a general population cohort study

# data[].attributes.subject
The association of migration and ethnicity with use of the Improving Access to Psychological Treatment (IAPT) programme: a general population cohort study

# data[].attributes.attachment_link.title
The association of migration and ethnicity with use of the Improving Access to Psychological Treatment (IAPT) programme: a general population cohort study - Social Psychiatry and Psychiatric Epidemiology

# data[].attributes.attachment_link.description
Background Common mental disorders (CMD), such as depression and anxiety, are an important cause of morbidity, economic burden and public mental health need. The UK Improving Access to Psychological Therapies (IAPT) programme is a national effort to reduce the burden and impact of CMD, available since 2008. Aims To examine ethnic and migration-related differences in use of IAPT-based psychological treatment using a novel epidemiological dataset with linkage to de-identified IAPT records. Method Data from a psychiatric morbidity survey of two South East London boroughs (2008–2010) were individually-linked to data on IAPT services serving those boroughs. We used Poisson regression to estimate association between ethnicity and migration status (including years of UK residence), with rate of subsequent use of psychological treatment. Results The rate of psychological treatment use was 14.4 cases per thousand person years [cases/1000 pyrs, 95% confidence intervals (95% CI) 12.4, 16.7]. There was strong statistical evidence that compared to non-migrants, migrants residing in the UK for less than 10 years were less likely to use psychological treatment after adjustment for probable sociodemographic predictors of need, life adversity, and physical/psychiatric morbidity at baseline [rate ratio (RR) 0.4 (95% CI 0.20, 0.75]. This difference was not explained by migration for asylum/political reasons, or English language proficiency, and was evident for both self- and GP referrals. Conclusions Lower use of IAPT among recent migrants is unexplained by sociodemographics, adversity, and baseline morbidity. Further research should focus on other individual-level and societal barriers to psychological treatment use among recent migrants to the UK, including in categories of intersecting migration and ethnicity.

# data[].attributes.headline
Exploring the cross-cultural validity of evidence-based psychological interventions offered by Improving Access to Psychological Therapies (IAPT) services

# data[].attributes.subject
Exploring the cross-cultural validity of evidence-based psychological interventions offered by Improving Access to Psychological Therapies (IAPT) services

# data[].attributes.attachment_link.readable_text
Faheem, Afsana (2022) Does one-size-fit-all? Exploring the cross-cultural validity of evidence-based psychological interventions offered by Improving Access to Psychological Therapies (IAPT) services. Doctoral thesis, Birmingham City University.

Abstract

Purpose. This thesis explored the effectiveness of evidence-based psychological interventions for Black, Asian and Minority Ethnic (BAME) communities accessing Improving Access to Psychological Therapies (IAPT) services in England, UK.

Methods. Multiple-methodologies were guided by the Transdisciplinary model of evidence-based practice. This included 1) a systematic literature review; 2) examination of predictors of recovery and therapeutic effectiveness; 3) exploration of whether therapies were suitable to BAME service users' needs; and 4) exploration of IAPT practitioners' cultural competency.

Findings. Findings from the systematic review highlighted scarce inclusion of BAME participants in clinical trials. Only two studies met the inclusion criteria which found that psychoeducation at an early stage of referral was more effective in reducing depression when compared to delayed access (N = total 217 participants). Examination of routine clinical data revealed that ethnicity, religion, age, and initial baseline severity were predictors of recovery (N = 13,710 patients). For therapeutic effectiveness, there were significant main effects for treatment modality and ethnicity after controlling for baseline severity and age, however, there was no significant interaction (N = 9,925 patients). Poor recovery outcomes (< 35%) were observed across the entire clinical sample. Findings from BAME service users recovery narrative (N = 9) revealed the importance of recognising cultural dissonance within therapy; the need for therapists to develop cultural competency; and evaluations of their road to recovery. Service users felt therapy was not a cure, but generally found it helpful. Interviews with therapists (N = 16) revealed that only nine therapists received one day of formal cultural competence training and seven received none at all. Therapists discussed the cultural dissonance encountered during therapy; the challenges in making cultural adaptations to therapy; and their cultural competency needs.

Conclusion. Overall, evidence suggests that the 'one-size-fits-all' approach adopted by Western evidence-based psychological interventions fails to consider the cultural complexities that may present in ethnically diverse communities. Implications and considerations for decision-making processes are discussed in the context of clinical psychology practice, education, leadership, policy and research.

Actions (login required)

View Item

# data[].attributes.attachment_link.title
Does one-size-fit-all? Exploring the cross-cultural validity of evidence-based psychological interventions offered by Improving Access to Psychological Therapies (IAPT) services

# data[].attributes.attachment_link.description
Faheem, Afsana (2022) Does one-size-fit-all? Exploring the cross-cultural validity of evidence-based psychological interventions offered by Improving Access to Psychological Therapies (IAPT) services. Doctoral thesis, Birmingham City University. Purpose. This thesis explored the effectiveness of evidence-based psychological interventions for Black, Asian and Minority Ethnic (BAME) communities accessing Improving Access to Psychological Therapies (IAPT) services in England, UK.

# data[].attributes.headline
Culturally adapted CBT – the evolution of psychotherapy adaptation frameworks and evidence

# data[].attributes.subject
Culturally adapted CBT – the evolution of psychotherapy adaptation frameworks and evidence

# data[].attributes.attachment_link.title
Culturally adapted CBT – the evolution of psychotherapy adaptation frameworks and evidence | the Cognitive Behaviour Therapist | Cambridge Core

# data[].attributes.attachment_link.description
Culturally adapted CBT – the evolution of psychotherapy adaptation frameworks and evidence - Volume 16

# data[].attributes.attachment_link.title
Heartbreaking Moment When Kids Learn About White Privilege | The School That Tried to End Racism

# data[].attributes.headline
Collection of articles related to being an antiracist practitioner within IAPT 

# data[].attributes.subject
Collection of articles related to being an antiracist practitioner within IAPT 

# data[].attributes.headline
Article on what it means to be an antiracist

# data[].attributes.subject
Article on what it means to be an antiracist

# data[].attributes.attachment_link.readable_text
Ibram X.Kendi is an American author and historian, whose latest book, How To be an Antiracist, is one of Amazon's best-selling titles about race. Image: James Hole for Penguin

RACIST: One who is supporting a racist policy through their actions or inaction or expressing a racist idea.

ANTIRACIST: One who is supporting an antiracist policy through their actions or expressing an antiracist idea.

Definitions anchor us in principles. This is not a light point: If we don't do the basic work of defining the kind of people we want to be in language that is stable and consistent, we can't work toward stable, consistent goals. Some of my most consequential steps toward being an antiracist have been the moments when I arrived at basic definitions. To be an antiracist is to set lucid definitions of racism/antiracism, racist/antiracist policies, racist/anti-racist ideas, racist/antiracist people. To be a racist is to constantly redefine racist in a way that exonerates one's changing policies, ideas, and personhood.

"The only remedy to racist discrimination is antiracist discrimination."

Since the 1960s, racist power has commandeered the term "racial discrimination," transforming the act of discriminating on the basis of race into an inherently racist act. But if racial discrimination is defined as treating, considering, or making a distinction in favor or against an individual based on that person's race, then racial discrimination is not inherently racist. The defining question is whether the discrimination is creating equity or inequity. If discrimination is creating equity, then it is antiracist. If discrimination is creating inequity, then it is racist. Someone reproducing inequity through permanently assisting an overrepresented racial group into wealth and power is entirely different than someone challenging that inequity by temporarily assisting an underrepresented racial group into relative wealth and power until equity is reached.

The only remedy to racist discrimination is antiracist discrimination. The only remedy to past discrimination is present discrimination. The only remedy to present discrimination is future discrimination. As President Lyndon B. Johnson said in 1965, "You do not take a person who, for years, has been hobbled by chains and liberate him, bring him up to the starting line of a race and then say, 'You are free to compete with all the others,' and still justly believe that you have been completely fair." As U.S. Supreme Court Justice Harry Blackmun wrote in 1978, "In order to get beyond racism, we must first take account of race. There is no other way. And in order to treat some persons equally, we must treat them differently."

One of the most defining questions for Kendi is whether 'discrimination is creating equity or inequity'. James Hole / Penguin

The racist champions of racist discrimination engineered to maintain racial inequities before the 1960s are now the racist opponents of antiracist discrimination engineered to dismantle those racial inequities. The most threatening racist movement is not the alt right's unlikely drive for a White ethnostate but the regular American's drive for a "race-neutral" one. The construct of race neutrality actually feeds White nationalist victimhood by positing the notion that any policy protecting or advancing non-White Americans toward equity is "reverse discrimination.

That is how racist power can call affirmative action policies that succeed in reducing racial inequities "race conscious" and standardized tests that produce racial inequities "race neutral." That is how they can blame the behavior of entire racial groups for the inequities between different racial groups and still say their ideas are "not racist." But there is no such thing as a not-racist idea, only racist ideas and antiracist ideas.

"An antiracist idea is any idea that suggests the racial groups are equals in all their apparent differences."

So what is a racist idea? A racist idea is any idea that suggests one racial group is inferior or superior to another racial group in any way. Racist ideas argue that the inferiorities and superiorities of racial groups explain racial inequities in society. As Thomas Jefferson suspected a decade after declaring White American independence: "The blacks, whether originally a distinct race, or made distinct by time and circumstances, are inferior to the whites in the endowments both of body and mind."

An antiracist idea is any idea that suggests the racial groups are equals in all their apparent differences-that there is nothing right or wrong with any racial group. Antiracist ideas argue that racist policies are the cause of racial inequities.

Understanding the differences between racist policies and antiracist policies, between racist ideas and antiracist ideas, allows us to return to our fundamental definitions. Racism is a powerful collection of racist policies that lead to racial inequity and are substantiated by racist ideas. Antiracism is a powerful collection of antiracist policies that lead to racial equity and are substantiated by antiracist ideas.

Once we have a solid definition of racism and antiracism, we can start to make sense of the racialized world around us, before us. My maternal grandparents, Mary Ann and Alvin, moved their family to New York City in the 1950s on the final leg of the Great Migration, happy to get their children away from violent Georgia segregationists and the work of picking cotton under the increasingly hot Georgia sun.

To think, they were also moving their family away from the effects of climate change. Do-nothing climate policy is racist policy, since the predominantly non-White global south is being victimized by climate change more than the Whiter global north, even as the Whiter global north is contributing more to its acceleration.

Land is sinking and temperatures are rising from Florida to Bangladesh. Droughts and food scarcity are ravishing bodies in Eastern and Southern Africa, a region already containing 25 percent of the world's malnourished population. Human-made environmental catastrophes disproportionately harming bodies of color are not unusual; for instance, nearly four thousand U.S. areas-mostly poor and non-White-have higher lead poisoning rates than Flint, Michigan.

Kendi's key argument is is that there is no such thing as being 'not racist' (or 'colourblind') - only being actively racist or actively antiracist. James Hole / Penguin

I am one generation removed from picking cotton for pocket change under the warming climate in Guyton, outside Savannah. That's where we buried my grandmother in 1993. Memories of her comforting calmness, her dark green thumb, and her large trash bags of Christmas gifts lived on as we drove back to New York from her funeral. The next day, my father ventured up to Flushing, Queens, to see his single mother, also named Mary Ann. She had the clearest dark-brown skin, a smile that hugged you, and a wit that smacked you

When my father opened the door of her apartment, he smelled the fumes coming from the stove she'd left on, and some other fumes. His mother nowhere in sight, he rushed down the hallway and into her back bedroom. That's where he found his mother, as if sleeping, but dead. Her struggle with Alzheimer's, a disease more prevalent among African Americans, was over.

There may be no more consequential White privilege than life itself. White lives matter to the tune of 3.5 additional years over Black lives in the United States, which is just the most glaring of a host of health disparities, starting from infancy, where Black infants die at twice the rate of White infants. But at least my grandmothers and I met, we shared, we loved. I never met my paternal grandfather. I never met my maternal grandfather, Alvin, killed by cancer three years before my birth. In the United States, African Americans are 25 percent more likely to die of cancer than Whites. My father survived prostate cancer, which kills twice as many Black men as it does White men. Breast cancer disproportionately kills Black women.

"We are surrounded by racial inequity, as visible as the law, as hidden as our private thoughts."

Three million African Americans and four million Latinx secured health insurance through the Affordable Care Act, dropping uninsured rates for both groups to around 11 percent before President Barack Obama left office. But a staggering 28.5 million Americans remained uninsured, a number primed for growth after Congress repealed the individual mandate in 2017. And it is becoming harder for people of color to vote out of office the politicians crafting these policies designed to shorten their lives. Racist voting policy has evolved from disenfranchising by Jim Crow voting laws to disenfranchising by mass incarceration and voter-ID laws. Sometimes these efforts are so blatant that they are struck down: North Carolina enacted one of these targeted voter-ID laws, but in July 2016 the Court of Appeals for the Fourth Circuit struck it down, ruling that its various provisions "target African Americans with almost surgical precision." But others have remained and been successful. Wisconsin's strict voter-ID law suppressed approximately two hundred thousand votes-again primarily targeting voters of color-in the 2016 election. Donald Trump won that critical swing state by 22,748 votes.

We are surrounded by racial inequity, as visible as the law, as hidden as our private thoughts. The question for each of us is: What side of history will we stand on? A racist is someone who is supporting a racist policy by their actions or inaction or expressing a racist idea. An antiracist is someone who is supporting an antiracist policy by their actions or expressing an antiracist idea. "Racist" and "antiracist" are like peelable name tags that are placed and replaced based on what someone is doing or not doing, supporting or expressing in each moment. These are not permanent tattoos. No one becomes a racist or antiracist. We can only strive to be one or the other. We can unknowingly strive to be a racist. We can knowingly strive to be an antiracist. Like fighting an addiction, being an antiracist requires persistent self-awareness, constant self-criticism, and regular self-examination.
This is an extract from How to be an Antiracist by Ibram X. Kendi.

# data[].attributes.attachment_link.title
Ibram X. Kendi defines what it means to be an antiracist

# data[].attributes.attachment_link.description
RACIST: One who is supporting a racist policy through their actions or inaction or expressing a racist idea. ANTIRACIST: One who is supporting an antiracist policy through their actions or expressing an antiracist idea. Definitions anchor us in principles.

# data[].attributes.headline
Cultural adaptation of CBT as a human rights issue: A UK study

# data[].attributes.subject
Cultural adaptation of CBT as a human rights issue: A UK study

# data[].attributes.attachment_link.title
Cultural adaptation of CBT as a human rights issue: A UK study

# data[].attributes.attachment_link.description
Cognitive behaviour therapies have been used widely across the world and have been recommended as the first line of psychotherapeutic treatment for multiple mental health disorders. However, such blanket guidelines for use of Western-generated psychotherapies discount the socio-cultural determinants and aspects of mental health when recommended unadapted across ethnicities, eventually creating disparities in the quality of care available to different populations. Examining the cultural relevance of these therapies for ethnic minority groups has therefore become an important avenue of inquiry.Recent decades have brought a revolution of cultural competency and adaptation research for such psychotherapies. Despite recent advances in cultural competency and adaptation research, the available body of literature in this domain remains limited and heterogenous. Furthermore, the lack of mandatory cultural competence training and the ineffectiveness of existing programmes increase the obvious discrepancy in the provision of mental healthcare services for certain minority groups, jeopardising equitable access and raising concerns about human rights protection.AimsThis study aimed to explore UK-based CBT therapists’ use of adaptations in their own practice, and understand what elements they tend to adapt, the impact and feasibility of their approaches, and the challenges faced by those who adapt and those who do not. The larger intention was to be able to gather information to recommend basic direction for policy and research to create plans for the benefit of ethnic minority groups for whom access to quality, tailored healthcare is currently largely overlooked.MethodThe study involved developing a survey informed by existing literature and distributing it to UK-based CBT therapists.ResultsThis study found that CBT therapists and their clients value cultural competency. It also found that therapists tend to believe that adapting CBT techniques and implementation and using culturally significant idioms and stories are impactful for their clients and practical to achieve as therapists. It further found that current barriers to adapting CBT for ethnic minority clients involves a lack of resources to study the efficacy of adaptations as well as a lack of well-established evidence-based adaptations in existing literature.ConclusionThe authors recommend that policymakers and service managers prioritise the regulation of cultural competence in psychotherapy and afford resources and incentive to researchers and clinicians that would eventually help to improve the effectiveness of their approaches and enhance mental health outcomes for ethnic minority groups. Future research could build on this study using qualitative methods or creating more robust surveys, using random sampling, and drawing larger sample sizes.

# data[].attributes.headline
Advancing Equality, Diversity and Inclusion at Exeter through Cultural Competence

# data[].attributes.subject
Advancing Equality, Diversity and Inclusion at Exeter through Cultural Competence

# data[].attributes.attachment_link.title
Cultural competence | Equality, Diversity and Inclusion | University of Exeter

# data[].attributes.attachment_link.description
We are committed to ensuring an inclusive environment which supports equality of opportunity, values diversity and where everyone can study, work and have fun without discrimination and harassment. We will not tolerate harassment and discrimination.

# data[].attributes.headline
Information on practicing cultural curiosity when engaging with children and families

# data[].attributes.subject
Information on practicing cultural curiosity when engaging with children and families

# data[].attributes.attachment_link.title
Practicing cultural curiosity when engaging with children and families - Emerging Minds

# data[].attributes.attachment_link.description
An overview of culturally competent and child-focused practices when engaging with children and parents from refugee and migrant communities.

# data[].attributes.headline
Reni Eddo-Lodge on race, social injustice and quotas

# data[].attributes.subject
Reni Eddo-Lodge on race, social injustice and quotas

# data[].attributes.attachment_link.title
Reni Eddo-Lodge on race, social injustice and quotas

# data[].attributes.headline
Useful Resources on Cultural Diversity and Mental Wellbeing

# data[].attributes.subject
Useful Resources on Cultural Diversity and Mental Wellbeing

# data[].attributes.attachment_link.title
Cultural diversity and mental wellbeing - Orygen, Revolution in Mind

# data[].attributes.attachment_link.description
Our Skills & Knowledge Division concentrates on growing the capacity of Australia’s youth mental health workforce with an emphasis on accessible expertise and innovation.

# data[].attributes.headline
Paper on Intersectionality and Adolescent Mental Health

# data[].attributes.subject
Paper on Intersectionality and Adolescent Mental Health

# data[].attributes.attachment_link.readable_text
Purpose

Intersectionality theory highlights the importance of the interplay of multiple social group memberships in shaping individual mental well-being. This article investigates elements of adolescent mental well-being (life dissatisfaction and psychosomatic complaints) from an intersectional perspective. It tests mental well-being consequences of membership in combinations of multiple social groups and examines to what extent such intersectional effects depend on the national context (immigration and integration policies, national-level income, and gender equality).

Methods

Using Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy, we assessed the role of the national context in shaping the interplay between immigration background, socioeconomic status, and gender, using data from 33 countries from the 2017/2018 Health Behaviour in School-aged Children survey.

Results

We found no uniform intersectionality effects across all countries. However, when allowing the interplay to vary by national context, results did point toward some intersectional effects. Some aggravated negative effects were found for members of multiple disadvantaged social groups in countries with low levels of income equality and restrictive migration policies, whereas enhanced positive effects were found for members of multiple advantaged groups in these countries. Similarly, mitigated negative effects of membership in multiple disadvantaged groups were shown in countries with higher levels of income equality and more inclusive migration policies, whereas mitigated positive effects were found for multiply advantaged individuals. Although for national-level gender equality results pointed in a similar direction, girls' scores were counterintuitive. High national-level gender equality disproportionately benefitted groups of disadvantaged boys, whereas advantaged girls were doing worse than expected, and reversed effects were found for countries with low gender equality.

Conclusions

To fully understand social inequalities in adolescent mental well-being, the interplay between individual-level and national-level indicators must be explored.

Implications and Contribution
Study findings highlight the context dependency of intersectional effects in adolescent mental well-being. On a policy level, the findings suggest that adolescents belonging to multiple disadvantaged social groups might disproportionally benefit from policies encouraging equality and inclusivity on all levels.

Many adult mental health problems have their onset in childhood and adolescence [,

]. The global prevalence rate of mental health problems among children and adolescents has been estimated to be 13.4% with little international or intercontinental variation [], rendering adolescent mental health a global public health priority [, ,

]. Adolescent mental health has been defined as an overarching, multifaceted concept that includes both the absence of mental health problems and the presence of subjective well-being. In the present article, we focus on elements of both parts of mental health and therefore use the term mental well-being throughout the article. Extensive research, based on ecological models, shows that adolescent mental well-being is influenced by a broad range of individual and contextual factors. From a sociology of health perspective, the effects of individuals' social group memberships are of special interest. Inequalities in adolescent well-being, based on their social group membership, are well documented. Although their magnitude is contingent on the social context, their direction tends to be quite stable with adolescents with (1) an immigration background, (2) from low socioeconomic status (SES) families, and (3) girls reporting lower levels of mental well-being than natives, adolescents from middle-to-high SES families, and boys [

,

, ]. However, people's experiences, resources, and identities are not only shaped by multiple individual characteristics such as immigration background, SES, and gender but also by their specific combinations. In line with this, intersectional theory stresses that membership in particular combinations of social groups represents a unique state of being and a particular set of social experiences with distinctive consequences for the lives and mental well-being of individuals, and particularly those of adolescents who are in the process of social identity formation [

].

From an intersectional perspective, it can thus be argued that studies that examine the effect of having such characteristics singularly, rather than combined, provide an incomplete picture of social inequalities in adolescent mental well-being, as the effect of membership in particular combinations of social groups might differ from the sum of the effect of each of those individual group memberships. According to the multiple jeopardy hypothesis [

], the negative effect of simultaneously being a member of multiple marginalized social groups is greater than the combined negative effect of all social group memberships. Thus, the combination of having an immigration background, coming from a low SES family, and being a girl may have an aggravating (multiplicative) rather than a simply cumulative (additive) negative effect on adolescent mental health.

To our knowledge, only very few studies have addressed the intersection of immigration background, SES, and gender on mental well-being among adolescent and young adult samples, and the few that have were exclusively conducted in the U.S. The results of these studies support an additive model, where the effect of membership in particular combinations of social groups equals the sum of the effects of each of those individual group memberships, rather than an intersectional one [

,

]. To assess whether the same holds true outside of the U.S. context, the present study, as a first step, aims to investigate the interplay between immigration background, SES, and gender by examining the effect of membership in all possible combinations of these variables using data from a large-scale, cross-nationally comparative study (including primarily European countries). Following the multiple jeopardy hypothesis, we assume that members of multiple disadvantaged social groups experience negative mental health effects that go above the combined negative effects of all their group memberships.

The role of the national context

Intersectionality theory does not only emphasize that membership in particular combinations of social groups establishes a unique set of social experiences and structural constrains [

] but also stresses that these experiences and constrains are shaped by the social context [,

]. Accordingly, the necessity of context-sensitive intersectional research is widely acknowledged in the field [

]. Quantitative intersectional research explicitly modeling this context dependency of the effect of membership in particular combinations of social groups, however, is extremely sparse [

]. Research examining the effect of immigration background and SES on adolescent mental well-being individually found that it varied with certain national-level characteristics. Specifically, in countries with inclusive immigration and integration policies [,] and low national-level income inequality [

, ,

], social inequalities in adolescent mental well-being according to immigration background and SES tend to be relatively small. For countries with high levels of gender equality, comparable processes may be at play []. The exact impact of these national-level characteristics on the mental well-being of adolescents belonging to particular combinations of social groups is unknown. However, given that national-level inclusive immigration and integration policies, income equality, and gender equality reduce social inequalities in adolescent mental well-being, we suggest that the aggravated (as opposed to cumulative) negative effect of membership in multiple marginalized social groups is less likely in more inclusive and equal countries.

The present study uses data from the cross-national 2017/2018 Health Behaviour in School-aged Children (HBSC) study to investigate the interplay between immigration background, SES, and gender on two indicators of adolescent mental well-being (life dissatisfaction and psychosomatic complaints) in a large, representative sample of adolescents between the ages of 10 and 16 years from 33 primarily European countries (Research question 1). It also tests whether this interplay varies between countries categorized according to indices of their immigration and integration policies and their national-level income equality and gender equality (Research question 2). To investigate this interplay, we use the new "gold standard" for research into health inequalities: Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) that allows for an exploration of the complex interaction structures between a large number of social group memberships [,

, ] (see Appendix for a more detailed discussion of the advantages of MAIHDA). In doing so, this study aims to shed light on the complex nature of social inequalities in adolescent mental well-being and how they are shaped by the national context. As outlined previously, the multiple jeopardy hypothesis assumes that the combination of having an immigration background, coming from a low SES family and being a girl, may have an aggravating rather than a simply cumulative (additive) effect on adolescent mental well-being. Given the general tendency for social inequalities in mental well-being to be less pronounced in more equal/inclusive societies, we argued that this aggravated effect may be less likely in countries with inclusive immigration and integration policies and in more income and gender-equal countries.

References

Why income inequalities matter for young people's health: A look at the evidence.

UNICEF Office of Research, Florence, Italy 2016 ()

Health Behaviour in School-aged Children (HBSC) study protocol: Background, methodology and mandatory items for the 2017/18 survey.

CAHRU, St Andrews 2018

Pattern of human concerns.

Rutgers University Press, New Brunswick, NJ 1965

2019 World Bank data BASE.

MCMC estimation in MLwiN.

Centre for Multilevel Modelling, University of Bristol, Bristol (UK) 2017

Article Info

Publication History

Footnotes

Conflicts of interest: The authors have no conflicts of interest to declare.

Disclosure: This supplement was supported by the World Health Organization European Office and the University of Glasgow. The articles have been peer-reviewed and edited by the editorial staff of the Journal of Adolescent Health. The opinions or views expressed in this supplement are those of the authors and do not necessarily represent the official position of the funder.

Identification

DOI: https://doi.org/10.1016/j.jadohealth.2020.02.013

Copyright

User License
Creative Commons Attribution - NonCommercial - NoDerivs (CC BY-NC-ND 4.0) |

How you can reuse

Permitted

For non-commercial purposes:

Read, print & download

Redistribute or republish the final article

Text & data mine

Translate the article (private use only, not for distribution)

Reuse portions or extracts from the article in other works

Not Permitted

Sell or re-use for commercial purposes

Distribute translations or adaptations of the article

Elsevier's open access license policy

ScienceDirect
Access this article on ScienceDirect

HBSC is a large cross-sectional, school-based survey carried out every 4 years in collaboration with the WHO Regional Office for Europe. The study included data from the 2017/2018 HBSC survey, for which 47 countries collected self-report data, nationally representative for 11-, 13-, and 15-year-old adolescents using a standardized study protocol. Samples were drawn using cluster sampling, with school classes or the whole school as the primary sampling unit. Data collection procedures and questionnaires were standardized and strictly followed the international research protocol [

Health Behaviour in School-aged Children (HBSC) study protocol: Background, methodology and mandatory items for the 2017/18 survey.

]. Each country obtained ethical board approval. Thirty-three countries collected data on all individual-level variables used in the present study. National-level data on income equality and gender equality were available for all 33 countries, and data on immigration and integration policies were available for 26 countries. For the different steps of analyses, sample sizes ranged from 127,556 participants in 26 countries to 154,229 participants in 33 countries. The share of girls ranged from 49.02% in Croatia to 54.5% in Albania. The share of immigrants ranged from 4.17% in Albania to 72.24% in Luxembourg. The age of participants in our study ranged between 10 and 16.5 years, coinciding with early and middle adolescence. The mean age per country ranged from 13.02 years in Norway to 13.92 years in Finland (for more sample information and country-specific descriptive statistics, see Appendix).

Dependent variables

Life Dissatisfaction

Life dissatisfaction was assessed with the Cantril ladder [

]. Participants rated how satisfied they were with their life on a visual analogous scale ranging from (0) "the worst possible life" to (10) "the best possible life." The Cantril Ladder is easily understood and has shown good reliability and convergent validity among adolescents []. For the purpose of this study, responses were reverse coded so that higher scores indicated more life dissatisfaction.

Psychosomatic complaints

Items from the HBSC Multiple Health Complaints Checklist were used to assess the frequency of seven health complaints (headache, abdominal pain, backache, feeling low, irritability, feeling nervous, and dizziness) [,

]. Adolescents indicated how often they had experienced each complaint over the last 6 months. Response categories ranged from (1) "about every day" to (5) "rarely or never." This instrument has adequate test-retest reliability and psychometric properties [] and is commonly used as an indicator of adolescent mental well-being (e.g., Hagquist et al. [

]). In our sample, the scale had an acceptable reliability (α = .80). The responses were reverse coded, and a sum score was built so that a higher number would indicate more psychosomatic complaints (range 0-28). In line with the literature [,], both dependent variables were treated as continuous.

Independent variables

Individual-level

Immigration background

Adolescents reported where they themselves, their mother, and their father were born. Participants were considered as having an immigration background if at least one of their parents was born outside of the survey country (for more information, see Appendix).

Family socio-economic status

Family SES was assessed using the revised Family Affluence Scale (FAS III) [

]. FAS measures material family wealth with six items, including, for instance, number of family cars, having a bedroom of one's own, number of bathrooms, and the number of family holidays in the last year [

]. Several studies have confirmed its validity [

,

]. Responses were summed in a total FAS score. To take the international differences in family affluence into consideration, we estimated FAS by comparing the individuals' summary scores on the FAS to that of all other participants of their age and gender in their respective country using a proportional rank [

Health Behaviour in School-aged Children (HBSC) study protocol: Background, methodology and mandatory items for the 2017/18 survey.

]. Subsequently, proportional ranks were categorized into tertiles.

Gender and age

Respondents were asked to indicate whether they are a boy or a girl and to report their date of birth (month/year). Based on this, their gender and their age at the moment of data collection were computed.

Country-level

Immigration and integration policies

Data were obtained from the Migrant Integration Policy Index (MIPEX) from 2014 [

], which has been developed by the British Council and the Migration Policy Group [

]. It consists of eight indicators, such as policies about labor market mobility, family reunification, education, and antidiscrimination. The higher the MIPEX score, the better the policy meets the highest standard for equal treatment of natives and immigrants.

Income equality

Income equality was measured with the Gini coefficient. The Gini coefficient measures income inequality at the national level and has a theoretical range from 0 (everyone having equal income) to 1 (one person having all the income). We used the most recent World Bank Gini estimate available for each country from the World Development Indicators online database [

] (see Table 1 in the Appendix). The income equality for each country was computed by subtracting the national Gini index from 1.

Gender equality

Gender equality was measured with the Gender Inequality Index (GII) obtained from the 2017 United Nations Development Program Human Development Report. The GII measures gender inequalities in three important aspects of human development: reproductive health, empowerment, and economic status. Gender equality was computed by inverting the GII.

All country-level indicators were categorized into tertiles: high, medium, and low (for more information, see Appendix, Table 1). Individuals with missing values on any of the variables were excluded from further analyses.

Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy was conducted [], which requires that all possible unique combinations of social group memberships (often referred to as strata) are treated as higher level units in a two-level hierarchical random effects model []. In our study, first, separately for both outcome variables, MAIHDA was performed with individuals nested in 12 strata representing all unique combinations of individual characteristics-immigration background (native/immigrant), SES (high/middle/low), and gender (boy/girl)-(Research question 1). Then, again separately for both outcome variables, the same analyses were repeated three times (i.e., once for each national-level variable) to investigate the role of country-level MIPEX, income equality, and gender equality in shaping this interplay (Research question 2). To this end, individuals were nested in 36 strata representing all unique combinations of the national-level variable in question (which was categorized into high, medium, and low) and individual-level variables of immigration background, SES, and gender ( Table 2 in the Appendix shows the sample sizes per stratum for all four sets of strata that were used). Analyses pertaining to Research question 1 were based on data from 33 countries. Analyses pertaining to Research question 2 were based on data from 33 countries when assessing the role of income equality and gender equality and on data from 26 countries when assessing the role of migration and integration policies.

In all four analyses, first, a null model was fit including only the overall intercept (i.e., the overall mean of the outcome variable) as well as the estimated stratum-level residuals for all strata (i.e., the difference between the stratum means and the overall mean). This model was additionally adjusted for age. In MAIHDA, the variance partition coefficient (VPC) of the null model serves as a measure of Discriminatory Accuracy [,]. Akin to a model fit statistic like R 2, it indicates how well individual scores on the outcome variable can be predicted based on the individual's combination of social group memberships (see Appendix for the formula used to calculate the VPC). Second, a main effects model was fit that additionally included dummy variables to control for the additive effects of all social group memberships []. We also controlled for age and survey country to take into account age and country differences in the distributions of life dissatisfaction and psychosomatic complaints. Because additive effects of social group memberships were adjusted for, in the main effects model, stratum-level residuals did not capture the difference between stratum means and the overall mean, but between stratum means and the means that would be expected for those strata by a purely additive model. Accordingly, inspection of stratum-level residuals and their associated credible intervals can reveal potential intersectional effects for particular combinations of social group memberships (Research question 1) or intersectional effects for particular combinations of social group memberships in particular national contexts (Research question 2). While stratum-level residuals, thus, provide us with a measure of stratum-specific intersectional effects, a measure of general intersectionality can be found in the Proportional Change in Variance (PCV) []. The PCV relates the variance of the stratum-level residuals in the main effects model (the difference between the stratum mean and the expected mean for that stratum based on an additive model) to the variance of stratum-level residuals in the null model (the difference between stratum means and the overall mean) and informs us about how much of the differences between individuals in different strata is explained by additive main effects. Accordingly, the unexplained part is attributable to intersectional effects (see Appendix for the formula used to calculate the PCV).

All models were fit in MLwiN 3.02 (University of Bristol, Bristol, United Kingdom) using Bayesian Markov Chain Monte Carlo estimation. The burn-in length was 500 iterations, and the total amount of iterations was 5,000. Bayesian 95% credible intervals for the fixed effect parameters as well as the strata-level residuals were obtained from the posterior distribution following procedures laid out by Fisk et al. [,

].

Main effects

Main effect parameters ( Table 1) revealed significantly increased levels of life dissatisfaction and psychosomatic complaints among adolescents with an immigration background, from low SES families, and girls when compared with natives, adolescents from middle and high SES families, and boys. Accordingly, based on an additive model, irrespective of the national context, we would expect the highest levels of both variables among low SES immigrant girls and the lowest among high SES native boys.

Table 1 Main effect regression coefficients for individual characteristics

Models are additionally adjusted for age and survey country. Individuals are nested in strata based on their immigration background, SES, and gender. Main effect parameters are comparable for other models tested and can be found in Table 3 in the Appendix. Bayesian 95% Credible Interval in parentheses. Natives, low family SES, and boys were set as the reference groups.

SES = socioeconomic status.

Discriminatory accuracy

Table 2 shows that for all estimated null models, VPCs were relatively modest, ranging from 3.1% to 6.4%. These show that immigration background, SES, gender, the national context variables, and their combinations contribute to individuals' life dissatisfaction and psychosomatic complaints but are by no means the only contributing factors.

The interplay of immigration background, SES, and gender

We did not find evidence for intersectional effects at all when investigating the interplay between immigration background, SES, and gender across all national contexts. PCV scores for both outcome variables revealed that differences between the 12 social strata are almost entirely (98.4% for Life Dissatisfaction and 99.9% for Psychosomatic Complaints) accounted for by cumulative (additive) main effects ( Table 2). In line with this, for neither life dissatisfaction nor psychosomatic complaints did any of the residuals associated with the 12 strata significantly differ from zero (see Figures 1 and 2 in the Appendix).

Table 2 PCV and VPC scores of the four models tested

MIPEX = Migrant Integration Policy Index; PCV = Proportional Change in Variance; VPC = variance partition coefficient.

Cross-country variation in the interplay between immigration background, SES, and gender

Table 2 shows that although PCV scores are generally lower when national context is considered, most interstrata differences can still be explained by additive main instead of intersectional effects. In line with this, only 24 of 216 stratum-level residuals significantly differed from zero (see Table 3 for an integrated summary of the stratum-level residuals displayed in Figure 3-8 in the Appendix).

General intersectionality in models investigating the interplay between national-level immigration and integration policies, immigration background, SES, and gender amounted to 4.3% for life dissatisfaction and 1.5% for psychosomatic complaints ( Table 2). Examination of stratum-level residuals revealed that in low and medium MIPEX countries (i.e., countries with relatively restrictive immigration and integration policies), low SES immigrant girls did worse on life dissatisfaction than predicted by a purely additive model, whereas specific groups of native girls (low SES native girls in low MIPEX countries and high SES native girls in medium MIPEX countries) did better than predicted. Conversely, in high MIPEX countries, high SES native boys did significantly worse than expected on life dissatisfaction, whereas low SES immigrant boys did significantly better. For psychosomatic complaints, only two stratum-level residuals showed significant intersectional effects. As we saw for life dissatisfaction, particularly low SES native girls were doing significantly better than expected in low MIPEX countries, whereas the same group was doing significantly worse than expected in medium MIPEX countries ( Table 3 and Figures 3 and 4 in the Appendix).

General intersectionality in models investigating the interplay between national-level income equality and immigration background, SES, and gender was even lower, with 2.8% for life dissatisfaction and .7% for psychosomatic complaints ( Table 2). Obtained stratum-level residuals revealed that in highly income equal countries, high and middle SES native boys did significantly worse, and low SES immigrant girls did significantly better on life dissatisfaction. In contrast, in countries with low levels of income equality, low SES immigrant girls scored significantly worse on life dissatisfaction than would be expected based on an additive model. Similar to life dissatisfaction, in highly income equal countries, high SES native boys showed more psychosomatic complaints than would be expected based on an additive model, whereas in countries with low levels of income equality, this same group showed fewer problems ( Table 3 and Figures 5 and 6 in the Appendix).

General intersectionality in models investigating the interplay between national-level gender equality, immigration background, SES, and gender amounted to 8.7% for life dissatisfaction and 3.5% for psychosomatic complaints ( Table 2). Inspection of stratum-level residuals revealed some seemingly counterintuitive results ( Table 3 and Figures 7 and 8 in the Appendix). These residuals showed that, in the most gender-equal countries, high SES girls, both immigrant and native, scored significantly worse on life dissatisfaction than would be expected based on additive effects. In contrast, in those same countries, low SES boys, both immigrant and native, scored significantly better than predicted. In countries with low levels of gender equality, the reverse was found to be true: low SES immigrant boys scored significantly worse, whereas high SES native girls scored significantly better than would be expected based on additive effects. For psychosomatic complaints, somewhat comparable patterns were found. As seen for life dissatisfaction, the only group in countries with low levels of gender equality doing significantly worse than would be expected based on an additive model were low SES immigrant boys. In those same countries, native girls were again doing better than would be expected. However, now this was only true for native girls with middle and low (instead of high) SES. In contrast, in countries with medium gender equality, low SES native girls reported significantly more psychosomatic complaints than would be expected .

Table 3 Significant intersectional effects for the interplay between immigration background, SES, gender, and the national context

Empty cells with "-" indicate no evidence for intersectional effects.

MIPEX = Migrant Integration Policy Index; SES = socioeconomic status.

Discussion

In the present study, we examined the interplay between immigration background, SES, and gender on adolescent mental well-being across 33 countries. We also examined national-level variations in this interplay, according to immigration and integration policies, income equality, and gender equality. As expected, across all national contexts, being a member of any of the three disadvantaged social groups (i.e., immigrants, adolescents from low SES families, and girls) increased scores for life dissatisfaction and psychosomatic complaints, in comparison to adolescents from less disadvantaged groups (i.e., natives, adolescents from middle- and high SES families, and boys). In line with the multiple jeopardy hypothesis [

], we conjectured that being a member of multiple disadvantaged social groups would have an aggravated (and not just additive) negative effect. However, no such effect and no evidence for intersectionality, in general, was found when examining the interplay without allowing it to vary between different national contexts: members of particular combinations of social groups did not report better or worse mental health than expected based on just adding up effects from separate social group memberships. However, when allowing this interplay to vary based on country-level immigration and integration policies, income equality, and gender equality, we did find evidence for intersectionality.

The observed lack of intersectional effects when examining the interplay between immigration background, SES, and gender over all national contexts might be because of its context dependency. While, for instance, in high gender equality countries, high SES native girls did significantly worse and low SES immigrant boys significantly better on life dissatisfaction than would be expected by an additive model, the exact opposite was the case for both groups in low gender equality countries. These intersectional effects in opposite directions depending on the national context might have canceled each other out. Results like this are relatively numerous in our findings and highlight the importance of taking the national context into consideration when investigating this interplay.

Although small in number, and accounting only for a small share of the overall social inequalities in adolescent mental well-being, the intersectional effects that were found for different national contexts are nevertheless meaningful and warrant some further exploration. In line with our hypotheses, we found aggravated negative effects of membership in multiple disadvantaged social groups in national contexts that were characterized by low levels of immigrant inclusivity and economic equality. Conversely, in those same countries, members of multiple privileged social groups were doing better than expected based on an additive model. Interestingly, in countries with high levels of immigrant inclusivity and income equality, members of multiple disadvantaged social groups were actually doing better than would be predicted by an additive model. Conversely, in those same countries, members of multiple privileged social groups were doing worse than would be expected based on an additive model. Possibly, vulnerable groups have a better chance of optimal development in countries that attempt to reduce social inequalities by focusing on inclusive immigration and integration policies and restricting income inequality than in other countries. Such contexts may reduce traditional real or symbolic privileges for advantaged groups.

To illustrate, in countries with relatively restrictive immigration policies, a clear aggravated negative effect was found in that the most disadvantaged group (i.e., low SES immigrant girls) reported more life dissatisfaction than expected based on additive effects. Conversely, in countries with the most inclusive immigration policies, a relatively disadvantaged group, that is low SES immigrant boys, showed less life dissatisfaction than an additive model would suggest, while the most privileged group (i.e., high SES native boys) reported more life dissatisfaction than would be expected. Similar intersectional patterns were found when examining income equality. Privileged high SES native boys showed more life dissatisfaction and more psychosomatic complaints in countries with high levels of income equality, whereas they showed less psychosomatic complaints than would be expected in countries with low levels of income equality. Conversely, low SES immigrant girls growing up in countries with the lowest national-level income equality showed higher life dissatisfaction, whereas the same group of girls reported less life dissatisfaction than expected in countries with high levels of income equality.

In the case of gender equality too, some evidence was found for the notion that aggravated negative effects of membership in multiple disadvantaged social groups are less likely in more equal contexts. However, what stood out here was the finding that high SES girls, either with or without an immigration background, were reporting more life dissatisfaction than expected in highly gender-equal countries, whereas low SES boys, again either with or without an immigration background, were reporting less life dissatisfaction than an additive model would suggest in this national context. Conversely, in countries with low levels of gender equality, low SES immigrant boys did worse than would be expected on life dissatisfaction and psychosomatic complaints and high SES native girls better on life dissatisfaction. In those same countries, less psychosomatic complaints than would be expected were reported by middle and low SES native girls. Previous literature has suggested that gender equality is positive for adolescent life satisfaction, and that this effect is significant for boys and girls even when controlling for national wealth and income equality [

]. However, the current findings suggest that high SES girls may not benefit from gender equality, whereas it is the low SES boys that do. A comprehensive understanding of the reasons behind this is beyond the scope of the paper, yet we can suggest some preliminary understandings. In line with previous studies and theory [

], we suggest that high levels of gender equality may actually place a burden on high SES girls, as they may simultaneously feel pressure to fulfill traditional gender roles as well as to achieve academically and succeed. This relates to a concept that has been termed the "superwoman ideal" [

]. This may be especially acute in adolescence, as young people are still trying to consolidate a gender identity [], based on identification and internalization of familial and social role models. At the same time, high levels of gender equality might place less emphasis on competition and masculine dominance [

], which may particularly put less pressure on the socially disadvantaged groups of boys (i.e., low SES immigrant boys).

There are some limitations to the present study. There are limits to the instruments we were able to use. In particular, the item "Are you a girl or a boy?" may conflate sex and gender and does not allow for a third option, accordingly some adolescents might have been unable to answer the question and had to be excluded from subsequent analyses or were misclassified. Furthermore, because the most up to date information on immigration and integration policies was from the year 2014, we cannot rule out that changes in these policies in the meantime might have led us to misclassify some countries as more or less inclusive than they are today. However, we want to argue that such misclassifications are not likely because the overall MIPEX score is a composite measure generated from 167 indicators from eight policy areas. Accordingly, although the different indicators may fluctuate over time, it seems unlikely that many of them have changed in such a short period. Furthermore, for our analyses, MIPEX scores were categorized into tertiles, and as such, to affect our results, changes would have had to be large enough to move a country from one category into another. In addition, although our outcomes have been used in ample former studies showing associations with relevant constructs for adolescents throughout Europe [,

], they are not without weaknesses. Although the Cantril ladder, which we used to assess life dissatisfaction, has been shown to have a good reliability and convergent validity among adolescents [], it might be susceptible to language effects and cultural measurement bias. Similarly, although our measure of psychosomatic complaints has adequate test-retest reliability and psychometric properties [], it might be prone to recall bias. Although these weaknesses are unlikely to have substantially contributed to the observed interaction patterns, we cannot rule out entirely that the results may have been impacted by differences in the validity of the instruments between different social groups and national contexts. In addition, our study would have benefited from the inclusion of mental ill-health indicators, such as anxiety, depression, ADHD, or conduct problems, as this would have provided us with a more complete picture of adolescent mental health. To test the generalizability of our findings, we encourage future studies to replicate our analyses with variables tapping into different aspects, or correlates (such as social relations), of adolescent mental health.

Another limitation lies in the fact that our sample largely consists of European countries, as such, results might not be generalizable to other world regions. A further limitation is the relatively small number of investigated dimensions. The inclusion of different individual and context characteristics, such as sexual orientation, ethnicity, or local or regional level area deprivation might have led to different findings. Finally, some caution is warranted regarding the distinction between qualitative differences in the lived experiences of individuals occupying particular intersections and quantitative differences in their scores on the investigated outcome variables. Qualitative research might deliver a more in-depth picture of the categories adolescents employ in making sense of society and their place in it and how they experience membership in combinations of those categories.

Using a novel methodological approach on a uniquely large scale, cross-nationally comparative sample, we were able to investigate the interplay between immigration background, SES, and gender on adolescent mental well-being and the variation in this interplay between different national contexts. Our research clearly showed that immigrants, adolescents from low SES families, and girls had a higher risk for reporting low mental well-being. Over all national contexts, no evidence of intersectional effects between those social group memberships was found. However, when allowing for potential variation in this interplay between different national contexts, we did find evidence for intersectionality. Particularly, findings suggest that in immigrant inclusive and income equal countries, members of multiple privileged social groups are doing worse and members of multiple disadvantaged social groups are doing better than would be expected based on a purely additive model. Albeit in different directions, both these processes reduce social inequalities in adolescent mental well-being in more inclusive and equal countries. Future studies are encouraged to further test the context dependency of the intersection of multiple social group memberships, particularly focusing on other indicators on the national level such as the quality of support or services and more proximal environments, such as the schools and school classes. On a policy level, findings support the importance of policies that encourage the mental well-being of immigrants, adolescents growing up in low SES families and girls. Schools particularly can also be encouraged to develop resilience programs for young people who are members of one or more socially disadvantaged groups. In addition, our results suggest the importance of policies that aim to reduce income inequality and stimulate the integration of immigrants to broadly decrease social inequalities in adolescent mental well-being. In addition, findings suggest that special attention should be given to high SES adolescent girls in countries with higher gender equality, as they may be worse off than expected in specifically these countries.

Acknowledgments

Health Behaviour in School-aged Children is an international study carried out in collaboration with WHO/EURO. The International Coordinator was Jo Inchley (University of Glasgow) for the 2017/2018 survey. The Data Bank Manager was Professor Oddrun Samdal (University of Bergen). The 2017/2018 survey included in this study were conducted by the following Principal Investigators in the 33 countries: Albania (Gentiana Qirjako), Austria (Rosemarie Felder-Puig), Azerbaijan (Gahraman Hagverdiyev), Belgium (Flemish: Bart De Clercq; French: Katia Castetbon), Bulgaria (Lidiya Vasileva), Croatia (Ivana Pavic Simetin), Czech Republic (Michal Kalman), Denmark (Mette Rasmussen), Estonia (Leila Oja, Katrin Aasvee), Finland (Jorma Tynjälä), Germany (Matthias Richter), Greece (Anna Kokkevi), Hungary (Ágnes Németh), Iceland (Arsaell M. Arnarsson), Ireland (Saoirse Nic Gabhainn), Italy (Franco Cavallo), Kazakhstan (Shynar Abdrakhmanova and Valikhan Akhmetov), Luxembourg (Helmut Willems), Malta (Charmaine Gauci), The Netherlands (Gonneke Stevens and Saskia van Dorsselaer), Norway (Oddrun Samdal), Poland (Joanna Mazur), Portugal (Margarida Gaspar de Matos), Republic of Moldova (Galina Lesco), Romania (Adriana Baban), Russia (Anna Matochkina), Serbia (Jelena Rakic), Slovenia (Helena Jericek), Spain (Carmen Moreno), Sweden (Petra Lofstedt, Lilly Augustine), Switzerland (Marina Delgrande-Jordan and Hervé Kuendig), Ukraine (Olga Balakireva), United Kindgom (Scotland: Jo Inchley; Wales: Chris Roberts).

Funding Sources

The collection of HBSC 2018 data was financed by each member country individually. There was no direct funding for this paper.

# data[].attributes.attachment_link.title
Intersectionality and Adolescent Mental Well-being: A Cross-Nationally Comparative Analysis of the Interplay Between Immigration Background, Socioeconomic Status and Gender

# data[].attributes.attachment_link.description
Intersectionality theory highlights the importance of the interplay of multiple social group memberships in shaping individual mental well-being. This article investigates elements of adolescent mental well-being (life dissatisfaction and psychosomatic complaints) from an intersectional perspective.

# data[].attributes.attachment_link.title
Cultural Humility | Juliana Mosley, Ph.D. | TEDxWestChester

# data[].attributes.headline
Research around addressing issues of race, ethnicity and culture within CBT

# data[].attributes.subject
Research around addressing issues of race, ethnicity and culture within CBT

# data[].attributes.attachment_link.title
Addressing issues of race, ethnicity and culture in CBT to support therapists and service managers to deliver culturally competent therapy and reduce inequalities in mental health provision for BAME service users | the Cognitive Behaviour Therapist | Cambridge Core

# data[].attributes.attachment_link.description
Addressing issues of race, ethnicity and culture in CBT to support therapists and service managers to deliver culturally competent therapy and reduce inequalities in mental health provision for BAME service users - Volume 12

# data[].attributes.attachment_link.title
BBC One - Panorama, Let’s Talk about Race

# data[].attributes.attachment_link.description
Naga Munchetty travels across the UK to understand what race and racism mean today.

# data[].attributes.headline
Video: Privilege/Class/Social Inequalities Explained in a $100 Race

# data[].attributes.subject
Video: Privilege/Class/Social Inequalities Explained in a $100 Race

# data[].attributes.body
What are your reflections as you watch?

# data[].attributes.attachment_link.title
Social Inequalities Explained in a $100 Race - Please Watch to the End. Thanks.

# data[].attributes.headline
OTR Bristol Project ZAZI: The Amplify Podcast

# data[].attributes.subject
OTR Bristol Project ZAZI: The Amplify Podcast

# data[].attributes.body
Amplifying Voices, Facilitating Change

# data[].attributes.attachment_link.description
Listen to The Amplify Podcast with Project Zazi on Spotify.

# data[].attributes.attachment_link.title
The urgency of intersectionality | Kimberlé Crenshaw | TED

# data[].attributes.attachment_link.title
Reni Eddo-Lodge: Why I'm No Longer Talking to White People About Race

# data[].attributes.attachment_link.title
The Diversity and Inclusion Calendar 2023 | Inclusive Employers

# data[].attributes.attachment_link.description
Never miss an important date with our comprehensive calendar of diversity and inclusion events, festivals and occasions.

# data[].attributes.headline
White Privilege: Unpacking the Invisible Knapsack 

# data[].attributes.subject
White Privilege: Unpacking the Invisible Knapsack 

# data[].attributes.body
Taking an intersectional view:

On your own, spend 5 minutes thinking about your own intersectional experiences. Consider any oppression, discrimination and privilege within this.

The technique: Serial testimony

- What are one or more ways in which you've had unearned disadvantage in your life?

- What are one or more ways in which you've had unearned advantage in your life?

- What is it like for you to think about these experiences of unearned advantage and disadvantage?

# data[].attributes.headline
Cultural Awareness in Clinical Psychology Podcast

# data[].attributes.subject
Cultural Awareness in Clinical Psychology Podcast

# data[].attributes.body
https://www.whataboutuspodcast.com/

# data[].attributes.attachment_link.title
Podcast | What About Us | University Of Bath

# data[].attributes.attachment_link.description
What about us? Cultural Awareness in Clinical Psychology is a podcast hosted by Afsana Faheem (Lecturer) and Dr Kate Cooper (Clinical Psychologist and Researcher). Each month, we chat with people from diverse backgrounds who have a keen interest in diversifying the clinical psychology profession and mental health services.

# data[].attributes.headline
Research around addressing issues of race, ethnicity and culture within CBT

# data[].attributes.subject
Research around addressing issues of race, ethnicity and culture within CBT

# data[].attributes.attachment_link.title
Addressing issues of race, ethnicity and culture in CBT to support therapists and service managers to deliver culturally competent therapy and reduce inequalities in mental health provision for BAME service users | the Cognitive Behaviour Therapist | Cambridge Core

# data[].attributes.attachment_link.description
Addressing issues of race, ethnicity and culture in CBT to support therapists and service managers to deliver culturally competent therapy and reduce inequalities in mental health provision for BAME service users - Volume 12

# data[].attributes.body
Your Kids Aren't Too Young to Talk About Race: Resource Roundup — Pretty Good (prettygooddesign.org)

# data[].attributes.attachment_link.title
Your Kids Aren't Too Young to Talk About Race: Resource Roundup - Pretty Good

# data[].attributes.attachment_link.description
Your kids aren't too young to talk about race. Here are a few resources to get your started.

# data[].attributes.attachment_link.title
Cultural adaptation of CBT as a human rights issue: A UK study

# data[].attributes.attachment_link.description
Cognitive behaviour therapies have been used widely across the world and have been recommended as the first line of psychotherapeutic treatment for multiple mental health disorders. However, such blanket guidelines for use of Western-generated psychotherapies discount the socio-cultural determinants and aspects of mental health when recommended unadapted across ethnicities, eventually creating disparities in the quality of care available to different populations. Examining the cultural relevance of these therapies for ethnic minority groups has therefore become an important avenue of inquiry.Recent decades have brought a revolution of cultural competency and adaptation research for such psychotherapies. Despite recent advances in cultural competency and adaptation research, the available body of literature in this domain remains limited and heterogenous. Furthermore, the lack of mandatory cultural competence training and the ineffectiveness of existing programmes increase the obvious discrepancy in the provision of mental healthcare services for certain minority groups, jeopardising equitable access and raising concerns about human rights protection.AimsThis study aimed to explore UK-based CBT therapists’ use of adaptations in their own practice, and understand what elements they tend to adapt, the impact and feasibility of their approaches, and the challenges faced by those who adapt and those who do not. The larger intention was to be able to gather information to recommend basic direction for policy and research to create plans for the benefit of ethnic minority groups for whom access to quality, tailored healthcare is currently largely overlooked.MethodThe study involved developing a survey informed by existing literature and distributing it to UK-based CBT therapists.ResultsThis study found that CBT therapists and their clients value cultural competency. It also found that therapists tend to believe that adapting CBT techniques and implementation and using culturally significant idioms and stories are impactful for their clients and practical to achieve as therapists. It further found that current barriers to adapting CBT for ethnic minority clients involves a lack of resources to study the efficacy of adaptations as well as a lack of well-established evidence-based adaptations in existing literature.ConclusionThe authors recommend that policymakers and service managers prioritise the regulation of cultural competence in psychotherapy and afford resources and incentive to researchers and clinicians that would eventually help to improve the effectiveness of their approaches and enhance mental health outcomes for ethnic minority groups. Future research could build on this study using qualitative methods or creating more robust surveys, using random sampling, and drawing larger sample sizes.

# data[].attributes.headline
Video for explaining intersectionality to CYP

# data[].attributes.subject
Video for explaining intersectionality to CYP

# data[].attributes.body
Thought this might be a useful resource, I've used in schools before and we signposted a lot at YoungMinds.

# data[].attributes.attachment_link.readable_text
We empower young people and educators across the UK to engage with Black British history 365 days a year.

One of our main goals since 2019 has been to embed Black histories into the UK national curriculum.

# data[].attributes.attachment_link.description
We empower young people and educators across the UK to engage with Black British history 365 days a year. One of our main goals since 2019 has been to embed Black histories into the UK national curriculum.

# data[].attributes.headline
Adapting Behavioural Activation for the Treatment of Depression in Muslims

# data[].attributes.subject
Adapting Behavioural Activation for the Treatment of Depression in Muslims

# data[].attributes.attachment_link.readable_text
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

doi: 10.1016/j.jad.2015.03.060.

Affiliations

1 Leeds Institute of Health Sciences, University of Leeds, United Kingdom. Electronic address: G.mir@leeds.ac.uk.

2 Leeds Institute of Health Sciences, University of Leeds, United Kingdom.

3 Centre for Health and Population Sciences, University of York, United Kingdom.

4 Department of Psychology, University of Washington, United States.

Free article

Free article

doi: 10.1016/j.jad.2015.03.060.

Affiliations

1 Leeds Institute of Health Sciences, University of Leeds, United Kingdom. Electronic address: G.mir@leeds.ac.uk.

2 Leeds Institute of Health Sciences, University of Leeds, United Kingdom.

3 Centre for Health and Population Sciences, University of York, United Kingdom.

4 Department of Psychology, University of Washington, United States.

Abstract

Background: Incorporating religious beliefs into mental health therapy is associated with positive treatment outcomes. However, evidence about faith-sensitive therapies for minority religious groups is limited.

Methods: Behavioural Activation (BA), an effective psychological therapy for depression emphasising client values, was adapted for Muslim patients using a robust process that retained core effective elements of BA. The adapted intervention built on evidence synthesised from a systematic review of the literature, qualitative interviews with 29 key informants and findings from a feasibility study involving 19 patients and 13 mental health practitioners.

Results: Core elements of the BA model were acceptable to Muslim patients. Religious teachings could potentially reinforce and enhance BA strategies and concepts were more familiar to patients and more valued than the standard approaches. Patients appreciated therapist professionalism and empathy more than shared religious identity but did expect therapist acceptance that Islamic teachings could be helpful. Patients were generally enthusiastic about the approach, which proved acceptable and feasible to most participants; however, therapists needed more support than anticipated to implement the intervention.

Limitations: The study did not re-explore effectiveness of the intervention within this specific population. Strategies to address implementation issues highlighted require further research.

Conclusions: The adapted intervention may be more appropriate for Muslim patients than standard therapies and is feasible in practice. Therapist comfort is an important issue for services wishing to introduce the adapted therapy. The fusion of conceptual frameworks within this approach provides increased choice to Muslim patients, in line with policy and research recommendations.

Keywords: Behavioural activation; Culture; Depression; Muslim; Psychotherapy; Religion.

PubMed Disclaimer

Similar articles

The perceived role of Islam in immigrant Muslim medical practice within the USA: an exploratory qualitative study.

Padela AI, Shanawani H, Greenlaw J, Hamid H, Aktas M, Chin N. Padela AI, et al. J Med Ethics. 2008 May;34(5):365-9. doi: 10.1136/jme.2007.021345. J Med Ethics. 2008. PMID: 18448718

Behavioural activation therapy for post-stroke depression: the BEADS feasibility RCT.

Thomas SA, Drummond AE, Lincoln NB, Palmer RL, das Nair R, Latimer NR, Hackney GL, Mandefield L, Walters SJ, Hatton RD, Cooper CL, Chater TF, England TJ, Callaghan P, Coates E, Sutherland KE, Eshtan SJ, Topcu G. Thomas SA, et al. Health Technol Assess. 2019 Sep;23(47):1-176. doi: 10.3310/hta23470. Health Technol Assess. 2019. PMID: 31524133 Free PMC article. Clinical Trial.

Cited by

Randomized control trial of a culturally adapted behavioral activation therapy for Muslim patients with depression in Pakistan.

Dawood S, Mir G, West RM. Dawood S, et al. World J Psychiatry. 2023 Aug 19;13(8):551-562. doi: 10.5498/wjp.v13.i8.551. eCollection 2023 Aug 19. World J Psychiatry. 2023. PMID: 37701541 Free PMC article. Clinical Trial.

Exploratory RCT of a group psychological intervention for postnatal depression in British mothers of South Asian origin - ROSHNI-D.

Husain N, Lunat F, Lovell K, Sharma D, Zaidi N, Bokhari A, Syed A, Tomenson B, Islam A, Chaudhry N, Waheed W. Husain N, et al. Acta Psychol (Amst). 2023 Aug;238:103974. doi: 10.1016/j.actpsy.2023.103974. Epub 2023 Jul 4. Acta Psychol (Amst). 2023. PMID: 37413896 Free PMC article. Clinical Trial.

# data[].attributes.attachment_link.keywords[]
national center for biotechnology information

# data[].attributes.attachment_link.title
Adapted behavioural activation for the treatment of depression in Muslims - PubMed

# data[].attributes.attachment_link.description
The adapted intervention may be more appropriate for Muslim patients than standard therapies and is feasible in practice. Therapist comfort is an important issue for services wishing to introduce the adapted therapy. The fusion of conceptual frameworks within this approach provides increased choice ...

# data[].attributes.attachment_link.readable_text
Equality versus Equity: What's the difference as we #EmbraceEquity for IWD 2023 and beyond?

The words equity and e quality are often used interchangeably.

Etymologically, the root word they share is aequus, meaning "even" or "fair" or "equal" - which led to equity being from the Latin aequitas, and equality from aequalitas. Yet, despite these similarities, equity and equality are inherently different concepts, and the IWD 2023 #EmbraceEquity campaign theme seeks to help forge worldwide conversation about this important issue and its impact.

So, what's the difference between equity and - and why is it important to understand, acknowledge and value this?

The IWD 2023 #EmbraceEquity campaign theme seeks to get the world talking about why "equal opportunities are no longer enough" - and can in fact be exclusionary, rather than inclusive.

Defining equality and equity

Image source: Robert Wood Johnson Foundation

Let's start with a basic definition of each word.

Equality means each individual or group of people is given the same resources or opportunities.

Equity recognizes that each person has different circumstances, and allocates the exact resources and opportunities needed to reach an equal outcome.

Examples of key differences

Let's hear from Belgium-based YouTuber Tamara Makoni, founder of Kazuri Consulting as she clearly explains the difference between equality and equity - and why it truly matters to #EmbraceEquity.

"Imagine that you are babysitting two children, and they are hungry. You go to the fruit bowl, and you start to pick up two apples to give them to each child. However, you remember at the last moment that one of the children is allergic to apples. Instead, you reach for one apple and one banana, and that way you're being fair," explains Tamara. "You still give one piece of fruit to each child, but you're also being equitable because you're giving each child a legitimate way of satisfying their hunger. If you had gone for two apples, the child who's allergic to the apple would on the surface have a way to satisfy their hunger, but they couldn't do that without getting ill. In this way you're being fair," says Tamara. "You're giving each child a piece of fruit but, you're also giving them something that is in line with their individual needs so they can be successful."

Articulating the difference between equality and equity

Equity can be defined as giving everyone what they need to be successful. In other words, it's not giving everyone the exact same thing. If we give everyone the exact same thing, expecting that will make people equal, it assumes that everyone started out in the same place - and this can be vastly inaccurate because everyone isn't the same.

The concept of ' fairness' can get tricky as it's often assumed that 'being fair' means that everybody gets the same thing. Often, this has been taught when we were growing up, but 'fairness' really only works when we're all the same to start out with.

Early examples in history

One of the earliest examples of equity is found in Medieval England, when English courts settled disputes according to Common Law. Justice was uniform and consistent, but not necessarily fair. For example, if two people both commit theft, but the stolen items have different value, should they receive the same punishment? Since then, Courts have adopted the principle of equity, taking a case-by-case approach to consider differing circumstances.

Equality and equity as political principles

In political terms, equality is one of the foundations of democracy. Equality is based on the belief that all people should have the same opportunities for a happy life. Equity is linked to the ideal that success is based on personal efforts and not social status.

However, ongoing conversation highlights whether equality is enough, and if instead we should look towards equity as a better principle to progress society. Equity acknowledges that people don't begin life in the same place, and that circumstances can make it more difficult for people to achieve the same goals.

Inequity affects many people, but most commonly historically it has marginalized communities such as women, people of color, disabled people, the economically disadvantaged, and those from the LGBTQ+ community.

The goal of equ ity is to change systemic and structural barriers that get in the way of people's ability to thrive.

Equity-based verses equality-based solutions

People who push for equality-based solutions to social issues may believe in impartiality, and that there should be no difference in services and policies.

However, equity-based solutions take into account the diverse lived experiences of individuals and communities, adapting services and policies according to these differences.

Equity is a long-term and sustainable solution, and is a process for addressing imbalanced social systems.

Applying equity to women's advancement

Equality focuses on providing all genders with equal opportunities, such as a woman's right to vote. Yet, women often require more than a level playing field. They need to belong in a global culture that actively promotes and supports them in all aspects of their life, from education to the workplace to health.

Gender is intersectional, and women as a group are truly diverse. Policies that benefit white women, for example, may not benefit women of color due to historical or current inequalities. A shift from gender equality to the process of gender equity is required for meaningful progress.

Working towards true inclusion

Leadership and inclusion specialist and former Criminal Barrister, Sharon Amesu, clarifies: "When we're talking about embracing equity, it's so important that we distinguish between Equity and Equality. Both are important, but they are very different. Here's why it's important to know the difference."

Let's also hear more about equity versus equality from Cammy Watkins through the Conversations for Change series by Inclusive Communities.

Show #EmbraceEquity videos as part of your IWD activity

Around the world people are having meaningful conversations about why equal opportunities aren't enough, and why equal isn't always fair. People start from different places, so true inclusion and belonging require equitable action. If we truly believe in, value and embrace equity, then women are more likely to have access to what's required to succeed. So on IWD engage in those impactful conversations. Raise awareness. Help forge positive change for women.

If you truly believe in forging an equal and inclusive world, then you will truly believe in the need for the world to better understand the difference between equity and equality.

Make it your mission to educate friends, family, colleagues, and the community on the need for equity.

Here's a quick TOP 10 #EmbraceEquity Videos to consider watching and showing.

Let's #EmbraceEquity - together!

# data[].attributes.attachment_link.title
Equality versus Equity: What's the difference as we #EmbraceEquity for IWD 2023 and beyond?

# data[].attributes.attachment_link.description
What's the difference between EQUALITY & EQUITY? What does the International Women's Day (IWD) 2023 #EmbraceEquity theme mean? What are some examples? Belgium-based YouTuber Tamara Makoni founder of Kazuri Consulting explains the differences between equity (the journey) & equality (the outcome)

# data[].attributes.body
Please add to this if you find anything helpful that you would like to share from today

# data[].attributes.attachment_link.title
Day 9 AM Working inclusively with CYP  families presentation slides (4)

# data[].attributes.body
Please remember to register your attendance via the My Exeter app. You will need to do this for both the AM and PM sessions.

MyExeter App | Current Students | University of Exeter.

# data[].attributes.body
Morning everyone,

Welcome to today's session.

We are delighted to welcome our guest speaker, Indiana Montaque, who will talk you through content related to working inclusively with CYP and families (including race, spirituality and culture), and cultural diversity core concepts. This is part of your Module 1 content.

Please join the zoom link as usual at 09:30 which can be found via the My Exeter app.

If anyone has any questions about this session or would like any support, please contact:

A.Gladders@exeter.ac.uk.