As part of the Government's Improving Access to Psychological Therapies (IAPT) agenda, group-based interventions have been rolled out through local mental health services across England. NICE guidance CG90 for recognition and management of depression in adults, has recommended group therapy for those with persistent sub-threshold depressive symptoms or mild to moderate depression.
In pursuit of this agenda, and recognising that BME communities face particular and culturally sensitive barriers to accessing these services, Birmingham and Solihull Mental Health NHS Foundation Trust, through the local ‘Birmingham Healthy Minds’ initiative, has adapted their local service. We have developed a culturally sensitive treatment group where patients can feel that their ethnic, cultural and spiritual beliefs were understood by the group facilitator and where specific barriers to access for these communities are addressed.
Aims and objectives
The aim of this initiative was, and continues to be, to increase the number of people being treated using evidence-based approaches within primary care.
Reasons for implementing your project
Birmingham Healthy Minds IAPT service provides brief psychological therapies for people aged 16 and over, in the form of psycho-educational groups for those meeting the criteria for step 2: a service user experiencing mild to moderate levels of depression and anxiety. Within the IAPT service these groups were not necessarily tailored or adapted for ethnic minority groups whose language and levels of literacy prevented people from engaging in therapy. Within the population that Birmingham and Solihull Mental Health Foundation Trust provides a service, 28.79% are from BME communities.
This is of particular relevance to the BME communities served by Birmingham Healthy Minds and especially a sub group of South Asian migrant women who tend to underutilise mental health services and whom are particularly difficult to reach, due to linguistic and cultural barriers. In particular, their lack of fluency in English and social support proves it difficult to obtain help (Gater, 2010). Other than Psychoeducational interventions on help seeking, there are no reported interventions for South Asian Women in the UK.
In IAPT service step two provides psychological low intensity support for mild to modearate level of depression and anxiety. It was identified that there was a gap in current provision of step two psycho-education groups within the IAPT service for South Asian Community. The South Asian Community were not offered any choice of treatment options such as attendance at evidence based treatment groups. They were only offered the traditional face to face therapy.
To address the gap in provision and to overcome the barriers identified, a psychoeducational group was developed to increase engagement of the South Asian women community within the service. An evidence-based treatment group which was culturally adapted was therefore needed.
In order to increase access for these communities a number of focus groups were arranged. The combined wisdom of staff, managers and service users led Birmingham Healthy Minds to make the following adjustments:
- Develop a culturally sensitive treatment group; where patients could feel that their ethnic, cultural and spiritual beliefs were understood by the group facilitator.
- Address any language barriers or literacy issues that might prevent the uptake of group interventions.
- Encourage uptake by the South Asian community; particularly women from the South Asian community.
- Increase the confidence of Psychological Wellbeing Practitioners (PWP) in delivering interventions in languages other than English. Therapy (CBT) continues to evolve, it is important that these developments are able to increase the engagement of the BME population.
Given that treatment choice and methods of delivering Cognitive Behavioural Therapy (CBT) continues to evolve, it is important that these developments are able to increase the engagement of the BME population.
How did you implement the project
The group offers support for patients with anxiety and depression. The Group set-up is informed by NICE guidance treatment recommendations in section 1.5 of NICE CG90 for persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression.
The group offers eight, three hourly, weekly sessions to deliver a group based intervention for South Asian women and is facilitated by 2 Psychological Wellbeing Practitioners who speak Hindi, Urdu, Punjabi or Bengali. Sessions are held in community centres in order to reduce the stigma and peoples’ reluctance to engage with mental health services (Sue & Sue, 2003).
The Group Adaptations: (what we did differently to other psycho-education groups to engage south Asian communities).
Psychoeducation interventions as outlined by NICE CG90 were used to help service users to understand their mental health. Psychoeducation of common mental health problems such as depression, anxiety, stress, panic and worry was provided. Pain management and sleep hygiene was incorporated into the sessions.
Tackling physical health
Extensive research indicates that culture is a significant predictor of somatic expression of distress, with non-western cultures reporting higher levels of somatic symptoms than western cultures (Sheikh & Furnham, 2012) and somatisation being particularly high in the Pakistani and Indian communities (Balarajan, Yuen & Raleigh 1991). This was echoed in the group with majority of the South Asian Women somatising their distress.
Strong links between somatisation and GP visits have been found; which adds to the increasing pressure and demands within primary care. Given these factors, it was paramount to address somatisation and psychological distress in the group in order to reduce GP visits and to allow long term management of their distress.
Pain management techniques were further incorporated as some patients present with chronic pain. Despite these developments, somatisation for depression within the Asian community within primary care still remained problematic. Therefore further work is needed to address the impact of long-term health conditions within the care pathway of all affected service users. Currently within BHM we have a long-term conditions (LTC) and medically unexplained symptoms (MUS) drop-in session for service users. These sessions are open to people to attend whenever they wish/feel able to, which we find service users value as it prevents people being discharged due to DNA or cancelled appointments that can occur more frequently in this client group. This approach can be adapted to meet the needs of BME service users with limited English or no English. This is probably one of the most difficult groups for services to engage, or for them to commit to ongoing therapy, because of the physical health difficulties, a lack of understanding of the relationship between physical and psychological heath in these service users and how LTCs and MUS symptoms affect IAPT recovery rates.
Behavioural Activation and Cognitive Restructuring
Emphasis was placed on adapting behavioural interventions such as Behavioural Activation and Activity Scheduling rather than cognitive interventions as behavioural change can incorporate the service user’s core beliefs and values without modifying values that are integral to south Asian women. This is significantly important for migrant South Asian women. The impact on migration can create significant pressures that are associated with depression as they experience isolation from family and their cultural origins. Evidence suggests immigration can increase the psychological and social vulnerability to depression (Bhugra, 2003).
Using culturally specific examples to depict concepts of CBT was therefore key in engaging clients throughout the workshop. This included drawing on their experiences of being a migrant woman and adjusting to new environments; with new cultural norms and changes in roles and responsibilities within the household.
Behavioural Activation focused on increasing time for prayers and religious practice throughout the day to reduce the sense of helplessness. The lack of fluency in English formed the basis to use visual representations when introducing the cognitive behavioural therapy model. Creating pictorial behavioural activation diaries through magazine cut outs further encouraged social interaction in sessions.
In consideration of the uniqueness of the group and importance of engagement of BME communities as highlighted by McGuire & Miranda (2008), the group requires a small budget for material and resources specific to the activities provided and adaptions of interventions. This budget is fairly small but nevertheless important to successful engaging service users and to their clinical recovery rate.
IAPT define recovery as a movement to a score below caseness from a score of caseness or above on the Patient Health Questionnaire (Kruenker, Spitzer and Williams (2001) and the Generalised Anxiety Disorder Scale (Spitzer, Kruenker and Williams (2006). Recovery was therefore measured through qualitative and quantitative analysis.
IAPT adopts a least intrusive intervention principle. Individuals are offered the least intrusive treatment initially at a Low Intensity (step 2) level for those with mild to moderate symptoms, followed by support at High Intensity (step 3) for those with moderately severe – severe symptoms.
Over the last six runs of the workshop, a total of 70 people attended the south Asian womens’ workshop; out of which 56 were identified as suitable for step two interventions and 14 were identified as requiring step three intervention. Analysis shows a recovery rate of 54% for the step two patients who completed the south Asian women’s’ workshop. 3 step three patients (14%) reached recovery by the end of the workshop and 11 step three patients (86%) required further 4-6 sessions of one-to-one therapy. The psychoeducational group therefore appears to be effective in achieving recovery for those with mild-moderate symptoms. Using a feedback form to measure the patient’s experience of the workshop, 95% reported a positive experience of the workshop.
The qualitative feedback from services users also suggests a movement into recovery subjectively. A reduction of symptoms has been identified with patients reporting reduced headaches, improvement in sleep, appetite and better pain management. Social isolation has decreased with patients engaging in mainstream activities. Furthermore meaningful changes have taken place over the duration of the workshop.
Patients described feeling very much at home because of the multi-lingual facilitators. They described enjoying meeting other people and most importantly they reported family members have also noticed a change in their wellbeing. Some further examples of the feedback can be found in table 1.
- “I started to realise that I should not think too much of myself as a depressed and begun understanding the condition more”
- “I was a bit reluctant to join the group but It helped me change my thinking”
- “The group has changed my life, I have found new opportunities to make some use of my existing skills”
- “This isn’t black magic”
- “Because of the group I have made good friends who understand me”
- “I’ve learnt I am not the only one and there is help out there”
- “I really enjoyed the healthy eating session”
This intervention group is therefore an effective intervention for patients with mild–moderate symptoms of depression and anxiety; however those with severe levels of depression and anxiety will require further one-to-one therapy following from this workshop.
Further research is needed to be done by contacting all the service users who attended group in last six months and will aim to look at the longer term effects of this psychoeducational group. This area has not being thoroughly explored or researched yet.
Key learning points
We have shown how CBT can be adapted and delivered in different languages in order to increase and maintain patient engagement in mental health services, whilst providing good clinical outcomes. The recovery rate for this workshop suggests it is an effective intervention for those with mild-moderate depression and anxiety.
It is therefore feasible to deliver a workshop in routine practice to ensure this client group is not isolated from mental health services. This challenges the notion that this client group do not engage in mental health services. Training practitioners further can support this new initiative to ensure practitioners are well equipped with understanding and managing the barriers services may face when engaging with the BME community.
We therefore encourage IAPT services to provide this effective, well received and valued Psycho-educational workshop for the South Asian women community across the UK, where they currently do not have this choice. Since depression and anxiety is prevalent in this population group and treatment is poor, this represents an important development. Conversations should therefore focus on how this unique psycho educational group can be taught and delivered on a wider, national scale to fill a much needed gap in primary care mental health services.