Improving Pathways to Mental Health Care: Amplifying Community Care
Guest Comment by Sorcha Ní Chobhthaigh, Josephine Musanu, & Camille Cox
Structural racism acts as both a risk factor associated with mental health difficulties and as a barrier to appropriate mental health care, often with those experiencing the highest risk being the same individuals and communities that experience the most significant obstacles to accessing care. Racism, as well as discrimination based on ethnicity or migration status, is deeply ingrained in policies, practices and norms, with a cumulative a trickle-down effect across structural, organisation, interpersonal and internalised levels.
Racism has been consistently documented as a predictor of poorer physical and mental health for adults and young people, whether experienced directly or vicariously (Cave et al., 2020; Tao & Fisher, 2022). At the same time, in the UK, minoritised young people access mental health care via different routes. They are more likely to be referred to mental health services via social care and youth justice, than through primary care, and are also more likely to be referred to inpatient and emergency services than their White British peers (Edbrooke-Childs & Patalay, 2019; Chui et al, 2021). As such, minoritised young people in the UK face a compounded burden of discrimination as a risk factor for poor mental health and as a barrier to accessing appropriate care.
However, it does not stop there. Additional barriers exist at the point of treatment, including insufficient language translation, barriers associated with migration status, limited treatment options, as well as a lack of cultural humility among clinicians (NHS Race & Health Observatory, 2022; Lekas et al., 2020). These barriers not only impact how well the service provider and user understand each other but also whether the help provided is right for and meets the needs of the service user, which in turn influences the effectiveness of the support. On top of that though, these barriers likely reinforce feelings of stigmatisation, perceived discrimination and distrust within the health system, further deterring help-seeking. Notably, when minoritised children and young people receive treatment through NHS mental health services, they are less likely to report measurable improvement. Receiving the “right” support from a provider, developing a shared understand of needs and goals is central to that (Ruphrect-Smith et al., 2023).
While it is crucial to understand and interrupt the processes driving these inequities in public sector mental healthcare, we also need to provide immediate solutions to meet the needs of minoritised young people and communities now by leveraging existing resources. There are ample third sector services, that have been serving communities for decades, often with very limited funding, and even less recognition. Community-based efforts to support mental health may also incorporate alternative or holistic approaches to meet different needs and preferences, including mentoring, peer support, stress-release practices or physical activities that promote emotional and behavioural regulation. It is important to respect that some individuals, kinship networks, and communities may feel more open to and safer accessing community-based alternatives, there is a need to understand the availability of services independent from NHS or Local Authority provision or commissioned. However, too often, potential service users do not know what alternatives exist or may be deterred if they do not know how to access them. For service providers, they are faced with an administrative burden of inquiries as well as attempts to reach their target audience.
Existing databases commendably offer some insight into service availability, however, they are limited in scope and can lack information on access or cultural safety (e.g. Hub of Hope). While community-specific (e.g. Bayo) databases are important, there remains a need to understanding what communities are being missed, service desserts or barriers to accessing community support based on access requirements and criteria.
As such, there is a need to amplify and understand gaps in community-based third sector provision, collate not only what exists and the types of support offered, but how to access them. It is necessary to examine whether the services explicitly claim to offer culturally safe, adapted, or at a very minimum, culturally sensitive (Curtis et al., 2019), care, as it may influence individuals attending specific services as well as the efficacy of the therapeutic match. Ultimately, by increasing awareness and transparency around access, this may lead to improved matches between service providers and users, highlight gaps in provision and identify opportunities for partnerships between organisations, facilitating organisations to refer to each other as needed.
In an effort to address this need, we have launched a 'Service Mapping' initiative, with the aim of crowdsourcing a directory of community-based alternatives to mental health support for children and young people. Together, we are a team made up of researchers and experts by experience, working in partnership with an advisory group of community and school-based providers, parent and policy expert. We want to work in partnership with communities, organisations, and support networks to build together a simple, useable Google map that shows what services exist, what support they provide and how to access them. Our hope is that this increases awareness, accessibility, and facilitates finding a better ‘match’ between services and the needs of children [MOU15] and young people, as well as reduce administrative burden and queries to services about eligibility and provision. To start, we are focusing on London and Manchester, in the future we hope to partner with services to expand this to all of England.
To allow community members, service users and providers to contribute the services they know, we have developed a simple survey. It asks for basic information on any community-based services that provide mental health support for children or young people. It takes 2-3 minutes to complete.
Here is a direct link to the survey: https://forms.office.com/e/sBdpLztkiD
Terminology:
Cultural Humility: Cultural humility refers to an attitude or a stance of critical self-reflection, being other-oriented, demonstrated through respect and openness towards an individuals’ conceptualisation of their cultural background and experiences (rather than assuming understanding or expertise) and maintaining a commitment to address power imbalances between patients and providers.
Cultural Safety: Cultural safety refers to practices that acknowledges the inherent power imbalance between service provider and user, and works to address inequalities, biases and stereotypes by proactively creating an environment where individuals feel safe, respected and free from discrimination.
Cultural Adaptation: Modifications made to standard service methods in order to make services more accessible, acceptable and appropriate for a specific population.
Cultural Sensitivity: Awareness of and respect for differences between cultures, beginning self-awareness of internalised ethnocentric, biased and prejudiced beliefs towards other cultures, race and ethnicity as well as the impact they may have on others.
References:
Cave, et al (2020). Racial discrimination and child and adolescent health in longitudinal studies: A systematic review. Social science & medicine, 250, 112864.
Chui, Z., et al (2021). Inequalities in referral pathways for young people accessing secondary mental health services in south east London. European child & adolescent psychiatry, 30(7), 1113-1128.
Curtis, E., Jones, R., Tipene-Leach, D. et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health 18, 174 (2019). https://doi.org/10.1186/s12939-019-1082-3
Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., ... & Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89.
Edbrooke-Childs, J., & Patalay, P. (2019). Ethnic differences in referral routes to youth mental health services. Journal of the American Academy of Child & Adolescent Psychiatry, 58(3), 368-375.
Hook, J. N., Davis, D. E., Owen, J., Worthington Jr, E. L., & Utsey, S. O. (2013). Cultural humility: Measuring openness to culturally diverse clients. Journal of counseling psychology, 60(3), 353.
Lekas, H. M., Pahl, K., & Fuller Lewis, C. (2020). Rethinking cultural competence: Shifting to cultural humility. Health services insights, 13, 1178632920970580.
NHS Race & Health Observatory (2022). Ethnic Inequalities in Healthcare: A Rapid Evidence Review.
Ruphrect-Smith, H., Davies, S., Jacob, J. et al. Ethnic differences in treatment outcome for children and young people accessing mental health support. Eur Child Adolesc Psychiatry (2023). https://doi.org/10.1007/s00787-023-02233-5
Tao, X., & Fisher, C. B. (2022). Exposure to social media racial discrimination and mental health among adolescents of color. Journal of youth and adolescence, 1-15.