What should any new mental health strategy post-2021 focus on?
Submission by the Lateef Project in collaboration with the Psychotherapy and Counselling Union regarding minority communities specifically the Muslim community.
The five year Forward View for Mental Health is failing it its 2010 Equalities Act duties with regards to religion, beliefs, race and ethnicity. The specific duties it fails in relation to, when making decisions, are the duty to take into account the need to: eliminate discrimination, harassment and victimisation; and to advance equality of opportunity. This is not just a failure of the strategy - it is a systemic failure across statutory health provision that also impacts the strategy.
Context: NHS England acknowledged ethnic mental health inequalities in 2003.1
Yet these inequalities continue regarding race/ethnicity and religion/belief. The strategy refers to such inequalities, to ethnicity and race not religion, and belief. These afford the impression of appearing to take inequalities into consideration and in line with the legislation, whilst also demonstrably failing to do so.
The strategy is evidence-based and reports that 90% of presenting mental health patients are seen in primary care. In this context, IAPT is the main strategic provision. Although DSM-52 is referred to in the NICE recommendations regarding assessment of common mental health problems treated by IAPT, no mention is made of DSM-5 supplements regarding the (new) Cultural Formulation Interview (CFI).2 The implication of this is that these factors are not considered in the majority of assessments of ethnic, or faith minority patients. Hence there is not the evidence of difference to take into consideration in treatment, to eliminate discrimination, or to make evidence-based decisions individually or systemically.
In ignoring culture, the strategy does not accept that presentations of mental illness can vary across cultures. For example, Afghans suffering from depression are more likely to present as ‘angry’ than ‘sad’. Research shows the most significant factor in therapeutic change is what the client feels safe to bring to the therapeutic relationship. IAPT is monitored in relation to its impact in regard to faith communities. However, IAPT’s3 2016 report identified that the Muslim faith is the second largest faith community and also the second least served faith community. As there is a lack of data collected in regard to faith across the system this has not fed into a process or re-evaluation of the strategy. This means IAPT-related practices potentially include unconscious bias in a time of well-documented increased Islamaphobia.
The strategy has not considered the data that exists indicating the complex nature of mental ill health within the community (see Amer & Hovey’s4 2011 study of Anxiety and depression in post-September 11 Arabs and Aslam, Zaheer, & Shafique5 (2015) research on Muslim women and the vertical transmission of domestic violence through victims. Additionally, the strategy has not considered IAPT’s access issues such as diversity of primary language within these communities, the lack of such diversity in its staff complement, the lack of appropriate training for mental health work amongst NHS commissioned translation services, the lack of languages availability in written IAPT self-assessments and the significant proportion of minority communities where the first language is oral not written.
Common mental health problems, anxiety, depression and PTSD are states that are often responses to life events and or negative conceptions of self-worth. Hence recovery is a personal process related to the restoration of value for the individual in a process that is valid for them. Recovery from these states relates to a person’s lived reality and identity. Research shows that the therapeutic relationship is as important as the model in determining outcomes (Norcross 2010)6 key to this being what the client can bring to therapy and what the therapist can empathise with. Further, clients consider that religious issues are generally appropriate in the counselling session7 research regarding the significance of faith in well-being is well documented (The Mental Health Foundation 2006)8. By its own statistics, and at best, IAPT has been shown to equate the long-term recovery rate of chance perhaps as low of 7% of referrals.9 Without a strategy to recognise religion and faith as salient factors in mental health the new mental health strategy post-2021 is unlikely to meet the needs of a significant minority of people. With the need for more effective treatments established, good models have grown from within the Islamic faith communities. These include: Mir et al.’s Adapted behavioural activation for the treatment of depression in Muslims 201510 and the independently evaluated long term studies of Islamic counselling as applied to anxiety and depression co-morbid with long term conditions or somatisisation, (Lateef Project 2014)11 However, while able to prove greater effectiveness in the Muslim community than the standard IAPT approach, and despite being innovative, these have not yet been scaled up to RCTs research to prove efficacy.
Instead, agencies working with Muslim communities such as Paiwan11 in North London, the Lateef Project in Birmingham and Nafsiyat12 in London that try to engage with the NHS through the strategy, receive the complex presentations referrals that statutory services cannot respond to. Informed organisations such as Paiwan, the Lateef Project and Nafsiyat are expected to address mental health issues with short-term interventions whilst also being under resourced. This is within the context of a quota driven strategy, where in 25% of people with mental health problems who are targeted to receive talking therapies, priorities 2 and 3 of the strategy are undermined in relation to Muslim communities. The undermining is by enabling statutory services to cherry pick patients who can more easily hit a services targets, whilst potentially avoiding more complex presentations amongst Muslims. Further, a strategy that does not recognise Muslims makes no connection between the mental health of Muslims and PREVENT, which operates within mental health. Recent research at Warwick University13 has shown some of the spurious reasons why Muslims are referred to PREVENT such as for watching Arabic TV or going on pilgrimage to Mecca. This not only decreases trust in the Muslim community of mental health services, it also indicates the way in which Muslims can experience unconscious bias instead of care.
When revising the policy, the Lateef Project recommends: NHS England ensure that the strategy complies with its Equalities Act statutory duties and within the UK’s pluralistic society, unconscious bias and Eurocentric notions of mental illness be considered in all aspects of service commissioning, provision, monitoring and development when revising the policy; that the mental health team in collaboration with affected parties investigate the factors which lead to lower recovery rates in minority faith and minority ethnic communities; that a general greater consideration of diversity be given to all minority communities; that any revision of the strategy monitors the lack of impact in the Muslim community and addresses the underlying mental health inequalities experienced; that the Cultural Formulation Interview (CFI) be applied where appropriate, that monitoring in relation to faith include the monitoring of the nature of treatments commissioned and how, treatment accessed, assessments, treatment outcomes and developmental planning in relation to felt/expressed need. Examples of good practice be prioritised and consulted, such as Islamic counselling (Birmingham) and Adapted behavioural activation (Leeds).
Sashidharan, S. P. Inside Outside: Improving mental health services for black and minority ethnic communities in England, 2003, Crown copyright. (Accessed 15 June 2018) http://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4084558
American Psychiatric Association (2013). Cultural formulation. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 749-759. Washington, DC: American Psychiatric Association.
NHS Digital. Psychological Therapies: Annual report on the use of IAPT services England, 2016-17. (2017). (Accessed 11 June 18) https://digital.nhs.uk/data-and-information/ publications/statistical/psychological-therapies-report-on-the-use-of-iapt-services/ psychological-therapies-annual-report-on-the-use-of-iapt-services-england-2016-17.
Amer, M. M. & Hovey, J. D. Anxiety and depression in a post-September 11 sample of Arabs in the USA. Social Psychiatry 47(3), 61, 409-18. February 2011.
Aslam, S. K., Zaheer, S. & Shafique, K. Is Spousal Violence Being "Vertically Transmitted" through Victims? Findings from the Pakistan Demographic and Health Survey 2012-13. PLoS ONE 10(6), June 2015
Norcross, J. Evidence Based Therapeutic Relationships, November 2010. www.Scribd. com/document/199113604/Norcross-Evidence-based-Therapy-Relationships.
Rose, E., Westerfeld, J., & Ansley, T. Spiritual issues in counseling: Clients' beliefs and preferences. Journal of Counseling Psychology, 48(1), 61. 2001.
Cornah, D. The impact of Spirituality on Mental Health: A review of literature The Mental Health Foundation, 2006. (Accessed 15 June 2018) www.mentalhealth.org.uk/sites/default/ files/impact-spirituality.pdf
Pybis, J., Saxon, D., Hill, & Barkham, M. The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: evidence from the 2nd UK National Audit of psychological therapies.BMC Psychiatry, 17:215, 1-13. (2017). (Accessed 11 June 2018) doi: 10.1186/s12888-017-1370-7.
Mir, G., Meer, S., Cottrell, D., McMillan, D., House, A. & Kanter, J. W. Adapted behavioural activation for the treatment of depression in Muslims. Journal of Affective Disorders. 180,190-199. 2015.
Lateef Project Description and Evaluation 2014 unpublished.
Paiwan (see Lateef Project. Community led Islamic counselling service. Birmingham. http://www.lateefproject.com/.
Nafisiyat. Intercultural therpay centre, London, UK. http://www.nafsiyat.org.uk/
Heath-Kelly, C. & Strausz, E. Counter-terrorism in the NHS - Evaluating Prevent Duty Safeguarding In The NHS. Warwick University. 2017. (Accessed 15 June 2018) https:// warwick.ac.uk/fac/soc/pais/research/researchcentres/irs/counterterrorisminthenhs/
Stephen Abdullah Maynard chair of The Lateef Project Registered Charity Number 1168459 June 2018 email firstname.lastname@example.org
Dr Philip Cox (Psych.D, C.Psychol) committee member the Psychotherapy and Counselling Union. https://pandcunion.ning.com/