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Increasing access to appropriate counselling services for Asian people: the role of primary care services
Gina Netto, Sabine Gaag and Mridu Thanki
Background: The low representation of minority ethnic people in counselling services is well-established. While this takes occurs within the context of wider inequalities of access to mental health provision, the appropriateness of counselling services, originating from Western models of thought, cannot be assumed for Asian people and other minority ethnic groups.
Aim: To examine the accessibility and appropriateness of counselling services for Asian people in the UK
Design of study: A qualitative approach was employed, using focus group discussions and semi-structured interviews
Setting: Community-based study in London and Edinburgh.
Methods: Two focus groups were organised with Asian men and women to identify issues of concern and inform the design of the questionnaires for individual interviews. 38 Asian men and women were interviewed; 19 were clients of counselling services and 19 were not. After preliminary data analysis, a further two focus group discussions were organised with Asian men and women to validate and refine the results.
Results: Awareness of counselling services among non-users of such services was low. However, once they understood the nature of counselling, non-clients were mainly positive about the service. Access to counselling services was influenced by familiarity of social networks and GPs with the service. Clients generally reported beneficial outcomes, including improved self-esteem and ability to cope with problems. Preferences for key aspects of the service, particularly counsellor variables, are related to participants’ adherence to cultural norms, fear of being judged, perceived importance of sharing culturally related values, sense of safety and ease of communication.
Conclusion: Primary care services should make greater attempts to increase the accessibility and appropriateness of counselling services for Asian people, including by effective consultation.
Keywords: mental disorder, ethnic groups, health services research, health services accessibility, professional-patient relations and health service need and demand
Inequalities between minority ethnic communities and the majority white population in the rates of mental ill health, service experience and service outcome have been well-established (NIMHE, 2003). It has been recognised that the focus for treating mental illness among minority ethnic groups has been predominantly in the secondary care area, and that important opportunities for early diagnosis and treatment of mental illness are missed in primary care settings (Bhal, 1999; Bhugra et al,1999). Despite increasing recognition of the importance of counselling services as an early intervention strategy in preventing the deterioration of mental ill health, and the rapid expansion of such services, including within the NHS, (Daines, 1997; McLeod and McLeod, 2001), minority ethnic people continue to be under-represented in counselling provision (Alexander, 1999; Commander, 1999). Very little research has examined communities’ perceptions of mental illness and treatment (Bahl, 1999); however one study of Asian people documented a dissatisfaction with mental health services, and the need for ‘someone to talk to’(Radia, 1996).
Although the need for developing the range and choice of complementary therapies for minority ethnic communities has been highlighted (Bahl, 1999), the appropriateness of counselling services, developed from predominantly European models of thought, cannot be assumed for people from other cultural backgrounds, given cultural relativism in the conception, experience and treatment of mental ill health (Fenton and Sadiq-Sangster, 1996; Kleinmann, 1997). Experiences of ‘talking therapies,’ such as counselling, from the user perspective, including that of non-Western users, have been under-researched (Moodley, 2000). The means by which non-Western users of the service might access the service has also not been examined (Moodley, 2000).
According to the highly influential model of mental health care in the community proposed by Goldberg and Huxley (1980), people with mental health problems pass through different levels of ‘filters’ before gaining access to different levels of mental health services. Initially, the mental health problem is identified within the community and in the vast majority of cases, the individual is seen by a GP, whose ability to detect the disorder influences the extent to which the individual is able to gain access to mental health services. If the GP does detect the disorder and diagnose its nature as psychiatric, the patient may be referred to a psychiatrist and then, based on the assessment, be referred to a psychiatric hospital. The model gives central place to the role of GPs in mental health care, viewing them as vital ‘gate-keepers’ through whom patients must pass. However, the limitations of this model to minority ethnic people has been indicated by several studies, including those which have evidenced the higher rate of compulsory detention by Afro-Carribeans (Watters, 1996), the lack of awareness among minority ethnic people of the role of the GP as a source of support for mental health problems (Jacob et al, 1998) , the inability of GPs to detect psychological problems in their Asian patients (Jacob et al, 1998) and the tendency of GPs to perceive the health needs of their minority ethnic patients on the basis of negative stereotypes (Ahmad et al, 1991) Seeking to establish an ‘alternate pathway hypothesis’ for minority ethnic people’s access to mental health care, Bhugra et el (1999) contend that adequate explanations for help-seeking behaviour need to account for factors operating at the individual, cultural and institutional levels, and the interaction between all three levels.
This paper seeks to examine UK Asian (of Indian, Pakistani and Bangladeshi origin) peoples’ views and preferences of counselling service, including those who have used the service as well as potential service users. It also examines the experiences of those who have used the service, including the means by which they had accessed the service and the outcomes of the service. The definition of counselling used in the study is closely aligned to that offered by the British Association for Counselling and Psychotherapy:
The purpose of counselling is to provide you with the opportunity to discuss your problems with a suitably qualified person. This person does not judge you, give you advice or talk about your situation to anyone else. He or she tries to understand your situation from your point of view and helps you to see yourself and your problems in a new light. This can help you to cope with problems better and bring about necessary changes in your life.
The study was conducted within the ethical framework developed by the Association of Social Science Research and took place in 2000. Two focus group discussions were organised, one with Asian men and one with Asian women to explore understandings of mental well-being and ill health, the extent of support available and their preferences for mental health services.
Analysis of these discussions informed the design of the topic guide for the interviews. 38 Asian people were identified for interview in Edinburgh and London. These included 19 people who identified themselves as suffering from stress, anxiety and depression and 19 others who had used counselling services. The former are referred to as non-clients while the latter are referred to clients. Contact with individuals was made through community-based workers providing services to Asian people. This sampling strategy resulted in the participation of a diverse range of individuals in terms of gender, age, length of time in the UK, fluency in English and employment status. Ranging in age from 21 to 75, the sample consisted of 15 men and 23 women. Most of the participants had migrated to the UK, with the number of years of residency in this country varying from three to 39 years. The overwhelming majority of participants were married with children. Most were able to speak English as well as an Asian language, with differing levels of confidence and facility in both languages. Half of the participants were either in paid employment or were caring for the home and children. A quarter were unemployed and the remainder were either students, retired or unable to work.
Interviews were carried out at a venue chosen by the participant. In most cases, this was their home. Participants were asked which language they would prefer the interview to be conducted in. Where an Asian language was preferred, this was mainly conducted by a researcher who could speak the language, and in a few cases, with the help of an interpreter. Interviews generally lasted between 60 to 90 minutes. All interviewees were assured that the information given would be treated as confidential and informed that they could choose not to answer any questions or end the interview at any point. Interviews were tape-recorded with the participants’ permission and transcribed before being analysed. Where an Asian language was spoken, the researcher concerned translated the transcript into English for analysis.
Full transcripts ensured that the analysis process was as structured and systematic as possible. Key characteristics of interviewees (such as age, gender, length of stay in the UK, client or non-client of counselling service) were analysed. Emerging themes in the transcripts were noted and a comprehensive coding frame built and used to code the text, using grounded theories and procedures (Glaser, 1992). This not only enabled the analytical framework to grow as new themes and issues emerged in the research process, but also allowed systematic re-checking and re-coding of previous transcripts, based on new categories emerging from the last interviews until data saturation was reached. Coding of the transcripts was initially undertaken by SG and MT and checked by GN, who read and compared all transcripts against the coding categories to ensure inter-rater reliability of the emerging codes.
An important technique for demonstrating the validity of qualitative findings is triangulation – comparing data obtained by one method with similar data obtained from another method (Denzin and Lincoln, 1994). Further, Lincoln and Guba (1985) have recommended that the most crucial technique for establishing credibility is through ‘member validation’, sharing reports with those either directly involved in the research or in the wider community (Seale, 1999). Accordingly, the main findings of the study and its implications were presented to two groups of clients (one consisting of male clients and the other, female clients) for validation and further refinements made. The views of the advisory group of clients, counselling service providers and academics were also taken into account in interpreting the results of the study. The research process was thus driven by the principle of maximizing user involvement in the design, conduct and outcomes of the study. Quotes used below are attributed to individuals by the use of psuedonymns.
Need for formal support
Most participants had family or friends in the UK who were either living with them or close to them. They reported mutually supportive relationships, within which they shared personal problems with people, who would also confide in them. However, recent migrants spoke about social isolation and of having to adapt to environmental changes without support:
‘I got married and I came to this country…and then my son was born, it’s a very big change, I became a mother and I’ve lost friends and family.’ (NC3)
‘Everyone is busy, someone in their shop, someone somewhere else.’(NC15)
Lack of trust, fear of losing respect within their communities and lack of confidence in being adequately supported were common themes, with many participants reporting that they held back from entirely confiding in their family and friends.
Closely related to this, the overwhelming majority of clients and some non-clients felt that formal support from a ‘neutral’ professionally trained person would be beneficial. However, counselling services were not universally perceived to be useful, with a small minority of non-clients expressing the need for advice or guidance. Shared understanding of cultural norms and values was also viewed as important, with some believing that this would not be found in counselling services. Despite this, in most cases, non-use of such services appeared to be linked to low awareness of their nature and purpose.
Those who had been clients of counselling services attributed their psychological distress to a range of external events - including bereavement, relationship breakdown, problems with alcohol abuse and redundancy, physical ill-health and changing values within the family – and their inability to cope with them:
‘Actually, this problem started from my work, you know, when I left my work…but at the same time I am thinking, why can’t I, with myself, be brave, and brave and brave, you know, fight, instead of depending on tablets…sometimes I am really feeling very bad in the morning…sometimes I think ‘what’s the point of living in this world.’(C8)
‘I wanted separation and they (her husband’s family) were saying ‘Oh, try again, make the marriage work.’ (C18)
‘We had to let him do what he (adult son) wanted to do, which (was) he wanted to move out, so that was a major thing and it really upset me, and really hurt me, and I still don’t think I’ve got over it’ (NC14)
These factors, operating at the individual level, correspond to Goldberg and Huxley’s (1980) first level, the individual in the community attempting to apply meaning to the distress that they are experiencing. It is significant that at least for some individuals, the difficulties they face are the result of pressure by others to conform to cultural norms (such as avoiding separation or divorce, even when unhappily married) and conversely, the reluctance of family members to conform to norms (such as staying with parents into adulthood), as illustrated by the last two quotes. However, individual decisions which lead the individual to acknowledge a problem and seek help also appear to be mediated by cultural norms and the influence of significant others, as will be illustrated below.
Prior to accessing counselling, the majority of client participants had low awareness of the service; consequently, there were few self-referrals. In many cases, contact had been initiated by a friend or family member. Others had been recommended for counselling by their GPs, some of whom made the initial appointment, often, without consulting the client. A few participants spoke about the stigma attached to mental health problems and their fear of being labelled as having ‘lost it’. A common view was that increased attention should be paid to publicising the existence, nature and range of counselling services, including through the use of outreach work
Among the small number of self-referrers, considerable problems in locating an appropriate agency or counsellor were reported:
‘We talked to our doctor, and the doctor said that they could arrange for some counselling…But when I asked a second question, ‘was it culturally sensitive’, the answer was not comfortable…he himself did not know where such services were available…My wife is a social worker, so that she had to use her network, right, to try and locate it’ (C12))
These results indicates that propensity to use counselling services is strongly influenced by the individuals’ social network and primary care services’ familiarity with available services and their perceptions of their relevance for the individuals concerned. The role of public bodies in increasing access to services by publicising their availability and making them acceptable, user-friendly and culturally sensitive is also clear. Knowledge, expectations and experiences of counselling
Although a substantial number of clients had little or no prior knowledge of counselling, most had a vague feeling that they would benefit in some way. With increasing familiarity of the service, many clients achieved a personal clarity of the nature of the service:
‘They will only listen to you, will not advise you…so one goes there and unburdens one’s heart.’ (C4)
There was substantial evidence of clients having used counselling services to confront difficult issues, work through psychological difficulties and arrive at means of dealing with problems:
‘He was on the ball, so sometimes I felt real discomfort, but I knew the more uncomfortable I felt, the greater the need to go back.’ (C7)
Some of the reported benefits included the ability to consider problems from a fresh perspective, greater sense of control over feelings, increased confidence and self-esteem:
‘(Someone to) label these things, put them into boxes and give me a framework that I could work with’ (C6)
‘Emotionally you feel inside you are coping well. You feel better. You get control over your emotions…more confidence. No feeling low…generally I feel very good.’ (C13)
Interestingly, several participants reported that the experience of counselling had alleviated physical symptoms such as panic attacks, chest pain, coughing fits and inability to sleep:
‘I just come out and then, after that, there was no temperature, no chesty cough, nothing…I slept right through at night-time.’ (C5)
However, a few client interviewees identified a number of factors which limited the benefits of the experience. These included issues of power and control which left them feeling intimidated, restrictive time boundaries for each session and inability of the counsellor to adequately assess their situation, giving rise to feelings of frustration and helplessness. Among those for whom counselling had only a limited impact, dissatisfaction was expressed about being mismatched with a counsellor who did not meet their needs or preferences. Concern was expressed not only about the lack of suitability of the counsellor but also about the lack of consultation in the process:
They went out of their way to find me an Asian doctor (psychiatrist) which was sort of stupid…I wouldn’t have liked an Asian doctor even if he could speak my language. I would have preferred it if they had told me ‘Well this is who we’ve found’, I would have said ‘No,’ and it would have saved me the trauma. (C17)
Expectations and preferences of counsellors and language of counselling
The majority of participants expressed satisfaction with their counsellor, seeing them as ‘caring’ and ‘professional’. Participants revealed that the qualities of the counsellor they valued most were active engagement in the process, being ‘heard’ and treated with respect:
‘Their role is not just to listen but to make the person think of other possibilities and reasons why they are undergoing this crisis.’ (NC2)
‘Counsellor has to be patient, polite and know how to approach problems and never ever show them that he is like a teacher, sitting over and above them in asking questions.’ (C15)
Clients’ preferences for counsellors were influenced by a number of factors, including concerns about confidentiality, the ease with which they could communicate in English, sense of safety and the extent to which they adhere to cultural norms. About half of all participants did not view the ethnicity of the counsellor as an important issue. In contrast, others had either a strong preference for an Asian counsellor arising from a belief that shared knowledge of cultural norms and values were vital to being fully understood, or, alternatively a strong aversion to a counsellor from their own ethnic background:
‘If I’m going to go out and see someone I’m not going to see someone who’s like my aunty, I don’t want to see someone like that – I don’t want to go. Call it my prejudices or presumptions or whatever.’ (C7)
This was due to a number of factors, including a fear of being judged on the basis of cultural norms which they did not share, or their reluctance to reveal personal circumstances to someone who might know them or their family.
Language preferences for counselling were linked not only to fluency in English but to concerns around confidentiality. For instance, although participants who did not feel comfortable speaking in English expressed a strong preference for someone who could speak their first language, a few of those who were equally comfortable in both an Asian language and English reported that rather than risk being seen by a counsellor who spoke the former and might be known to them, they would opt for an English-speaking counsellor. The use of interpreters in counselling was universally seen to be inappropriate, due to the private nature of the service.
Gender preferences were clear, with women expressing a stronger preference for a counsellor of their own gender than men. This preference was linked to a sense of ease and safety, of being more fully understood and religious beliefs. However, a small minority of participants stated that they would prefer a counsellor of the opposite sex. Counsellor maturity and experience was unanimously viewed as important. However, the counsellor’s religion was generally viewed as irrelevant.
The study evidenced the need for independent, formal support in coming to terms with issues such as change, loss and separation from loved ones and bereavement among Asian people. Low awareness of counselling services and fear of stigma did not hinder non-clients from perceiving the usefulness of counselling, once they had understood its nature. This again dispels commonly held stereotypes that the non-use of counselling services by Asian people is due to stigma or lack of perceived relevance. Instead, the study shows that the confidential element of the service is highly valued. The lack of ability of many participants in the study to confide in family and friends due to fear of loss of confidentiality and loss of esteem within the community highlights the need for primary care professionals to question any assumptions Asian people might have about alternative sources of support which might impact on whether or not they choose to refer them onto counselling services. This is supported by the finding that major life events and the intervention of family and friends were the main factors which precipitated client participants into using counselling services.
The current study supports other research which has indicated the limitations of Goldberg and Huxley’s model of pathways to mental health care (Bhugra et al, 1999; Watters, 1996), by evidencing familiarity of social networks and ability of GPs to make effective referrals to counselling services as a crucial variable affecting access to the service. However, once they had gained access to the service, Asian participants of the study were actively engaged in the therapeutic process and assessed how much they could trust the counsellors, like other groups of clients (Rodgers, 2003; Millar, 2003; Everall and Paulson, 2002). As found by other studies, the relationship of the client with the counsellor was crucial in ensuring a positive outcome (Rodgers, 2003; Millar, 2003; Everall and Paulson, 2002). Clients’ preferred choice of counsellor was influenced by a complex interplay of individual, cultural and institutional factors, including concerns about confidentiality, adherence to cultural norms, fluency in English and trust in the service to respond sensitively to intimate issues, highlighting the need for GPs to take these into account in identifying a safe and effective therapeutic context. Contrary to what might have been expected, the Western origins of the service did not appear to prevent the majority of Asian clients from experiencing positive outcomes as a result of using the service.
However, the Asian participants in this study appeared to face greater difficulties in accessing counselling services and in finding counsellors who matched their preferences, particularly along the basis of ethnicity and languages spoken. This appeared to be mainly due to lack of familiarity with the service. In many cases, primary care services were unable to make effective referrals due to lack of recognition of the relevance of the service for them, lack of effective consultation and lack of knowledge of appropriate services for them. Further, the polarity of Asian participants’ preferences for counsellors in terms of ethnic background and familiarity with their cultural framework is indicative of the existence of a wide range of allegiances to traditional cultural values and norms. As has been borne out by the results, the psychological distress faced by some individuals is associated with pressure by family to conform to norms they do not wish to uphold or the reluctance of others to conform to expectations which are culturally related. Indeed, the aversion of some participants for a counsellor of the same background due to fear of being judged on the basis of normative cultural values or loss of confidentiality is suggestive of shifting cultural identities and supports Brah’s observation (1992), cited by Watters (1996), that ‘cultural identities are simultaneously cultures in progress.’
The limited role played by GPs in facilitating access to the service is perhaps symptomatic of wider difficulties in communicating with Asian patients, established in other studies (Bowes, 1995; Katbamma, 2002). This study calls for greater awareness on the part of the GPs and other primary care professionals of the need among Asian people for improved access to counselling services, taking account of their right to better information of the range of services available, choice of treatment and respect. It also highlights the need for a more individualistic approach to treatment which takes into account both the complexity and fluidity of cultural identities. Evidence of heterogeneity in the needs and preferences on the part of actual and potential Asian clients relating to crucial aspects of the counselling service demand that stereotypical assumptions of what might be required be set aside in favour of a more nuanced, flexible and comprehensive analysis of needs as a basis for the referrals process. As a parallel process, the potential for differential rates of referral to counselling services based on ethnicity suggest the need for greater transparency in the form of regular ethnic monitoring, review and appropriate action to address current inequalities in access to the service.
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First Published May 2006