No abstract

Conversations around improving access to psychological therapies for BAME (Black, Asian and minority ethnic) service users have been ongoing for many years without any conclusion or resolution. BAME service users are often under-represented in primary care mental health services, and often have worse outcomes, leading to them being portrayed as ‘hard to reach’, and to deterioration in their mental health. They are over-represented in secondary care mental health services. The authors of this article argue that more resources are required in order to understand the barriers to accessing mental health services, and improve both access and recovery for BAME service users. This paper examines concepts such as race, ethnicity and culture. It aims to support service managers and therapists to develop their confidence to address these issues in order to deliver culturally competent psychological therapies to service users from BAME communities, with a focus on primary care. It is based on our experiences of working with BAME communities and the feedback from our training events on developing cultural competence for CBT therapists. The paper also discusses the current political climate and the impact it may have on service users and the need for therapists to take the wider political context into consideration when working with BAME service users. Finally, the paper stresses the importance of addressing structural inequalities at a service level, and developing stronger ethical guidelines in the area of working with diversity for CBT therapists in the UK.Key learning aims(1)To examine concepts such as race, ethnicity and culture and to provide a shared understanding of these terms for CBT therapists.(2)To assist CBT therapists and supervisors to develop their confidence in addressing issues of race, ethnicity and culture with BAME service users within the current political climate and to deliver culturally competent therapy.(3)To assist service managers to promote equality of access and of outcomes for service users from BAME communities.(4)To understand how unequal expectations of therapists in services impacts on CBT therapists from BAME communities.(5)To widen understanding of some of the structural inequalities at service level which the CBT community needs to overcome, including recommending stronger ethical guidelines around working with diversity in the UK.

Background: Cognitive behaviour therapy (CBT), self-help and guided self-help interventions have been found to be efficacious and cost effective for victims of trauma, but there are limited data from low- and middle-income countries on culturally adapted interventions for trauma. Aims: To investigate the feasibility and acceptability of culturally adapted trauma-focused CBT-based guided self-help (CatCBT GSH) for female victims of domestic violence in Pakistan. Method: This randomized controlled trial (RCT) recruited 50 participants from shelter homes in Karachi and randomized them to two equal groups. The intervention group received GSH in nine sessions over 12 weeks. The control group was a waitlist control. The primary outcomes were feasibility and acceptability. Secondary outcomes included Impact of Event Scale-Revised (IES-R), Hospital Anxiety and Depression Scale (HADS) and the WHO Disability Assessment Schedule 2 (WHO DAS 2). Assessments were carried out at baseline and at 12 weeks. Results: Out of 60 clients who met DSM-5 criteria for post-traumatic stress disorder (PTSD), 56 (93.3%) agreed to participate in the study. Retention to the intervention group was excellent, with 92% (23/25) attending more than six sessions. Statistically significant differences were noted post-intervention in secondary outcomes in favour of the intervention. Conclusions: A trial of CatCBT GSH was feasible and the intervention was acceptable to Pakistani women who had experienced domestic violence. Furthermore, it may be helpful in improving symptoms of PTSD, depression, anxiety and overall functioning in this population. The results provide a rationale for a larger, confirmatory RCT of CatCBT GSH.

Recently there have been a number of developments in cognitive behaviour therapy (CBT) that have led to cultural adaptations of specific interventions and a greater awareness of how in general CBT might be adapted for Black and Minority Ethnic (BME) service users. These developments, however, involve change at the level of the individual therapist and particular treatment approach, but involve very few considerations of what needs to happen at the levels of teams or services in order to best meet the mental health needs of British South Asian and other BME populations. This paper summarizes the way that services need to understand how minority populations use services and how to involve those populations in developing services in order to ensure their needs are best met.

Culture plays a significant role in psychotherapy practice, with cultural adaptations being implemented more commonly as globalisation and cultural awareness increase. An abundance of systematic reviews, meta-analyses and randomised controlled trials exploring culturally adapted interventions have been published across the globe. In this paper, we present the historical background to cultural adaptation by summarising and evaluating previous frameworks, as well as reviewing current evidence for such adaptations and highlighting routes for further research. Around twenty cultural adaptation frameworks have been published, covering various population demographics and intervention types, providing general guidelines for the implementation of cultural adaptations to psychosocial interventions. Nearly all the frameworks used previous literature and research to develop models on culturally adapted interventions. Some even implemented stakeholder discussions, randomised control trials, and even pilot studies. A variety of cultural adaptation factors have been outlined and discussed; however, there is no agreement on which elements work and which do not. Existing evidence indicates that culturally adapted interventions are effective, regardless of intervention type or population. While cognitive behavioural therapy (CBT) was the most common intervention in trials, there are, at present, no high-quality comprehensive meta-analyses or systematic reviews on culturally adapted CBT which include all literature on this topic. This is needed in order to provide a holistic and detailed comprehension of where current understanding lies. We conclude our paper with recommendations for researchers, trainers and commissioners. Key learning aims (1) Current theoretical frameworks guiding the development of culturally adapted frameworks will be outlined. Gaps in current literature will be highlighted. (2) An overview of the current literature of culturally adapted psychotherapies, specifically CBT and its efficacy in improving outcomes for patients, will be provided. (3) The need for culturally adapted CBT and comprehensive guidelines for the development of these interventions will also be discussed, with clinical implications highlighted.