Talk of certain groups as ‘hard-to-reach’ crops up often in the third sector and social care, where the need to improve connections between the most vulnerable or isolated regions of our society and mainstream services is now more-or-less widely appreciated.
The idea is sometimes understood to be like a game of tag – that, for whatever reason, a group in clear need of support are intentionally evading being caught by the people wanting to help them.
This interpretation doesn’t hold much credence with those on the ground who have come to understand that the obstacles to engagement are numerous and complex, and exist at least as much on the side of service providers as within a community.
Mental health services for the UK’s new arrival and refugee communities have made some headway with addressing these issues, recognising the critical need for mental health support for people facing increased threats to their mental wellbeing due to social isolation, experiences of trauma and the prospect of an uncertain future.
At the end of this article are links to some key reports from the past few years that explore in detail the barriers to access for ethnic minority groups and refugees. What comes first are a few reflections on the obstacles highlighted and how they manifest in the day-to-day work of a mental health practitioner.
Perceptions of authority figures and statutory services
The first challenge for anyone reaching out to a ‘hard-to-reach’ community is often the difficulty of knowing how you’re perceived. This inevitably depends on the community’s previous experiences of dealing with the authorities. I heard from one mental health worker supporting asylum seekers for Lancashire Mind how he’d earned the nickname ‘MI5 man’ before proving his credentials as a supportive and trustworthy project worker.
I often find myself in situations where I’m sure people see me as ‘the paperwork woman’. A few months ago I was with a few colleagues working with a group of Nepalese senior citizens. We had a captive audience, waiting and eager for a wellbeing workshop and ESOL lesson. But in the end translating and organising the paperwork became the main event and we left without doing much but burying our captive audience in a snowdrift of forms.
There’s no doubt that experiences like these cause mental health services to lose credibility in the eyes of the ‘hard-to-reach’. When bureaucracy becomes a barrier to access services lose their chance to prove their relevance.
Within some communities, misconceptions of mental health services are still having a serious impact in deterring individuals from seeking support. A Somali mental health worker described to me recently his first visit to a UK mental health ward and how he had expected to find distressed patients chained to their beds. He explained how the practice of chaining had been common in Somalia and that, of course, this inevitably had a strong negative impact on his community’s perception of mental health treatment.
Language, cultural barriers and social isolation
Non-fluency in English is arguably a more significant barrier to accessing mental health services than it is to obtaining treatment for a physical health issue. It takes courage for anyone to speak out about difficult emotional experiences, and the challenge of finding the right words in a second language can be enough to put someone off from speaking out at all.
Interpreting services, although available, are sometimes difficult to arrange and don’t necessarily resolve the issue of communication. When patients rely on friends or family as interpreters, confidentiality is inevitably compromised and it is very difficult to know how honest the patient feels they can be.
Many services rely on telephone interpreters but again it is difficult to guarantee that the patient feels comfortable and that the interpretation is exact.
Of course, effective communication is not just about speaking the same language. Knowing that your cultural or religious values are understood can go a long way to making someone feel comfortable with asking for advice. A mental health advocate for North West London’s Somali community told me how people were choosing to travel across boroughs just to go to a chemist run by Somali pharmacists, or to pay privately for a short appointment with a Somali doctor.
For the communication gap to be bridged, service providers must be proactive in seeking to understand the cultural perspectives of their clients. They must also work with the community’s own mental health professionals and respected leaders to build trust in the services they offer.
The big taboo
Mental health stigma exists in all communities, rearing its ugly head in different ways. For new arrival communities which are often small and relatively close-knit the damage to social standing of revealing a mental health issue within the family is a very real fear. I heard from a Somali man who was diagnosed with Schizophrenia his fear of coming forward feeling that the whole of London and the whole of East Africa would know his business as soon as he opened his mouth.
There is a lot that community engagement can do to tackle mental health taboo through challenging some of the common misconceptions, namely that those with mental illness never recover, that they are dangerous, that they can’t work or have a family. Campaigns such as those by Maslaha and Time to Change have started important conversations in a sensitive and engaging way that can be replicated in other areas of London and the UK.
I have also seen how, once voices from within a community start to speak openly about mental health, this creates an environment where others naturally feel they can come forward and gradually the attitudes of a whole community begin to change.
The right priorities?
Although obstacles to access within BMER communities are becoming increasingly difficult to ignore, for as long as services are feeling the pressure to cut budgets, it seems unlikely that equal access will be given the attention and resources it needs.
The shortage of money, time, interest and understanding from commissioners, local and national government are still big obstacles, as is the pressure on service deliverers to reach demanding targets.
With other priorities in mind, authorities often don’t make the best use of the resources available to them. Equality and diversity is now a core part of public sector policy, but there is still much to be done to avoid this becoming a meaningless tick box exercise.
At an equalities event run by a local council a few weeks ago, I heard how their HR department provided all of their equalities training to staff online. This seemed like such a missed opportunity when their employees have access to one of the most diverse communities in the country, right on their doorstep. How can staff be expected to see the relevance of a diversity policy that fails to connect them directly with the people they are serving?
Bridging the gap
Once they are recognised, these obstacles are not insurmountable and there are some great examples of organisations working effectively within their community and with service providers to change attitudes and instigate creative new projects.
This article is just a starting point for exploring the good work that already exists and how we can help it to grow so that all Londoners have easy access to a mental health service that they feel to be relevant, culturally sensitive and effective.
Some further reading
Better Practice in Mental Health for BME Communities (Race Equality Foundation, Mental Health Providers Forum, 2015)