9. Developing Culturally Appropriate Interventions for Mental Health

What is the definition of race?

biological basis, race science & racial hierarchies, visible, physical differences, often externally classified: distinguish between large groups of people, highlight commonalities 'human race'

What is the definition of ethnicity?

social characteristics of a group: faith/religion, language, traditions. common ancestry: may share distinctive cultures, some overlap with nationality

What is the definition of culture?

shared beliefs, values, customs, 'norms', attitudes, behaviours. Influences perception and interpretation of experiences by 'in-group' individuals and what is considered acceptable / unacceptable

What is cultural competence?

possessing the necessary skills or knowledge to effectively understand, appreciate and interact with people from a specific culture

What is cultural humility?

ongoing process of self-exploration and self-reflection combined with willingness to learn from others. Entering relationships with others, intentionally honouring their beliefs, customs, and values

How does culture and context shape individuals lived experience and mental health?

symptoms, presentation, attribution, meaning, coping styles, family influences, help-seeking behaviours, stigma, insider/outsider perspectives, trust

What does cultural formulation highlight the effect of culture on?

symptom expression (cultural explanation 'models' of mental illness), definition of illness (cultural factors related to the psychosocial environment), treatment (what is acceptable? impact of culture on clinician patient relationship)

What are the ethnic mental health disparities with psychosis rates?

elevated incidence of psychosis and schizophrenia among migrant and minoritized groups especially people of African and Caribbean origin.

What are the psychosis rates in people of African and Caribbean origin?

Caribbean IRR 6.7, Africans IRR 4.1

What are the negative care pathways due to psychosis rates?

40% more likely to access care via CJS, 37% black vs 9% white prisoners' schizophrenia disorder, 4x more MHA detentions

What are the ethnic mental health disparities with psychosis care?

more coercive care - higher rates injectable anti-psychotic mediation than their white counterparts, worse clinical/non-clinical outcomes, lack of culturally informed care, 'culturally naive' staff, lack of psychological therapies, often labelled hard to reach

What are the NICE guidelines for psychosis treatment?

individualised treatment plan options: 16 planned sessions of CBT, early intervention in psychosis (EIP) and 10 sessions of Family Intervention(FI)

Describe evidence for family intervention in schizophrenia and psychosis care?

clinically & cost effective, reduces family tension, facilitates engagement & improved clinical care, reduces relapse rates, decreases lengths of stay in hospital

What is the problem with family intervention for schizophrenia & psychosis?

uptake especially low in african, caribbean and other minoritised groups, limited evidence for effectiveness, accessibility with minoritised groups, urgent need to develop culturally informed care

What does CaFI stand for?

culturally adapted family intervention

What are the three main phases of CaFI Feasibility Study design?

1. co-production of CaFI through qualitative work and consensus conference 2. developing and delivering culturally informed therapist training 3. feasibility trial evaluating fidelity to therapy manual, and acceptability

What are the feasibility study aims?

1. Evaluate the feasibility culturally adapting, implementing, and evaluating Family Intervention with Caribbean origin service users diagnosed with schizophrenia and related psychoses, their families, and other key stakeholders 2. Establish the feasibility and acceptability of delivering Family Intervention with "proxy families" (Family Support Members) where service users' biological families unavailable

What is co-producing research?

"… an approach in which patients, researchers, practitioners and the public work together, sharing power and responsibility from the start to the end of the project, including the generation [and sharing] of knowledge."

What does co-production with stakeholders involve?

literature review, focus groups & consensus conference

What does literature review involve?

to generate typical components of culturally adapted psychosocial interventions to serve as initial framework, need to incorporate important concepts

What does focus group involve?

(with service users, professionals) structure and core components, address stereotypes and misconceptions of cultures, racism

What does consensus conference involve?

to refine content, outcome and delivery

What does CaFI therapy involve?

10 x 1 hour sessions: hybrid model - CBT based with BFT, delivered by lead and co-therapist, bespoke therapy manual and resources, family support members as therapy partners

In the Bespoke Training Programme for Therapists, what does 'Cultural competency' in family work involve?

1. Core competence to work with service users experiencing psychosis and families 2. Impact of culture on family work 3. Relationship between racism, discrimination, adversity, and psychological distress 4. Power and prejudice in building trusting therapeutic relationships

In the Bespoke Training Programme for Therapists, what does the CaFI manual involve?

1. context of CaFI (historical, cultural and social context of african-caribbean mental health in UK) 2. development of CaFI, 3. CaFI's 'ethos of delivery', 4. components of bespoke resources 5. delivering therapy in research

What are two components of the bespoke training programme for therapists?

'cultural compentency' in family work, CaFI manual

What were the findings of the feasibility study results?

30 service users randomised, 24/26 families completed all therapy sessions - all service users, families and therapists found CaFI acceptable and would recommend it to others

What were issues with the feasibility study?

lack of control, insufficient power to assess effectiveness, caribbean origin only, 'more culturally informed therapy resources' needed

What were the service user benefits for CaFI?

Improved understanding of illness and symptoms, Better function - going to work, university and volunteering, Better communication

What were the family member benefits for CaFI?

increased understanding of diagnosis/condition, Better engagement and supports with service users

What were the health care professionals benefits for CaFI?

More cultural awareness and understanding of needs of Caribbean people, Using CaFI skills/materials in everyday practice

What is the CaFI randomised controlled trial (RCT)?

National RCT with family units of Caribbean & Sub-Saharan African origin, evaluate cost and clinical effectiveness compared with usual care, embedded process evaluation: implementation barriers/facilitators, accessibility, fidelity, acceptability

What was the progress and challenges of CaFI randomised controlled trial (RCT)

start deferred for 24 months, covid 19 impact - recruitment, access/engagement barriers, lack of NHS therapy capacity, closed to recruitment in november 2023, N=145 recruited

What are some implications for the research with CaFI?

research WITH people currently under-represented in research and clinical practice throughout research processes, different approaches and same models (real world vs research therapy, funding - hidden costs, success criteria - what matters to who?)

What are implications for practice (FI psychosis)?

individualistic, holistic, needs-led, communication, therapy models, therapy partners, training and supervision, NHS workforce and structures, peer support/lived experience practitioners

What are some of the implications for policy?

delivering race equality in mental health, culturally informed/appropriate care, mental health act review, patient & carer race equality framework, evidence based interventions, evidence for cultural adaptation