The key focus has been on providing culturally specific therapy services and resources, working alongside community organisations, providing education about the service and offering psychoeducational workshops within community settings. To summarise, we offer clinics in Bengali (offered by a Bengali speaking Clinical Psychologist and three Bengali speaking Psychological Wellbeing Practitioners), run educational workshops within community settings, and create resources for working with people from BME communities (e.g. translated materials, relaxation CDs recorded in different languages and creating groups in different languages). We have also been involved in research projects examining the experience of BME service users, thinking about how we can improve access, engagement and recovery for their communities.
What We Did
We work for iCope Psychological Therapies Service, which forms part of the Improving Access to Psychological Therapies National Programme (IAPT). iCope provides NICE recommended psychological therapies for some of the estimated 37,00 people in Camden experiencing anxiety and depression. We are integrated with primary care and offer treatment to people in over 90% of Camden GP practices.
Every year there are about 9,000 referrals in Camden, 6,000 people access the service and over 5,200 receive treatment in the service. An objective of Camden and Islington NHS foundation Trust is to make our services more accessible to under-represented groups including older people, black and minority ethnic (BME) groups, and people with long-term health conditions.
Within iCope, we have a BME working group which meets every six weeks. The working group has three goals: 1) improving access for BME clients, 2) improving engagement for BME clients and 3) improving recovery rates for BME clients. Initially the working group was focused on improving access for the Bengali and Somali communities (as these are communities identified within the Camden area). Recently this has broadened to including the wider Black community and the Irish and Chinese communities. The group includes 7 members of staff (both High Intensity and Low Intensity).
The key focus has been on providing culturally specific therapy services and resources, working alongside community organisations, providing education about the service and offering psychoeducational workshops within community settings. To summarise, we offer clinics in Bengali (offered by a Bengali speaking Clinical Psychologist and three Bengali speaking Psychological Wellbeing Practitioners), run educational workshops within community settings, and create resources for working with people from BME communities (e.g. translated materials, relaxation CDs recorded in different languages and creating groups in different languages). We have also been involved in research projects examining the experience of BME service users, thinking about how we can improve access, engagement and recovery for their communities. From these projects we are thinking about how to use this information to inform our clinical practice. Below is brief summary of the work we have done and continue to do for each of the communities. We have more resources for the Bangladeshi community since there is more Bengali speaking clinician in the working group.
Offering culturally specific services in Bengali Sylheti dialect
The Bengali speaking therapy service offers psychological therapies, guided self-help and community linking. We have 1 Clinical Psychologist and 3 Psychological Wellbeing Practitioners, all of whom are Bengali-English speaking. Therapy in Bengali considers the impact of cultural, familial and social contexts in the emergence and maintenance of emotional problems. We have been adapting mainstream cognitive behavioural therapy (CBT) approach to include systemic theory and practice. Some of our clinicians are have training in Foundation Course in Systemic Approaches. We have developed peer supervision group to discuss complex cases, theory-practice links and challenges of working with this population group. Additionally, we have individual supervision for our BME role.
We have facilitated a 6 week ‘Staying Well Group’ run by two Bengali speaking Psychological Wellbeing Practitioners. Each weekly group covered a topic (e.g. CBT framework, challenging thoughts, changing behaviours, relaxation, staying well) where theory was discussed and clients were given tasks to practice. The group is being facilitated again in 2017.
Finally, we jointly work with Camden Diabetes Integrated Practice Unit (Royal Free Hospital) to administer the ‘Stress Management and Diabetes’ session in Bengali as part of the DESMOND Type 2 Diabetes Education Programme. This is a self-management and diabetes education programme for people diagnosed or living with diabetes. This intervention is particularly crucial to administer to the Bangladeshi community where diabetes is most commonly diagnosed but poorly managed. We facilitate these in community centres (including Chadwell Healthy Living Centre, Queen’s Crescent Community Centre, Somers Town Community Centre).
Research is underway to improve access, engagement and recovery for Bangladeshi community. Some of the research we are focusing on include:
• Working systemically with Bangladeshi clients
• ‘Staying Well Group’ pilot interviews and report
• Guidelines on adapting CBT assessment and treatment and improving clinicians ability to engage Bangladeshi clients
• A service related project was recently completed to explore the experience of Bengali patients who have used the iCope psychological therapy service. Suggestions were made around improving the service:
1. Patient’s spoke of the importance of therapists explicitly discussing that confidentiality extends to interpreters
2. Patients spoke of the importance of feeling encouraged to attend appointments. The BME working group plans to design a leaflet in both English and Bengali to be sent to new patient’s outline how the service works, what is offered and to explain the confidentiality policy.
3. Patients spoke of more willingness for therapists to discuss cultural issues
4. Patients spoke of the importance of linking in with community venues such as mosques and community centres.
5. A suggestion was made for groups to take place in Bengali. With this in mind the BME working group run the ‘Staying Well Group’ Bengali
We use translated PHQ/GAD measures and the IAPT adapted Enablement Instrument to measure outcome for this population.
The Mindfulness Based Relaxation CD
We have produced the first Mindfulness Based Relaxation audio recording in Bengali Sylheti dialect. We worked jointly with Camden Hub to design, print and disseminate the CD across Camden community centres.
Chinese Community – Workshops
We delivered a workshop on ‘Living positively in later life’ in Chinese for older adults in the Camden Community Centre. We anticipate that this will continue.
We delivered a workshop on perfectionism and stress to UCL students in Chinese.
Black Community – Research
A service related research was carried out last year and reported higher PHQ and GAD scores for Black community members and low recovery rates. The study found that Black community presented with more social factors. From this, we are exploring how we can improve the recovery rates i.e., needing more significant drop to achieve recovery and look at how ‘recovery’ is defined.
Another service related research is currently being underway. This is looking at Black members experiences of having accessed the service.
Irish Community – Community Links
We have good links with the Irish Centre and have attended a few events including the launch of a Book. There we had a stall with our service information. We will continue pursuing work with the Irish Centre.
Wider Active Support
We work closely with a range of Partnership organisations to help to drive this work forward. One of our key links is with Voluntary Action Camden (VAC) who are an independent charitable organisation whose mission is to work with the people of Camden to support, develop and promote voluntary and community activity. VAC works closely with a range of community organisation and they will often help us to establish links within these communities to facilitate our community linking work and workshops.
We have close links with Nafsiyat who offer intercultural therapies. We meet with Nafsiyat quarterly to help to facilitate our working relationship and to think about supporting the cultural needs of the communities within Camden.
Furthermore, we have been working closely with Camden Hub who was commissioned to complete a Social Participation Pilot which aimed to explore access for Bengali Women, Black men and Irish Women. We have been involved heavily with the Bangladeshi women’s project. The Bangladeshi community is one of the largest minority communities with a population in Camden of 11,700 (5.7%). It is one of the most deprived BME communities with high prevalence of housing problems, poor education, unemployment and low paid jobs, financial problems, immigration and integration stress, isolation, marital problems and relational difficulties. There is evidence to indicate that these factors often result in stress that can lead to anxiety and depression. However, there is generally a low take-up of mental health services by the Bangladeshi community members. There are number factors for this:
a) A lack of knowledge of local mental health services
b) The taboo of mental illness which hinders help-seeking behaviour
c) Language and communication difficulties making it challenge for Bengali speaking individuals to access therapy services
d) Services not offering culturally specific treatment that allows for mental health problems to be conceptualised in social, historical, familial and cultural contexts.
In the last year and with the hope of tackling some of these challenges within the Bangladeshi community, we have participated in some projects and developed several helpful services. We worked jointly with Camden Hub, a Mental Health Wellbeing Centre aimed at supporting people who are socially isolated and experiencing mental health difficulties. Together we produced a video that has and continues to be aired in GP practices across Camden. The video is in Bengali language with expert speakers including a psychologist Dr Shimu Khamlichi (from iCope), NHS Mental Health Commissioner Nadia Haque, religious leader Mufti Ahsan Ahmed, and the Mayor of Camden Nadia Khan. The mission of the project is to de-stigmatise mental health problems and offer religious permission to access support outside of family. The content orientates the viewer to mental health problems, signs and symptoms, and how to access psychological therapies via their GP.
We feel it is important to involve service users in helping to drive forward our BME Working Group projects. We have conducted service related projects examining the service user experiences for service users from certain communities and we also have a Patient Advisory Group which helps us to think about service improvement. Through our work with the Patient Advisory Group we were able to create sections on our website (www.icope.nhs.uk) in Turkish, Somali, Bengali and Chinese.
Looking Back/Challenges Faced
Upon reflection the BME working group began its journey through trying to forge links with local community organisations and this was based on local census information and current access rates for different community groups. Whilst this was helpful this in turn meant that this was not driven by service user feedback. Our research examining service user feedback has taken place at a much later date and this has also facilitated and enhanced our engagement with community organisations. Therefore looking back I feel we could have worked more closely with service users from the outset in order to guide our work.
In addition to this the aims of the BME working group have been to facilitate access in to the service. We have more recently begun to explore the patients’ journey once they have accessed the service. One identified need was supporting clinicians in working with this client group. As a working group we have recently begun discussions about establishing a case consultation forum.
As a service we have worked hard to work with community organisations in order to increase access for BME groups, however often we have found it difficult to establish links with community organisations and we have found that being persistent in enquiring about meeting staff has been crucial in order to establish these links.
Additional challenges have been identifying that whilst we have some translated materials for working with this client group these resources are limited and often our client groups do not read or write in their mother tongue and therefore these resources cannot be used. Identifying this we have begun to develop a series of audio resources in Bengali and Somali.
This work has been ongoing for a number of years and often when staff members move on this work has been lost. In order to ensure that the work is sustainable we have created a database containing contact information for each of the organisations we form links with. As each organisation now has a clear link person should this individual leave our service we now have a handover process in place (in which the individual contacts this organisation informing them they are leaving and provides contact information for the new link). This system worked well when our Chinese Speaking therapist left our service.
In addition to this, we also keep a database logging the work we have completed with each organisation with clear instructions about where resources can be found on our shared drive).
In addition to this in order to ensure that we do not lose information on groups run in different languages transcripts for the groups have been audio recorded.
• Improve and establish good outcome measures that captures recovery and change
• Continue offering Bengali Therapy Service (step 3 and step 2 level) and use the Enablement Scale to measure recovery and change
• Continuing attending Peer Supervision to improve our learning and work
• On-going research and continuing providing support and supervision for this
The Staying Well Group
The write up of the pilot includes conducting one to one interviews for further qualitative findings and feedback from attendees and making adaptions and improvements for future groups. We aim to conduct two of these groups annually and evaluate the effectiveness of the groups.
Currently a Bengali assistant psychologist is doing a dissertation on the problems that are predominantly reported by Bangladeshi clients at assessment stage. Following from the findings, we aim to facilitate workshops on these issues on a quarterly basis.
• Produce more audio / translated materials
• Write up Good Practice Guide for our service so English speaking clinicians offering therapy to Bangladeshi clients may adapt or improve their approaches. The guide will focus on some of these areas:
• Practical support and liaising with other agencies
• Establishing a social support network.
• Orientate to systemic ideas (clients as resources, relational importance, social and cultural stories)
• More psycho-education, visual and concrete, setting clear goal and focus on behaviour change
• More skills training/workshops (i.e., assertiveness, confidence)
As an IAPT service we are always monitoring our performance in line with KPI targets. As a working group we have been able to extract information from IAPTUS which enables us to see the number of individuals from each ethnic group who have been referred to our service and to examine the recovery rates for each of these ethnic groups. This information is gathered by the Service Manager and is feedback to the BME Lead.
Recently we were able to identify that individuals identifying themselves as having a ‘black’ ethnicity appear to have lower recovery rates compared to other BME groups. We have therefore agreed that a Trainee Clinical Psychologist will complete a service related project examining this further.
As these projects and services have recently emerged, we have yet to establish results that will show the impact. However, I would like to take this opportunity to mention how people have responded to the work that we have been doing.
The Mental Health Video
This has been aired in GP surgeries since January 2017. We have received positive feedback about the video from the GP surgeries across Camden, NHS commissioner, Mayor of Camden, and service managers. We look forward seeing the effects this has on our referral rates and access (to be monitored and evaluated). We are continually receiving referrals for individuals who report the video led to them referring themselves or their family member to our service.
The Mindfulness Based Relaxation CD
This is in its early days in terms of distribution. Thus far, it has been distributed in 3 community centres (December 2016) and will be screened in 8 other community centres in the upcoming year. These centres have high attendance of Bangladeshi women. Over 50 copies were given to women and 55 left at the centres. In terms of feedback, anecdotally it has been very positive. We have not yet processed evaluation sheets, which have more in depth feedback.
‘Staying Well Group’
The preliminary feedback suggests that the attendees found it helpful being in a group with practitioners speaking their language. They found psycho-education, 5 areas CBT model, relaxation, and behavioural activation most helpful. Currently we are preparing to interview the attendees and produce a qualitative report to improve and facilitate future groups.
High Intensity Individual Therapy (CBT and Systemic Approaches)
The feedback we are receiving for the therapy sessions have been inspiring and moving. To find an approach that works and actually leads to real changes in Bangladeshi men and women has been refreshing! Below is a comment from a husband of a woman that was referred for individual work for depression.
“I am not sure what happened since our last session but we talk more at home. We (wife and husband) are spending more time together instead of her spending her whole day spending money in the saree shop. My son is also focusing on himself rather than worrying about her. He started working full time and is now helping to pay rent. Arguments between them (wife and son) has reduced and I feel that I have more control over what happens in our family” … (clients feedback was in agreement and the PHQ, GAD and Enablement Scale indicated recovery and improvement)
Diabetes and Stress Management Sessions
We facilitate presentation on diabetes and stress management to Bangladeshi men and women living with diabetes in community centres. In one session, all 12 participants who attended were well engaged and found it helpful to have a Bengali speaking psychologist running the session. The session was measured using the IAPT adapted Enablement Instrument. The results indicate the session was helpful.
As a working group we feel that sharing our work is important. We contribute to the iCope newsletter with updates regarding recent projects within the BME Working Group and also complete presentations within team meetings to ensure that the work is disseminated to others.
In addition to this we also regularly meet with Nafsiyat to inform them of the work we are doing and to think about how we might be able to work together. We also provided translated materials to the Social Participation Pilot as part of their work.
Furthermore we have been in contact with other BME working groups within London to discuss the work they have been doing and to disseminate any resources created (e.g. Islington iCope, Newham Talking Therapies and Tower Hamlets IAPT service).