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Psychotherapy has become a fundamental aspect of mental health provisions (Campbell, 2013; Lister-Ford, 2007; Johnstone & Dallos, 2013), as it attempts to address psychological distress and/or impairment in a non-invasive manner (National Health Service (NHS), 2018; National Institute for Mental Health (NIMH), 2018; Burns and Burns-Lundgren, 2015). Primarily this may be in the context of interpersonal interaction (one to one or group), however other methods such as art or music are also used (NHS, 2018; Wampold, 2010). Although psychotherapy may be predominantly construed as a psychotherapist responsibility, other professionals such as psychologist, counsellors, social workers also deliver psychotherapy (Bateman, Brown & Pedder, 2010). Nevertheless, the effectiveness of psychotherapy has been advocated through a mass of research, culminating in it being an evidence-based intervention extensively utilised within mental health care (Lister-Ford, 2007).
Freud’s (1923) psychoanalysis concept; whereby bridging the gap between the conscious and unconscious mind contributes to psychological well-being, has often been purported as underpinning 21st century psychotherapy (Lister-Ford, 2007; Bateman, Brown & Pedder, 2010). The linking of the conscious and unconscious is attained by allowing patients to freely discuss their thoughts/feelings, with a view to disclosure of unconscious facets of their psyche. These facets are namely the id (instinctual desires/needs), superego (moral standards /conscience) and ego (solution finder, for indulging both the id and superego adequately/mediator) (Freud, 1923). Freud (1923) theorised that resolution of continuous internal (unconscious) conflict, resulting in mental disorders, fostered psychological well-being (Davey, 2008; Lemma, 2016). However, the development of Freud’s (1923) theory, by his former students, daughter, amongst others, focused on the therapeutic relationship, transference, countertransference and challenging thoughts/feelings (Gabbard, 2010). Which are predominant aspects of 21st century psychotherapy (Johnstone & Dallos, 2013; Short & Thomas, 2015). Albeit literature also argues that psychotherapy originates from religious and cultural practices which predate Freud’s 20th century concept (Bateman, Brown & Pedder, 2010; Midlarsky et al, 2012; Langman, 1997).
Although aspects of psychotherapy stem from the psychodynamic school of psychology (Campbell et al, 2013; Bateman, Brown & Pedder, 2010), the postmodern psychological era has culminated in varying schools of thought (Jones & Elcock, 2001). Cognitivism: focuses on mental processes (learning, remembering, problem solving, etc.) contribution to how individuals perceive their environment/circumstances; Behaviourism: concentrates on behaviour as an entity which is shaped and changed by environmental (external) stimuluses; Humanism: emphasises that innate drives foster the need for personal growth and self-actualisation, which affects psychological well-being; amongst others, are consensually regarded as psychological schools of thought by psychological organisations (i.e. American Psychological Association, British Psychological Society) and are included in psychology teaching curriculums (Davey, 2008). Thus, the evolution of psychotherapy has culminated in delivery through diverse theoretical approaches, with the founding psychodynamic methodological principles (Johnston & Dallos, 2013). Cognitive Analytic Therapy (CAT), Psychoanalytic Psychotherapy, Cognitive Behavioural Therapy (CBT), Gestalt Therapy, amongst others, are some of the current psychotherapies utilised in mental health care and stem from postmodern psychological schools of thought (Wampold, 2010; Short & Thomas, 2015; Lister-Ford, 2007; American Psychological Association, 2018).
Considering that psychotherapy is now a pertinent aspect of mental health care within predominantly western cultures (Bateman, Brown & Pedder, 2010; Johnstone & Dallos, 2013), it can be argued that psychotherapy is a western culture phenomenon, intended for white populations (Midlarsky et al, 2012; Langman, 1997). However, western societies, such as the UK, have become increasingly multicultural and statistics emphasise significant differences between White and Black & minority ethnic (BME) populations, in terms of mental health care (NIMH England, 2003; Mental Health Foundation, 2017; Ethnicity & Religion Statistics, n.d.; Jefferies, 2005). Measures have been taken to provide more inclusive psychotherapy provisions within the National Health Service (NHS) (Paniagua & Yamada, 2013; Bhui & Morgan, 2007). This is comprised of educating and/or training trainees and professionals who deliver psychotherapy and aims to address racial, gender, income, amongst other factors, which may be relevant to diverse populations (Pickren & Burchett, 2014). With a view to ensuring acknowledgement, empathy and holistic comprehension of what such factors may entail are also demonstrated during psychotherapy (Neville et al, 1996). For example, race, gender and socioeconomic status issues can all result in psychological distress, stemming from alternate contexts; i.e. intrapersonal or interpersonal. Awareness and understanding of such concepts are essential for fostering positive therapeutic relationships, based on understanding and empathy and also underpin appropriate/effective psychotherapeutic approaches (Smith et al, 2006; Fuertes et al, 2015). Thus, amalgamating multicultural theory and varying psychotherapy concepts.
Nevertheless, despite such measures being employed significant differences still remain between White and BME populations within the UK (NIMH England, 2003). BME populations have been indicated as having increased issues related to mental health provisions, such as delays between onset and therapy, access, treatment completion and treatment pathways, amongst others (Mental Health Foundation, 2017; Memon et al, 2016; Thompson et al, 2004). Although such information demonstrates a worrying trend, in terms of an inclusive mental health service. It also highlights that a subgroup of the population with ethnic origins not historically stemming from Western societies (Hogg & Vaughn, 2014) have prominent issues with mental health care in the UK. Despite mental health services taking action to ensure that mental health provisions are of a multicultural nature (British Psychological Society (BPS), 2017; National Institute for Health and Care Excellence (NICE), 2011; Smith et al, 2006; Pickren & Burchett, 2014). Consequently, it can be argued that exploration of a predominant factor such as ethnic identity is necessary. Considering that literature purports ethnicity (a social factor) as affecting how mental health is dealt with and is often associated with help seeking behaviour (a psychosocial factor) (Suresh & Bhui, 2006; Atkinson & Gim, 1989; Soorkia, Snelgar, & Swami, 2011). Studying ethnic identity’s influence on help seeking behaviour may demonstrate an in-depth perspective; to the notion that BME populations often demonstrate negative attitudes pertaining to seeking psychotherapy (Atkinson & Gim, 1989; Paris et al, 2005; Magaard et al, 2017).
Ethnic identity is a term used to describe the extent to which an individual identifies with their ethnic heritage (Hogg & Vaughn, 2014). Individuals with an increased ethnic identity have been found to self-report that they take part in cultural activities and speak a language of their ethnic origin, in addition to strong sense of belonging to their ethnic group (Phinney, 1992). As opposed to individuals with decreased ethnic identity who often self-report not taking part in cultural activities, not actively seeking information pertaining to their ethnic background and not having a clear sense of the role that ethnicity plays in their life (Lee, 2006). Additionally, ethnic identity has been associated with psychological well-being and self-esteem (Phinney, 1989; 1996).
An array of literature openly and ambiguously purports that BME populations often have negative attitudes towards seeking psychotherapy (Atkinson & Gim, 1989; Paris et al, 2005; Soorkia et al, 2011). Various social and demographic factors have been cited for this such as, mistrust/fear, cultural differences, gender, socioeconomic status, amongst others (Ojeda & Bergstresser, 2008; Midlarsky et al, 2012; Kim & Omizo, 2003; Townes et al, 2009). Such findings are relevant in the topic area of ethnic identity and attitudes towards seeking psychotherapy. As they depict a pattern of behaviour, which may underpin whether or not treatment is sought and/or how well it is received. Moreover, they also help to differentiate between help seeking behaviour, a psychosocial factor and other factors, such as gender and socioeconomic status, which may also influence treatment (Magaard et al, 2017). However, such studies often recruit BME populations who, in accordance with Phinney’s (1992) definition of strong ethnic identity, have high ethnic identity levels. For example, participants partake in cultural practices and speak their ethnic language, amongst other, high ethnic identity level, indicators (Phinney, 1992). Such studies have also been informative in the facilitation of multicultural psychotherapy, with a view to providing an inclusive service (Hogg & Vaughn, 2014; The Sainsbury Centre for Mental Health, 2002). Nevertheless, in order to provide a justly inclusive service, the perspective of BME populations with low ethnic identity levels needs to also be clearly established and utilised. Bearing in mind that literature indicates that increased acculturation (greater acceptance of another culture), in Western societies, by ethnic minorities fosters positive attitudes towards psychotherapy and decreased acculturation fosters negative attitudes towards psychotherapy (Atkinson & Gim, 1989, Cassidy et al, 2004). Divergently, other studies suggest that high ethnic identity acts as a shield against psychological distress and fosters psychological well-being (Sellers & Shelton, 2003; Branscombe et al, 1999; Cross, 1991). This psychological safeguard, is underpinned by a sense of belonging which emanates from strong ethnic identification with one’s ethnic group (Sellers & Shelton, 2003). Collectively, such findings demonstrate that ethnic identity levels play a role in how/if psychological assistance is sought or utilised. Considering that these studies demonstrate varying perspectives on how ethnic identity fosters attitudes and behaviours pertaining to seeking psychotherapy and psychological distress, respectively (Atkinson & Gim, 1989, Cassidy et al, 2004; Magaard et al, 2017; Sellers & Shelton, 2003; Branscombe et al, 1999).
Despite such literature being insightful with regards to how BME populations understand and approach a westernised standard of mental health (Hogg & Vaughn, 2014), this may also culminate in the stereotype that all BME individuals have a negative attitude towards seeking psychotherapy due to high ethnic identity. Which in turn can reinforce inappropriate mental health provisions, which are not person-centred/idiosyncratic (Memon et al, 2016). Due to the perspective of varying ethnic identity levels, of BME individuals, not being accounted for. Thus, not being used in multicultural psychotherapy facilitation. Only the polar opposite perspectives of Western and Non-western cultures have been purported, in terms of ethnic populations (Hogg & Vaughn, 2014). Whereas a high percentage of the UK BME population are 2nd, 3rd and 4th generations who were born in the UK (Ethnicity & Religion Statistics, n.d.; Jefferies, 2005) and may not be representative of members of their community with a higher ethnic identity or White British individuals. Whom they may feel psychotherapy is adapted for or tailored to, respectively (Midlarsky et al, 2012). Nonetheless, different ethnic identity levels should not be construed as wrong or right but must be holistically accounted for in the context of mental health provisions. As such differing perspectives are essential to the facilitation of bespoke and inclusive mental health services.
This current study endeavours to explicitly demonstrate that some BME individuals hold varying beliefs and attitudes on their ethnic identity level and seeking psychological help, respectively (Cassidy et al, 2004). Thus, advocating previous study findings (Hipolito-Delgado, 2016; Paris et al, 2005) and/or establish an alternate UK BMEs perspective. In addition to broadening the literature scope, with regards to an in-depth exploration of how the paradigm of ethnic identity (Phinney, 1992; 1996; Sellers & Shelton, 2003; Branscombe et al, 1999; Cross, 1991) is related to help seeking behaviour. By clearly exhibiting ethnic identity level’s association with attitudes towards seeking psychological assistance.