Recognition of mental health problems

Inability to recognise symptoms of mental illness and unwillingness to accept a diagnosis of mental illness were mentioned as key barriers to seeking help from health services, particularly for individuals who had grown up in their native countries. For instance, one woman stated that in Africa she “never heard of mental health or being depressed” (Female L. FG1). This was compounded by a cultural belief that mental health was sometimes not to be discussed openly with family members. As a result, health seeking for psychological problems was reported to be delayed and to lead to presentation as a crisis or emergency because people “hide it, until last minute when it is very bad” (Male J. FG2).

Social networks

A network of family and friends within the community was seen as key in providing a safe framework for the discussion of problems and could play a valuable role in accessing mental health services, particularly in crisis: “There were so many gaps in the services. My mum was seeing them all the time. She was having to do so much just to get him assessed” (Male J. FG1). However, social networks could also be perceived as a barrier either through their absence, or by providing an alternative to professional services.

One woman highlighted that a lot of people who grew up in their native country may not have family or social connections in the UK and “the mental health service does not always understand. That we are really, really isolated” (Female I. FG1). Social isolation was also relevant for people who lived alone, or whose family structure had broken down: “if your family structure breaks down you find yourself so incredibly isolated. It is then that you might realise that, it is not to do with intelligence or anything, it is just like, where to go to find help is really hard […]” (Female H. FG1).

Informal social support structures could be perceived as a viable alternative to accessing professional mental health services, particularly where there was an element of distrust within the community towards formal healthcare provision: “In the West Indian community […] people do not trust psychiatrists particularly […] in terms of where my family and friends would turn in experiences of bad mental health or whatever is towards family structures. Informal structures, friends.” (Male D. FG1).

Sex differences

Many participants suggested that BME men were less willing or less able to talk about their problems, particularly with mental health professionals: “Men, we tend to keep things to ourselves. We do not think that by exposing our own insides to outside will bring any solution at all […] I am a man, I can sort it out” (Male B. FG2). Participants also perceived services were not “available for men of colour who have mental health issues” (Male J. FG1). Although a large number of male participants emphasised the importance of discussing concerns, the ability to deal with problems was often described in terms associated with a wider masculine identity, for example, ‘pride’ (Male B. FG2) and strength.

Cultural identity and stigma

Significant emphasis was placed on cultural identity and stigma towards mental health as barriers to accessing services. Participants commented on how cultural background and identity defined acceptable responses to mental health problems and appropriate coping mechanisms. One woman described the attitude within her community where individuals were expected to “deal with it…you are supposed to be strong. You are from Africa” (Female L. FG1). Mental health was often perceived as a socially unacceptable topic for discussion: “Stuff like that is never talked about” (Female L. FG1). Mental illness was also typically viewed negatively, or in the context of extreme cases the services were seen as serving “crazy people only” (Male L. FG2). Owing to the stigma towards mental illness within the community, individuals were reluctant to openly acknowledge symptoms, thus restricting access to the services. One participant explained that “our people cannot go to mental health services because […] he thinks it is only crazy people going there” (Male L. FG2). In addition, the participants explained that people might also be reluctant to seek help on behalf of another member of their community due to social stigma: “if you tell those in authority, ‘Please my friend has a mental health problem and I am worried’, then what will happen? I am from Sudan. My community will come to me and say, ‘Why are you doing this to him?’ because in our culture, in our country, it is wrong” (Male J. FG2). The consequences of cultural stigma attached to mental health were recognised as reaching beyond the individual. One participant described how a mental health diagnosis could stigmatise the whole family, affecting employment prospects and standing in the community: “in our country if you hear about somebody in this family sick, is mental, you lose trust in this person and whole family, maybe relative as well. And, […] they whisper about the whole family and maybe talk about grandmother, grandfather, and they lose respect” (Male J. FG2).

Financial factors

The cost of using complementary medicine or therapy, which is not covered under the NHS, for example, relationship counselling “‘Relate’ costs you money” (Male U. FG2), was seen as a barrier to accessing the services: “If you want the alternatives you have to physically go and find them and you have to pay” (Female F. FG1). Most participants reported that they were unable to pay for these therapies and this often meant their illness would remain untreated: “There is no money. We just cannot afford it […]. You just have to do it yourself. Then you end up just leaving it” (Male B. FG2). A number of participants believed that community support groups and organisations are important in providing an informal structure for activities, discussion and support; but that a lack of funding for the associated costs of running these groups was an issue “We cannot afford it (to hire a hall for community meetings). You can apply for council funding but you have to have this and that”. (Male Q, FG2).

Waiting times

Several participants highlighted long waiting times as a barrier to accessing services and expressed frustration that services were unable to respond quickly to mental illness: “He has now been 6 months on the waiting list—my friend's son. He died about 2 weeks ago. […] There is such a long waiting list, and why have they not got sufficient people to address these…? This is our future, these young men” (Female C. FG1). Lengthy waiting times for assessments and services were identified as negatively impacting on the outcome for individuals by allowing a mental health problem to escalate in severity: “she was told there was a four month waiting list before she could get any support. […] her state went from being one in which she was quite open to getting help to one where […] basically her situation declined significantly […]” (Male D. FG1).

Language

Language was seen as a common barrier to access. Participants emphasised that some people within the BME community had little or no understanding of English, especially if they were recent immigrants. The inability to effectively communicate with healthcare professionals prevented individuals from accurately articulating their problems: “They do not know how to explain their problems. That is why they do not want to go to GP many times. So they remain with their illness. That is our big problem” (Male H. FG2). As a consequence, an individual might experience additional stress, withdraw from healthcare services or receive inappropriate investigation and treatment: “I know one person, he has struggled and struggled. He said what he could say but the limit of the words, the real words he wanted to say to the GP, he did not know the meaning of them in English. Then in the end they end up getting the wrong treatment” (Male B. FG2). Although one participant noted that interpreting services were better provided for in recent years, concerns were still raised over inadequate provision of interpreters, particularly in primary care “the interpreter service does not send to the GP because of the ten minute time” (Male L. FG2).

Communication

Poor communication between service user and healthcare provider was indicated as a key barrier to developing an effective relationship. Failure in communication arose not only from the linguistic challenges described above, but from doctors' perceived inability to listen to the concerns and needs of service users. Participants felt that healthcare providers took a generalised approach and failed to listen to individual needs: “you treat everybody with the same brush […] you go in and […] you are just like the next person. They do not take time to listen to you. And I do not think it is because of colour or anything like that. In talking to a lot of people, including White people, they encounter the same thing …” (Female F. FG1). A further challenging area of communication lay in the reluctance of professionals to engage with friends and relatives attempting to access mental health services on behalf of an individual with mental health problems: “I think getting services to respond when a parent is telling them needs to happen more […] Listen to the family telling them that this person has got a problem. There might be reasons why they have not gone to the services” (Male J. FG1). It was often felt that healthcare providers “just did not want to get involved and give him the help that he needed” (Male J. FG1) and, despite evidence of escalating problems, concerns were dismissed: “She had to fight to get him assessed and they were telling her ‘no, there is nothing wrong […] From the first time he was sectioned after an overdose. They were not there—they did not help her […]” (Male J. FG1).

Responding to needs

Participants felt that healthcare providers did not adequately recognise or respond to their needs. They felt that the system lacked flexibility, leaving it unable to support individual or cultural preferences, particularly in relation to available therapies. One participant described the general response to symptoms of depression as “just fill this form in and say how your mood is and I will give you some antidepressants” (Female L. FG1). Many participants described receiving “pills that I do not want” (Female L. FG1) and felt their reluctance to start medications was disregarded, and that the use of complimentary/alternative therapies was not explored. One participant explained “for me it really felt like they were wasting my time. He did not give me any help whatsoever” (Male B. FG2). Many participants wanted “to access people who will listen to us, who will allow us to talk” (Female C. FG1) and raised concerns that talking therapies were not readily provided, and organisations offering creative approaches such as expressive writing workshops were not encouraged. One participant described the experiences of his friend: “she had the choice between medication and down the line when her situation declined then you have got the opportunity to be sectioned, which is not really an opportunity” (Male D. FG1). Participants felt that if healthcare professionals “widened their cultural knowledge of what was normal” (Male K. FG1), it would allow them to consider a greater range of therapies and supportive techniques.

Power and authority

Interactions with clinicians were described in terms of “being talked down to” (Male D. FG1). There was concern that clinicians had “the power simply with the stroke of a pen to decide whether you are going to be sectioned or whether you are going to be sent away for some counselling. Or […] administered some really, really high doses of whatever kind of medicine” (Male D. FG1). It was felt that there was “a clash between the professional expertise that the doctor has and is often given privilege over someone's knowledge about their own mental state and mental health and experiences” (Male D. FG1). Although some participants expressed a need to “try and change that balance of power between the two of you” (Male D. FG1), they also described a sense of helplessness and passivity with regard to healthcare interactions and treatment: “We have to follow what the professional said. If we do not want to follow what they are saying, it is our problem […]” (Female N. FG1). A worsening of the service user and healthcare provider relationship and exclusion from services were seen as possible consequences of assertive behaviour: “I asked for a change of CPN [community psychiatric nurse] and they crossed me off […] She was not able to give me what I needed. […] I got made an appointment to see a psychiatrist and the psychiatrist said that we can no longer offer you any services or help” (Male M. FG1). The need for a positive interpersonal connection between service user and healthcare provider where the consultation was “a dialogue” (Male D. FG1) was seen as an important factor in engaging with mental health services.

Cultural naivety, insensitivity and discrimination

Participants described how healthcare providers often struggled to understand BME people's experiences. A few participants expressed annoyance at having to explain “the Black experience” (Female I. FG1) to healthcare professionals feeling that this interfered with effective therapy. One woman described “humouring the therapist so that they can actually give me the help that I really need. And I have also found that when you, for instance, talk about racism that actually a lot of them cannot deal with it” (Female I. FG1). When accessing services, many participants wanted “to see someone like me, someone who understands my culture who […] is going to welcome me with open arms and is going to get what I am saying” (Female E. FG1). Participants perceived that White British GPs and specialists were unable to understand or sympathise with the realities and experiences of those from a BME background. Services were often seen as insensitive to the needs of Caucasian service users, and they were often categorised: “They do not want to be aware of what we are trying to say. So, they just put in a category. Just White British way” (Female G. FG1). Some participants felt they had received inadequate or different treatment “because of our skin or where we have come from” (Male B. FG2). One participant expressed her frustration over her experiences in accessing treatment: “I got an English friend and she said to me that she has got the same problem […] her GP transferred her to her consultant to see her problem and her problem was solved. Why would my GP not transfer me to a consultant instead of giving me a different tablet every time? I just feel like I am really angry and really frustrated because they transferred her because she is English and I am not English” (Female E. FG2).

Awareness of services

General lack of awareness—among healthcare professionals and the wider community—of the services available within mental healthcare and how to effectively access them was another barrier. Participants felt they did not know “how we get help” (Male G. FG2). One woman illustrated: “If we don't know that something is available, how are we going to access it?” (Female F. FG1). Participants wanted to be informed of available services for further help and support, but felt GPs “need to be aware of community organisations, because they are not” (Female E. FG1). There was a sense of frustration that “when we access the doctors if they do not know that there are these kind of groups we can turn to, then it is a futile exercise” (Female F. FG1). Lacking wider knowledge of organisations available to provide mental health support meant GPs could not discuss the full range of treatment options available and were unable to signpost service users to appropriate services: “If they are not equipped to deal with us I would rather they sent us to a support group” (Female E. FG1). One participant expressed how this lack of awareness of alternative therapy could contribute to the apparent unresponsiveness to service users' needs (described above): “The NHS […] needs to be educated to the point that they know that there are other avenues that they can turn to if they are not working for that individual person” (Female F. FG1).