Dr Emma Morris

Dr James Bourne

Philippe Mandin

CYP IAPT National Conference

5th November 2013

Aim to bring together clinicians, managers and researchers at an early stage of CYP IAPT to share their experience of its implementation within various community groups,

Particular focus on the use of Routine Outcome Measures (ROMs) across cultures.

First forum (28.02.13): 25 representatives from London partners, GIFT partnership and Anna Freud/ UCL.

On-going dialogue to improve and disseminate good practice.

The experience of Adult IAPT: People from Asian and Black ethnic groups were under‐represented. (Glover 2010).

IAPT BME Positive Practice Guide 01/2009

Common themes from research:◦ E.g. Breaking the Circle of Fear 2002 Sainsbury Centre for mental

health, The DOH Inside Outside (2003); DRE program (2005); Dutt2011

◦ Disparities in mental health care for BME clients.◦ Higher levels of mental distress exacerbated by social

disadvantage and exclusion and experiences of discrimination.◦ Clients from BME communities are less likely to be referred for

talking therapies but more likely to be mis-diagnosed, prescribed medication and compulsorily admitted to hospital

BME samples are frequently under-represented in RCT & EBP - ‘Evidence informed’ Practice (Clarke 2009)

Recommendations for recording of Ethnicity, community involvement, clinical training and organisation change

Requires that listed public authorities in carrying out their functions shall have due regard to the need to:

eliminate unlawful discrimination promote equality of opportunity promote good race relations between

people of different groups

5

Culture constructs many of our basic notions taken for granted such as:

◦Self

◦Kinship

◦Mind / Body

◦Notions of well-being

◦Treatment(Malik & Mandin 2012)

Engaging with local communities

Validity Of ROM’s across culture

Impact on Therapeutic alliance and engagement

Clinical skills

Political context

Organisational change

It is important to ensure that the measure used to track outcomes is valid and does not impact negatively on engagement.

1. Does the measure make meaning of the problem in a way that both the clinician and the young person/family can relate to?

2. Does the young person/family hold any adverse associations with form filling?

How does my own culture fit with or differ from the culture of the family I am about to see?

What do I need to know about the culture of this particular family?

Might I need to tailor my practice at this stage?

Is it possible that there is some difference in the way the problem is constructed across generations?

Based on what I know from the referral, what is the family’s likely relationship to authority/ professional figures, and what is their experience of form filling?

What language does the form need to be in?

Do I need an interpreter, and have I prepared them to use ROM?

Might I need to bring an additional alternative to symptom measurement to the first session?

Will the first session need to be longer in order for me to be able to complete the forms?

Explore: How can I explore this family’s construction of the problem in a way that allows us to develop a shared understanding?

Acknowledge: How can I acknowledge differences in the way problems are constructed and empower families to say in cases where ROM might not 'fit'?

Address: How can I address issues of power and authority?

Bridging: How can I find a shared language or understanding that will facilitate completion of the forms?

Introduce the idea of measurement. However, if it is likely that completing ROM might impact on engagement, do them in the next session. Be prepared to complete ROM over more than one session if need be. Prioritise engagement and building a shared narrative with the family when selecting which ROM to use.

If your clinical judgement is that using ROM will have a significant negative impact on treatment, do not use them- but be sure to discuss this in supervision and with your cultural lead so that they are aware of issues within the service and can feed this back to the broader network.

Discuss in supervision any challenges in engaging across cultures. With the information you now have, you can go back to the 'before session' questions and develop your understanding of the use of ROM with this family.

We all have a culture; culture is dynamic and negotiated differently by different individuals. Clinicians should be curious about the particular meanings that culture holds for the individual clients they are seeing and what they choose to conform to or contest.

Bringing it all together: Embedding positive practice within the organisation

- Describing the local demographic

- Identifying the needs of local communities

- The role of the 'cultural lead'

- Creating a local context for reflexive practice to develop

- Building relationships, locally and nationally

- Sharing resources and experience, locally and nationally

Organisational Change

(establishing and embedding

positive practice)

Community Profile of

the family to be seen

(pre-session thinking,

linking with resources)

Clinical practice: Exploring,

Acknowledging, Addressing

Bridging and Flexibility

Reflexive

practice, use of

supervision and

curiosity with

the individual.

Both Groups: What challenges do you experience in engaging with children, Young people and families that are from a different culture than your own (at a personal, practical and/or organisational level)

Clinical discussion group: How much do these suggested guidelines resonate with your own clinical experience? Which questions are most useful? Which are more challenging?

Organisational discussion group:To what extent is positive practice embedded within your organisation already? What are the barriers? What would be the tasks of your cultural lead?

Department of Health (2008) Commissioning IAPT for the whole community

Improving Access to Psychological Therapies

Glover et al (2010) ‘IAPT – A review of the progress made by sites in the first roll

out year’http://www.iapt.nhs.uk/silo/files/iapt-a-review-of-the-progress-made-

by-sites-in-the-first-roll8208-out-year.pdf

Jassi, C (2008) IAPT for BME Communities. Advancing Practice in Bedfordshire Volume 5: Number 3 (2008) ISSN: 1743-1611

http://www.iapt.nhs.uk/downloads/resources/?keywords=&filter=last_updated&order=asc&p=1

Malik & Mandin (2012) Engaging within and across culture In Krause, I,B (Karnac) Culture & Reflexivity In Systemic Practice

National Institute for Mental Health in England (2003) Inside Outside: Improving

Mental Health Services for Black and Minority Ethnic Communities in England.

London: DoH.

Netto, Gaag, Thanki, Bondi & Munro (2001) Perceptions and experiences of counselling services among Asian people. Joseph Rowntree Foundation. Patel N, Bennett, Denis M, Dosanjh N, Mahtani A, Miller A, Nadirshaw Z (2000) Clinical Psychology – Race and Culture: a training manual. Leicester: BPS Books

http://www.centreformentalhealth.org.uk/pdfs/breaking_the_circles_of_fear.pdf