A recent article published in Psychiatric Services interviewed healthcare providers involved in early intervention in psychosis (EIP) community-based programs to understand structural barriers to successful treatment. The international study was led by psychologists Nev Jones and Sarah Kamens.
The researchers focused on the impact of racial and cultural marginalization as well as economic disadvantage. According to those interviewed, these kinds of cultural and structural disadvantages significantly affect both retention and quality of engagement with EIP programs.
“A substantial body of research suggests that structural disadvantages (e.g., poverty and residential segregation) and culture-related adversities (e.g., migration, asylum, and racial profiling) heighten the risk for developing psychotic symptoms. Independently of psychosis, these adverse experiences are widely considered to be risk factors for educational under attainment, unemployment, poor general medical health, and incarceration.
Furthermore, within the broader psychosis literature, poverty, and minority race-ethnicity have been found to be associated with disparities in access to and quality of care, including higher rates of involuntary hospitalization and disability,” Jones, amens, and their co-researchers write.
Despite the prevalence of this research, a biomedical understanding of psychosis is still the norm and treatment for psychosis that targets many of the environmental factors involved—what some call “structural competency”—is uncommon. This is the case both in Western psychiatric practice as well as Global Mental Health interventions.
The current study examines the views of early intervention in psychosis (EIP) providers on various issues, such as the impact of racial/cultural marginalization and economic disadvantage on treatment outcomes.
The authors interviewed 164 providers working at EIP programs in different countries, including the United States, the United Kingdom, Canada, Australia, and Chile. The mixed-methods study included a survey that asked both open and closed-ended questions on issues such as:
- Whether the providers’ programs incorporated assessment of trauma and cultural issues
- Whether the programs consulted with “cultural insiders.”
- Whether peer workers and others (e.g., family members, partners) were included in the treatment
- How providers understand barriers to treatment related to structural issues
- Whether the programs featured changes in relation to observed needs, related to, for example, cultural competency
The researchers used both statistical analyses of the quantitative variables and content analysis coding of the qualitative variables to understand the data.
Many of the providers interviewed (33%) were directors or team supervisors, while others were therapists/psychologists (26%), psychiatrists/nurses (25%), or case managers (18%). Reflecting a limitation of the study’s sample, 74% were Caucasian/White, 66% were female, and 52% had a master’s degree.
The study’s “penetration,” or how thoroughly it received responses from programs in different countries, was high in many places—100% of EIP programs in Chile responded, 60% of programs in Australia, 30% in the U.S. and UK, and 13% in Canada.
The study found that 75% of providers stated that their programs served “significant numbers of clients from ethnic-racial minority communities or structurally and economically disadvantaged communities,” though the exact demographics of minority groups, for example, varied by regions—such as Irish Traveler itinerant groups in the UK, indigenous-aboriginal peoples in Canada and Australia, and African American and Latinx populations in the U.S.
The “overwhelming majority” of providers stated that cultural differences and disadvantages significantly impact treatment success. 83% of programs treating “significant numbers” of disadvantaged individuals reported higher disengagement rates from their programs related to race, ethnicity, culture, or disadvantage.
59% of participants described economic disadvantage as having a significant negative impact. Even when economically disadvantaged service users stayed in these programs, the quality of treatment was said to suffer because of immediate concerns around housing and other basic needs. Several participants noted the intersectionality of these issues, with economic issues connecting to racial/ethnic disadvantages. One provider explains:
“SES [socioeconomic status] has a huge impact on our clients . . . and intersects with cultural factors, such as distrust of White, mainland interventions and institutions, which is rationally based on a long history of being mistreated by these institutions.”
Almost all participants described the strategy of addressing these issues as involving traditional case management practices, such as “assistance with welfare applications and linkage to subsidized housing and social welfare supports.” At least ten of the providers mentioned that this was not enough to meet service users’ needs.
A handful of different approaches were also mentioned, such as culturally adapted trauma interventions, direct involvement of service users with their own communities, and culturally diverse treatment teams or teams that include peer workers/family members.
60% of participants noted some form of “concern or unmet need” related to cultural and economic issues. Many noted that even though they have theoretical awareness of these problems, it is difficult to develop concrete “operationalizable” understandings and interventions. According to the authors, this may explain why some research has “identified only a small number of variables relevant to trauma, structural disadvantages, and cultural differences.”
Other cultural barriers were described by participants as well, such as difficulties translating between the belief systems of service users and providers:
“A client of ours is of Pacific Island descent. The client believes in reincarnation. Her narrative involves a story of conflict with Japanese ancestors. The therapist insists on calling this the client’s ‘delusion.’ My concern is that this young woman’s experience has been dismissed by the therapist. Were the therapist to [actually] approach this young woman’s experience with cultural humility and openness, together they might create more respect and healing within the possible context of the client’s belief system.”
Finally, in addition to the broader inclusion of peer workers and family members, many participants believed that service users’ involvement and their broader social networks in the designing of services themselves would be beneficial.
The authors conclude:
“Findings suggest significant gaps and challenges related to equitably engaging and meeting the needs of clients and families from racial-ethnic and cultural minority groups and those experiencing poverty or other structural disadvantages.
Research on the client and family experience of EIP services, how such programs intersect with these topics, how they affect engagement, and potential strategies and innovative practices should be prioritized, along with more widespread assessments of acculturation, previous adversity, and socioeconomic and structural disadvantages.”
Jones, N., Kamens, S., Oluwoye, O., Mascayano, F., Perry, C., Manseau, M., Compton, M. T. (January 12, 2021). Structural disadvantage and culture, race, and ethnicity in early psychosis services: International provider survey. Psychiatric Services. (Link)