Who is really ‘hard to reach’?

As a Clinical Psychologist with a remit for improving psychological therapy services for black and minority ethnic communities, a term that I find especially problematic is ‘hard to reach’. Often used to describe those who are under-represented in mainstream services, what concerns me is that it locates ‘the problem’ of access in the people or communities themselves.

Hard to reach is often attributed to people on the basis of their ethnicity, gender, class or immigration status rather than, for example, having negative experiences with services and being understandably wary of them. It also stops us from looking at how difficult it can be for them to access suitable services.

In my experience, it is relatively easy to interest people in psychological therapies. What is more difficult to navigate are the barriers erected by services. From the requirement to be referred, therefore facing referrers’ stereotypes and assumptions about who benefits from therapy, to arduous assessment processes, requiring the completion of numerous questionnaires, often in English, to the judgements made of ‘psychological mindedness’, ‘motivation’ or ‘readiness to change’, which are based on unarticulated and Eurocentric cultural values.

Additionally, services may be offering models of therapy that don’t fit well with people’s values or feel relevant to their problems. In discussing the many barriers that exist, Clinical Psychologist, Iyabo Fatimilehin, asked whether it is us, the professionals, who are, in fact, ‘hard to reach’?

There are serious consequences in continuing to apply this term to communities. Locating the difficulty within the community suggests the need for interventions, such as raising awareness of services or by psychoeducation to improve ‘readiness for therapy’ or ‘motivation to attend’. This approach often fails to bring about the hoped-for improvement in access.

Meanwhile, people still struggle to access services and by continuing to see people as hard to reach, these services continue to validate the idea that it is the person, or their community, that is lacking in some way and needs to change.

Why is this idea so persistent? Perhaps because it provides both an excuse for inaction and an explanation when initiatives fail. The failure of interventions is located in the community and the system is absolved of responsibility.

It is sometimes argued that, although we know it’s not true, it is pragmatic to keep using this term as it allows us to attract funding for community-focused work. We have to stop using the term because it is both unjust and can take us in directions that are likely to fail and continue to be used to maintain the problem.

We need to turn the lens around to look at how we can provide services that are genuinely accessible and relevant to the communities we serve. Doing this doesn’t ignore the factors that may stop people coming forward or wanting to engage with services.

So, what can we do to stop being ‘hard to reach’ professionals? East London NHS Foundation Trust has services in Hackney and Tower Hamlets dedicated to making psychological therapies accessible and culturally relevant to local communities. Our model involves working in partnership with community and faith-based organisations, which are trusted and accessible. Developing trust is key and involves a recognition of structural racism and ways in which communities have been marginalised and pathologised within mental health services.

We acknowledge and draw on the expertise of communities in addressing the needs of their members. By working together to develop and deliver interventions in accessible community settings, such as community centres, churches and mosques, therapeutic strategies are co-produced and aim to be culturally relevant. This goes beyond simply translating materials into different languages and involves considering how people understand their mental distress, their preferred ways of coping and their vision of recovery.

Examples include approaches incorporating people’s faith or foregrounding the knowledge of communities such as the work of Ncazelo Ncube Mlilo, who developed the Tree of Life and COURRAGE methodologies, which she explained in her Synergi Talks interview with Catalyst 4 Change Co-Director Sandra Griffiths.

As a white person doing this work, I am often questioned about my motivation or ability to practice in this area. This pushback generally comes from within the profession itself and often from other white people.

I have even been told that it is ‘ridiculous’ that I am in this role. However, I believe that white people have a responsibility for addressing the inequalities that exist as a result of the structural racism and the whiteness of our profession.

There is a special kind of injustice in expecting people who have been systematically excluded to find ways to include themselves. This is not to deny that there are legitimate concerns about what white people bring to this work, and the risk of imposing concepts and upholding whiteness.

We need to do our own work and to strive for accountability and genuine partnerships with community and faith groups. This also involves acknowledging that such partnerships are often unequal in terms of distribution of power and resources, and to use our influence wherever possible to address this.

For example, small culturally-specific groups and organisations have been badly hit by funding cuts and I feel passionately that we should not be neutral about this, but should use our influence to advocate for their survival, wherever possible.

If we are to really address inequalities in access to psychological therapies, we need to stop locating the problem in the communities and acknowledge that it is us Clinical Psychologists who have been ‘hard to reach’ all along.

Angela Byrne is a Clinical Psychologist at the East London NHS Foundation Trust, in a service to improve psychological therapies provision for black and minority ethnic communities in Tower Hamlets, London. You can read her full bio here.