Introduction

It is widely documented that Black, Asian and Minority Ethnic (BAME)Footnote ¹ communities experience poorer mental health, and have a poorer experience of mental health services, than those from White British backgrounds. Individuals from minoritised communities are often under-represented in primary care mental health services, yet over-represented in secondary care mental health services (Butt et al., Reference Butt, Clayton, Gardner and Huijbers2015). Indeed, research has shown that those from a BAME background are four times more likely to be diagnosed with a severe mental illness and detained under the Mental Health Act than those from a white background (Barnett et al., Reference Barnett, Mackay, Matthews, Gate, Greenwood, Ariyo and Smith2019). Individuals in BAME communities are often labelled as ‘hard to reach’ (Butt et al., Reference Butt, Clayton, Gardner and Huijbers2015; Memon et al., Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and de Visser2016), without fully understanding barriers to access and engagement with mental health services such as fear and discrimination (Memon et al., Reference Memon, Taylor, Mohebati, Sundin, Cooper, Scanlon and de Visser2016). Given that those from minority ethnic and racial groups are more likely to experience psychological difficulties, for example due to their experiences of racism, discrimination and social inequalities (Allen et al., Reference Allen, Balfour, Bell and Marmot2014; Wallace et al., Reference Wallace, Nazroo and Bécares2016), it is imperative that timely and equitable access to mental health services is available.

The NHS Talking Therapies for Anxiety and Depression Service (formerly known as IAPT) was commissioned in 2008 to provide increased access to first-line psychotherapeutic interventions for individuals presenting with common mental health problems. Those practitioners and therapists employed by these services work with an increasingly diverse client population (Faheem, Reference Faheem2023); however, individuals from BAME communities continue to experience lower access, treatment and recovery rates compared with White British individuals (Baker and Kirk-Wade, Reference Baker and Kirk-Wade2023). The Office for National Statistics (ONS) (2022) reported that between April 2017 and March 2018, individuals from an Asian ethnic background were under-represented in NHS Talking Therapies Services, and treatment rates were also lower for individuals born outside of the UK and those whose first language was not English. Further research has found that racial and ethnic minority groups were less likely to self-refer to these services, or if they did, were less likely to (a) receive an assessment, and (b) receive treatment if assessed (Harwood et al., Reference Harwood, Rhead, Chui, Bakolis, Connor, Gazard and Hatch2023). Encouragingly, the gap in recovery between White British and BAME individuals has narrowed in recent years. However, concerns remain that this improvement has not been sustained post-pandemic (National Audit Office, 2023). Indeed, authors have advocated for NHS Talking Therapies services to address barriers to accessing treatment for minoritised groups, and eradicate racial inequalities that exist within service provision (Beck et al., Reference Beck, Naz, Brooks and Jankowska2019; Cénat, Reference Cénat2020). Despite this, providing equitable access to treatment for all ethnic populations is not currently included as a key performance target by the NHS (Lawton et al., Reference Lawton, McRae and Gordon2021).

There are inevitably complex, entrenched and systemic injustices that impede individuals from BAME communities from receiving appropriate psychological therapy in services such as the NHS Talking Therapies Services. Whilst there are evidently problems that require solutions at a structural level, there is an increasing focus on individual therapists being accountable for undertaking anti-racist professional practice, and for delivering therapies such as cognitive behavioural therapy (CBT) in a culturally competent way. Indeed, the updated national curricula for CBT training programmes now more clearly stipulate the competencies that all therapists should develop during their training in order to achieve this (British Association for Behavioural and Cognitive Psychotherapies (BABCP), 2022a, 2022b; Health Education England, 2022). This is an important development, particularly as authors have variously documented the difficulties that therapists experience in meeting the needs of BAME individuals meaningfully as part of treatment. Many therapists lack the confidence to open up discussions with service users about their race, ethnicity or culture due to fears about making mistakes, causing offence, appearing racist or culturally incompetent and coming into conflict with the client (Beck, Reference Beck2019; Faheem, Reference Faheem2023; Naz et al., Reference Naz, Gregory and Bahu2019). White therapists may also experience difficult emotions such as anxiety, guilt and shame when addressing such issues (Naz et al., Reference Naz, Gregory and Bahu2019). The emotional context of exploring service users’ cultural identities can lead to therapist avoidance behaviours, resulting in problem formulations that are not culturally informed, and which fail to contextualise the person’s distress in a way that validates their experiences of being of BAME heritage. This may be further exacerbated by the use in CBT of models which are heavily influenced by the majority culture (Hays and Iwamasa, Reference Hays and Iwamasa2006) and which understand psychological distress in a way that is separate to the person’s cultural context and experiences (Beck and Naz, Reference Beck and Naz2019). As such, therapists can struggle in practice to work in a culturally sensitive way when using these models, or else can overlook the importance of doing so. Indeed, therapists have reported difficulties in this respect, for example finding it difficult to engage BAME service users in a treatment model that assumes autonomy and independence, when their own cultural context assumes familial expectations, community and collectivism (Faheem, Reference Faheem2023). Further difficulties reported by therapists when working with service users from BAME communities include the challenges of working effectively with interpreters, a lack of culturally adapted therapeutic resources and the absence of key therapeutic words or terms in their own language (Faheem, Reference Faheem2023). Outside of these more practical considerations, it has been strongly advocated that therapists have self-awareness of their own prejudices, bias and stereotypes (Beck and Naz, Reference Beck and Naz2019) and be conscious of how these might present in the interpersonal transactions with the service user (Lawton et al., Reference Lawton, McRae and Gordon2021).

In short, whilst cultural competency is a core skill in psychotherapy, many therapists struggle to work effectively with service users from BAME backgrounds for a range of different reasons; this contributes to poorer treatment outcomes for minoritised groups compared with those from a White British background, and may be in part due to inadequate training in this area (Faheem, Reference Faheem2023). The current evidence, although sparse, would support this position. Authors have suggested that therapists rarely receive training that is sufficient in terms of enabling them to work inclusively (Edge and Lemetyinen, Reference Edge and Lemetyinen2019) or that encourages them to examine the role of their own cultural identity, biases and positions of power and privilege (Sue, Reference Sue2001). Bassey and Melluish (Reference Bassey and Melluish2012) found that CBT therapists working in NHS Talking Therapies Services viewed their training as insufficient in addressing issues of equality, diversity and inclusion, with trainees advocating for more reflective learning activities, culturally competent supervisors, and increased opportunities to learn from peers and lived experience colleagues from BAME backgrounds (Bassey and Melluish, Reference Bassey and Melluish2012). Some authors have suggested that training programmes often focus on helping trainees to build self-awareness and other-awareness, but give insufficient time to helping them to develop the skills required for competent cross-cultural practice post-training (Jones et al., Reference Jones, Kawena Begay, Nakagawa, Cevasco and Sit2016). Others have noted that cultural competence training often improves therapist knowledge but fails to change attitudes or develop skills, and that this calls for a more integrated approach to teaching and learning strategies (Benuto et al., Reference Benuto, Casas and O’Donohue2018). Furthermore, such an approach should normalise discussions of difference and diversity within safe spaces where trainers model offering their own experiences, beliefs and limitations (Benuto et al., Reference Benuto, Casas and O’Donohue2018; Calloway and Creed, Reference Calloway and Creed2022).

Despite the clear importance of ensuring that therapists working in NHS Talking Therapies Services are equipped via training to meet the needs of BAME service users, very little research has been conducted to investigate whether this is the case. Given the additional prominence that cultural competence now has in the national curricula for such training courses, it seems timely that programmes evaluate their own teaching and learning strategies in this context. As such, the present study sets out to perform an initial, exploratory evaluation of the integration of issues relating to equality, diversity and inclusion in the Postgraduate Diploma in CBT at the author’s employing university, using the lived experience perspectives of course graduates working in the NHS.