Introduction
There is a growing consensus among mental health practitioners, policymakers and researchers about the moral imperative to design and provide culturally appropriate mental health services for ethnic minorities and culturally diverse populations (Jacobson and Farah, Reference Jacobson and Farah2012; Minas, Reference Minas, Bhugra and Bhui2017; Naeem, Reference Naeem2019; Sofouli, Reference Sofouli2021). This is endorsed by the World Health Organization ‘Mental Health Action Plan 2013–2030’ (WHO, 2021), which highlights the importance of accessing a broad spectrum of integrated culturally appropriate interventions encompassing mental health promotion, prevention, treatment and in particular, recovery-oriented services. However, despite the growth of an extensive body of research on mental health recovery, this literature has often failed to include the concepts of culture and ethnicity (Levy-Fenner et al., Reference Levy-Fenner, Colucci and McDonough2022) and the social determinants of mental health (Jacobson and Farah, Reference Jacobson and Farah2012) within conceptual models of recovery (Slade et al., Reference Slade, Amering, Farkas, Hamilton, O’Hagan, Panther, Perkins, Shepherd, Tse and Whitley2014; Leamy et al., Reference Leamy, Bird, Le Boutillier, Williams and Slade2011). In addition, the perspectives of minority ethnic groups about recovery have seldom been captured (Whitley, Reference Whitley2016).
These gaps highlight the problem of mental health services implementing recovery values and principles in practice for ethnic minority and culturally diverse groups. For example, it has been suggested that members of cultural groups with a collectivistic value orientation tend to see their life goals as intimately linked to those of their communities and families, as opposed to more individualistic cultures (Tse and Ng, Reference Tse and Ng2014; Levy-Fenner et al., Reference Levy-Fenner, Colucci and McDonough2022). This paper contributes to these debates by exploring the topic of culturally appropriate recovery approaches in the context of mental health service provision for an ethnic minority group in Ireland called Irish Travellers (or Mincéirs).
Conceptual framework
It has been suggested that the process of ‘personal recovery’ and its focus on connectedness, hope, identity, meaning and empowerment (CHIME), which may be considered possible proximal outcomes for interventions, stands against the dominant ‘clinical recovery’ based on symptomatology (Leamy et al., Reference Leamy, Bird, Le Boutillier, Williams and Slade2011). This approach challenges the mainstream biomedical model of symptom reduction by focusing more on enhancing mental well-being, agency, and hope and ensuring that people are in control of their lives.
A growing body of evidence supports this paradigm shift by suggesting that factors such as employment, housing, income, and social connections can be considered ‘recovery influencers’ (Norton and Swords, Reference Norton and Swords2021). These factors support people’s recovery by enabling them to reach their full potential, gain a sense of purpose in life and experiencing full citizenship and community integration (Ramon, Reference Ramon2018; Topor et al., Reference Topor, Boe and Larsen2022; Larsen et al., Reference Larsen, Friesinger, Strømland and Topor2022). It has been argued that while mental health systems can possibly support recovery, they might not necessarily be sufficient to achieving it (Jacobson and Farah, Reference Jacobson and Farah2012).
This evidence indicates that the recovery model echoes the principles of a mental health promotion approach, which embraces a holistic approach to health creation by enhancing supportive environments, addressing the social determinants of mental health, enabling access to resources and strengthening protective factors for good mental health (WHO, 2014; Barry et al., Reference Barry, Clarke, Petersen and Jenkins2019).
In this regard, the fields of Health Promotion and Recovery converge as they both emphasise assets and strengths-based approaches instead of focusing on illness, deficits and curative services (Slade, Reference Slade2010; Kobau et al., Reference Kobau, Seligman, Peterson, Diener, Zack, Chapman and Thompson2011). This study is, therefore, placed at the intersection between the health promotion and recovery conceptual frameworks. Evidence from both research fields recognises that health and recovery are generated within a socio-ecological context that comprises individual factors alongside broader societal and environmental elements (Leamy et al., Reference Leamy, Bird, Le Boutillier, Williams and Slade2011; WHO, 2014).
Towards a reorientation of mental health services
An additional point of convergence between these two fields of enquiry is their call for a reform, or a reorientation, of mental health services. The health promotion pillar of ‘Reorient Health Services’, included in the Ottawa Charter of Health Promotion (WHO, 1986), encourages the healthcare sector to embrace a more comprehensive mandate that is open to collaborating with the broader economic and socio-political environment to address the social determinants of mental health, rather than solely treating illnesses.
Similarly, it has been argued that in a modern recovery-oriented service, professionals would engage more with families and communities, promote social inclusion, address stigma and discrimination, become more outward-looking and shift away from working solely with individuals (Leamy et al., Reference Leamy, Bird, Le Boutillier, Williams and Slade2011; Tew et al., Reference Tew, Ramon, Slade, Bird, Melton and Le Boutillier2012; Whitley, Reference Whitley2016; Davidson et al., Reference Davidson, Rowe, DiLeo, Bellamy and Delphin-Rittmon2021). In Ireland the ‘National Framework for Recovery in Mental Health 2024-2028’ confirms this broader role by suggesting that ‘a recovery-orientated service requires everyone including people who use services, the voluntary sector, other public service departments, agencies and the community at large to be involved’ (HSE, 2024, p.13).
The role of Peer Support Workers in mental health services represents an example of this new mandate for health services, which is underpinned by a shift of power, resources and knowledge from hospitals and medical staff towards lay workers, service users and communities (WHO, 1978; Catford Reference Catford2014). While employed by mainstream mental health services, these workers are experts by experience who use their lived experience of mental health challenges to empower service users, encourage their engagement in society, instil hope and bridge the gap between healthcare services and the communities (Hunt and Byrne, Reference Hunt and Byrne2019; HSE, 2024).
Peer Support Workers also contribute, with their lived experience of recovery, to inform service improvement and embed recovery values within the services. This process, an essential component of co-production in mental health, can help steer mental health services towards a person-centred recovery-orientated practice and a new expanded role beyond the traditional biomedical model (Slade et al., Reference Slade, Amering, Farkas, Hamilton, O’Hagan, Panther, Perkins, Shepherd, Tse and Whitley2014; Hunt and Byrne, Reference Hunt and Byrne2019; HSE, 2024).
Since the ideas around ‘personal recovery’, as opposed to ‘clinical recovery’, stem from the experiences of people who have endured mental health difficulties, the recovery model and movement have been centred since their foundation on the ‘lived experience’ perspective (Boardman and Shepherd, Reference Boardman and Shepherd2012). Advocates of the recovery movement, rooted in the civil rights, consumer, and survivor movements during the 1970s, asserted that their symptoms and impairments should not permanently hinder their ability to achieve personally valued life goals and that they wanted to regain agency and greater independence (Boardman and Shepherd, Reference Boardman and Shepherd2012).
However, the concept that individuals with a mental disorder are primarily responsible for their own recovery and that their role should not be exclusively to receive care passively but also to live ‘life in the community’ and pursue life goals while still experiencing symptoms, is a relatively recent one (Davidson et al., Reference Davidson, Ridgway, Wieland and O’Connell2009). This shift towards valuing ‘lived experience’ and recognising the active role service users play in their own recovery, along with societal factors, is the real transformation advocated by the recovery movement, as recovery cannot be achieved without self-determination (Davidson et al., Reference Davidson, Ridgway, Wieland and O’Connell2009).
Meeting the mental health needs of Irish Travellers in the healthcare setting
Irish Travellers (hereafter ‘Travellers’) experience disproportionately high levels of poor mental health and suicide compared to the general population (AITHS, 2010). Travellers’ mental health inequities are rooted in a history of marginalisation and poverty, discrimination, homelessness, unemployment, educational disadvantage and social exclusion (AITHS, 2010; Villani & Barry, Reference Villani and Barry2021). Travellers are a traditionally nomadic ethnic minority group, accounting for less than 1% (32,949 people) of the total Irish population (CSO, 2022). The community has historically faced widespread hostility from the majority population, which consigned Travellers to the margins of society.
As a result of traditional cultural norms around gender roles, marriage and education, Travellers on average marry younger, have larger families and drop out of school earlier compared to their peers from the general population (CSO, 2022). While it has been documented that fear of judgement and ostracism can inhibit making choices that are against cultural norms, more open and progressive views around marriage, sexual orientation and gender roles have started to appear among younger Traveller generations and parents (Villani et al., Reference Villani, Kuosmanen, McDonagh and Barry2023).
It has been reported that, for Traveller men, providing for their family takes precedence over education (Hodgins and Fox, Reference Hodgins and Fox2012). However, Travellers also report that their withdrawal and poor engagement with mainstream schools is also the result of teachers’ lower expectations toward Travellers, bullying and traumatic school experiences (Villani & Barry, Reference Villani and Barry2021), and the practice of segregated classes or schools for Travellers (Brennan et al., Reference Brennan, Cummins, Leane, Súilleabháin, McGovern and Quilligan2024).
These circumstances, exacerbated by widespread anti-Traveller sentiments, have had, over time, a detrimental impact on Travellers’ sense of identity, both at an individual level and as a cultural group in Irish society. This may have triggered a feeling of oppression (David Reference David2013) and systemic racial trauma (Ranjbar et al., Reference Ranjbar, Erb, Mohammad and Moreno2020; Cénat Reference Cénat2023) among Travellers, as they are exposed to multiple race-based traumatic events over their lifetime. Travellers’ mental health inequities are heightened by their inadequate engagement and dissatisfaction with the Irish mental health services, which may be a barrier to recovery (AITHS, 2010; Villani & Barry, Reference Villani and Barry2021).
This highlights the importance of reorienting health services towards Travellers and creating a more equitable healthcare setting that ‘is sensitive and respects cultural needs’ as advocated from both a health promotion (WHO, 1986) and recovery perspective (Jacobson and Farah, Reference Jacobson and Farah2012). Research conducted in the United States (O’Keefe et al., Reference O’Keefe, Cwik, Haroz and Barlow2021), Canada (Montesanti et al., Reference Montesanti, Fitzpatrick, Fayant and Pritchard2022), and Australia (Minas, Reference Minas, Bhugra and Bhui2017; Upton et al., Reference Upton, Ford, Wallace, Jackson, Richard and Upton2021) indicates that involving Indigenous communities and marginalised groups more actively in service delivery, and enhancing the cultural sensitivity of service providers, may result in greater utilisation of services by minority groups like Travellers in Ireland. It is plausible that this, in turn, may help to facilitate their recovery process. Creating a healthcare environment that is inclusive, respectful and sensitive to the needs of a diverse population requires adopting trauma-informed practice and cultural humility frameworks (Mosher et al., Reference Mosher, Hook, Captari, Davis, DeBlaere and Owen2017; Ranjbar et al., Reference Ranjbar, Erb, Mohammad and Moreno2020). Cultural humility entails a critical examination of cultural awareness among mental healthcare staff, developing partnerships that address power imbalances, and building openness to others and new cultural information (ibid.).
Several authors have advocated for the creation of culturally appropriate services for Travellers in Ireland (AITHS, 2010; Villani & Barry, Reference Villani and Barry2021); however, there is a lack of evidence in the academic literature as to what this means in practice for the community. While there is a dearth of studies on recovery from the perspective of ethnic minorities (Levy-Fenner et al., Reference Levy-Fenner, Colucci and McDonough2022), it has been suggested that barriers and facilitators to recovery are generally shared among different ethnic-racial communities (Whitley Reference Whitley2016), with the exception of spirituality and support networks (Leamy et al., Reference Leamy, Bird, Le Boutillier, Williams and Slade2011; Whitley, Reference Whitley2016), which seem to be more important recovery enablers for ethnic minorities. In this regard, the topic of mental health recovery for Irish Travellers has not yet been investigated.
Current study
This paper is reporting on data relevant to recovery from a larger study on Traveller mental wellness and suicide prevention (Villani et al., Reference Villani, Kuosmanen, McDonagh and Barry2023). More specifically, it addresses current gaps in the literature by focusing on the following objectives related to the service provision component of the larger study:
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1. To examine the meaning and nature of culturally appropriate mental healthcare services from the perspective of Travellers,
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2. To identify the core requirements for the development of a comprehensive continuum of care for Travellers (mental health promotion, suicide prevention, treatment, recovery) which can be integrated into mainstream mental health services.
This study, therefore, can help define how to implement a culturally appropriate recovery approach for Travellers accessing mental health services in Ireland.
Methods
Design
This study employed a community-based participatory research approach. Thirteen qualitative participatory workshops and five individual interviews were conducted with adult members of the Traveller community in ten different counties in Ireland by seventeen Traveller peer researchers. It is widely reported that intercultural health studies related to members of the Travelling community, and other marginalised groups, greatly benefit from the involvement of peer researchers (Condon et al., Reference Condon, Bedford, Ireland, Kerr, Mytton, Richardson and Jackson2019; Reference Condon, Curejova, Morgan, Miles, Barry and Fenlon2022). This also aligns with the research objectives of understanding the lived experience of Travellers about mental health challenges, use of services and recovery strategies.
The workshop protocol was based on a list of opening questions and prompts to guide group discussions (Villani et al., Reference Villani, Kuosmanen, McDonagh and Barry2023, p.106). Case scenarios and a short video were used to encourage discussion. The advantage of workshops is that they allow more freedom concerning moderation and are in line with peer-led participatory approaches (Jennings et al., Reference Jennings, Slade, Bates, Munday and Toney2018).
A research Advisory Group, comprising members of the Traveller community and external experts in mental health, guided every stage of the research project, making sure that all the steps taken were relevant and meaningful for Travellers. In line with previous studies (Condon et al., Reference Condon, Bedford, Ireland, Kerr, Mytton, Richardson and Jackson2019; Reference Condon, Curejova, Morgan, Miles, Barry and Fenlon2022), the Advisory Group helped to promote engagement and participation of key stakeholders.
Peer researchers
Seventeen peer researchers were recruited to work in pairs. All Traveller peer researchers attended an initial one-day face-to-face training and a subsequent half-day session online. The training consisted of an orientation to the research project, interview and group facilitation skills, review of interview protocol and practice in pairs on administering the workshop protocol, use of recorders, privacy and anonymity, confidentiality and safety (Villani et al., Reference Villani, Kuosmanen, McDonagh and Barry2023, p.102). One member of the Traveller community (Margaret McDonagh), who is a co-author of this paper, was recruited as a Research Assistant to assist with data analysis and coding.
Participants
Due to the stigma around mental health among Travellers, the study participants were selected through convenience sampling. The sample was recruited by local Traveller organisations across designated sites nationally with the help of Traveller peer researchers. Previous studies confirm the crucial role of gatekeepers in encouraging Travellers to participate in research (Condon et al., Reference Condon, Bedford, Ireland, Kerr, Mytton, Richardson and Jackson2019).
The sample included 87 adult Travellers (83% female), age range of 18–78 years (M = 33). The majority of the participants (78.2%, N = 68) reported having left education on or before the legal age of 16 years. Over half of the participants (56.3%, N = 49) reported not currently being in education or employment.
Analysis
The recordings from the workshops and interviews were transcribed and then analysed using thematic analysis (Braun and Clarke, Reference Braun and Clarke2006). Codes were identified, and agreed upon, by all authors. The generation of themes was conducted in a collaborative one-day workshop with thirteen peer researchers, who had also been involved in data collection, based on the participatory methods of analysing qualitative data outlined by Jackson (Reference Jackson2008).
Each code, along with a brief extract, was printed on a piece of paper. Peer researchers were instructed to collaborate in teams to categorise the codes into themes and sub-themes. An additional online session lasting two hours was held with the peer researchers two weeks later. During this session, a thematic map of the themes and their relationships was agreed upon, and a name and description were created for each theme.
Results
Four overarching themes were identified through the data analysis: Health and Community Services, Culture and Identity, Life Opportunities and Choices and Discrimination. Under each of these overarching themes, only data relevant to recovery were extracted and are presented below under each theme heading. Illustrative quotes under each of the themes and sub-themes are included in Table 1.
Illustrative quotations
Health and community services
This theme includes Travellers’ ideas about service improvements to make the services more friendly, accessible and suitable for Travellers. The suggested improvements concerned building trust in services, cultural awareness training, and increasing representation of Travellers within mental health care staff and co-production of services.
Study participants consistently commented that building trust with mental health professionals is crucial to improving access and enjoying better healthcare provision. The possibility of being attended to and supported by someone from the Traveller community was also raised by several participants.
Travellers shared their dissatisfaction with mental health services during the participatory workshops, citing a lack of support and feeling like just a name on a list. They expressed a desire to talk about their difficulties but did not feel encouraged to do so. This perception of inadequate care has led to a lack of trust in mental health service providers who, according to participants, fail to provide a safe and comfortable environment for Travellers to discuss their problems. Concerns about confidentiality and anonymity also contribute to this lack of trust, further hindering Travellers’ willingness to open up.
Some participants felt that Travellers are misunderstood and not taken seriously when they seek mental health support from A&E during a crisis. Cultural awareness training for mental health providers can create a better understanding of Traveller culture and their specific mental health needs, thus creating a ‘Traveller-friendly atmosphere’ where they are respected as members of Irish society. This type of training was deemed essential, by many participants, as they consider it a crucial element to create cultural appropriate services for Travellers and as a means of debunking outdated preconceptions. According to Travellers, with this training mental health professionals will be more equipped to comprehend the origins, living conditions, values, and some of the difficulties faced by Travellers.
One participant mentioned, for instance, how young Travellers may experience stress because of the Travellers’ custom of ‘early marriage’, which the majority population may not be aware of. Another participant conveyed their dissatisfaction with the advice of a service provider, which they interpreted as a suggestion to abandon their culture to avoid cultural and family pressure. Participants also suggested that all Irish schools and healthcare personnel conduct training on Traveller cultural awareness. This would help everyone understand that the Traveller community is a distinct cultural group with its background and customs.
Another key component to develop culturally appropriate services for Travellers is the employment of a Traveller workforce within the mental health services. A number of suggestions were made during the workshops and interviews regarding this topic. Participants pointed out that Travellers could be employed in various roles such as receptionists, mental health workers, counsellors, and support workers. Moreover, they suggested that the list could be expanded to cover all supporting staff within the Health Service Executive (HSE), as this would create a more welcoming and familiar environment for the community. Seeing a friendly face and having fellow community members employed in public services would help Travellers feel at ease and proud; it would also demonstrate the government’s commitment towards equality.
The participants also suggested that Traveller employees would have a deep understanding of their culture, which would enable them to better interpret the needs of Traveller service users. This, in turn, would help them to navigate and access services more efficiently. Furthermore, Traveller employees would be able to work proactively on solutions to address any issues before they are even raised by the service users.
During one workshop, it was suggested that having the possibility to communicate with a Traveller worker would alleviate the anxiety of being judged by non-Travellers. On a related note, a number of participants proposed that Travellers could undergo training to become Mental Health Support Workers, which would help reduce barriers to access including lack of awareness, stigma, and low literacy levels.
One of the participants suggested that Counsellors should visit Traveller organisations and interact with Travellers in person. This could help them understand that Travellers are just like any other human beings. The participant believed that building connections and creating opportunities for mental health practitioners to interact with the community could lead to a change in attitude and help to break stereotypes and stigma around Travellers. Additionally, this could also provide a platform to share information that can be passed on to the wider community and to provide community-based services.
The topic of partnership and co-production was mentioned in several workshops and focuses on Travellers’ opinions regarding their participation in service improvement plans and strategies that could impact their lives and mental health. During the workshops, it was evident that Travellers felt left out, lacked control and had no influence on the policy-making processes concerning their community. These feelings were reflected in the statements made across the workshops, as shown in Table 1.
It is acknowledged that Travellers often face decisions regarding their health, housing, education, and employment made by individuals in government departments, local authorities, and public services who may not fully understand Travellers and their unique needs. Travellers consider this unacceptable and would prefer a co-production approach.
Culture and identity
This theme includes participants’ narratives on how cultural identity and cultural expression support Travellers’ mental health and well-being. Comments focused on the pride felt in features of Traveller culture and the embarrassment at having to hide one’s identity to avoid racism. Family and religion were consistently discussed as crucial aspects of Travellers’ culture. The family was largely viewed as a positive influence on mental health and well-being. Living in close proximity and upholding family values were considered inherent parts of Traveller culture. Family was seen as a vital source of support, and seeking help from family and friends was considered the first step when experiencing mental health challenges.
Religion was also highlighted as a significant source of support for mental health and well-being, providing hope and comfort. Prayer was seen as a way to open up and seek help.
Life opportunities and choices
This theme focuses on the importance of offering equal opportunities to Travellers and helping them find fulfilment and purpose in life. Specifically, having prospects for future employment and a good living environment were highlighted as crucial factors for Travellers’ well-being. Many study participants highlighted the need to increase employment opportunities for Travellers. They shared that having nothing to do and nothing to look forward to led to feelings of despair, worthlessness, and lack of purpose. Conversely, keeping oneself occupied with work or hobbies was consistently mentioned as a way to safeguard one’s mental health.
When the participants were asked about what would make the most significant difference in enhancing Travellers’ mental health, several emphasised the importance of a supportive physical and social environment. A safe and stimulating living environment would help promote healthy development and flourishing, while poor living environments were viewed as hindering Travellers’ ability to make positive life choices and prioritise their own well-being. Participants also discussed how difficult it is to find suitable accommodation through the private rental market and the stress ensuing from these circumstances. Several participants expressed feeling ‘locked in’ to overcrowded sites that were segregated from society.
Discrimination
This theme was particularly dominant across the workshops, where Travellers shared their experiences of discrimination and racism and its negative impact on their mental health. The theme covers various contexts where discrimination against Travellers is most prevalent, including schools, seeking employment, finding housing, and social spaces. Travellers’ discrimination is so widespread and occurring over the life course that the majority of participants considered this to be one of the root causes of the Travellers’ mental health crisis. In particular, there were poignant accounts of how Travellers are forced to hide who they are to avoid racism, with negative repercussions on their mind-set and a feeling of shame around their identity (see Table 1).
The resulting negative psychological consequences of discrimination were identified as low self-esteem, feelings of shame, embarrassment, annoyance, upset, and physical pain. A common topic discussed in the workshops was the internalisation of negative stereotypes and the process of believing in the negative labels that are put on Travellers.
Discussion
This paper reports on the meaning of culturally appropriate mental healthcare from the perspective of eighty-seven members of the Traveller community. The findings provide insights into the core requirements from a Traveller perspective on how to develop a comprehensive continuum of mental healthcare for Travellers. No research to date has been conducted on the topic of mental health recovery for Irish Travellers, and this study can shed some light on how to implement a culturally appropriate recovery approach for Travellers accessing mental health services in Ireland.
The findings suggest that a reorientation of mental health services is required to meet the needs of Travellers and encourage their recovery. This would entail changes in how services are delivered, including diversifying the profile of healthcare staff and improving interaction, trust, and partnership between service providers and Traveller service users. It would also require an expanded mandate for mental health services beyond individual care and towards intersectoral action in addressing the social determinants of Travellers’ mental health.
Participants identified trust between mental health providers and Travellers as a key factor in improving service delivery. This trust is critical for improving relationships, access, and engagement with services and, ultimately, for enhancing Travellers’ mental health outcomes and recovery. The creation of a ‘trusting environment’ is also considered critical for recovery in the context of culturally responsive and trauma-informed services (Sofouli, Reference Sofouli2021; Levy-Fenner et al., Reference Levy-Fenner, Colucci and McDonough2022) and quality interactions between clinicians and service users (Leamy et al., Reference Leamy, Bird, Le Boutillier, Williams and Slade2011). Establishing trust-building mechanisms can be an effective way to foster better communication and collaboration. For example, holding regular meetings, participating in human rights campaigns, and organising lunch group discussions can foster a safe, inclusive, and supportive environment. Tew et al. (Reference Tew, Ramon, Slade, Bird, Melton and Le Boutillier2012) confirm the value of this approach for recovery, as attitudinal change can happen through personal contact, opportunities for interaction, and dialogue.
Several participants suggested establishing partnerships between mental health services and Travellers. They also proposed developing initiatives and service improvements through a co-production approach and designing strategies that can be owned by the community. This approach is at the very core of the recovery model, which promotes partnership and respectful dialogue between service users and providers in the planning, development and evaluation of services and their care and treatment plan (Boardman and Shepherd, Reference Boardman and Shepherd2012; Slade et al., Reference Slade, Amering, Farkas, Hamilton, O’Hagan, Panther, Perkins, Shepherd, Tse and Whitley2014; HSE, 2024). According to Montesanti et al. (Reference Montesanti, Fitzpatrick, Fayant and Pritchard2022), mental health service design and delivery must consider Indigenous voices; a process which can lead to more equitable outcomes (Minas, Reference Minas, Bhugra and Bhui2017).
This calls for developing a ‘Traveller Lived Experience Panel’. Members of the panel, having recovered from mental health challenges would be able to join service improvement committees as equal partners and advise on how to create culturally appropriate services and recovery strategies suitable for Travellers. The study findings clearly demonstrate that the Traveller community can contribute significantly to co-produce services, through sharing their experiential knowledge of mental health challenges and/or supporting family members, and in terms of contextualising service delivery for their community.
According to participants, the cultural responsiveness of mental healthcare services can be improved by hiring more Travellers within the health system. Many participants believe that a Traveller worker would be better equipped to understand their needs and help them navigate the health system more effectively. There is substantial evidence supporting the positive impact of recruiting mental health professionals from minority/Indigenous communities (Upton et al., Reference Upton, Ford, Wallace, Jackson, Richard and Upton2021; O’Keefe et al., Reference O’Keefe, Cwik, Haroz and Barlow2021; Montesanti et al., Reference Montesanti, Fitzpatrick, Fayant and Pritchard2022). The benefits of such recruitment include a better understanding of cultural norms, expectations, attitudes, and communication styles, which can facilitate trust, improve retention rates, and ultimately lead to better therapeutic outcomes.
These studies are in line with existing evidence on the fundamental role played by peer-organised services and the recruitment of mental health peer support workers. Peer support work is seen as a crucial pillar in the recovery journey (Leamy et al., Reference Leamy, Bird, Le Boutillier, Williams and Slade2011; Tew et al., Reference Tew, Ramon, Slade, Bird, Melton and Le Boutillier2012; Boardman and Shepherd, Reference Boardman and Shepherd2012; Slade et al., Reference Slade, Amering, Farkas, Hamilton, O’Hagan, Panther, Perkins, Shepherd, Tse and Whitley2014; Hunt and Byrne, Reference Hunt and Byrne2019). This is based on the idea that being supported by peers who have gone through similar experiences is therapeutic. Findings from randomised control trials indicate that peer support work can improve social outcomes (connections), clinical outcomes (symptomatology), and subjective outcomes (hope, empowerment) (Slade et al., Reference Slade, Amering, Farkas, Hamilton, O’Hagan, Panther, Perkins, Shepherd, Tse and Whitley2014). Creating a specific Traveller mental health peer support workforce would also help to embed a network of ‘experts by experience’ in the healthcare sector, which is considered a significant step towards a recovery orientation of the health system (Slade et al., Reference Slade, Amering, Farkas, Hamilton, O’Hagan, Panther, Perkins, Shepherd, Tse and Whitley2014).
The participants of this study expressed the need for mental healthcare staff to be more culturally aware and sensitive towards Travellers; a finding also emphasised by studies conducted in the USA and Canada (O’Keefe et al., Reference O’Keefe, Cwik, Haroz and Barlow2021; Montesanti et al., Reference Montesanti, Fitzpatrick, Fayant and Pritchard2022). This would enable mental health professionals to offer advice and therapeutic plans that align with Traveller’s cultural norms and values.
A young Traveller woman highlighted clearly the need to reorient services to meet the cultural needs of Travellers. She pointed out that counsellors in Ireland may not be aware of the practice of ‘early marriage’ among Travellers and thus would not see it as an issue. The participant explained that mental health providers would not consider the pressure to get married early in life to be significant in mainstream society. This example elucidates how the individualisation of mainstream mental healthcare and recovery services may clash with social and structural dynamics, which may cause distress and hinder the recovery process (Levy-Fenner et al., Reference Levy-Fenner, Colucci and McDonough2022). In addition, this example epitomises the lack of cultural sensitivity of service providers and how Traveller service users, with a collectivistic value orientation and a family-oriented culture, may not be properly supported by providers with a more individualistic value orientation and with a stronger sense of personal agency.
The findings suggest that the Irish mental healthcare sector needs to adopt a cultural humility approach. This would help practitioners to show appreciation towards the cultural background of their Traveller service users and it would encourage them to ask questions about Traveller cultural norms (Mosher et al., Reference Mosher, Hook, Captari, Davis, DeBlaere and Owen2017). This approach can build partnerships but would also require service providers to be mindful of their assumptions based on their majority culture. The process of acknowledging and valuing Traveller culture within clinical practice can help Traveller service users to improve their positive self-identity, in line with the CHIME dimensions of recovery (Leamy et al., Reference Leamy, Bird, Le Boutillier, Williams and Slade2011). In addition, Travellers’ comments on the importance of family and religion for their mental health corroborate evidence suggesting that spirituality and support networks are crucial recovery enablers for ethnic minorities (Leamy et al., Reference Leamy, Bird, Le Boutillier, Williams and Slade2011; Whitley, Reference Whitley2016).
Comments from participants, vis-à-vis Travellers’ history of marginalisation and discrimination, also support the adoption and strengthening of trauma-informed care. This would require practitioners to understand Travellers’ oppression and its psychological consequences and avoid re-traumatisation. Research has shown that the process of internalising negative attitudes and beliefs can hinder the recovery process for individuals. This internalisation can lead to lowered self-esteem, less hope, decreased self-efficacy, and a lack of confidence in engaging in regular social interactions (Tew et al., Reference Tew, Ramon, Slade, Bird, Melton and Le Boutillier2012). Therefore, it is important for healthcare professionals to address the concept of ‘internalised oppression’ in their clinical practice, especially in cognitive-behavioural therapy (CBT) (David, Reference David2013; Naeem, Reference Naeem2019). This can help challenge the negative automatic thoughts that people from oppressed communities may have developed.
The study findings related to the impact of discrimination and the importance of employment and a positive social and physical environment for Travellers, substantiate research suggesting that full citizenship and social inclusion should be considered the basis to achieve recovery, rather being regarded as an outcome (Ramon, Reference Ramon2018; Norton and Swords, Reference Norton and Swords2021; Davidson et al., Reference Davidson, Rowe, DiLeo, Bellamy and Delphin-Rittmon2021). These findings raise the question of how can we expect oppressed and marginalised populations to recover from mental health challenges without having a job, an income, a house, and participating in community life. As recovery happens in a social milieu, contextualised by culture, oppression and privilege, mental health services cannot implement recovery services solely focused on the individual effort of service users, disconnected from socio-economic and structural factors (Jacobson and Farah, Reference Jacobson and Farah2012).
Therefore, mental health professionals need to be catalysts for social change and be more involved in promoting social inclusion and addressing the social determinants of mental health, as clearly argued in the literature (Jacobson and Farah, Reference Jacobson and Farah2012; Davidson et al., Reference Davidson, Rowe, DiLeo, Bellamy and Delphin-Rittmon2021). Expanding the work of Mental Health Housing Coordinators, and programmes such as the Individual Placement Support (Slade, Reference Slade2010), specifically for Travellers within the Irish mental health statutory services, may support this expanded mandate of the healthcare sector and support Travellers’ recovery.
Study strengths and limitations
A major strength of this study is the participatory methodological approach and the involvement of Traveller peer researchers at all stages, including in data analysis. This is consistent with emerging evidence on the importance of Patient and Public Involvement in qualitative data analysis of mental health research (Jennings et al., Reference Jennings, Slade, Bates, Munday and Toney2018), which can provide unique insights and increase community capacity.
The use of convenience sampling is a limitation that may have reduced access to less commonly heard voices among the Traveller community, leading to a self-selection bias. In addition, the one-day training session with peer researchers prior to data collection could have benefited from an additional day to allow for a more in-depth discussion and further improvements of peer researchers’ facilitation skills.
Conclusions
This study supports the integration of Traveller lived experience perspective in mental health services in Ireland. It has demonstrated that implementing a recovery approach for Travellers requires a reorientation of the services, in line with Travellers’ definition of culturally appropriate mental healthcare. This entails building a Traveller mental health workforce, with an emphasis on peer support workers, embedding an ethos of cultural humility, Traveller cultural awareness and strengthening trauma-informed care within mainstream services. Traveller recovery-oriented mental health services would also involve practitioners in creating a trusting environment and working in partnership with Traveller service users to co-produce strategies that are owned by the community.
Findings from this study endorse the need to increase collaboration between mental health service providers and non-mental health agencies and a reorientation of care towards empowering Traveller service users to achieve their social aspirations and build a positive self-identity. If recovery is engendered within a socio-ecological environment and through the complex interaction of individual and societal factors, mental healthcare staff need to advocate and work in partnership across sectors to address the social determinants of Travellers’ mental health, moving the focus beyond individual care strategies. This will help to shape an equitable and inclusive healthcare setting that promotes Travellers’ mental health and recovery.
Acknowledgements
We would like to express our gratitude to all members of the Traveller community who took the time to participate in this study, to the Offaly Traveller Movement and all Traveller organisations that assisted in the delivery of workshops and interviews and all Traveller peer researchers who were involved in recruiting participants, leading workshops and analysing data. We thank all the members of the Research Advisory Group and the Network of HSE Mental Health Service Coordinators for Travellers whose support was invaluable in fostering links with the Traveller community. Finally, we would like to acknowledge the funders of this study.
Financial supports
This study was funded by the National Office of Suicide Prevention and the National Office of Mental Health Engagement and Recovery, Health Service Executive.
Competing interests
Jacopo Villani is employed in the National Office of Mental Health Engagement and Recovery, Health Service Executive.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. The study protocol was approved by the ethics committee of University of Galway (Reference Number 2021.11.001). Informed consent was sought from all participants.
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