Cognitive–behavioural therapy (CBT) can be used across cultures, but only if appropriately adapted (Rathod et al, 2010). A personalised and pragmatic therapy, CBT uses reasoning to provide a conceptual framework of mental illness that is not inconsistent with Eastern and other philosophies (Rathod & Kingdon, 2009). The client (patient) and therapist develop a collaborative understanding of the client's perceived problems, so that a mutually respectful exploration of the problem can be developed to work on the issues identified (Bhui & Bhugra, 2004). The collaborative approach allows the patient to take an active role as an expert of their own culture and the therapist to personalise the therapy to the patient's needs.
People with depressive illness and anxiety usually have beliefs about the self, others and the world that are unhelpful. Cognitive–behavioural therapy involves exploration of these core beliefs and attempts to modify them, and there is a strong focus on involvement of the patient in the therapeutic process. However, core beliefs, underlying assumptions and even the content of automatic thoughts might vary with culture (Padesky & Greenberger, 1995). The practice of CBT without adaptation in minority groups can adversely affect the therapeutic alliance between patient and therapist and risks disengagement of patients from therapy (Rathod et al, 2005). In patients, this can lead to disappointment and loss of hope, particularly as people from ethnic minority groups are less likely to trust mental health services in the first place (Thornicroft et al, 1999). In therapists, a patient's disengagement might leave them feeling incompetent, especially if they do not understand the cultural issues involved.
Griner & Smith (2006), in their meta-analysis, provided suggestive evidence that culturally adapted interventions are effective. Some findings pointed to the possibility that clients who had the greatest need for accommodations (i.e. poorly acculturated, non-English-speaking adults) received the greatest benefit from such adaptations. Small pilots from many cultural groups have found adapted CBT to be successful in ethnic minority populations (Patel et al, 2007; Rojas et al, 2007; Rahman et al, 2008). Muñoz and colleagues have conducted a number of studies on the cultural adaptation of CBT for the treatment and prevention of depression in adults from ethnic minority groups in the USA (e.g. Kohn et al, 2002; Miranda et al, 2003; Muñoz & Mendelson, 2005).
Whilst there may continue to be some disagreement about the precise nature and extent of mental illness amongst homeless people, commentators generally view social and health policy as playing the major part in its causation and consequently it has the potential to alleviate it. Bassuk et al. (1984) have said that explanations for the marked increase in the numbers of homeless people include unemployment and the economic recession, deinstitutionalization of mental patients, unavailability of low-cost housing, reduced disability benefits and cutbacks to social service agencies. Policy developments may be viewed therefore as directly responsible for the increased incidence of mental illness in homeless people. Alternatively, changes occurring in society, for example, the reduction in importance of the extended family and increase in divorce rates, may not have evoked the necessary policy response to minimize adverse effects.
People with mental illness will be particularly vulnerable to being made homeless. In a competitive market for homes, those with severe and enduring mental illness will be disadvantaged by their lack of employment, disabilities consequent on their illness and stigmatization. Securing accommodation may therefore be difficult and maintaining it equally problematic for much the same reasons. In turn, housing difficulties are life events and circumstances predisposing to relapse and persisting disability. Of particular consequence therefore, has been the availability of low-cost housing in the public or private rental sector. Both areas are known to have reduced over the past decade (recently reviewed comprehensively by Everton, 1993). This has occurred in part because of the encouragement of owner-occupation, now supported in the UK by both major political parties.
A brief summary of the epidemiological evidence of suicide, the risk factors and the strategies for preventing it is presented. This chapter begins by considering the widespread beliefs that prevention of suicide is an activity with relatively little prospect of success (Morgan, 1993) and even one which is ethically misguided: why should anyone who wishes to do so be prevented from ending his or her own life? As social circumstances, such as unemployment, are important determinants of suicide risk, is there very little that can realistically be done by individuals – even in specialist mental health services – to reduce incidence?
Reduction in avoidable mortality is an aim of most health services and the many other government departments which deal with safety issues. For instance, death from road traffic accidents – transport and environmental departments determine safety standards on roads and in vehicles, adding considerably to the cost and inconvenience of the passenger, e.g., structural modification to vehicles, safety barriers on motorways and seat-belts in front and rear of cars. Health services have also improved techniques for managing accidents, e.g., improvements to ambulances and developments in surgical and intensive care technique. In England, this has been successful such that road traffic deaths have now been reduced to around 4000 per year. More deaths occur from suicide which, until recently, has received relatively little direct preventative attention. Suicide rates have remained at much the same level throughout the twentieth century.
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