Barriers to Care

Addressing the challenges of mental health care access across the globe

BY MEGAN RUBINER ZINN

Smith College School for Social Work (SSW) has a rich international community of faculty, students and alumni who bring diverse experiences with mental health care to the School, and who take the SSW’s innovative approaches and perspectives back across the globe. As practitioners, researchers and residents, Ora Nakash, Fareeda AboRass, Anne Ford M.S.W. ’88, Aquila Vera M.S.W. ’12 and Shveta Kumaria all have firsthand experiences with mental health care outside the United States. When they talk about mental health in their part of the world—especially barriers to accessing care—it becomes clear that while there are some roadblocks specific to their countries, most of the roadblocks are universal and most could be resolved with significant investments in mental health resources.

Ora Nakash, M.A., Ph.D., professor and director of the SSW Ph.D. program, and postdoctoral researcher Fareeda Abo-Rass, M.S.W., Ph.D., work together to research barriers to mental health care in Israel and to determine how the country can improve quality, equity and access to care among historically marginalized communities. Since completing her M.S.W. degree, Anne Ford has worked in England. She spent 29 years with Oxford University’s Counseling Service, where she developed a peer support program, training students in such topics as listening skills, suicide prevention, crisis management and psychoeducation, before starting a peer support training consulting business in 2017. Aquila Vera is a social worker in Harare, Zimbabwe, working in a psychiatric hospital with children and adolescents, and she is a junior lecturer at the University of Zimbabwe, teaching clinical social work to undergraduates. Shveta Kumaria, M.A., Ph.D., LCSW, is a SSW assistant professor who specializes in scholarship on pedagogy of clinical social work and research on clinician wisdom and effective influences in early therapist training. Her research has included one of the first studies of psychotherapists in India.

Nakash, Abo-Rass, Ford, Vera and Kumaria all describe mental health care systems in these countries as under-resourced and facing significant challenges. Israel, the United Kingdom and India have universal health care that includes mental health care, so in theory, every citizen has the opportunity to access mental health care. But in reality, many are unable to do so.

In each of these countries, the barriers to care are an interplay of factors like economics, culture, education and geography. The primary issue is an acute lack of providers. In India, there are only 0.75 psychiatrists for every 100,000 people (the desirable number is above three), and individuals may have to wait in line for hours to see a psychiatrist for a prescription and then wait hours to get medication. In her research, Nakash found that among the Hebrew-speaking population in Israel, the gap between the number of providers available and the number of individuals in need was 50 percent; among Arab-speaking populations it was 70 percent. In the UK there are long waits to see NHS providers—however, there are plenty of independent therapists for those who can pay and who know how to access them. In Zimbabwe most providers are in urban areas, making care inaccessible to rural populations.

Quality of care is also an issue. According to Ford, the UK government’s current approach to mental health care is early intervention and quick fixes, except in cases of severe mental illness. Poor cultural competency among some providers further weakens quality of care. In their research, Nakash and Abo-Rass found that marginalized populations who are able to access care, specifically Palestinian citizens in Israel, have higher rates of negative experiences with providers, reporting high levels of microaggressions and misdiagnoses.

To some extent, in any country, stigma plays a role in keeping people from seeking care. In some places, this has lessened. Ford noted that when she first arrived in the UK, mental health wasn’t something people discussed, and while there is still some cultural stigma, there is much more discussion and acceptance. But among some populations, like ultra-Orthodox Jews and Bedouins in Israel, where mental illness can have an impact on a family’s social standing, it remains hidden and untreated.

A lack of mental health literacy can further limit access. Nakash and Abo-Rass look particularly at mental health literacy among Bedouin communities—their understanding of mental health issues, ability to identify problems and knowledge about how to utilize services. “It’s a huge predictor of access to care,” said Nakash. Vera also identifies a lack of understanding of mental health as a key barrier in Harare, although that has been changing since the COVID-19 pandemic. “People are starting to say, ‘We’ve always known how to take care of ourselves as communities, but we didn’t put it as mental health care.’”

In the face of these barriers, practitioners and educators around the world employ creative interventions to help clients and communities as much as possible. On the macro level this has included anti-stigma and mental health literacy campaigns, with sports stars and other public figures talking openly about their mental health struggles. India has launched life skills trainings in schools and has set up health lines to address suicide, which is a huge issue among young people. In recent years, Ford has seen a new and growing activism in the United Kingdom’s therapeutic community. In particular, she’s seen increased demands from providers for better funding and holistic care from the government and more awareness among providers of their own biases.

On a micro level, there have been concerted efforts to find ways to supplement the inadequate numbers of providers. One of the rare silver linings of COVID-19 has been the broadening of telehealth. India, for example, has launched 23 telehealth centers with 900 trained providers. Kumaria also spoke of efforts in India to integrate mental health into training programs of allied professions. Physicians, nurses and staff of not-for-profit organizations, among others, are being trained in basic mental health assessment, treatment and referral skills.

The incorporation of lay people into mental health care can also be an effective intervention. Vera has worked with The Friendship Bench, a program that trains community members to provide psychoeducation, teach problem solving skills and provide referrals for further care. This works well in Zimbabwe, given that care has traditionally been communitybased, and because meeting outside of a therapy office removes the power dynamic, which can often be an issue.

Ford also emphasizes the role that peer support can have in navigating barriers: lessening stigma, helping people to feel seen and providing education and referrals. “Because the sense of community here has dissipated, there is such a high level of people feeling lonely and disconnected. And peer support is about making those connections.”

Given the limited amount of time they may have with clients, providers will look to brief but effective interventions. Vera has found eye movement desensitization and reprocessing (EMDR) therapy to be particularly useful. “Stabilizing techniques have been of paramount importance in my work because I can help increase the resilience of someone who I know cannot get out of the situation,” she explained.

The ways to remove barriers to mental health access in their countries are clear to these practitioners and researchers, but they know it will take systemic changes to approaches and funding. “I would like to see the discourse around mental health issues rise at all levels,” said Abo-Rass. “There is a need to build a holistic intervention program that works on removing the barriers related to stigma, the barriers related to attitudes and the instrumental barriers.”

It is not simply that many more practitioners are needed—practitioners are needed who are culturally competent and who understand intersectional pressures on individuals. Practitioners are also needed who are representative of marginalized communities, who can develop more culturally-appropriate approaches, and who can help build trust in the therapeutic community. “One of the things that I want to impart to students is that they can understand human beings and come up with their own conclusions, which is what theory is, in an Indigenous way,” said Vera.

There should also be more recognition in government programs of the value of community and lay interventions, not as stop-gap measures, but as part of a broad, holistic approach.

“In India, people are cured in a certain context of family,” Kumaria said, “but I don’t think that context is talked about enough, except as a burden. If we can find ways to support caregivers and families, I think that is definitely a step ahead.”

Nakash and Abo-Rass also call for concerted efforts to improve mental health literacy. This would include creating targeted, culturally-sensitive and linguistically-appropriate psychoeducational programs to change misconceptions about mental health and to teach about causes, treatments, coping methods and how to access information, professionals and services.

Finally, Vera, Kumaria, Ford, Nakash, and Abo-Rass agree on a key aspect of mental health care. As important as it is to have broad and thorough

preventative and acute mental health care, to see significant improvements in mental health, governments and societies must also better address the socioeconomic factors—housing, employment, health and food insecurity, racism, misogyny and violence, etc.—that underlie them. ◆