Perceptions and experiences of counselling services among Asian people
Counselling provision is expanding rapidly with increasing recognition of its value in supporting physical and mental well-being.
Given this, the continuing low uptake of counselling by black people is a matter for concern. Despite the considerable attention which has been paid to patterns of illness in black people, relatively little is known about their experience of mental health services, including counselling.
A suitable space examines the views of counselling held by Asian people experiencing stress, anxiety and depression. It considers the views of those who have first-hand experience of such services as well as those who have not. Whilst most users had a keen appreciation of the benefits of counselling, their accounts also highlight a number of clear preferences for provision which are currently not being met. Drawing on these accounts, the authors consider policy implications for improving voluntary sector counselling services provision for both Asian people and for black people in general.
Despite increasing recognition of the value of counselling in supporting mental well-being, and the rapid expansion of such services, uptake by black people remains low. This study, carried out by the Scottish Ethnic Minorities Research Unit in Edinburgh College of Art/Heriot Watt University, evaluated the accessibility and appropriateness of counselling provision in the voluntary sector based on the accounts of Asian people.
- Awareness of counselling among people who had not used the service was low, although all were experiencing stress, anxiety and depression. When informed about the nature of the service, many felt it would be useful since informal support available to them was limited or constrained by other issues.
- Most people who had used a counselling service had done so after major life events such as bereavement, marital breakdown and redundancy. Most found that counselling had a very positive impact: it provided time and a safe space to explore their circumstances and feelings, to build self-esteem and develop coping strategies.
- Both clients and non-clients of counselling expected counsellors to enable them to work through their feelings and problems, and to treat them with respect, as equals. Their main preferences were to be consulted on the choice of counsellor and language used. The gender, age and ethnicity of the counsellor were important considerations for most people, but not always in ways that conformed to professional assumptions.
- Generally, agencies' ability to provide clients with choice was limited. The tendency of most mainstream agencies to provide counselling only in English was worrying, given the very limited number of black-led agencies providing counselling.
- Black-led agencies stressed the importance of possessing a deep understanding of the racial and cultural background of their clients. In contrast, most mainstream agencies tended to trust that issues about race or religion would emerge in counselling sessions and that counsellors would learn the significance of these issues from their clients.
- Few mainstream agencies involved in this study had specifically targeted black communities in publicising their services. Some were wary of creating demand they could not meet due to lack of capacity, or lack of confidence in dealing with black clients.
Although there has been increasing recognition of the value of counselling and a rapid expansion of such services, the uptake among black people continues to be low. This study evaluated counselling provision in the voluntary sector on the basis of the experiences of people who have been for counselling and the perceptions of those who have not. It was not concerned with examining the applicability of theoretical models of counselling to Asian people.
Although the specific focus of the study was Asian people, the findings and policy implications are broadly relevant to increasing use of the service by other black people. The diversity of the Asian population was recognised throughout the research and in the full report (which used people's own definitions of their identity).
Being clear about 'counselling'
The nature of services loosely named 'counselling' is diverse. The British Association for Counselling distinguishes between activities it recognises as counselling (the focus of this study), and those identified as utilising 'counselling skills'. Counselling is understood to take place only when the counsellor and the client explicitly agree to enter into a counselling relationship. Counselling skills, on the other hand, may be used to enhance another professional helping role such as social work or vocational guidance.
There is considerable scope for confusion and therefore a need for greater clarity among policy-makers, funding bodies and potential referrers as to the precise nature of available services and the extent of their cultural sensitivity. Agencies also need to be transparent about the nature of the service they offer and make appropriate referrals, as required.
Limitations in supportive relationships
Although most participants had family members or friends they could talk to, many held back from entirely confiding in them. Issues of confidentiality and trust were often of considerable concern. Some felt reluctant to disclose concerns over family issues to their friends for fear of losing respect within the community. Many people who had not used counselling spoke about feeling lonely and alone with their problems.
While people who had used a counselling service were positive about the benefits of professional support, non-clients were mixed in their views about its potential usefulness. Many felt that talking to someone who was of the same background and who shared their cultural values and norms was very important; but they did not seem to think that this was possible within a counselling service.
Experiences and impact of counselling
Those people who had used a counselling service indicated that they initially had few expectations, beyond a vague feeling that they would be helped. As they grew familiar with the service, they arrived at a clear understanding of its purpose and process, for example:
It's about expressing one's anxieties and bringing out a solution.
Benefits included building self-esteem and a sense of control over one's life, alleviation of physical symptoms, and a feeling of comfort and relief.
I used to talk about what was in my heart, tell her all my pain. My heart felt very comfortable because all the lava brimming in my heart, I took it out.
I just came out and then after that, there was no temperature, no chesty cough, nothing ... I slept through at night time.
Emotionally you feel inside you are coping well. You feel better. You get control over your emotions ... More confidence. No feeling low ... generally I feel very good.
Views on counsellors
Most clients were satisfied with their counsellor, seeing them as 'caring' and 'professional'. A few felt the experience had been of limited value. Dissatisfaction was linked to feeling 'mismatched' with a counsellor in terms of ethnicity or gender, a sense of not being fully understood and not being in control of the process, and failure on the part of the agency to consult about preferences for counselling.
Preferences for counselling
People's preferences varied widely, and not always in ways that conformed to professional assumptions about 'matching' counsellors and clients.
If I'm going to go out and see someone I'm not going to see someone who's like my aunty.
Participants expected counsellors to be active in enabling them to work through their feelings and problems and to treat them with respect as equals in the process. People who had used a counselling service were unanimous in preferring a counsellor who was mature and experienced. Everyone expressed a strong wish to communicate in the language in which they felt most comfortable. For some, this was English. For others, this was an Asian language, or a mix of languages. Some strongly preferred a counsellor of the same ethnicity while others were averse to working with someone from the same ethnic background, citing the small size of the community and the likelihood of social contact outside the sessions. Preferences were also mixed about using either a mainstream or a black-led agency.
A few preferred a counsellor of the opposite sex, but most preferred a counsellor of the same sex as themselves, with women expressing a particularly strong preference for this.
I just don't feel comfortable talking to a man.
Although people who had used a counselling service were mostly satisfied with the location of counselling sessions, those who had not wanted the option of seeing a counsellor at home.
Awareness of and access to counselling
Generally, the circumstances which led people to seek counselling followed major life-events, such as bereavement, marital breakdown or redundancy. Concerned family members, friends or an involved professional then suggested counselling as a means of enabling them to cope with their circumstances.
Some people found that their access to appropriate counselling services was inhibited by the lack of awareness of General Practitioners and other professionals (about the services and/or about the distress of the individual). As a result, these professionals were unable to refer them to appropriate services.
Several people were concerned about the low awareness of counselling in their communities. They felt that increased attention should be paid to publicising the existence and nature of counselling services, particularly through outreach work:
Go out to like temples ... or women's groups ... you'd have to make them more aware ... that this service is there, and that no one would find out, if anybody has used it or not ... that kind of confidence building has to be installed in them.
However, there was little evidence that the mainstream agencies involved in the study were targeting black communities when publicising their services. Some agencies attributed this to the difficulty of dealing with existing clients and their inability to develop their services strategically due to the nature of short-term funding. A few agencies reported a lack of confidence in dealing with black clients, resulting in reluctance to promote the service in black communities.
Lack of culturally sensitive services
Most mainstream agencies tended to trust that counsellors would learn the relevance of cultural and religious issues from their clients during the sessions. There was little recognition among these agencies that it was important to enhance cultural sensitivity through continued exposure to black clients.
In contrast, black-led agencies felt that it was important to have a deep understanding of the cultural and religious background of their clients. Several black counsellors expressed concern about the adequacy of existing training courses in preparing counsellors for meeting the needs of black clients.
Most mainstream agencies readily acknowledged the importance of a culturally diverse workforce in attracting black clients. Despite awareness of the shortage of trained black counsellors, few agencies had invested any effort in encouraging black applicants for training courses. An isolated example of good practice was a mainstream agency which recruited a black person with relevant experience and provided counselling training.
Agencies' ability to provide clients with choice
Overall, most agencies were limited in their ability to provide clients with choice with respect to counsellors, the language used and the location of counselling. In some cases, clients were faced with a trade-off between having their preferences met and having to wait a long time for counselling to begin.
Black-led counselling agencies were generally able to provide counselling in a number of languages. However, the tendency of most mainstream agencies to trust that these agencies would cater to the needs of clients who did not speak English was worrying, given the very limited number of black-led agencies.
Monitoring and evaluation of services
Although counsellors usually review their counselling sessions with clients on an on-going basis, most agencies did not carry out ethnic monitoring or routinely follow-up clients who had completed counselling. Valuable information about the nature of problems faced by black clients, their routes of referral, their satisfaction with the service and longer-term impact was thus not available.
Improving counselling services for black people
The following strategies by counselling providers - and those who fund them - would increase the accessibility and appropriateness of counselling for black people. The full report also sets out clear recommendations, questions and suggestions aimed at service providers, potential referrers (e.g. GPs, social workers), community leaders, training bodies and funders on how to improve access and appropriateness.
Increasing access to counselling: increasing the number of external referrals by liaising with agencies or professionals whose work brings them into contact with black people; encouraging a greater number of self-referrals through developing a targeted outreach and publicity strategy; providing more flexible services e.g. drop-in services, surgeries in black-led agencies.
Increasing appropriateness of counselling: increasing the number of trained counsellors from diverse communities by providing financial support for training; increasing cultural sensitivity of existing counsellors through adequate training and by involving black counsellors or professionals with relevant experience; collaborating with and learning from agencies with relevant expertise.
Reviewing service provision: carrying out ethnic monitoring; maintaining contact with black clients who have completed counselling to examine the long-term impact of the service; organising focus group discussions with black clients to obtain feedback.
Black communities too have a role in promoting awareness and acceptability of counselling services by examining their own attitudes to mental health and encouraging people from their communities to seek appropriate support with psychological difficulties and distress.
About the study
Exploratory focus group discussions were organised at the beginning and end of the fieldwork with users of two black organisations which provide counselling. In-depth interviews were conducted with 38 Asian people, who were identified through liaising with black-led organisations. Nineteen of the participants had identified themselves as experiencing anxiety, depression or stress while the rest had been for counselling.
Ten counselling providers in the voluntary sector in Glasgow, Leeds, Bristol and London were identified, including those intended to serve the whole population (mainstream) and those which catered specifically for the needs of one or more minority ethnic groups (black-led). Additionally, the policy and practices of three umbrella organisations with strategic responsibility for the planning and provision of services were also examined.
The cooperation of Saheliya in Edinburgh and EACH (Ethnic Alcohol Counselling in Hounslow) in London was extremely valuable in ensuring that users were involved at key stages of the research.