So, I'm starting us off with this slide that talks about the social distribution of treatment. This is some information that is excerpted from the Pilgrim and Rogers textbook, that's one of the suggested sources for the course. And in that chapter, what they're talking about is how who you are makes a difference in terms of the kind of mental health care treatment that you can access. So, we've already talked about the fact that our treatment options in the mental healthcare system are constrained because of social issues and political issues. What this actually introduces now is the idea that even within those constraints, it's possible that because of who you are, you may not have access to the full range of treatment options that are available. And what the Pilgrim and Rogers book really gets us to think about is how that is connected to other social problems in our society, how it's a representation of the kind of issues that we're already facing in terms of inequities in social distribution. If I look at this list, I am certainly reminded of the research that says Afro-Caribbean people in the UK are more likely to be facing involuntary treatment than other groups. the fact that men are more likely to receive coercive treatment we've certainly seen that in Canada with our community treatment orders. There are more men on those community treatment orders, and actually, if you look at racial and ethnic minority groups in that context as well, what you often see is that people are receiving, are being put on to this mandatory outpatient treatment orders after not refusing treatment, but not being able to get voluntary treatment. So, actually that course of treatment method is a replacement, a substitute for voluntary accessible care. And then on that final point about psychotherapy being offered mainly to White, well-educated, and younger people, there's a literature that speaks very clearly to the fact that psychotherapy simply isn't offered to many populations because of assumptions and let's face it, stereotypes. Maybe even sexist, racist, age, or stereotypes about who benefits from psychotherapy and who's interested in it. And so clinicians, service providers make these decisions without actually consulting clients. They decide that this type of client is suitable for psychotherapy and another one is not. And this type of client needs to be in, on mandatory outpatient treatment but but somehow isn't a good candidate, candidate for a voluntary outpatient treatment. And as Pilgrim and Rogers suggest, this has to do with larger social issues. So that's what we're talking about in this section on treatment access. So, let's start by defining the term, access. Many people understand access to services as just meaning whether or not people can actually get into services, but service access actually means much more. Service access refers to the capacity to receive services and also receive benefit from services. So, for example, it's not enough that there's a healthcare center in your neighborhood. It's not considered a fully accessible healthcare service unless people are able to receive services from it and people receive the same benefits from that service regardless of their race, gender, class, disability status, sexuality, etc. There are many things that create barriers to full access of services. Some of these things are, some of these things are issues that prevent people from receiving care, things that prevent people from receiving care in a timely manner, things that prevent people from receiving care that is effective, care that will actually help them, and things that prevent people from receiving care under safe circumstances or from receiving care that is actually safe for them. These are all factors that contribute to the mental health disparities that we see among, among marginalized populations. And they are the kind of issues that are being signaled, when the social determinants of mental health refers to health services as one of the determinants. Some of the barriers that have been identified as being relavent to mental healthcare services include, user fees and insurance requirements. Even in regions where there is a state-sponsored or universal healthcare plan, people may not be able to access mental healthcare because they need to pay additional fees or can only afford it if it is covered by private insurance. There may be men, mental health cares available without fees. But sometimes, an additional barrier is created by long waiting times for receiving those services. Lack of information about services could be another barrier. If you are in the right networks and you may know about what services are available and how they can be accessed, but if you're not in those social networks, you may not have that information and therefore, are not able to get that kind of help. A group that often faces this barrier is immigrants or newcomers to a country. But certainly, social class and basic literacy, can also make a difference in terms of access to information about mental healthcare services. Language barriers are another barrier. It is very difficult to access effective mental healthcare if the person who is providing service does not speak the same language as the person who is seeking services. This is an issue that is especially pronounced in the context of mental healthcare because communication between the clinician and the client is the primary method for assessment, diagnosis, and treatment. Simple unavailability of services is a barrier to receiving mental healthcare. Some people simply do not have a service to access. In many parts of the world, mental health professionals are scarce and people seeking help do not have anywhere to go to get that help. And even in places where services and health professionals may be available, services may not be available because they're not in locations that are close to the populations that need them or they operate during days and times when people can't go to them. That's a service barrier that often affects people who are working class because they can't leave their jobs to go to healthcare services. And finally, culturally insensitive, culturally appropriate, inappropriate, and culturally harmful services are also a barrier to receiving effective mental healthcare. You will hopefully remember how this was discussed in the lecture on social determinants of health and in that paper about colonialism as a determinant of health. People cannot get effective mental healthcare if they have to seek it in, in an environment that has no respect for their culture or understanding of their culture. And this is something we'll talk about again in the next lecture. Culturally insensitive and inappropriate services create one kind of barrier. Systemic racism, sexism, and other types of bigotry and prejudice present another significant barrier. There has been a great deal of research that talks about how these kind of systemic issues present problems for people seeking help in mental healthcare, healthcare system. And there is wide recognition that services, as a whole, need to be equipped to not only deal more effectively with cultural difference and other types of difference, but they must also work from the bottom up to ensure that service experience and service providers do not expose clients to racism, sexism, homophobia, and other types of prejudice and discrimination. All of these issues are addressed in detail in the reading that you have about racial and ethnic disparities in mental health and mental illness. So, to summarize, we have a mental healthcare system that we already know is somewhat constrained in terms of the options it makes available to people seeking care. And the work that has been done looking at access and equity in the mental healthcare system suggests that even within those constraints, there are people who are systematically excluded from getting the benefits of those available treatments. So, what's to be done about that situation? Well, the very reason that I do research on access to health services is that I believe something can be done about this. I would like to think that there are ways we can work to make sure that everyone who needs mental healthcare can get it and benefit from it. And while it's discouraging to consider that even in a country like the one that I live in, Canada, where we have universal healthcare not everyone has full access to healthcare. There are things that can be done to remedy that situation. The Primm article suggests the following interventions. I hope you're noticing that this list includes several things that have been referenced in the lecture in the course already. Social support seems to suggest intervening to address social determinants of health. The suggestion of surveillance and research, which sounds kind of sinister, is actually just a recommendation to do more comprehensive tracking of the kind of mental health issues various populations are dealing with. Cultural competency is a term that we used to talk about increasing the cultural sensitivity of services. The suggestion of more widespread public health information about mental healthcare services directly addresses the information barrier that has already been mentioned. And the assertion that we need evidence-based approaches takes us back to the idea from an earlier segment that we want to make sure that whatever we are doing, we have proof that it is having its intended beneficial effects. The suggestion of social marketing is an interesting one and one that we are hearing more and more in the context of healthcare. There are new methods of public education about health issues that are boring for marketing approaches that are used in the private sector. Using the methods that are used to sell goods and services, we hope to sell good health and service access to the masses. There are a few more interventions that I would suggest based on coming from a social justice orientation because the problems of access to service are not just about whether people can get to services, but also the fact that social inequities contribute to people being prevented from accessing services. In my mind, questions about access to services must always be paired with questions about equity in services. So, coming from that perspective, I would support Primm's suggestion that we need to target social determinance. But I would say, that we need to target much more than social support. If we want to be serious about tackling mental health disparities among marginalized populations, then we have to look at the broad range of social determinants. Because, as we've already discussed, the broad range of social determinants contribute to mental health disparities. I will share Primm's belief that researchers needed to understand what is going on with communities but I would advocate for community-based research, which means research that is developed with communities and done based on priorities identified by communities. There are many groups who have had negative experiences with researchers coming in and doing studies that just made things worse for them, sometimes reinforcing negative stereotypes and increasing stigma that they faced. Research needs to be done in partnership with communities so that they can contribute to it meaningfully and ensure that it's actually going to benefit them rather than marginalizing them further. Finally, I'm a believer in cultural competency. I think it has a valuable contribution to make, to imporving health care services for racial and ethnic minority groups and other groups. But I think we need to challenge our service organizations and our service provider work force even further by suggesting that they not only be culturally sensitive but that they actively work to eradicate racism and other types of oppression that affect the delivery of services and the experiences of receiving care in the mental healthcare system. A full discussion of this type of organizational change in training is beyond the scope of this lecture. But I just want to leave you with the idea that it's not enough to be sensitive to the diversity of, of people. We also need to be welcoming, respectful, and supportive of the diversity of people. So, that bring us to the end of this lecture. I'm going to do the wrap-up next.
