‘Safe space’ A qualitative evaluation of a women-only therapy centre Isobel Harrison

2. ‘Safe space’ A qualitative evaluation of a women-only therapy centre Isobel Harrison University College London

3. Background Gender, common mental disorders (CMD) and intersectionality • Women > men: depression (Girgus et al., 2015); CMD (Kuehner, 2003) • CMD risk factors affect women: low income, socioeconomic disadvantage, gender based violence and responsibility for the care of others (WHO, 2016) • ‘Women’s Mental Health: Into the Mainstream’ (DoH, 2002) emphasised that women from Black and Minority Ethnic (BME) groups particularly vulnerable to CMD • Refugees report increased rates of post-traumatic stress disorder, depression and anxiety (Vostanis, 2014; Najaet al., 2016) Accessing services • Women’s views on specialist counselling for women experiencing gender-based violence concluded swift access to services crucial (Bohne, 2016) • Consistent finding: language acts as barrier to accessing services in BME groups (Li et al., 1999; Tabassum et al., 2000; Memon et al., 2016)

4. Background (contd.) Women-only mental health services • Mental health policy: gender-specific services, sensitive to women’s needs and recognise social and family context • Women more likely than men to express preference for same gender therapist (Landes et al., 2013) and favour female care providers in health settings (Liddon et al., 2018) • Research on effectiveness is sparse. Focus group study of women attending gender-specific services – ‘woman-only’ aspect essential (Corry et al., 2018). Evaluation study of long-term women-only counselling service – clients reported a reduction in psychological distress post-counselling (Payne et al., 2014)

5. The Maya Centre Founded in 1984, women-only therapy service in Islington • Free talking therapy (one-to-one and group) to those on zero or low incomes, in native language (11 different languages) • Many clients are from BME groups, are refugees and/or experienced trauma or gender-based violence • All staff and therapists are women (latter BACP or UKCP trained) • One-to-one therapy offered for maximum =24 sessions (previously one year duration) • Aims to enable clients to achieve recovery, develop resilience and avoid future harm • Recent quantitative service evaluation found significant improvements in client’s psychological distress post-therapy (Wilkinson, 2017) The current study aims to expand and enrich this evaluation by exploring, qualitatively, the views of staff and clients of the Maya Centre, including aspects they considered most beneficial and those that may require improvement.

6. Methodology Setting • The centre staff: 17 sessional therapists, director, deputy director (clinical lead), community support worker, clinical administrator and finance officer. • 80 clients. Participants (max n=18) • Clients: 18years+, currently or within last 3/12 attending therapy at centre • Staff: all therapists eligible, director and community support worker • Diverse range of women re. age, ethnicity, time attending the centre (clients); length of time spent working at the centre (staff) Procedures and data collection • Ethical approval – UCL Research Ethics Committee • Topic guides • Clients – access to centre, type and experience of therapy, suggestions for improvement • Staff – value of centre, wider context of role, experience of delivering therapy, suggestions for improvement (operation staff – centre strengths and weaknesses)

7. Methodology (contd.) Recruitment • Staff: clinical meeting attended, study information sent to therapists absent • Clients: study information sent by centre staff to all clients • Written informed consent • Audio-recorded in-depth interviews May-July 2018 Analysis • Interviews transcribed verbatim, anonymised then entered into Nvivo 11 for data management and coding • Thematic analysis (Braun & Clarke, 2006) conducted to identify themes, transcripts read and re-read and coding frame iteratively developed to aid theme identification • Findings and emerging themes tested for validity by discussion with an expert in qualitative research in mental health services • Two transcripts recoded by independent peer researcher applying coding frame

8. Results Interviews with seven clients (12.5% of total eligible) and seven staff (5 therapists, centre director and community support worker Client characteristics (N=7) Staff characteristics (N=7)

9. Themes

10. Culture The ethos of the centre as a gender-sensitive space where clients felt nurtured and secure Safe space “It's such a beautiful place. Just being here is so very soothing, isn't it? It's just the whole environment is very feminine, if you want to say. And at the moment, I think that everything that is very much feminine, that soothes me, I find it soothing. The male environment scares me. And I think… I find this, even the place is very soothing” (Client 4) “One more thing I wanted to say, is that before coming here my main support was [service name] but that is a mixed space. And the difference I’ve found coming here and just being with women, is enormous – it’s an enormous difference, in terms of feeling that you’re in a space where you’re not going to be bothered or harassed” (Client 1) “Also, we do cater for women only. It might sound that we're being discriminatory, but there is a purpose behind it because we offer them a very safe space” (Staff 1)

11. Processes Clients accessed the centre through a variety of routes including self-referral. Engagement with the staff was a good experience for the majority of those interviewed, often beginning with the first call. Matching of therapists to clients regarding age and cultural background was an important and appreciated aspect Access and assessment “I didn’t want somebody young who didn’t have any experience of life” (Client 3) “So I was looking for a lady, and preferably someone who'd understand the cultural side of my situation” (Client 4) “I remember leaving, feeling like, okay, I’m not just hanging by a thread here, there is a safety net somewhere. Yes, I remember it now I’m talking about it, I remember leaving here, thinking, whew, because it would have been quite scary to leave, feeling that, no, I don’t think this will help. Yes that would have been scary” (Client 1)

12. Structures The differing and interacting ways in which the centre delivered support Community embeddedness “I think it's very good that we are placed in Islington, and we have these opportunities. Because that allows, I think, women to see themselves a little bit more as a whole, and not being this, okay, I'll go to the Maya centre, do counselling. But then I go out of the Maya centre, there is a whole world out there, and I'm lost in this world” (Staff 2) “For picking up the slack in such a... You know, there are some downsides to raising awareness around mental health and getting rid of stigma. More people come. More people, more people” (Staff 6)

13. Therapy content The experience of therapy for clients and staff, benefits were often related to the specific expertise of the therapist Talking therapy “Because it’s a women’s therapy centre, we are kind of like quite rooted in supporting women who suffer domestic violence, so either injustice. I think domestic violence is a kind of tumour in the society and no woman… It’s going to be here in the society forever and it’s historically always there. It’s going to be here, but we are kind of like providing a service to support them in a quite… It’s not a practical way, you know, in a psychological, deep way, to support them” (Staff 3) “I was absolute destroyed and broken, if you want to say. And the moment when I met her, because I had past traumas which I always kept hidden. Never ever, ever, ever talked to anyone, nobody ever knew anyway” (Client 4)

14. Challenges For staff, challenges arose from working within and adapting to change in the context of funding constraints. How they responded to challenges was discussed in terms of how the perceived weakness of women in society was echoed in the centre. Resources “Also the clients, they are surviving. They can’t grow and they don’t think they can grow. They have no concept of growing. Just survive on a daily basis. And us as well. We survive year by year. Every year there’s a threat” (Staff 3) “Partly it is because we are a women's organisation. And I think as women, we're not separate to the system in which we're growing up, and living. And I think society overall undermines women a lot. And I think we do that to ourselves as well. And it's a lot of… I think within… It's all played out, whatever happens outside, whatever the system, whatever… Where… It's all really playing out in here…and I think there is a lot of, as well, playing out in terms of anxiety, and being worried about the new things, and new challenges” (Staff 2)

15. Overcoming challenges The evolving developments at the centre have led to staff reflecting on the identity of the centre. The need to adapt to less funding and higher numbers of complex referrals has been unavoidable but seems to have resulted in increased flexibility and innovation in the delivery of therapy. Reviewing the vision “But I think it was a lot as well about it tied in with Maya centre thinking about, okay, so what we are as an organisation. If we're bringing community services, are we wellbeing centre? Are we community centre? Are we counselling centre? And that plays a lot into challenges of implementing the service” (Staff 2) “And I so like the fact that we have had to learn to do short-term work. And actually, short-term work does call for you to be much more focused and to... you work harder. You’re just work a lot harder in terms of really trying to say, okay, this is what you’re going to come out with. This is what the goal is. Keep it goal-orientated and you go off. You know, it’s a very different way of working and we’ve had to learn the new skill and that’s always a good thing, so I think we’re adjusting well” (Staff 6)

16. Main Findings • Able to access centre without obstacle, facilitating access for disadvantaged groups • Women-only space and specific skill of therapist essential to recovery, further evidence to earlier findings that these are crucial to effectiveness (Payne et al., 2014; Bohne, 2016) • Recent changes presented initial challenge for staff but now assimilated into practice, and led to innovation re ways of delivering support • The Maya Centre provides individual and group therapies which are valued very highly by clients and staff. Particular strengths that enhance access to vulnerable women include its gender-sensitive ethos, the employment of multilingual therapists and the fact that it is a free service.

17. Clinical implications • Individual therapy in native languages is invaluable, enabling help-seeking in hard-to-reach populations. The ability of the centre staff to be sensitive to this need, from the first point of contact onwards, demonstrates how services can function sensitively within inner-city settings which may include refugees. • Aspects of the centre which increased its presence in the community have enormous benefit for both staff, clients and the wider community. How staff are addressing the resulting increase in referrals has implications for other non-statutory services in liaising with other agencies regarding referral rates, appropriateness and funding. • Policy initiatives recommending the provision of easily-accessible, gender-specific services are essential to this client group and this study is further evidence on their effectiveness. The multiple forms of support offered at the centre allow women access to a form of therapy which is helpful for them at whatever stage of distress or recovery, and models what an inclusive responsive women-only service can look like.

18. Limitations Future research • The sample did not include clients of the service receiving therapy in their native language so unable to evaluate the service from their perspective • Participants were self-selecting so findings may not be generalisable to all clients and staff of the centre or other gender-specific therapy services • Mixed method evaluation of larger sample of women attending gender-specific services combining in-depth interviews with quantitative outcome measures of recovery pre and post therapy. • Clinical and cost evaluation comparing different forms of therapy eg long-term psychodynamic versus short-term cognitive behavioural therapy in similar settings

19. Thank you