Huge progress has been made in the development of evidence-based psychotherapies for a wide array of mental disorders¹. However, significant socioeconomic and sociocultural divides exist in the access to these interventions. The unavailability of psychotherapies for a large proportion of the world’s population presents a major challenge to the future of mental health care.

There are currently both structural and attitudinal barriers to accessing psychotherapies. In relation to structural barriers, a ma­jor problem is that, in many countries worldwide, evidence-based psychotherapies are scarcely available in public mental health services, being mostly practiced by psychologists and psychiatrists in their private offices, which creates a socioeconomic divide in accessing them. The introduction of e-mental health was expected to fill some of these gaps in access to psychotherapies. However, digitally and socioculturally disadvantaged and minority groups remain underrepresented in studies of e-mental health and effective uptake of e-health. Indeed, the digital and language skills required for e-mental health engagement are beyond the reach of many, particularly from minority ethnic groups².

Attitudinal barriers play an equally, if not more, significant role. The dominant model of psychotherapy is largely pro-rich and pro-highly educated, and therefore is met with suspicion and/or is felt to be out of reach by many. Moreover, psychotherapists are often poorly trained to accommodate the highest level of need, and the ethnic and cultural diversity of mental health professionals rarely reflects the diversity of the population³. These problems are exacerbated by the large-scale international migration of families presenting with the consequences of the enduring psychological impact of displacement, uprooting and culture change. Data from the World Mental Health Surveys show that, even in Western countries, reluctance to seek help for mental health problems due to suspicion about the treatments on offer is a far more important barrier than structural barriers to initiating and continuing treatment, and predicts 39% of treatment dropout⁴.

The implicit value system behind evidence-based psychotherapies presents a poor fit in relation to some ethnic and cultural groups. For instance, is the prioritization of individual agency implicit in psychotherapy universal or is it a peculiarity of Western cultures? Socioeconomically deprived individuals are underrepresented in clinical trials for most common mental disorders. Our knowledge of the effects of psychotherapies is largely limited to data from so-called “WEIRD” (Western, Educated, Industrialized, Rich and Democratic) individuals, who comprise 90% of study participants in psychological studies, from countries constituting only 12% of the world’s population⁵. In this respect, the COVID-19 pandemic has magnified underlying social inequalities, with new remote therapy platforms, for instance, often failing to reach those who may need mental health support the most.

What can be done to increase access to psychotherapies, par­ticularly by socioeconomically disadvantaged people and socio­cultural minorities? First, the applicability of psychotherapies needs to be broadened to include non-traditional service providers and self-help interventions. Programmes ongoing in low- and middle-income countries to train “barefoot” therapists by creating e-learning platforms represent an important model. These programmes ensure increased reach by trusted and familiar individuals, as well as high levels of fidelity, and direct supervision providing quality control and outcomes reporting⁶.

Second, interventions need to be adapted to specific populations. Studies suggest that, when interventions for mental health problems are adapted to make them culturally appropriate, they are typically as effective in minority groups as in the populations for which they were originally created and tested. Likewise, increasing the multicultural competence of psychotherapists has been associated with improved treatment outcome⁷. This suggests that disadvantage does not rest with the disadvantaged; rather, it results from the unwarranted assumption of psychological universalism, namely that no adjustments need to be made when reaching out to the “hard-to-reach”.

Third, the field of mental health needs to actively engage with racial and other issues of inequalities. For example, a history of exploitation of certain racial groups inevitably leaves its psychological mark, and the pervasiveness of racism in many Western societies generates microtrauma which, if not explicitly addressed, leaves psychotherapies to be experienced as irrelevant to the concerns of minoritized groups. Consistent with these assumptions, areas with a high density of minority groups are associated with an increased prevalence of mental health problems and poor treatment seeking, but only when combined with low levels of social support and cohesion. Similarly, social deprivation and minority ethnic status have been associated with delays in initiating treatment for mental health problems, but not with continued treatment once engagement is achieved⁸.

Early adversity defines a transdiagnostic ecophenotype that has been associated with earlier onset of mental health problems and high service utilization, but poor treatment response and high levels of dropout⁹. Beyond preventing early adversity, increasing social capital – that is, the resources available to individuals through social relationships with an emphasis on reciprocity, trust, collaboration and kindness – may be an important component of countering social inequalities relevant to access to mental health care. People with a relatively high degree of power tend to focus on themselves as individual agents, while marginalized individuals with low economic power tend to focus on their communities. When that community support is absent, those with low power are, as a result, both more vulnerable to mental health problems and at the same time less inclined to seek help.

Finally, the way the effectiveness of psychotherapies for mental health problems is depicted by the media may have an important impact on their use and perhaps also their effectiveness, decreasing or reinforcing stigma related to mental health problems. Without explicitly addressing issues of stigma and shame, those who feel alienated with mental health needs will remain mistrustful of those perceived as privileged, while, at the same time, those offering support will continue to place responsibility on those appearing to be unwilling to accept help.

We need to empower a massive trusted workforce to deliver effective psychotherapies, harvesting the results of over five decades of research, to the large numbers in our societies who need them. This will require not only a significant change in the training of those delivering these treatments, but also an increased willingness on the part of mental health professionals to immerse themselves in the concerns of minority groups. Allyship requires a commitment which is long-term, not just during crises.

在开发针对各种精神障碍的循证心理治疗方面取得了巨大进展¹。然而，在获得这些干预措施方面存在显着的社会经济和社会文化鸿沟。世界上很大一部分人口无法获得心理治疗，这对精神卫生保健的未来构成了重大挑战。

目前，获得心理治疗存在结构性和态度上的障碍。关于结构性障碍，一个主要问题是，在世界范围内的许多国家，公共精神卫生服务中几乎没有循证心理治疗，主要由心理学家和精神科医生在其私人办公室进行实践，这在获得这些服务方面造成了社会经济鸿沟. 电子心理健康的引入有望填补这些在获得心理治疗方面的一些空白。然而，在电子心理健康和有效采用电子健康的研究中，在数字和社会文化方面处于不利地位的少数群体仍然代表性不足。事实上，电子心理健康参与所需的数字和语言技能超出了许多人的能力范围，尤其是少数族裔群体².

态度障碍起着同样重要的作用，如果不是更重要的话。心理治疗的主导模式主要是支持富人和受过高等教育的，因此遭到怀疑和/或被许多人认为遥不可及。此外，心理治疗师往往训练不足，无法满足最高水平的需求，心理健康专业人员的种族和文化多样性很少反映人口的多样性³. 家庭的大规模国际移徙加剧了这些问题，这些家庭带来了流离失所、背井离乡和文化变革的持久心理影响。来自世界心理健康调查的数据表明，即使在西方国家，由于怀疑所提供的治疗而不愿就心理健康问题寻求帮助是比开始和继续治疗的结构性障碍更重要的障碍，并预测 39%治疗辍学⁴．

循证心理治疗背后的隐含价值体系与某些种族和文化群体不符。例如，心理治疗中隐含的个人能动性的优先级是普遍存在的还是西方文化的一个特点？在大多数常见精神障碍的临床试验中，社会经济贫困者的代表性不足。我们对心理治疗效果的了解主要限于来自所谓的“WEIRD”（西方、受过教育、工业化、富人和民主）个人的数据，他们占心理学研究参与者的 90%，来自仅占 12% 的国家。世界人口⁵. 在这方面，COVID-19 大流行放大了潜在的社会不平等，例如，新的远程治疗平台往往无法覆盖最需要心理健康支持的人。

可以做些什么来增加获得心理治疗的机会，尤其是社会经济弱势群体和社会文化少数群体？首先，心理治疗的适用性需要扩大到包括非传统服务提供者和自助干预。在低收入和中等收入国家正在进行的通过创建电子学习平台来培训“赤脚”治疗师的计划代表了一个重要的模式。这些计划确保可信赖和熟悉的个人扩大覆盖面，以及高水平的保真度和直接监督，提供质量控制和结果报告⁶。

其次，干预措施需要适应特定人群。研究表明，当针对心理健康问题的干预措施经过调整使其在文化上适合时，它们在少数群体中通常与在最初创建和测试它们的人群中一样有效。同样，提高心理治疗师的多元文化能力与改善治疗结果⁷相关联。这表明劣势并不属于劣势者；相反，它源于心理普遍主义的无根据假设，即在接触“难以触及的”时无需进行调整。

第三，心理健康领域需要积极参与种族和其他不平等问题。例如，对某些种族群体的剥削历史不可避免地会留下其心理痕迹，而在许多西方社会中普遍存在的种族主义会产生微创伤，如果没有明确解决，心理治疗就会与少数群体的关注无关。与这些假设一致，少数族裔人口密度高的地区与心理健康问题和寻求治疗不力的患病率增加有关，但前提是与低水平的社会支持和凝聚力相结合。同样，社会剥夺和少数族裔地位与心理健康问题的治疗延迟有关，⁸ .

早期逆境定义了一种跨诊断的生态表型，该表型与较早出现的心理健康问题和高服务利用率有关，但治疗反应差和辍学率高⁹. 除了预防早期逆境之外，增加社会资本——即通过强调互惠、信任、合作和友善的社会关系为个人提供的资源——可能是消除与获得精神卫生保健相关的社会不平等的重要组成部分。权力相对较高的人倾向于将自己作为个体代理，而经济权力较低的边缘化个体倾向于关注他们的社区。当缺乏这种社区支持时，那些权力低下的人就更容易出现心理健康问题，同时也不太愿意寻求帮助。

最后，媒体对心理健康问题心理治疗有效性的描述方式可能对其使用产生重要影响，或许也对其有效性产生重要影响，减少或加强与心理健康问题相关的耻辱感。如果不明确解决污名和羞耻问题，那些感到与心理健康需求疏远的人将仍然不信任那些被视为特权的人，同时，那些提供支持的人将继续将责任放在那些似乎不愿意接受帮助的人身上.

我们需要赋予大量值得信赖的劳动力以提供有效的心理治疗，将超过五年的研究成果收集到我们社会中需要它们的大量人群中。这不仅需要对提供这些治疗的人员的培训进行重大改变，还需要精神卫生专业人员更加愿意将自己沉浸在少数群体的关注中。盟友关系需要长期的承诺，而不仅仅是在危机期间。