In Pakistan lack of professional skill, lack of awareness about CBT among clients and lack of financial resources to support the treatment are the major issues. Please see these references

Psychologists experience of cognitive behavior therapy in a developing country: a qualitative study from Pakistan

Views of depressed patients in Pakistan concerning their illness, its causes, and treatments F Naeem, M Ayub, D Kingdon, M Gobbi

Qualitative health research 22 (8), 1083-1093

Thank you for your prompt answer. 

Thanks for your very interesting and relevant question, Lucio. I concurred with Muhammad on his observations and appreciated his reference.

In the literature on multicultural psychotherapy and my experiences as a practitioner and teacher in the United States and Hong Kong, I've found the stigma of mental disorders and a lack of culturally competent adaption of CBT and other psychotherapeutic approaches for Chinese/Chinese Americans to be two main barriers among many others.

I discussed these internal and external barriers in my book chapter:

Cheung, S. (2009). Asian American immigrant mental health: Current status and future directions. In Jean Lau Chin (Ed.), Diversity in mind and in action (Vol. 1, pp. 87- 104). New York: Praeger Press/ABC-CLIO.

In Chin's three-volume book, there are many additional excellent ideas.

Thanks for posting this thought-provoking question for discussion, Lucio.

I should have mentioned cultural adaptation. We have been working on cultural adaptation of CBT in Pakistan for last 10 years and our experience is that nuances of language and culture are important factors in acceptance and usefulness of CBT. These are some references

Preliminary evaluation of culturally sensitive CBT for depression in Pakistan: findings from Developing Culturally-sensitive CBT Project (DCCP)

F Naeem, W Waheed, M Gobbi, M Ayub, D Kingdon

Behavioural and cognitive psychotherapy 39 (02), 165-173

University students’ views about compatibility of cognitive behaviour therapy (CBT) with their personal, social and religious values (a study from Pakistan)

F Naeem, M Gobbi, M Ayub, D Kingdon

Mental Health, Religion & Culture 12 (8), 847-855

Development of Southampton Adaptation Framework for CBT (SAF-CBT): a framework for adaptation of CBT in non-western culture.

F Naeem, M Ayub, M Gobbi, D Kingdon

Journal of Pakistan Psychiatric Society. 6 (2), 79-84

A multicentre randomised controlled trial of a carer supervised Culturally adapted CBT (CaCBT) based self-help for depression in Pakistan

F Naeem, I Sarhandi, M Gul, M Khalid, M Aslam, A Anbrin, S Saeed, ...

Journal of affective disorders 156, 224-227

The accessibility of psychotherapy for people with mental illness is certainly a key factor, in addition, the motivation for psychotherapy as well as the attitude, also of the social environment on mental illness and psychotherapy. An additional factor is the lack of recognition of mental disorders by primary care physicians.

In international comparison, Germany is one of the countries with best powered psychotherapy (also because the treatment costs are largely taken of the statutory health insurance), but for only about 15-20% of people epidemiologically relevant an outpatient psychotherapeutic setting is available. The waiting times are long, many patients have to resort to inpatient psychiatric and / or psycho-pharmacological treatment alternatives or are not qualified, specially treated (eg psychosomatic diseases exclusively medical).

In contrast, psychotherapy is not only effective but also efficient, for the latest result of psychotherapeutic health services research in Germany  the return on investment is 2-5, with an average duration of therapy of 40 sessions.

We recently have described the situation for Germany (https://www.researchgate.net/publication/269572241_Versorgung_psychisch_kranker_Erwachsener_in_Deutschland_-_Bedarf_und_Inanspruchnahme_sowie_Effektivitt_und_Effizienz_von_Psychotherapie). Important for the health policy debate in Germany is argument that (outpatient) psychotherapy includes only about 7.5% of the cost of mental illness (€ 1.5 billion to € 20 billion) and is more efficient than other treatment alternatives.

Article Versorgung psychisch kranker Erwachsener in Deutschland - Be...

Dear Liliana, I believe it's better to answer in English so that also other colleagues can read and understand your interesting point of view! By the way your Italian is excellent  ;-)

To answer that question in the Brazilian context should be emphasized, that this country demographically and culturally is large and varied. Then I will highlight What else do slows the advance of several therapies. On this surrounding context access due to the social inequality, the quality of professional qualification or who wish to work with the poorest population considering that this group is it the majority, accreditation or credibility in the benefits arising from the therapy, the focus on medicalization arising from the medical figure, still the adherence the services offered

Both in the public sphere and In private practice, the issues are lack of funding, the politics of evidence (weak independent research etc cheaper solutions favoured not because they are better evidenced, but because they are cheaper), lack of knowledge among referrers, members of the public more likely to seek pharmaceutical solutions would rather take a drug than talk to a therapist).  

Thank you for all your answers and references given. So far, I take the attention you have shown to my question as a support of its importance, or a confirmation that it is a problem abroad as well as in Italy.  

Thanks also to Gary Winship, who reminds to us that luckily there are cheaper solutions than others, and these solutions are also better evidenced, albeit still more research is obviously needed (as effectiveness is never 100%).

I Australia (NSW) it could be postcode. This is the tendency of psychologists to cluster in where they live and practice while those who require their services live in other areas of the city.

there is also availability. To go privately requires funding. the Federal government here provides 10 sessions associated with primary care management of the mental illness. this then can run into the geography issue or the psychologist may not be happy with the government fee and expect the patient to pay as well.

there is good evidence for this being cost effective for the government insofar as it gets people back to work. the is work done by Lord Layard (an advisor to Tony Blair). he wrote a Penguin book on Happiness and the researches are referenced.

The almost total lack of trained personnel. The problem is exacerbated by the highly variable quality of clinical psychologists, who range from the well-qualified and motivated to the utterly inept. Get any of my clinical colleagues talking on the subject to hear some horror stories!

And behind this, the utter neglect of mental health in the Irish health services. Ten years ago we had the lowest proportion of health spending on mental health in the EU, and this proportion has declined ever since. Irish graduates will not apply for jobs in Ireland because of the appalling working conditions, as a response to which the Health Services Executive spent millions recruiting Pakistani psychiatrists from unaccredited medical schools to work in Irish psychiatry. 

Apart from that, things look great for mental health in ireland. 

Well, thanks for all your answers and papers (albeit I cannot read German).

So far, as I have understood, I have gathered the following barriers:

- lack of public funding and/or attention to mental health services.

- lack of personnel properly trained in performing effective psychotherapy.

- lack of cultural adaptations of most effective psychotherapy procedures to non-western cultures.

- social stigma towards mental disorders.

- lack of recognition of mental disorders by primary care physicians.

- lack of knowledge among referrers and members of the public about psychotherapy.

- lack of funding and/or attention to independent experimental research on psychotherapy.

It's perfectly possible that some other source of barriers to CBT/effective psychotherapy is not included in this list, but I feel that these are the most important. Also, it is obvious to me that some of these barriers are interconnected.

What is emerging, however, is that whatever great a contribution psychotherapy is able to provide to mental health (and evidence is growing that it's great) it is either largely underestimated and/or unused. Perhaps in different proportions from Country to Country, according to the relevance of the different barriers.

In Italy, we have launched the initiative FATE (Favorire l'Accesso alle psicoTerapie Efficaci) to favour the access to effective psychotherapies. Albeit with little support, we expect that the current scarce access to the media will increase.

Anyway, please, let me have your thoughts on how to remove those barriers.

Just to add some more information for those interested, we have recently launched in Rome, with the support of the Physicians' Providence Institute, a new program aiming at reducing the barriers to the use of effective psychotherapies. It's called FATE from (F)avouring (A)ccess to (E)ffective psycho(T)erapies (in Italian, of course). The first step will be a cycle of seminars, open to the population, about what psychotherapy is and what it can do. We hope to remove some stereotypes against and reduce ingnorance about psychotherapy.

The seminars will be hold in the hall of the Insitute, in a very popular and crowded area of Rome, will start next month and end next november. The speakers will be psychologists and psychiatrist trained in Center for Research in Psychotherapy (CRP).

Do any of you know of similar experiences around the world?