Several years ago, I spent my sabbatical year in Taiwan. Although I had lived in Taiwan for a couple years as a teenager and could speak the language at a 3-year-old level, the country had changed so much since I was 17 that I knew very little about where I would spend the next year of my life. One of my non-academic goals for the sabbatical was to regularly engage in my favorite hobby—mountain biking.
Taiwan is full of mountains. There are almost 300 peaks over 3,000 meters tall, I could speak a little bit of the language, there’s this little thing called the Internet, and I’m pretty resourceful, so I figured it would be easy to find great mountain biking trails. It turned out to be much, much harder than I had anticipated. It took several months to even get information about the mountain biking trails in the mountain behind my apartment. And, after I learned the name of the main trail—Graveyard DH (downhill)—I went to the graveyard to look for it. I rode all over that graveyard but could not find the trail. So, I went back 3 days later. Same result. I went back again and again and never found it. I spent a year in Taiwan, and my only real mountain bike ride was with a bike shop owner who served as my guide. I had utterly failed to achieve my goal to mountain bike regularly in Taiwan.
Grappling with Misconception
I tell this story to illustrate how someone who knows a lot about doing something in their own culture can still have a hard time doing it in another culture; here, I’m talking about getting help for one’s problems. Asian Americans use mainstream mental health services at about half the rate of the general population (8.6% vs. 17.9%; Abe-Kim et al., 2007). Why is that? There are a number of factors, including the stigma associated with having a mental illness and the feelings of shame that, for many Asian Americans, is felt not just by the person with the problem, but also by their families. It is this collective sense of shame that makes the stigma that much more of a barrier to seeking help. In response, mental health professionals need to be creative in finding solutions to make services less stigmatizing and more accessible, and sometimes this requires us to step outside of our cultural frames.
When I went to Taiwan, I had mistakenly assumed that mountain biking was going to be a popular form of biking, and I only learned after I arrived that most of the cyclists there did their biking on the roads, not the mountains. In a similar way, how mental illness is conceptualized differs across cultures, and whether one is able to get help for their mental illness depends on whether one’s conceptualizations of mental illness and of help match those of the culture. In many Asian and Asian American cultures, health is considered more holistically, such that emotional, mental, physical, and spiritual aspects of self are interconnected. In contrast, mental health in the US is commonly thought of as separate from physical and spiritual health.
Furthermore, how one thinks about one’s health impacts how one seeks help for health problems. For example, my colleagues and I conducted a study (Chang, Chan, & Yeh 2014) looking at a nationally representative sample of Asian Americans and found that 13.5% of them used complementary and alternative medicine (CAM) for emotional problems or problems with nerves over the past 12 months. Despite the fairly widespread use of CAM, hospitals and mental health services agencies in the U.S. don’t often ask clients about their CAM use, and clients often don’t often volunteer that they use these services because they’re afraid that mental health professionals might frown upon it.
To counteract that, my colleagues at RAMS and I (Chang, Chiu, & Mayeda, 2012) developed an intake questionnaire to ask Asian American clients if they had used CAM to cope with the problems for which they were seeking help. We found that, just as in the general population, 13% of the Asian America clients at a local community mental health center had used CAM to cope with their presenting problems. About 42% of these same clients had used CAM at some point in their lives.
Accessibility, or the lack thereof, is another major barrier to mental health. People may not use services because they don’t know about them, and, even when they do know about services, they may not use the services if providers aren’t familiar with their culture or don’t speak their language. This is a common problem for many immigrant communities, including Asian American immigrants.
In San Francisco, for example, some Southeast Asian American communities, like Laotian, Cambodian, and Vietnamese Americans under-utilize mainstream mental health services, and one of the reasons is that there aren’t very many service providers who are familiar with those communities and who are fluent in Lao, Khmer, and Vietnamese. We (Chang, Witter, Ah Soon, & Tam, 2016) sought to address these barriers by working with social service agencies in those communities to develop and translate screeners for depression, anxiety, and PTSD into Lao, Khmer, and Vietnamese.
In our work with these social service agencies, we learned how mental health problems in Laotian and Cambodian cultures were tied to spirituality through the use of terms that, when translated into English, mean “lost soul” or “under a bad spell or curse.” Likewise, we learned how community members would often go to temple in response to their problems because that was a culturally compatible way to cope; but, at the same time, there weren’t many other practical options. Our work at these agencies only addressed an initial entry point to getting help, and so much more work needs to be done to provide culturally sensitive and accessible services to these underserved communities.
To come full circle, a couple of weeks ago I happened to be on a local mountain biking trail, descending a steep section with lots of loose sand and rocks, when I saw a biker riding up the same section. I managed to come to a full stop without crashing, and it took me a little while longer to grasp what I was seeing. I had never seen anyone ride up this section of the trail before and didn’t think it was even possible. After a few moments I realized that what enabled him to accomplish what I had thought was an impossible task was not incredible skill, power, or will, but a boost from an electric motor. Similarly, to reach underserved communities, mental health service providers have an uphill road to climb, one where we will need to embrace change in our field and put our energies toward providing help in ways that may be completely different from what we’re accustomed.
This Guest Author blog was written by Associate Professor and Assistant Program Director of the Clinical Psychology PsyD program at our San Francisco campus, Dr. Tai Chang