“The help seeking process serves as an important filter such that only a portion of those who need professional mental health treatment actually seek such assistance”
Ponterotto et al. (1995), p.416
Reasons to suspect that barriers exist
It is known that ethnic minority groups are reticent about seeking mental health assistance, and those who do suffer from premature termination. In a study of 135 African-American outpatients only 25% of those seeing a white therapist returned after the first session, as compared to 43% who were seeing a same race therapist suggesting client-therapist ethnic match to be an important factor. Interestingly, the figures suggest that 57% of the population who were seeing a same race therapist didn’t return and this would indicate that the ethnic match is far from the complete solution. Another study in a similar vein was conducted across 17 community mental health centres across the Seattle area of the USA – over 50% of Asian patients prematurely terminated therapy after just one session, as compared to a 29% rate for Caucasian patients. These observations were explained in terms of a difference in attitudes and beliefs regarding mental illness and psychotherapy, and also that the failure of therapists to consider these attitudes resulted in a failure to develop trust, rapport and a working therapeutic relationship. In a study where 83 black and 66 white university students were recruited by telephone, the white group were 6 times more likely than the black group to have sought help from a psychologist or psychiatrist.
Semi structured interviews were conducted with 48 psychiatric patients recruited from mental health care facilities. The Asian group (consisting of Filipino, Korean, Japanese and Chinese people) had the longest delay between diagnosis of mental health problems and participation in a treatment programme, indicating a degree of reluctance to engage in the help seeking process. In the interim, it was found that this group had more extended, persistent and intensive family involvement than either the Black or Caucasian groups. The authors commented that psychiatric problems in Asian families may be taken as a threat to the homeostasis of the family as a whole. The family participate actively in denying such problems.
Using a random sample of migrants from India to the UK, other researchers have found that they showed less evidence of emotional disturbance drug rehab when compared to a matched English sample, using a scale which had been validated for both groups in question. This begs the question – do Asians utilise services less because they have less cause to do so, as opposed to there being barriers to obtain such help? Given equal numbers of stressful life events, as social support systems increase, one would expect the likelihood of experiencing psychological distress (and subsequently seeking counselling) to decrease. It is known that Asian communities in Britain tend to have strong links with the extended family, with family homes sometimes consisting of three generations. It may be that this support acts as a buffer during emotionally difficult periods. Other findings refute this suggestion – depression is thought to be diagnosed less commonly among West Indian and Asian patients in Psychiatric hospitals than among the British born, although this does not reflect the actual occurrence of depression in the community.
What are the known barriers?
There may be barriers at an institutional level – the geographic inaccessibility of mental health services to the ethnic community; lack of child care; focus on an intra-psychic model and strict adherence to time schedules. In one study, environmental constraints were ranked second as reasons for leaving therapy prematurely. Equally, there may be financial barriers (such as medical insurance within some countries, or time off work in order to attend); cultural barriers (such as language and attitudes to mental health problems). It is thought language barriers and cultural differences are less of an issue for second or third generation Chinese, who have integrated into the host country. Indeed, the English language has a rich source of adjectives to describe internal experience – such as despondent, despairing, disillusioned, gloomy, unhappy, miserable and so on – there may not be so many direct equivalents in the Asian languages. More probably, Asian clients may struggle to find English equivalents for words that they know perfectly well in their own mother tongue.
Over 2000 adults were interviewed about their perceptions of barriers to help seeking for two specific problems – alcoholism, and severe emotional problems. The Caucasian group perceived less barriers than any of the other Asian groups, and this remained so after controlling for various sociodemographic variables. A sense of shame was rated quite highly across each non-Caucasian ethnic group, and this is discussed in more detail later in the section. The second most popular response across groups was that services were inappropriate, or that they just weren’t aware of them. Interestingly the least most important factor was accessibility of services and ethnic match of the therapist. In one of few studies carried out with Indian participants, a content analysis of the responses given by Tamil women suffering with depression in India has been made. Consistent with earlier findings, treatment seeking behaviour was influenced by the stigma associated with their condition, and another deterring factor was lack of knowledge that treatment was available. The issue of shame seems further emphasised in that the women expressed feelings of wanting to ‘wither away’ rather than seek treatment.
The shame of needing to seek help
Shame has been equated with mental health problems within Asians, for sufferer and family alike – perhaps because it reflects a failing in upbringing, or some inherited component which would affect the families standing in the community. Mental illness seems to be taken by Asians as a weakness of character and the need to seek professional help is seen as a disgrace. In eastern thought there is a strong belief that all events are influenced to some degree by unseen forces, and any personal difficulty is a reflection of the misfortune of the sufferer. Isolation can set in, where people in the community tend to avoid associating with such a person, or the family. It is suggested that ancient codes of India mean psychiatrically ill individuals did not qualify for certain social privileges, and this stigma around mental illness is clearly present in contemporary India. An escape from such stigma may be to conceal the difficulties – perhaps on a conscious level in the avoidance of professional sources of help, and also in the sub-conscious denial of all problems that are not physical. For the Chinese, mental illness seems to be seen as a disgrace and sufferers become family secrets, to the extent that the illness is denied proper care.