SINGH / The Utilization of Mental Health Services by South-Asian Immigrants 15 Introduction South Asians—people from India, Pakistan, Bangladesh, Nepal, and Sri Lanka—are one of the fastest growing immigrant groups in the United States. According to the Immigration and Naturalization Services (2001) the second largest number of legal immigrants to the U.S. came from India, totaling 70,290 and constituting 6.6% of the total U.S. population. This paper examines why South-Asian immigrant communities, as compared to other ethnic groups, underutilize mental health and social services. It is important to note that this paper looks at general characteristics of tradition- al South-Asian families; the information presented cannot be applied to all South Asians. While it is important to avoid homogenizing South Asians, it is arguable that traditional families share a common set of values, beliefs, and practices. Due to the apparent lack of research on South Asians and mental health utilization, one can look to the research on Asian immigrant populations— which arguably hold values similar to those of South Asians—to gain a sense of how much this group utilizes services. One study looking at the uti- lization of outpatient mental health treatment by individuals who identify as Asian American (Futa, Hsu & Hansen, 2001) was conducted over a five- year period in the Los Angeles area. This area has a significant Asian popu- lation, yet of the 230,441 clients utilizing outpatient mental health treatment, 3.1% were Asian American, whereas European Americans constituted 43%. Asians are not only underrepresented in their utilization of mental health services, but also report being, in general, less satisfied with their therapists and reportedly terminate therapy after an average of only 2.35 therapy ses- sions. TTHEHE UUTILIZATILIZATIONTION OFOF MMENTENTALAL HHEALEALTHTH SSERVICESERVICES BYBY SSOUTHOUTH--AASIANSIAN IIMMIGRANTMMIGRANT CCOMMUNITIESOMMUNITIES ININ THETHE UUNITEDNITED SSTTAATESTES Meher Singh South Asians are one of the fastest growing immigrant groups in the United States. This paper identifies possible reasons why South Asians in the U. S. underutilize mental health services compared to other immigrant communi- ties, and offers suggestions regarding how mental health services can be tailored to better meet the needs of this particular ethnic group. Columbia University Journal of Student Social Work Volume 1, Number 1 16 Importance of Family and Family Pride Family is arguably the single most important characteristic of South- Asian culture. Traditional South-Asian families are composed of nuclear and extended families, as well as the community in which they reside. The rela- tionships between these three systems are extremely close-knit; each is inter- related and intertwined with the other. A related characteristic is the value of family pride. When contemplating personal decisions, individuals are expected to make choices that will bene- fit—and reflect positively on—the larger family and community. Engaging in activities outside of what is culturally or socially appropriate, particular- ly if these behaviors negatively impact the family, is discouraged. In their discussion of child sexual abuse, Futa, Hsu, and Hansen (2001) illustrate this value, stating that the issue of abuse often remains hidden because of fear that it will shed negative light on the family. The importance of family in South-Asian culture can influence mental health service utilization both positively and negatively. It is undeniable that strong family ties provide individuals with tremendous support, particularly in a new country. However, the importance placed on familial relationships and family pride may restrict individual choices and hinder the making of independent life decisions. Through my work with South-Asian teens, I have discovered that these youth are highly influenced by their parents’ expecta- tions regarding career choices, favoring careers with high salaries and sta- tus. Coping with Stress South Asians handle life stressors differently than other ethnic groups. If an individual is faced with a problem, he or she is expected to employ the assistance of family or to cope with it on his or her own. An individual who seeks assistance outside of the family would likely be perceived as having a weak character and going against the value of family pride. In the eyes of a traditional South-Asian family, speaking to therapists about individual or family problems would bring unwanted negative attention to the family (Futa, Hsu & Hansen, 2001). A primary reason South Asians do not seek assistance—particularly out- side of the family unit—is because this is not a socially-accepted nor social- ly-respected means of solving one’s problems. Ow and Katz (1999) state that “secret keeping is a strategy at the other end of the disclosure continu- um in the management of distressful information that may be potentially dis- ruptive to the group” (p. 2). Although this article focused on Chinese fami- lies, the notion of protecting the family cuts across most Asian cultures. SINGH / The Utilization of Mental Health Services by South-Asian Immigrants 17 Stigma of Mental Illness The stigmatization of mental illness in South-Asian culture directly impacts utilization of mental health services. Because families are so con- cerned with hiding this problem from the community, individuals with men- tal illness often remain untreated. “Seeking help for psychiatric problems usually occurs only in severe cases and may start with the pursuit of indige- nous treatment modalities in the community” (Ahmed & Lemkau, 2000, p. 95). Some families may first attempt to use herbal remedies and prayers prior to seeking professional help. The final decision regarding treatment, however, would most likely be dependent on the family’s religious back- ground. Non-Verbal Expression & Gender Roles Interpersonal characteristics, like self-expression, impact South-Asian use of mental health services. “Although direct eye contact is highly valued in American culture as a sign of honesty and engagement, South Asians usu- ally avoid eye contact in relationships where they feel deference and respect” (Ahmed & Lemkau, 2000, p 91). In addition, South Asians tend to swing their heads horizontally instead of nodding to mean “yes. ” A practi- tioner’s familiarity with culturally-based communication patterns can facil- itate effective work with South-Asian clients, breaking down barriers and enhancing the client’s level of comfort. In this author’s experience, South Asians are more likely to express affec- tion through actions than through words. For example, a father may show love for his children by providing them with a college education rather than by saying “I love you. ” This lack of verbal expression makes it difficult for South Asians seeking mental health treatment to adjust to traditional modes of psychotherapy, which focus on the client’s verbal expressions and feel- ings. South-Asian families have rigidly defined gender roles, with males at the top of the hierarchy in all aspects of life—familial, social, and political. Understanding this patriarchal hierarchy is relevant to mental health treat- ment because providers may find that South Asians prefer to receive treat- ment from male clinicians. Because traditional South-Asian culture views females as subservient, female clinicians may not be given the same level of respect as male clinicians. Acculturation and Adaptation The U.S. is becoming increasingly diverse, and immigrating to this coun- try can be overwhelming. To cope with this stressful transition, some South- Asian immigrants choose to live in neighborhoods that are predominantly South-Asian because they provide a “safety net. ” Families that have lived Columbia University Journal of Student Social Work Volume 1, Number 1 18 in the U. S. for a longer time can provide support and information to make the transition easier. Acculturation has an enormous impact on South-Asian immigrants. Some immigrant families come to the U. S. with the aim of making money. Many, however, soon find themselves in low-wage, unskilled jobs, strug- gling to make ends meet. This causes a huge strain on an individual’s health as well as on the family unit. Children of immigrants face unique issues, as many find themselves caught between the world of their parents and that of their peers, resulting in serious intergenerational conflict. Immigrant children often assimilate more quickly than their parents because they are exposed to American culture on a day-to-day basis in school. In order to assimilate, some children may begin adopting similar ways of dressing and behavior as their non-South-Asian peers. The stresses associated with immigration and assimilation point to some reasons why South-Asian immigrants might benefit from mental health treatment. Ahmed and Lemkau (2000) emphasize the seriousness of this issue, stating that “this culture shock is a form of transition shock, with symptoms ranging from anxiety, depression, and helplessness to full-blown physiological stress reactions, paranoia, and psychosis” (p. 92). Utilizing the Family in Treatment Researchers have suggested that mental health practitioners utilize a fam- ily-based approach when working with South Asians as a more appropriate method of dealing with the problems of this ethnic group. Hong (1988) sug- gests that having ongoing interaction with one clinician who can be looked upon as a resource to consult when a family faces difficulties has many ben- efits. This approach requires no actual termination of treatment; the practi- tioner would be available to the family indefinitely and on an as-needed basis, becoming increasingly familiar with all members of the family and gaining their trust. Furthermore, the flexibility of this treatment may not be as threatening to South-Asian families. The lack of formality in this model— the fact that there is no beginning or end to treatment—enables South-Asian families to feel more comfortable seeking help and less like they are being “treated” for an illness. One downfall of this approach, however, is that some family members may not feel comfortable seeking the assistance of the clinician if the issue involves another family member. This could conceivably happen during times of intergenerational conflict. It would be imperative for the practition- er using this approach to discuss rules of confidentiality with the family so that individual family members feel comfortable seeking assistance. Therapists would also have to be careful not to sympathize with one family SINGH / The Utilization of Mental Health Services by South-Asian Immigrants 19 member over another. As Hong (1988) states, “the therapist might become overly identified with or sympathetic to a particular client and lose objec- tivity when other family members are seen” ( p. 8). Community-Based Services Using a “grassroots” approach to encourage utilization of mental health services is one effective way of reaching the South-Asian community. If planned well, outreach can reduce stigma against mental illness and mental health treatment. For example, outreach should be spearheaded by someone respected in the community, such as a male, South-Asian doctor. A non- threatening method of outreach could provide the community with some kind of educational services; a physician, for instance, could provide a lec- ture on how the strain of acculturation can lead to depression. Normalizing stressful problems and acknowledging that many people experience similar difficulties may reduce an individual’s hesitation to seek services. Another way to increase mental health utilization is to have community- based clinics staffed with culturally competent, bilingual providers. For some, it may feel less intimidating and less “institutional” to visit a clinic in one’s neighborhood rather than going into a large hospital. Conclusion The stress South Asians face as a result of coming to the U.S. clearly points to a need for mental health services. However, there are a myriad of reasons why South Asians do not utilize services as much as other ethnic groups. Mental health practitioners can increase South-Asian utilization of services by tailoring treatment to the needs of this particular group. This could mean trying new modes of therapy or starting a community-based practice. While these ideas are feasible, community outreach is arguably the most important method of increasing utilization of services. Providers need to go into the community, gain the trust of the people they are trying to serve, and slowly begin reducing stigma around mental health and mental illness. References Ahmed, S. & Lemkau J. (2000). Cultural issues in the primary care of South-Asians. Journal of Immigrant Health, 2, 89-96. Futa K., Eugenia, H., & Hansen D. (2001). Child sexual abuse in Asian-American families: An examination of cultural factors that influence prevalence, identification, and treatment. Clinical Psychology, 8, 189-220. Greene, Roberta R. (1999). Human Behavior Theory and Social Work Practice. Hawthorne, NY: Aldine De Gruyter. Columbia University Journal of Student Social Work Volume 1, Number 1 20 Hong, George K. (1988). A general family practitioner approach for Asian-American mental health services. Professional Psychology: Research and Practice, 19, 600-605. Keum-Hyeong, C. & Wynne, M. (2000). Providing services to Asian- Americans with developmental disabilities and their families: Mainstream service providers’ perspective. Community Mental Health Journal, 36, 589-595. Ow, R. & Katz, D. (1999). Family secrets and the disclosure of dis- tressful information in Chinese families. Families in Society, 80, 620-628. Saleebey, D. (2001). Human behavior and social environments: A biopsychosocial approach. New York, NY: Columbia University Press. Shonfeld-Ringel, S. (2000). Dimensions of cross-cultural treatment with late adolescent college students. Child and Adolescent Social Work Journal, 17, 443-454. Meher Singh is a first-year MS student at the Columbia University School of Social Work. She is currently an intern at Soundview Throgs Neck Community Mental Health Center in The Bronx, New York. She holds a BA in Women’s Studies from the University of Massachusetts at Amherst.