In Any Language: Mental Health Care for Immigrants

Broadcast beginning week of April 10, 2007

In this hour, we explore Mental Health Care for Immigrants, with host Dr. Peter Kramer. Guests include Dr. Arthur Kleinman, professor of medical anthropology and psychiatry at Harvard Medical School and one of the world's leading experts in medical anthropology and cross-cultural psychiatry; Dr. Jane Delgado, a clinical psychologist and the president and CEO of the National Alliance for Hispanic Health; Dr. Mohamed Farrag, a psychologist and the clinical director of ACCESS: the Arab Community Center for Economic and Social Services in Dearborn, Michigan; and Dr. Yinka Akinsulure-Smith, a psychologist from Sierra Leone who works at the Bellevue /NYU Program for Survivors of Torture.

Dr. Peter Kramer begins with an essay in which he says that we know now that in psychiatry, and across medicine, culture can play an enormous role in shaping the expression of illness. In this country, issues of cultural understanding have become all the more important as certain communities -- Asian and Hispanic, in particular -- form ever-larger segments of the population.

Reporter Gabriel Spitzer offers the first of two segments looking at the Asian-American community. Asian-Americans and Pacific Islanders experience mental health problems at about the same rate as the rest of the population. Yet, very few receive treatment. According to the largest study of the issue, only about 1 in 6 of those having problems sought care -- in the population at large, the number is twice that. Part of the problem is that almost half of all Asian Americans will confront language barriers when seeking care. But there is another reason as well. Cultural obstacles and a deep-rooted stigma attached to mental illness prevent many from even acknowledging the problem. Spitzer attended an event in Northern California where people are committed to changing that -- a fundraiser sponsored by the Culture to Culture Foundation to provide scholarships for young Chinese-Americans who want to become social workers, psychologists, and psychiatrists.

The event's centerpiece was a play about a family confronting mental illness. The play has an unusual cast -- the main characters were portrayed by two prominent politicians, California Assemblymember Leland Yee and Alameda County Supervisor Alice Lai-Bitker. Both were mental health professionals before they went into politics, and they were eager to participate in the play to try to lessen the stigma surrounding mental illness in Asian communities. To contact the Culture to Culture Foundation, please write to: Culture to Culture Foundation, 1121 Douglas Ct., Alamo, CA 94507.

Dr. Kramer interviews Dr. Arthur Kleinman to give an overview of the importance of culture in mental health care, and a closer look at specific factors at work in the Asian-American community. Dr. Kleinman is one of the world's leading experts in medical anthropology and cross-cultural psychiatry. He is professor of medical anthropology and psychiatry at Harvard Medical School, and for thirty-five years, he has been examining the relationship between illness and culture in Chinese and American societies.

Dr. Kleinman says that culture can profoundly influence the way people experience mental illness. For example, in many cultures -- in the U.S. and abroad -- people experience depression in bodily terms (headache, trouble sleeping, stomachache, etc), which can often lead to misdiagnosis. Language issues can further complicate diagnosis. To describe sadness, a Chinese person may use a term that is often translated as "congested." A doctor who does not understand the subtleties of the expression might offer treatment for allergies or the flu, rather than depression.

Dr. Kleinman says it is critically important that doctors use professional translators. Because a person's mental illness often takes a toll on loved ones, family members should not translate. They may intensify the stress on the ill person or offer a distorted history. He adds that not all professional translators are created equal -- they, too, must be oriented toward mental health issues. He gives an example of a doctor who wanted to ask a Chinese patient if she were delusional, that is hearing voices. The translator asked, "Are you hearing voices?" and the patient responded, "Yes, you and the doctor." The translator then told the doctor, "Yes, she is hearing voices." These kinds of mistakes can have grave consequences. They then discuss the issue of stigma and how, in Asian cultures, it can extend beyond the individual to the entire family. Psychiatry, itself, also carries a strong stigma. Some mental health professionals label their clinics with names like "psychosomatic services" or "psychological medicine" or "family services" to avoid having to call themselves "psychiatric."

To contact Dr. Kleinman, please write to: Dr. Arthur Kleinman, Professor of Medical Anthropology, Department of Social Medicine, Harvard University, William James Hall 332, 33 Kirkland Street, Cambridge, MA 02138. Or visit his web page at Harvard University.

Hispanics make up the largest minority group in the United States. In California, they're no longer even a minority. But are people in the community seeking mental health care when it's needed? And, when they do, are providers aware of the needs of this diverse community?

Dr. Kramer interviews Dr. Jane Delgado, a clinical psychologist and the president and CEO of the National Alliance for Hispanic Health, an advocacy organization, as well as the author of Salud: A Latina's Guide to Total Health, and Ms. Deisy Fuentes, who was born in El Salvador and is now a student in New York City. She's been diagnosed with bipolar disorder, also known as manic depression.Ms. Fuentes begins by telling a bit of her story. She was first hospitalized when she was 22 years old, but she did not receive a correct diagnosis of bipolar disorder until six years later. It was then that she accepted she needed to take medication for her illness. Still, she's had four relapses, all for noncompliance with medication. Dr. Kramer asks her how her family handles her illness, and she says that when she's in the hospital, they tell people it's for gastritis.

Dr. Delgado says that these reactions by Ms. Fuentes and her family are typical for Hispanics. There is an expectation that people will resolve their problems on their own, and there is serious stigma surrounding mental illness. It is definitely not something people often discuss with others.

Like Dr. Kleinman, Dr. Delgado emphasizes the importance of having providers who understand the language and culture of their patients. She says that even when a patient speaks English, there may be things he or she can only express in Spanish. Ms. Fuentes comments that when she was recently hospitalized for a manic episode, she was asked to translate her doctors' comments for her mother, which puts her in an awkward position.

Dr. Delgado says that, in general, the problem of believing one should cope on one's own is compounded by the problem that many Hispanics do not have health insurance, which is further compounded by the fact that even when patients get in the door, they may be seen by providers who do not understand their language and culture. All this can make finding competent, appropriate treatment very difficult. To contact Dr. Delgado, please write to: Dr. Jane Delgado, President and CEO, The National Alliance for Hispanic Health, 1501 Sixteenth Street, NW Washington, DC 20036. Or visit: http://www.hispanichealth.org

The Infinite Mind's Marit Haahr takes an in-depth look at two diverse immigrant communities - Arabic and African - and the difficulties they face when in need of mental health care in America. Haahr begins with Dr. Yinka Akinsulure-Smith and Dr. Mohamed Farrag. Both are psychologists -- she's from Sierra Leone, and he's from Egypt. Here in the U.S., they're facing the same dilemma -- trying to bring mental health care to people from their own cultures -- Africans and Arabs -- living in this country. People who may not realize they have a mental illness, people who may have been tortured or witnessed atrocities of war, people for whom mental illness is enormously embarrassing and stigmatizing.

Dr. Yinka Akinsulure-Smith works at the Bellevue Hospital/New York University Program for Survivors of Torture. She's also the co-founder and co-chair of Nah We Yone, a non-profit organization that provides services for Sierra Leonean and other African war victims and refugees.Dr. Mohamed Farrag is the clinical director of ACCESS: the Arab Community Center for Economic and Social Services in Dearborn, Michigan. Dearborn is home to one of the largest Arab-American populations in the country.

Haahr also speaks with Mohamad Naboulsi, who immigrated to New York from Lebanon in 1980. Naboulsi recalls when he thought mental health services were only for crazy people. That changed after a serious car accident in 1987. He was in a coma for 45 days, and when he came out of it, he had serious disabilities. He had to go for physical and psychological therapy, and he credits both with changing his life. Immediately after the accident, he became depressed, or "gloomy," because he lost his job, his wife left him, and he was having difficulty accepting his disabilities. He says therapy helped him to believe in himself and feel proud of himself, and he wishes more people in his community would overcome the stigma.

After reporting how finding culturally appropriate mental health care can be difficult for immigrants -- cut off from traditional methods of healing, unfamiliar with the idea of therapy, afraid of stigma -- Haahr then says that the problems for refugees fleeing violence in their homelands are even greater. Many of the thousands of refugees coming to this country every year have witnessed atrocities or been victims of torture. The stakes are high -- untreated, they are at great risk for severe depression, anxiety, post-traumatic stress disorder, and substance abuse.

We hear from Jacques Sylvain Tayou Tapchom, who fled to the US from Cameroon. He had been tortured for his political views, and when he arrived in New York -- where he received political asylum -- he was "emotionally broken." He began going to the Bellevue/NYU Program for Survivors of Torture and says, "I remember I used to cry all night, and my nephew always ask me what was going on, but when I went to that center, my nephew noticed that I was really changing, and happier, and really benefited a lot from that center emotionally." Dr. Farrag and Dr. Akinsulure-Smith describe the elements of proper, sensitive treatment. Most important is establishing an environment of trust and safety. Because individual psychotherapy can be a foreign concept, Dr. Akinsulure-Smith uses a lot of group therapy. Both doctors say that for some patients, it is important to integrate aspects of the native culture and religion into therapy. And, above all, doctors must understand their patients' background and values. To contact Dr. Akinsulure-Smith, please write to: Dr. Adeyinka Akinsulure-Smith, The Bellevue/NYU Program for Survivors of Torture, Bellevue Hospital Center, 462 First Avenue, CD710, New York, New York 10016. Or call: 212-683-7446. Or visit: http://www.survivorsoftorture.org To contact Dr. Farrag, please write to: Dr. Mohamed Farrag, ACCESS, Psychosocial Rehabilitation Division, 6450 Maple Road, Dearborn, MI 48126. Or visit: http://www.accesscommunity.org

Finally, commentator John Hockenberry meditates on what it means to belong in American society. He says, "... immigrants in modern America are forced to consider their eligibility in everything they do. Language, work, health, the success of immigrant children all revolve around this very un-American notion of legitimacy."

Heard on this week's program:

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