You are my candy girl...

Last Wednesday morning, I spent 20 minutes standing in the rain outside Candy's door. My left hand w/a fist against her door. My right hand repeatedly pressing the redial button on my cell phone. She didn't answer, neither the phone nor the door. "Candy", I tried calling out through the door. I know it probably wasn't the smartest thing, to be standing on the corner of a street in Bayview Hunter's Point for 20 minutes by myself with the entire liquor store crowd watching me from across the street. I didn't want to stay, but I didn't want to leave either. I know it's a problem of mine, not really knowing when to throw in the towel. It was raining hard so I walked back toward my car, careful not to make eye contact with the liquor store crowd even though I could feel them watching my every move. I didn't see Candy that morning. I wondered if I ever would again. It was just an unpleasant feeling in the gut.

Candy is the newest addition to my caseload. She is a 59 year-old transgender African American w/metastatic breast cancer. The doctors say she has less than a year left to live. It's my job to help her make peace with her life, to cope with the excruciating pain she experiences from the cancer, and to support her as she faces the rest of her life. I try my best, but its hard because she's schizophrenic and developmentally challenged. I wonder how it is that this person I've really come to grow fond of has so much working against her.

Every session she is the same. Manic, disorganized, tangential. Through her pressured speech, I've slowly been able to piece together her life...all 59 years. There's her earliest memory of being told that her father tried to suffocate her during her infancy...twice. Her mother saved her and since then has always been God, capable of giving and taking away life. There's the magic trick, the one where the boys stuck her in a cardboard box and stuck sharp sticks through thinking they could remake the swords through the box trick. There's her expulsion from jr. high, how she was told never to come back to school after refusing to play football with the boys. And then there's the incident at the country club, where she was fired for walking through the front door instead of the back door. Somewhere between dressing drag in Hollywood and losing her teeth to the police in Oakland, there was a trip to Tijuana for the $50 silicone injections. And then there was the day she learned she had breast cancer. "It's leaking all over my body" she told me, "into my bones, back, all over, just all over".

I'm fond of her, she's a wealth of knowledge, a walking account of the civil rights era, a real life "Precious", a detailed character from a James Baldwin novel. Even so, I'm not going to pretend I enjoy our visits because I don't. She hurls graphic descriptions at me w/her brother's "doped up girl" taking a hammer to his knees and her mother dragging her out into the snow screaming "fag". I don't always feel like I can take it, but I do anyways.

She tells me she loves herself and her mother and doesn't care about anyone else. She believes in Jesus and the Baptist radio preacher, the one who tells her she's damned. "I know I'm going to hell" she says, "I'm a homosexual, but you know I haven't really had sex with anyone in a really really long time I try not to indulge in sin". I'm speechless. I want to know why she listens to the radio. I even try to convince her to stop. She shakes her head. "Excuse me, I listen everyday...every morning, because it feels good to know Jesus is out there for me and I hear Him through the preacher I am a believer of Jesus Christ I've always been I went to Sunday school read the Bible Jesus loves me but I'm going to hell oh well but I know my momma will be just fine so I feel good". I want to cry, but I can't. I want to run, but I can't. So instead I say, "Candy, girl you're right, Jesus does love you...so much" and then I squeeze my eyes shut for a few seconds.

We filed a missing person's report on Candy yesterday. I hadn't heard from her and neither had the case manager. I'd been thinking about her all week. She's tangential, disorganized, not the best at reaching out, but she's always picked up her phone and answered her door. Not an answer for 6 days, neither phone nor door. "Candy, girl where are you? Jesus does love you...so much".

Loving the Elderly...

In June 2009, President Obama proposed a cut in Medicare benefits to help cover the uninsured. A month later, Charles Mann described the effects of the national trend toward increased longevity in his article “The Coming Death Shortage”. In November, the Senate voted to reduce home health-care services for seniors. At the same time, the demographic profile of the United States, with its rapidly aging baby-boomer generation will become even more elderly-concentrated; the U.S. Census Bureau predicts in 2030, 21% of Americans will be age 65 and older. As the older adult population constitutes one of the fastest growing populations, the need for addressing its mental health concerns grows ever more urgently. With ageism creeping into the health reform debate and the continued perception that it is shameful to be mentally ill, the lack of initiative to properly care for these members of our society will have serious consequences on the mental health of our nation.

Elderly Asians are a unique subpopulation within the aging population due to their rising numbers and the particular challenges created by their cultural legacy. (It is expected that between 2000 and 2030, the Asian elder population will quadruple from 800.000 to 3.2 million.) Because of this, my long-term career goal is to lower the barriers of access to mental health services for minority elders, especially those of Asian descent. I want to increase awareness of mental health issues among Asian communities while educating healthcare professionals about the unique cultural context of such issues. I plan to do this by creating culturally appropriate materials, providing referral guides, and training primary care providers on how to conduct effective screenings and interventions to Asian elders. Furthermore, I want to work on integrating mental health practitioners into primary care settings and eventually implementing the standard of a single door of entry for comprehensive physical and mental health.

My interests in both the minority experience and racial and ethnic disparities can be traced back to literature. Through detailed first-person reflections created by minority writers like Toni Morrison, James Baldwin, Amy Tan, and Jumpa Lahiri, I came to see how one's identity is forged through cultural, ethnic, and social contexts. The biography, Finding Iris Chang impressed upon me the necessity to study the stigma of mental illness within a sociocultural context in order to understand its origins, meanings and consequences. With this in mind, it is no surprise that my graduate studies focus on health care disparities and policy for minority elders.

During my first year, I was involved in a project that sought to identify the existing barriers for minority elders in utilizing mental health services. Through interviews with service providers, it became clear that minority elders face severe barriers that prevent them from utilizing mental health services. For older adults, more expensive private pay programs are more available than community-based programs. This presents a challenge to minority elders as many lack the educational and financial resources to access such programs. My volunteer work with City Team San Francisco – a non-profit organization serving the poor and homeless – illustrated both the reality and gravity of this situation all the more. I saw firsthand how minority elders are more likely to face poverty, live in low-income housing, and have poorer access to benefits and pensions in comparison to their non-minority counterparts.

While similar risk factors for depression exist for the elderly, certain factors compound that risk for minority elders. One factor is language. In conducting therapy in Mandarin with Chinese elders, I came to realize that language issues are vital to the delivery of mental health services. Many Asian elders speak languages with no equivalents for words like depression. Others lack the communication skills needed to access resources for preventative care. Cultural context further complicates matters. I noticed that Chinese elders stigmatize mental health problems and tend to equate common, treatable depression with insanity. This stigmatization causes many Chinese elders to somaticize emotional problems and look to other explanations for depressive feelings; they seek medical help only as a last resort. Finally, mobility is another obstacle. By conducting psychotherapy in nontraditional settings—homes, residential communities, day programs, and hospitals—I witness how physical constraints isolate minority elders and prevent them from accessing proper care and services.

Identifying and understanding mental health service barriers for minority elders challenged me to think about developing effective treatment approaches for this demographic group. After careful consideration, I decided to evaluate the delivery of mental health for minority elders in the county of San Francisco. San Francisco has the highest percentage of older adults in any national urban area, with a largely Asian sub-population. Through research and agency visits, I discovered that the ratio of available programs to people in need of services is too low. Next, I interviewed mental health workers and case managers at the San Francisco Department of Public Health in order assess the service needs for Asian elders. I found that the most prevalent health issue facing Asian elders is late life depression. Many Asian elders immigrate to the U.S as adults and suffer from the stress of relocation and adjustment to a completely different culture. Furthermore, many have to cope with prolonged separation from family members or are confronted inter-generational conflicts between the older and younger generations.

My clinical and research experiences have led me to conclude that effective treatment for minority elders cannot occur without employing culturally competent practices. Working with a diverse older adult population at a community-based organization has increased my understanding of culture-specific manifestations of distress, coping mechanisms, and help-seeking patterns. For example, I noticed that Asian elders prefer to discuss concrete solutions to problems rather than negative emotions. They are more likely to experience physical pain in response to stress and seek help from primary care physicians. As such, the need to reframe culturally sensitive terms such as “mental health” into “wellness” is critical to the clinical treatment and assessment of this population.

My desire to become a psychologist who focuses on ethnic minority health disparities began with literature, news stories, and statistics. In my quest to understand the causes and consequences of such disparities, I discovered that geriatric services for minority elders, especially for those of Asian descent, are an unmet need that is growing quickly and will only intensify over time. Furthermore, my professional experiences have convinced me that one must address the mind and body collaboratively as mental health is an important component to managing most health problems. I believe shifting toward the use of interdisciplinary or collaborative care models to provide psychological services to this population in a primary care setting, can increase prevention and improve both mental health and health outcomes. Through the Mental Health and Substance Abuse Services Predoctoral Fellowship, I hope to contribute to the field of ethnic minority geriatric mental health by providing community-based assessment and intervention services to minority elders, teaching primary-care providers, conducting research, and eventually becoming involved in health-care policy development.