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.
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