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Meeting the Mental Health Needs of Asian Elders

(From the Asian-American Geriatric Mental Health Alliance, sponsored by the Asian-American Federation and the Geriatric Mental Health Alliace of New York.)

Older adults from minority cultures who have mental health problems face an array of issues above and beyond the usual geriatric mental health problems. These include issues of language, cultural understanding, workforce shortages, eligibility for services, insurance coverage, and more.

In the summer of 2005, The Asian American Federation of New York and the Geriatric Mental Health Alliance formed The Asian American Geriatric Mental Health Alliance (AAGMHA), an advocacy group dedicated to address and improve the quality of mental health care for Asian older adults in New York. Comprised of agency administrators, direct service providers, representatives of NYC government, as well as researchers, the AAGMHA has been working to:

• Develop policy recommendations;
• Identify innovative and culturally competent practices;
• Increase training in Asian geriatric mental health; and
• Facilitate more effective and efficient recruitment of bilingual mental health providers.

(One strategy has been to attract more Asian bilingual social work students into the field of geriatric mental health by providing them with educational, networking, and mentoring opportunities, as well as assistance in job search or career development.)

The Asian Geriatric Mental Health Alliance has identified four major areas of critical need:

1. Access to effective treatment for older Asians with mental and/or substance abuse disorders

2. Services that address the social circumstances of older Asians with mental health and/or substance abuse problems in combination with good treatment

3. Efforts to maintain mental health, and

4. Workforce development.

This paper provides an overview of what needs to be done in New York State to address these needs.

Access to Effective Treatment

To ensure access to adequate, effective, and quality mental health care requires:

• Bi-lingual service,
• Cultural competence of providers,
• Outreach and education for the Asian community,
• Home and community-based services,
• Use of best practices, and
• Increased service capacity.

Language

Providing care in the languages understood by Asian older adults is essential in the provision of quality mental health care. In most cases, however, this is not possible because: 1) more than half of older Asian Americans are not proficient in English; 2) there are more than 100 Asian languages spoken by more than 40 Asian subgroups; and 3) there is a severe shortage of professional bi-lingual providers.

We recommend the following:

1. More bicultural translators who can act as cultural brokers who are trained and equipped to provide accurate translation in a clinically sound culturally-relevant manner.

2. Leveraging existing community resources by taking advantage of existing bilingual paraprofessionals and frontline workers already working with diverse ethnic Asian populations in natural settings such as temples, churches, or senior centers. If they are provided with more training and better equipped to deal with mental health issues, these frontline workers, as “trusted entities” within these communities, can fill gaps to services by assisting to recognize basic mental health symptoms or perform basic screenings; provide basic culturally-relevant interventions in the appropriate languages spoken by these ethnic Asian subgroups; and facilitating effective referrals to higher levels of services if necessary.

3. The use of Asian older adults themselves to serve in roles to help their own peers, taking advantage of their own existing language skills and familiarity with the respective cultures as well. Like the frontline workers, these seniors or volunteers should also be provided with necessary basic training to serve in these roles.

Cultural Competence

Most mental health professionals do not have a sound understanding of Asian cultures and adequate knowledge of culturally-competent practices. As a result, it is important to recruit bi-cultural and/or bilingual mental health providers and train existing providers in effective culturally competent practices.

Literature and research suggest that quality of care, service usage, and the rate of treatment dropout are often associated with the level of culturally competent and culturally-relevant services provided throughout the continuum of care. In addition to education and training, many programs need to be redesigned to provide culturally- specific and appropriate interventions.

Also, to better reflect and address the psychosocial and mental health-related challenges Asian older adults face on a daily basis, we encourage efforts to increase and cultivate Asian professional leadership and the inclusion of Asian Americans on the governing bodies of provider organizations.

Outreach and Education

The concept of mental health is foreign and unfamiliar to many Asians since Asian cultures rarely conceptualize the mind and body as separate entities. In addition there is great stigma attached to mental illness. Therefore, many Asian older adults who require mental health care do not seek it. And those who might seek it are often unaware of available treatment services.

However, we have found that community outreach and education work to address stigma and encourages Asian Americans to seek necessary mental health services. For example, Project Liberty reached many Asians, who would not have ordinarily sought mental health-related help. They were more open to it when mental health issues were presented through community-based otreach focusing on education promoting wellness.

Home and Community-Based Services

Many Asian elderly are home bound and/or socially isolated. More mental health services need to be made available in the home. In addition, many Asian elderly will accept mental health services if they are offered in indigenous community settings. Therefore, both home and community-based services should be made more readily available.

Best Practices

We are very concerned that evidence-based practices for the most part have not been tested on Asian older adults. The development of clinical services research involving Asian populations is critical. In the meantime, we believe that there is widespread consensus about what works best and that efforts should be made to identify best practices through consensus building exercises.

Service Capacity

There is a vast shortage of mental health services for Asian-Americans. Only 1% of those served in New York State’s public mental health system are Asian even though Asian Americans constitute 5.5% of New York State’s population. Since 75% of New York’s Asian population resides in New York City, increasing service capacity in Asian American neighborhoods of NYC is a key need.

Addressing Social Circumstances

Many older Asian-Americans live in very difficult social circumstances. In addition to providing access to good treatment, it is important to address these social problems. Two problems of particular concern are (a) social isolation and (b) family burden.

Overcoming social isolation

Many Asian older adults live in isolation either because of physical limitations or because of depression and/or anxiety. Being isolated and mentally ill is a vicious cycle. Depression leads to isolation and isolation leads to depression. In addition, in the Asian community, it is a matter of shame that an older adult is living in isolation rather than with considerable contact and support from their families. Efforts to address social isolation and to rebuild connections with family if possible will be key to meeting the mental health needs of Asian older adults living in isolation. We recommend training home health aides, Meals on Wheels workers, landlords, and the like to be more knowledgeable about recognizing mental health symptoms and when to make a referral to higher levels of mental health care.

Family Support

The obligation of families to provide care for family members with physical and/or mental disabilities is very powerful in the Asian community. As a result, very few Asian older adults go to nursing homes. However family caregivers in the Asian community are vulnerable to developing anxiety, depression, and physical disorders. But they often neglect these stresses of caregiving because of their sense of obligation. These family caregivers need support services such as affordable counseling, support groups, respite, and responsive crisis services.

Additional consideration must be given to family caregivers who are older adults themselves. The challenges they already face with their own self-care, as they experience their own deteriorating health, socioeconomic difficulties, and limited language capabilities to access care present significant psychosocial stressors on both fronts, making supportive services even more critical for this group.

Wellness

One’s mental health status is closely associated to his or her physical health. As a result, efforts to address developmental challenges associated with aging, nutrition, exercise, and smoking cessation are critical. Efforts addressing health or well-being and/or concrete, daily needs are helpful to Asian older adults and are also effective as methods of outreach. Topics included in these community outreach or education efforts should include such issues as retirement, decline in physical health, loss of friends or family, or facing the inevitability of death. These discussions would naturally lead to education on the availability of social benefits and of community-based social and mental health services.

Workforce Development

Because of the need for more bi-lingual/bi-cultural staff, developing a workforce of Asian Americans and culturally competent mental health professionals is essential. This should include:

• incentives to become geriatric mental health professionals,
• mentoring,
• improved professional education, and
• on-going training of current professionals.

There is also a need to improve the clinical and cultural competence of people working in the health and aging systems—especially primary health care providers.

Finally, to address the shortage of bilingual workers, we once again advocate the creation of roles where Asian older adults can play larger roles in providing basic outreach within their own Asian, ethnic communities. By helping others using their innate strengths and talents, they may feel more empowered and maintain their sense of well-being in their golden years.

Conclusion

The challenges are many, but we are encouraged by the steps that New York State has recently taken to address the crucial needs older adults. We applaud the passage of the Geriatric Mental Health Act, the creation of the Geriatric Mental Health Planning Council, and the establishment of a demonstrations grants program.

But we are concerned that, as the most underserved population in New York State, Asian- Americans may not benefit as much as they should from these new developments and from those to come. We will be active advocates for meeting the mental health needs of Asian American elders. And we are prepared to work collaboratively with City and State officials who share our perspectives on the special needs of this population.

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