Mental health services have not been available for many AAPI and other minorities even before the pandemic: Viewed from Korean immigrants and their families’ perspective.
Since the pandemic, there has been an increase in depression, anxiety, substance use, and suicidality (CDC, 2020 June). With various mental issues on the rise during the pandemic, there are reports of many people turning away from waiting lines for mental health services (Caron, 2021). However, it has been even more challenging for Asian immigrants in many states who do not have any psychotherapists to go to.
Interestingly, a recent article found the percentage of Asian populations receiving health services and perceived unmet needs is the lowest among all the racial and ethnic groups (Conroy, J., Lin, L., & Stamm, K. (2021).
However, we need to verify this finding with what has recently been happening in reality. Due to a recent surge of hate crimes (Abrams, 2021), more Asians (75%), including Koreans (45%), live with fear and anxiety (Radio Korea News, 2021). According to NPR News (2021), there were 3,800 incidents of discrimination against Asian Americans reported nationwide in 2020. Though crimes against Asian Americans got aggravated due to Covid-19, similar targeting of them by others happened throughout the history of Asian Americans in the US.
Many Korean American store owners who suffered from PTSD from the LA riot had to endure it without mental health services. However, it was not because they did not find any need for any services, but because of the lack of education and not enough available providers who would understand and speak their language.
According to Maslow’s (1970) hierarchy of needs, psychological needs come only after survival and security needs are met. Many people in the majority culture have been enjoying better mental health services, while many minority communities have been living a life of survival, thinking of mental health services as a luxury that they can only afford after overcoming their more pressing issues such as making a living either as an immigrant or poverty-stricken family. Even among Korean family members, second-generation children first tend to seek mental health services for the sake of the first-generation immigrant parents or their better relationships.
The recent hate crimes committed by many former inmates after serving many years of incarceration indicate that our prison system may not have been geared toward rehabilitating the inmates’ mental health but the seclusion of them from society. It can be a serious social problem if the untreated population is let out due to prison overcrowding, especially during Covid-19.
If one community enjoys the benefits of mental health services while others are unaware of their importance nor utilize them, there will be a spillover of the problems from the untreated communities into the relatively intact communities. The irony is that the first target of the spillover becomes neighboring minorities who would take the brunt of the trauma without having the resources to get the proper treatment, as we saw in the case of the Los Angeles riot. As the bullying against the bullied has continued in our school environment, without timely intervention by the community, it may be the way generational transmission of the unequal mental health conditions of the society is perpetuated mostly among the untreated minority cultures.
In this sense, the role of the community leaders, such as politicians, is crucial in educating the community and modeling how to take care of mental health and planning for the unforeseen future as roads and bridges are periodically repaired. Mental health issues from traumatic experiences, whether through their family or society, can be the most crucial cause of stress and future health problems if timely treatment is not done. We have witnessed that the most detrimental impact of Covid-19 was all due to health issues. Many healthcare professionals agree that many health problems are linked to the patient’s emotional problems. Once again, the first target of the blame for Covid-19 fell on the neighboring AAPI community, which has neither developed enough awareness nor resources to deal with the trauma.
The good news is that there has been an increase in interest in mental health services in the Korean-American community, as reflected in the rise in the number of mental health providers in major metropolitan areas such as Los Angeles and New York. There will be more than 100 mental health workers in Los Angeles in 2021 (Table 1) compared to a few in 1994 when the Los Angeles Riot occurred. The rising interest in mental health may also be due to the influence of the trend in Korea, which has been experiencing the highest rate of suicide among the O.E.C.D. Countries for more than a decade.
However, in so many states in the U.S., except in metropolitan areas, few or no service providers can understand their Korean culture and language.
“I have given up finding help for my family problems. Psychotherapists in my area will not understand my culture and my husband. He came from Korea as an adult, so he only speaks Korean.”
Mrs. P., whose real name is not disclosed to protect her privacy, drove 1,500 miles from Oklahoma with her husband, who speaks Korean as his primary language, to see me two years ago, even before the pandemic. As a second-generation Korean-American, she was desperate to seek help from someone who would understand Korean culture and speak the same language because, otherwise, she would not feel comfortable sharing her family conflict.
Recently, Mrs. P. called again to request, this time, a teletherapy service. She has been more depressed, dealing with intensified conflict during the pandemic. When she drove to my office two years ago from her state, intensive counseling for a week was not enough to solve her ongoing family crisis. I had to tell her to find someone locally since, as an out-of-state psychologist, five days allowed by the Oklahoma Board of Examiners of Psychologists in her state through temporary permission would not be enough to help her deal with the ongoing family conflict.
“I feel uncomfortable if I see a counselor with an interpreter. I do not want strangers in the same room when I discuss my problem.” Her concern seemed legitimate, considering seeking mental health services is highly stigmatized in Asian culture. Besides, through an interpreter, the original message and its nuance can be easily delivered wrongfully.
Even before the pandemic, many states had few to no licensed psychologists who spoke the same languages and understood foreign-born residents’ cultures. At my practice in California, I have had clients who flew from Hawaii, New Mexico, Arizona, and many other states on the east coast to have brief counseling sessions before returning home. A Korean client drove weekly to fulfill the court-mandated counseling requirement from Las Vegas, where there were no Korean psychologists. Unfortunately, this client even got involved in a traffic accident.
However, I have never realized how serious and urgent a matter can be until the pandemic. Since the beginning of the pandemic, I have had more inquiries about teletherapy from out-of-state clients.
While mainstreamers have been frustrated waiting in line for mental health services since the start of COVID-19, many immigrant families are further out of luck because there is no line to wait since no licensed psychotherapists speaking the same languages are available in their states. The small window of getting services through out-of-state counselors granted by many states, which temporarily relaxed the licensure requirement during COVID-19, may not be enough to motivate them to seek mental health services for their ongoing emotional problems.
American Psychological Association (APA) has proposed a request for temporary suspension of the state requirements for teletherapy services in March of 2020 for psychotherapists during COVID-19. As a result, “16 states temporarily lifted licensing requirements,” and “22 states either expanded their policies for out-of-state providers to temporarily practice in their states or instituted emergency expedited registration for out-of-state providers” (Owings-Fonner, 2020).
Though many states have been updating their restrictions with more relaxing requirements, the concern is not for a temporary five-day to 90-day window permitted during COVID-19 but for more chronic issues faced by many immigrant populations that have existed before COVID-19. If any chronic mental health issues are left untreated, they can worsen or progress to more serious mental crises even with a minor trigger. Many immigrant families, therefore, may fear ending the COV-19 crisis when the temporary window to get help from out-of-state psychotherapists is closed.
Our constitution upholds that every lawful resident of the US deserves equal access to healthcare services. It means everyone should have access to appropriate mental health services through qualified professionals from similar cultural and language backgrounds.
A number of federal and state laws have been passed requiring cultural competency training for the licensure of doctors, including Title VI of the Civil Rights Act of 1964 and Medicare/Medicaid. Contrary to other medical care, however, psychological care requires a practitioner to understand the culture and language of the patients. Even American-born native English speakers from immigrant families may not seek help unless they feel culturally understood by the practitioners.
Migration Policy Institute (MPI) (2019) states that approximately 1.06 million Korean immigrants reside in the United States. While 40% of Korean immigrants were concentrated in the greater metropolitan areas of Los Angeles, New York, and Washington, DC, 60% of them were scattered in various cities in the US (The US Census Bureau, 2000). However, in 2015, more than half of the Korean immigrants (ages five and older) reported having limited English proficiency (PRC, 2017, September 8). It means they cannot express their emotional pain in English comfortably and effectively enough to get the needed help from English-speaking psychotherapists. Even without counting the rising cases of recent hate crimes against them, many Korean immigrants are still under the cultural influence of Korea, which has had the highest suicide rates in the OECD. countries for more than a decade (Kung et al., 2018). Even before the pandemic, the suicide mortality rate of Korean Americans was twice that of other ethnic groups (Kung et al., 2018).
More than four decades ago, while stressing the importance of cultural and language match between clients and therapists, Sue and Sue (1977) warned that when the communicators’ first languages are different, the messages delivered can be in short sentences and ambiguous with different nuances, creating significant misunderstandings. In an APA article titled, “Recommendations for the Treatment of Asian-American/Pacific Islander Populations,” Iwamasa (2012) stressed that Asian-America Pacific Islanders need bilingual treatment providers who must be trained in culturally competent treatment models and educated on the prevalence, manifestation, and treatment of Asian culture-bound syndromes (Iwamasa, 2012).
However, many psychologists from the same cultural and language background mainly practice in major metropolitan cities such as Los Angeles and New York without the motivation to seek licensure, let alone even a temporary one, in those states where there appears not enough Korean population who would seek psychological help. Presently, over 6,000 Koreans in Oklahoma and 13,800 Koreans in Nevada are scattered around various cities (The US Census Bureau, 2017), while there are no available Korean psychologists in their states. Surprisingly, there are 23 states that do not have any Korean-speaking licensed psychotherapists; eight states have one; and nine states have less than five (Psychology Today, 2021).
It is critical that psychologists are available even in a non-crisis situation to meet the needs of these patients to prevent a potential future crisis by providing necessary education and services, which the federal government has now declared critical and essential (CDC, 2020). The temporary measure currently allowing 5 to 60 days of teletherapy to other state practitioners during the COVID crisis is not enough to tackle the ongoing psychological problems that will take longer to resolution, and any conscientious, responsible and competent psychotherapists would agree with me.
The federal legislation does not supersede state licensing laws, and licensed psychologists cannot provide services across state lines in a non-crisis situation, except through temporary licensure during a crisis like COVID-19. Therefore, I call for suspensions of state licensing laws and regulations regarding teletherapy services indefinitely to meet the critical needs of these vulnerable populations.
Many Korean residents who may wish to get help from culturally compatible psychotherapists will give up their search if no such provider is available locally, in addition to their shame of seeking mental health help, which is culturally stigmatized. Their search is even more limited if the tendency of Asian males to feel more comfortable seeking help only through male counselors is considered.
This problem may extend to many minority communities, who may have difficulty finding culturally compatible psychotherapists due to their unique cultural, religious, or sexual orientation backgrounds. It also applies to many immigrant populations with limited English proficiency and no access to licensed counselors who share the same mother tongue and culture in their states. These immigrant populations include those speaking Cantonese, Mandarin, Japanese, Indian, Thai, Pakistani, Malay, Burmese, Vietnamese, Indonesian, Filipino, Hmong, Persian, Arabian, and many other foreign languages.
In a mature society, community leaders and policymakers can lead the way to the better mental health of minority members even when they are not aware of its importance. The wise question the policymakers can ask is what we should do if the community suffers from trauma and crimes does not perceive the needs and importance of mental health services. Who are we versus them in the minds of our community leaders?
Thanks to the COVID-19 crisis, a significant potential civil rights issue under the radar due to our oversight has surfaced. If stringent rules and laws enforced by each state regarding teletherapy can be relaxed across the state lines, especially for the minority populations, these desperate clients may meet their psychological needs and prevent a potential crisis by not giving up or traveling hundreds of miles to see out-of-state psychotherapists who match their culture or language.
Figure 1: Percent Korean, 2000. (The U.S. Census Bureau, 2000)
Table: Number of Korean Speaking Psychologists available in various states in the U.S.
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