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stigma

Stigma of mental illness preventing Asian immigrants in seeking help – what it takes to overcome the stigma and find the help they need

Stigma of mental illness preventing Asian immigrants in seeking help – what it takes to overcome the stigma and find the help they need

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Imagine living in a world in which everyone feels free to talk about their therapy sessions openly without judgement, as they do about dentist or physiotherapy appointments. Although psychotherapy is a common practice in some cultures, this scenario is unheard of in the Asian immigrant community in which discussions of mental health are hushed, therapy is shunned, and seeking help takes tremendous courage. Not only is heavy stigma associated with mental illnesses, feeling shame and guilt for having a mental health issue also makes Asian immigrants reluctant to get help. Additional cultural challenges, such as the desire to “keep it in the family” or “not washing dirty linens in public” (to prevent outsiders from discovering one’s mental health issues), fear of being ostracized by their communities, seeking help as being seen as a “weakness”, concerns of confidentiality, and the possibility of losing “face” or bringing shame to their families can further prevent them from even acknowledging/admitting that they are experiencing mental health problems (Chen, Kazanjian, & Wong, 2009; Thomson et al., 2018; CBC/Radio Canada; 2018).

Back in their countries of origin, their main supportive networks may consist of close family members, friends, and co-workers. Immigration to a new country can significantly reduce the accessibility of social support networks in their home countries, which can greatly increase their vulnerability to mental health problems. It can be difficult to find new sources of support in a foreign country, yet many are still resistant to getting help. It has been shown that Canadians of Asian ethnicities are the least likely to utilize mental health services in their communities (Durbin et al., 2015; Li & Browne, 2009; Tiwani & Wang, 2008).

Due to possible linguistic barriers, strong feelings of shame, guilt and denial deeply rooted in cultural values, visiting a psychologist is usually seen as a last resort in Asian immigrant communities. Receiving professional help is often seen as taboo and people who experience mental health problems live in fear of being labeled as “crazy” or “insane”. Refusing to seek help or dropping out prematurely during psychological treatment is common. Symptoms of those who make it to the psychologist’s office are often more severe and more difficult to treat than Canadians of other origins (Fang, 2010). In addition, Asian immigrants may mistake psychosomatic symptoms for physical illness due to the importance and attention they give to physical health, yet they lack awareness of, or perhaps avoid, issues related to mental health.

Furthermore, there may be numerous misconceptions in the Asian community of what a clinical psychologist does and the services that he/she can offer, possibly due to media and/or cultural beliefs. For many Asian immigrants, psychology comes across as a western subject matter, with treatment values and perspectives developed in western individualistic cultures that focus on improving the life of the individual. This may be in direct contrast to collectivistic cultural values, which are more typical of Asian cultures, in which focusing on self-improvement may be viewed as selfish and even induce guilt.

Finally, the role of psychologists can be drastically different in their home countries compared to that in Canada. In some countries where the profession of psychology is young and not as well regulated, immigrants may have experienced different and perhaps ineffective psychological treatment, which misconstrues the potential benefits of psychological services. In Canada, psychologists must be licensed with their provincial regulation boards (e.g., Order of Psychologists in Quebec) and must have strict academic and clinical credentials to be eligible to do so. If you are looking for a psychologist who fits your patient’s needs, visit the official website of the Order of Psychologists of Quebec to find a suitable match: http://www.ordrepsy.qc.ca/.

So what can we do as health practitioners to help immigrants overcome stigma and find the help that they need?

1) Normalize seeking help from psychological services in Canada and encourage them to look for a psychologist within their provincial regulation board (e.g., the Order of Psychologists of Quebec)

2) Reduce the stigma by encouraging them to think of psychological problems as getting a “cold” psychologically. Encourage them to seek help instead of letting symptoms drag on until the issue becomes a psychological “fever” (more severe)

3) Encourage immigrant populations to seek out community support – e.g., at their local community and cultural centres that offer support services in their language of preference

4) Assist them in utilizing community and online resources to educate themselves about issues related to immigration and mental health.

5) Address “the elephant in the room” – racism and discrimination issues that immigrants often face

6) Practice cultural sensitivity when seeing clients of a different cultural background. Be curious and willing to learn about your clients’ issues and try to understand their cultural context

7) Provide psychoeducation regarding the close association between one’s physical and mental health

8) Utilize cultural consultation services such as: https://www.mcgill.ca/tcpsych/clinical/ccs


Zhen Xu is a Ph.D. candidate in clinical psychology at McGill University and a therapist at Connecte Montreal Psychology Group. The team at Connecte loves writing about ways to boost our mental health and bring psychology into our everyday lives. For more helpful tips, check out Connecte’s blogspodcast, follow @connectepsychology on Instagram, or like us on Facebook.


References

CBC/Radio Canada. (2018, March 1). 'The unspoken ones': How race and culture complicate Asian-Canadians' access to mental health care [News Release]. Retrieved from https://www.cbc.ca/radio/thecurrent/facing-race-the-current-s-town-hall-event-in-vancouver-1.4558134/the-unspoken-ones-how-race-and-culture-complicate-asian-canadians-access-to-mental-health-care-1.4558354.

Chen, A. W., Kazanjian, A., & Wong, H. (2009). Why do Chinese Canadians not consult mental health services: health status, language or culture?. Transcultural psychiatry, 46(4), 623-641.

Durbin, A., Moineddin, R., Lin, E., Steele, L. S., & Glazier, R. H. (2015). Mental health service use by recent immigrants from different world regions and by non-immigrants in Ontario, Canada: a cross-sectional study. BMC health services research, 15(1), 336.

Fang, L. (2010). Mental health service utilization by Chinese immigrants: Barriers and opportunities. Canadian Issues, 70.

Li, H. Z., & Browne, A. J. (2009). Defining mental illness and accessing mental health services: Perspectives of Asian Canadians. Canadian Journal of Community Mental Health, 19(1), 143-159.

Thomson, M. S., Chaze, F., George, U., & Guruge, S. (2015). Improving immigrant populations’ access to mental health services in Canada: a review of barriers and recommendations. Journal of immigrant and minority health, 17(6), 1895-1905.

Tiwari, S. K., & Wang, J. (2008). Ethnic differences in mental health service use among White, Chinese, South Asian and South East Asian populations living in Canada. Social psychiatry and psychiatric epidemiology, 43(11), 866.

 Understanding Borderline Personality Disorder: Part 1—What is BPD and How to Get Help That Fits

Understanding Borderline Personality Disorder: Part 1—What is BPD and How to Get Help That Fits

Photography by      Joanna Rosciszewska

Photography by Joanna Rosciszewska

In my July Blog post, I referred to what happens when certain personality traits are too high or too low, causing life difficulties. Borderline Personality Disorder (BPD) is one psychological diagnosis or label that mental health care professionals and clinicians use to describe a specific pattern of problems. Typically, this pattern involves intense, chaotic relationships with both the self and others. Even though some of the traits involved are amplified versions of normal personality traits, many people with BPD will experience problems that are serious, and that most people never experience (Paris, 2017). Although there are some commonalities and a general pattern, individuals with BPD do not all have the same problems or experiences.

Let’s think of Jessica for example. She was recently diagnosed with BPD. She’s always felt something was “off”. She suspected early in life that she wasn’t feeling the way others around her felt: her emotions have always been so intense, it was as though she was walking around with no skin. She’s noticed she reacts impulsively to these intense feelings, which change from one moment to another. One moment she can be thrilled, the next, filled with sadness or rage. Along with these strong emotions is also an emptiness inside that she’s not sure how to describe to others.

Sometimes she feels her life is not real and asks herself “what’s the point?”. She often thinks of suicide, wondering if it’s the only way to stop her suffering. She’s even attempted to end her life a few times by taking pills, with mixed feelings when hospitalized and treated for these overdoses. She questions who she is, often feeling like a bad person who isn’t worthy of love. When she gets into a relationship, she’s afraid the person will leave and looks for ways to prevent this, or to have her partner reassure her that they won’t. Eventually, the ups and downs and efforts to avoid being broken up with cause a lot of stress in the relationship and it ends.

Jessica has received many diagnoses by health professionals in the past, including Generalized Anxiety, Depression, Attention Deficit and Hyperactivity Disorder, and Bipolar Disorder. She has tried therapy numerous times and felt frustrated because nothing seemed to “stick”. Recently, a new psychiatrist she was seeing diagnosed her with BPD.

Receiving a BPD diagnosis

It’s important to remember that a diagnosis, especially one of BPD, is not an identity: it describes a cluster of problems in someone’s life—what’s not working for them. Receiving the BPD diagnosis can be the key to getting the right help. When Jessica first got diagnosed, she went home and looked it up online. She was angered to find that much of what she was reading suggested there is something wrong with her personality and that she would be “difficult to treat”. She felt ashamed and angry with her psychiatrist, who she had no intention to return to see. She felt as though another health professional had let her down.

Despite this, she also felt some relief that she could make sense of what’s been going on, and eventually decided she would go for another visit to ask a few questions. Although she was hesitant, she told her psychiatrist how angry she was and was surprised that this led to a conversation during which she felt understood and even hopeful about the future.

Jessica learned that this diagnosis would allow her to get more specialized help, and together she and her psychiatrist came up with a plan. With treatment that fits (and some patience), Jessica can go from being diagnosed with BPD to no longer meeting any of the criteria and leading a more satisfying life. It’s also important to remember that when the label no longer describes someone’s current problems, it no longer applies.

Unfortunately, because of stigma around BPD, many people are reluctant to accept or disclose their diagnosis, which can get in the way of receiving appropriate help.

Photography by      Joanna Rosciszewska

Photography by Joanna Rosciszewska

Why the stigma?

Compared to other disorders, BPD is a fairly new diagnosis, with treatments having only been developed in recent decades. There are times individuals with BPD feel like their experience is unbearable. Their symptoms often reflect the intensity of their distress; When Jessica went to see the psychiatrist, she had cut herself badly and said she wanted to give up on life. Although her psychiatrist identified her diagnosis, some health care professionals may not recognize BPD or know how to help, leaving all parties feeling frustrated. In fact, people with BPD are often not diagnosed or treated at all. Sometimes, they are offered treatments that do not fit their problems. Since intense emotions are part of the experience, speaking about what’s most painful with a health care professional, who is often a stranger, can be quite challenging.

It is not surprising that there would be friction between someone consulting for a situation that feels urgent and impossible, and a health care professional who isn’t sure how to help. Sometimes, the clinician may themselves react unfavourably when feeling unsure or helpless. As you can imagine, these reactions would not be well-received by someone in distress who already feels let down.

In fact, it is likely that someone seeking help for these symptoms has already had many frustrating experiences in the health care system. As a result, they might express anger (even rage) or withdraw from treatment, which in turn might lead to the clinician distancing themselves even more. This can become a continuous self-fulfilling cycle and can help explain some of the frustrations that people with BPD as well as clinicians face (Aviram, Brodsky & Stanley, 2006). Unfortunately, cycles like this one perpetuate the stigma and contribute to a reluctance toward both pursuing treatment (on the part of those seeking help) and providing treatment (on the part of clinicians).

Maybe you relate with parts of (or all of) Jessica’s experience, and you’ve experienced these frustrations yourself. If you’ve been feeling helpless, hopeless, and chaotic on the inside (and maybe outside too), or like no diagnosis has made sense so far: Remember there is the right kind of help out there—help you can use to help yourself.

What to do if you think you might have BPD and want to consult:

1- Take a deep breath. Remember these are words to describe problems you are experiencing, and that having these words means you can communicate to get the help you need.

2- Look for someone who is qualified to assess and work with personality in therapy, or ask for a referral to someone who does. You can look online, or ask your GP or most health care professionals.

3- Be prepared to speak with someone by taking note of what’s most important to share about what you are experiencing.

4- When meeting a health care professional, observe whether you are feeling intense emotions, and challenge yourself to be open—to stick around and share your experience as best as you can, even if lots of uncomfortable emotions rise to the surface. Ask yourself: how can I help this person help me? Sharing your difficulties and what you are looking to work on are some ways to collaborate.

5- Give the person time to get to know you and figure out how to help. They may not know right away.

Don’t give up on getting the help you’re looking for. Sometimes, it takes meeting with a few different professionals before you feel you’re on the right track.


Danit Nitka received her PhD from the Clinical and Research Psychology program at Concordia University in Montreal, Quebec, and is a therapist at Connecte Montreal Psychology Group. The team at Connecte loves writing about ways to boost our mental health and bring psychology into our everyday lives. For more helpful tips, check out Connecte’s blogspodcast, follow @connectepsychology on Instagram or like us on Facebook.


References

Aviram, R. B., Brodsky, B. S., & Stanley, B. (2006). Borderline personality disorder, stigma, and treatment implications. Harvard review of psychiatry, 14(5), 249-256.

Paris, J. (2017). Stepped care for borderline personality disorder: making treatment brief, effective, and accessible. Academic Press.

Michael Phelps: Breaking records, smashing stereotypes

Michael Phelps: Breaking records, smashing stereotypes

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Have you ever heard someone suggest that ‘Depressed people are lazy, and they just need to toughen up’? Not only can such statements be extremely hurtful, but evidence flies in the face of such thinking.

Case in point: Olympic athlete Michael Phelps’s battle with depressive symptoms and suicidality. One thing that makes his story so compelling is that he is a record-breaking gold medalist whose training undoubtedly requires tremendous focus and dedication, and who most people would certainly not consider to be ‘weak’ or ‘lazy’.

In recent years, he has opened up about his experiences (1, 2). Let’s take a look at what he has shared, and how this might relate to mental health more broadly:

1. He cited social support as an important factor which helped him realize that suicide was not a good solution.  My clinical experience has shown me that people with depression often tend to isolate themselves. Low mood seems to say ‘just stay in bed, cocoon yourself under the warm covers, things will seem quieter and safer there, and you won’t have to struggle to expend energy interacting with people or doing activities.’  Sometimes people feel like they would be burdening others with their problems, or that others won’t understand what they are going through. But the reality is that isolating ourselves from the people who truly care about us can contribute to further worsening our mood, resulting in a vicious cycle where low mood makes us want to isolate ourselves, which in turn can contribute to further lowering of our mood. And ironically, sometimes the periods when our mood is lowest and our inclination to confide or socialize is plummeting can actually be among the most important times to do the opposite and reach out.

2. He reported having been critical or disappointed with himself when he did not beat a certain world record. This suggests that he may have had a focus on outcome goals, where the motivation is tied to the result (e.g. winning a competition), as opposed to process goals where the focus is on the steps involved (e.g. hard work, love of learning) (3). This may have left him feeling like a failure when he did not achieve his desired outcome. Indeed, some research has found that process goals can have certain advantages, including more enjoyment (4). I’ve often heard clients say things like ‘I’ll be happy when I achieve x goal / when I hit x milestone / when x is over’, but as clinical sports psychologist Kristen Keim noted, it is important to take pleasure in the process and in the moment (5).

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3. He reported that his sense of self-worth declined after he retired from swimming. Sports psychologist Dr. Goldman noted that equating identity with sport can lead some athletes to lose their sense of self (5). It can be very risky to put all of your eggs in one basket by linking your sense of self-worth to any one area of life (be it academic performance, romantic relationships, or physical appearance) because of the negative ramifications for mood and/or self-esteem when we don’t perform as well as we would have liked in that area, or when our involvement in that area diminishes. As such, some therapies encourage clients to develop and value multiple domains of life (6).

4. He noted that he had not reflected on his accomplishments along the way. Perhaps it is surprising that someone who has won so many gold medals during his career would not have already reflected on his successes. But many of us can relate to being focused on getting things done; it can feel like we are running on a treadmill that is going so fast that we struggle to keep up and to catch our breath, making it a real challenge to focus on the present moment and to practice mindfulness. See my colleague Natsumi’s blogpost to learn more about mindful awareness and how you can begin to incorporate it (7).

5. He was initially reluctant to get help, and anxious about the idea of change. Some people think – if you’re not doing well, you should jump at the chance to feel better, right? In reality, things often aren’t that simple. In many ways, we are creatures of habit, and we often find comfort in familiarity, even if that familiarity isn’t ideal. The idea of some unknown change can feel risky or scary, and people may wonder if they are capable of change, if that change will be sustainable, or if they will be fundamentally different people when their depressive symptoms have improved. These are all valid questions; make sure to raise them with your therapist if they are of concern to you.

6. Having benefitted from treatment, he went on to raise awareness and develop a foundation aimed at promoting stress management for youth. Although not everyone will have their own foundation, some people are eventually able to make meaning or see the silver lining in their experience, for instance, by noting that their own struggles have improved their ability to empathize with others and to demonstrate self-compassion.

Bottom line: Struggling with depression does not make someone weak or lazy. And the wide variety of people coming forward about their own experiences demonstrates that very accomplished, hard-working and motivated individuals can struggle with mental health problems. Michael Phelps’s experience illustrates this point well, as well as the importance of factors like social support, motivation, self-worth, and mindfulness in mental health.


Simcha Samuel is a clinical psychologist in Westmount, Montreal, Quebec, at Connecte Montreal Psychology Group. The team at Connecte loves writing about ways to boost our mental health and bring psychology into our everyday lives. For more helpful tips, check out Connecte’s blogspodcast, follow @connectepsychology on Instagram or like us on Facebook.


References

  1. http://www.cnn.com/2018/01/19/health/michael-phelps-depression/index.html
  2. https://www.cnn.com/2017/07/03/sport/olympics-michael-phelps-swimming-mental-health/index.html
  3. Qu, Y.., Pomerantz, E. M., & Deng, C. (2016). Mothers’ goals for adolescents in the United States and China: Content and transmission, J Res Adolesc., 26, 126-141.
  4. Wilson, K. & Brookfield, D. (2009). Effect of goal setting on motivation and adherence in a six-week exercise program. International Journal of Sport and Exercise Psychology, 6, 89-100.
  5. https://www.theatlantic.com/health/archive/2016/08/post-olympic-depression/496244/
  6. Fairburn, C. G. (2008). Cognitive Behavior Therapy and Eating Disorders. New York, NY: The Guilford Press. 
  7. https://connectepsychology.com/blog/2016/1/11/3-simple-mindfulness-practices-for-coping-with-difficult-experiences-and-emotions-in-day-to-day-life