Understanding the role of cultural stigma on seeking mental health services

By Dr. Sheila Modir, pediatric psychologist; Baleska Alfaro, licensed marriage and family therapist; and Dr. Ava Casados and Dr. Sarah Ruiz, post-doctoral fellows at CHOC

For some people, making an appointment with a mental health provider may be a personal and independent decision. For others, the decision to seek therapy services may be influenced by their culture or community, as each culture has its own understanding, interpretation and beliefs around mental health symptoms.

Our own culture also teaches us ways to cope with distress and whom to rely on for support during difficult times. This may impact whether a person seeks mental health services and treatment, or their decision not to seek care at all.

In many cultures, negative stigma about mental health symptoms or therapy services is a major obstacle to getting professional help. Research shows that people in racial and ethnic minority groups in the U.S. are less likely than White people to seek outpatient therapy services. Many ethnic minority groups are more comfortable going to their primary care physicians or family members for assistance with mental health symptoms as opposed to speaking with a mental health provider. We all want to be accepted by our communities, and sometimes fear of shame or embarrassment prevents people from seeking mental health treatment.

For instance, Black families may be understandably reluctant to seek mental health therapy due to the longstanding history of discrimination, racism and mistreatment the Black community has experienced at the hands of providers in the U.S. Instead, they tend to take an active approach in handling adversities independently and directly. They also tend to rely more on spiritual resources for emotional support. While these beliefs and approaches are valid, overly negative views of therapy can keep children who do need a higher level of care from getting that help.

Studies show that Latinx (a gender neutral reference to a person of Latin American cultural or ethnic identity in the U.S.) families are also less likely to trust mental health providers compared to White families and are more likely to rely on social support from extended family and other community members. When Latinx individuals do tell others about their experiences with stress or emotional difficulties, they often focus on physical symptoms such as trouble sleeping or loss of appetite and are less likely to discuss the thoughts or feelings that are bothering them.

For Asian American and Middle Eastern American communities, cultural beliefs that seeking mental health treatment will bring shame and dishonor to the family leads some people to internalize their symptoms instead of seeking therapy. Many Asian American children have described feeling pressured to appear perfect and successful, and therefore keep their symptoms secret. For Middle Eastern American adolescents, research has found that they tend to seek support from other family and religious community members.

While these beliefs and approaches are valid, overly negative views of therapy can keep children who do need a higher level of care from getting that help.

These examples are broad, but they illustrate just a few of the reasons why ethnic minority children are much less likely to receive therapy when they need it. Ultimately, it is the responsibility of the mental and medical health system to make services more accessible to under-served families, and to spark change to counteract myths about the stigma of mental health symptoms and mental health treatment. Parents can also play an important role in examining their family’s own cultural beliefs about treatment and identifying ways to advocate for their children to get expert help whenever they need it.

How our community can end mental health stigma

So, how do we, as parents, healthcare professionals and the community begin to work on eliminating the stigma surrounding mental health disorders and accessing mental health services? After all, one in five children experiences a mental health disorder.

Here are some tips that can help our children and families feel more comfortable with identifying, discussing, managing and accessing services for mental health.

1. Seek reliable information — A first step that we can take to end mental health stigma is to seek out reliable and accurate information about mental health disorders, treatment options and resources in our community. Trusted sources can include, but are not limited to:

When speaking to children about mental health, use resources that are age-appropriate and engaging. A young child may find books helpful, while an older child may prefer to get information online. Look over resources with your child to help them find reputable sources of information and avoid popular social media platforms as your only source of information. Not sure how to start? Here are a few resources for kids:

2. Use appropriate language — The resources listed above can help you understand how to talk to your children about mental health issues, as well as how to dispel mental health myths they might have heard about conditions and treatment. Using correct language can reduce any shame or guilt you or your family and friends may have about mental health and can create a space that makes it easier for children and teens to speak openly about their own struggles and seek help.

3. Celebrities normalizing mental health conditions — Because so many people live with and manage symptoms related to a mental health condition, it isn’t hard to find a celebrity or well-known public figure your child admires who has a mental health condition. We can use celebrity or public figure examples to help normalize mental health conditions and access to mental health treatment. Our children will be more open to discussing their mental health condition and to trying out mental health services if they know that their favorite singer, actor or athlete also lives with a mental health condition.

4. Learn to explain your child’s mental health condition to your support system and community — Once we have accurate information about our child’s mental health condition and treatment plan, it could help to share this information. If we share information about mental health with our families, schools or places of worship, as well as other members of our support system, they can each better understand the child’s mental health and how they manage symptoms. Sharing information can also help increase empathy and support for the child’s well-being.

5. Seek support in your community — Children and teens with mental health conditions may not know anyone else with a similar diagnosis, which can impact their self-esteem. For teens especially, finding support from an online community may be a helpful way to openly speak about their mental health condition. Parents may also benefit from knowing other parents with children who have mental health conditions, as this can allow families to find a sense of community or support. Your local National Alliance on Mental Illness chapter offers peer support groups for parents and individuals with mental health conditions.

6. Advocacy — Engaging in advocacy is another way that parents and community members can help break down mental health stigma. Organizations like National Alliance on Mental Illness engage in advocacy and policy change using individual’s stories. Advocacy can help raise awareness about important mental health issues and help dispel myths and break down stigma. It could also have positive impacts for those who are engaging in advocacy, helping to develop a sense of solidarity and common purpose.

Learn more about mental health services at CHOC.

Mental health resources to share with patients, families during COVID-19

We know living through a pandemic can compound existing mental health problems or introduce new ones for young patients. And for many providers, the COVID-19 pandemic has prompted a flurry of tough questions from patients and their families: How do I explain this to my children? How do I help my child understand why their birthday party is canceled? How do I maintain normalcy while my child is out of school and stuck at home?

If you’re also fielding these questions from worried caregivers, this compilation of resources from CHOC — with more to come — can help address these questions and more:

Information, strategies for children, teens with depression, anxiety

Tips for parents of teens

Stress-busting tips

Strategies for kids of all ages

En Español

Self-care tips for parents

Find more information to share with patients and families about COVID-19 at choc.org/coronavirus.

CHOC awarded ACEs Aware grant funding to provide trauma-informed care training

CHOC has received $180,000 in grant funds from the Office of the California Surgeon General and the Department of Health Care Services to participate in the state’s ACEs Aware initiative.

The initiative seeks to change and save lives by helping Medi-Cal providers understand the importance of screening for Adverse Childhood Experiences (ACEs) and training them to respond with trauma-informed care.

CHOC will use its grant funds to conduct supplemental training to promote the ACEs Aware initiative among the Medi-Cal provider community in Orange County. Through this training, providers will learn the importance of incorporating ACE screenings into their clinical practice, as well as how to administer screenings, use clinical protocols to determine evidence-based treatment plans, and provide trauma-informed care. Trainings will also include mental health providers and school professionals to encourage communication and coordination between important systems in children’s lives.

“At CHOC, trauma-informed care is embedded into our treatment and interactions with our patients and families,” said Dr. Heather Huszti, CHOC’s chief psychologist. “The COVID-19 emergency underscores the critical need of using trauma-informed care to treat the whole child. We are so grateful to have received this funding to help teach providers throughout Orange County about the importance and practice of trauma-informed care.”s

CHOC was among 100 organizations throughout the state to receive a total of $14.3 million to extend the reach and impact of the ACEs Aware initiative. These grants will provide funding to organizations to design and implement training, provider engagement, and education activities for providers and organizations that serve Medi-Cal beneficiaries.

“We are looking forward to working in partnership with this amazing group of community leaders to further our efforts to help health care providers become ACEs Aware,” said California Surgeon General Dr. Nadine Burke Harris. “This work is critical, now more than ever, given the stress so many Californians are experiencing as a result of COVID-19 and the role of racial injustice as a risk factor for toxic stress. A trauma-informed health care workforce is vital for helping our state heal.”

The grant funding will provide critical support to community organizations serving Medi-Cal providers and beneficiaries, which have been experiencing increased stress during the COVID-19 emergency. Grant activities will augment California’s efforts, underway since the summer of 2019, to develop provider training and engage providers, including the promotion of payments to Medi-Cal providers for screening their patients for ACEs.

Added Dr. Karen Mark, DHCS medical director: “DHCS is committed to preserving and improving the overall health and well-being of all Californians. The ACEs Aware initiative is a vital part of the Medi-Cal program’s response to the COVID-19 emergency. These grants will help us reach Medi-Cal providers who serve diverse and often at-risk populations throughout the state, and will help to ensure that Medi-Cal members receive the high-quality, integrated care that every Californian deserves.”

Funding for the ACEs Aware grants was previously authorized in the 2019-20 budget using Proposition 56 funds for provider training on how to conduct ACE screening in the Medi-Cal population. In light of the COVID-19 emergency, the grant funding will provide critical support to the community organizations serving Medi-Cal providers and beneficiaries.

View the full list of ACEs Aware grantees.

DBT in IOP setting shown to reduce intensity, frequency of suicidal thoughts in teens

Data shows that CHOC intensive outpatient program (IOP) for high school teens is successfully intervening on suicidal behaviors in participants.

Clinicians examined self-reported data gathered from patients and their parents since the launch of CHOC’s IOP in March 2018. Participants reportedly experienced less distress after completing the program, a sentiment echoed by their parents. Further, the specific sets of behaviors treated by the IOP (e.g., suicidality, emotion dysregulation and impulsivity) demonstrated reliable improvement.

“It is incredibly rewarding that our patients and their parents are experiencing meaningful improvements from CHOC’s intensive outpatient program,” says Dr. Micaela Thordarson, the program’s lead psychologist. “This data shows that we are effectively reducing stress and high-risk behaviors in our patients, which is part of the mission we set when developing and launching the IOP.”

How CHOC’s program differs

Employing dialectical behavioral therapy (DBT), the premier treatment package for suicidal adolescents, CHOC’s IOP is held four days a week for eight weeks during after-school hours. Programming includes caregivers and a variety of experiential activities. Family sessions are held as needed and optional group programming for graduates is offered.

Phone coaching is also available to allow IOP patients access to their clinicians outside of program hours to gain coaching in moments when they really need it.

By contrast, a traditional DBT program – the most widely researched – is held over a 16-to-32 week period with one weekly individual session and one weekly skills group session that includes caregivers. A 16-to-32 week graduation program and phone coaching, follow.

“This means that the clinical service CHOC provides is delivered in one-quarter to one-eighth of the amount of time as a traditional DBT program, and at a much greater intensity,” Dr. Thordarson says. “So, despite the significantly shorter time period, we are still able to get meaningful outcomes.”

Patients served

Here’s a snapshot of the population served by CHOC’s program during the approximate two-year period:

  • The IOP served 105 patients.
  • 65 percent of patients identified as female, 27 percent identified as male, and 8 percent identified as gender nonconforming.
  • 39 percent of patients were white, 31 percent were biracial, 21 percent were Latino, and 9 percent were Asian.
  • 52 percent of patients were referred from a higher level of care, such as an inpatient psychiatric unit or a residential treatment program; 17 percent from the emergency department; 21 percent from outpatient providers or from school; and 10 percent from other sources. This is significant because it means about half of the teens who are admitted to IOP are able to be diverted from an inpatient hospitalization by accessing the IOP-level of care.
  • About 80 percent of participants graduated from the program, 11 percent discharged against clinical advice, 7 percent needed a higher level of care, 2 percent needed a lower level of care, and 1 percent required a transfer for specialty care.

Measuring progress

To measure patients’ progress over the course of their time in program, teens and their parents complete the Youth Outcomes Questionnaire 2.0 (YOQ). The YOQ is a broadband measure of emotional and behavioral functioning that includes six subscales: intrapersonal distress, somatic symptoms, interpersonal relationships, social problems, behavioral dysregulation and critical items. Higher scores indicate greater distress.

At the start of the IOP, patients on average self-reported a total distress score of 92.8. At the end of the eight weeks, patients self-reported a mean score of 70.61.

Their parents reported a baseline assessment of their children’s total distress at 83.8 on average and at the program’s conclusion, reported a mean score of 56.39.

Looking more closely at the critical items subscale – which assesses suicide, self-harming behaviors, and other high risk indicators – patients at the beginning of their program reported on average a score of 12.75, followed by a mean score of 9.41 at the conclusion of their program.

Parents reported a baseline critical items subscale score of 9.78 on average, followed by a mean score of 5.53 at the program’s conclusion.

”We were table to analyze these numbers to determine not only whether they were statistically important changes, but also whether they were clinically meaningful,” Dr. Thordarson says. “These changes represent medium-to-large effect sizes. In other words, they demonstrate moderate-to-significant changes in reported distress.”

As another means of assessing program progress, patients also completed the Life Problems Inventory (LPI), a measure of the skills deficits that are specifically targeted by DBT. Like the YOQ, higher scores indicate greater distress as well as less employment of adaptive skill use. 

At the beginning of the program, patients self-reported a total mean score of 164.26; at the end, 140.

In looking at the LPI’s subscales, each decreased across the board: on average, confusion-about-self scores dropped 5.65 points; impulsivity decreased by 4.19; emotion dysregulation decreased 8.22; and interpersonal crisis dropped 6.2. These changes also represent small-to-large effect sizes.

Next steps

Looking forward, clinicians hope to gather long-term data with several goals in mind: to further assess the effectiveness in continued suicide prevention; determine any difference in outcomes when the IOP was augmented with phone coaching; review data to determine ways to further enhance the program; and continue efforts to build a referral network for ongoing family support after program completion.

“We are so thrilled to offer a very important service to teens and families who are in crisis and need extra support,” Dr. Thordarson says. “The team at CHOC is unparalleled in its enthusiastic dedication to innovation and excellence in the care of children.”

The IOP is a component of CHOC’s landmark pediatric mental health system of care launched in spring 2015 to ensure children, adolescents and young adults with mental illness get the health care services and support they need.

Learn more about CHOC’s intensive outpatient program.

Outpatient providers interested in receiving referrals from the IOP should email iop@choc.org.

Stress coping tips for providers during COVID-19

By Melanie Fox, PsyD and Carolyn Turek, PhD. 

Any time of uncertainty commonly leads to increased stress, and the COVID-19 pandemic is the perfect definition of uncertainty. Things are changing daily, we are learning in real time, and we cannot predict with certainty exactly what is going to happen.

What we do know with certainty though is that if providers don’t practice self-care during these tumultuous times, you cannot be as effective for patients, your team and your family.  

While it can feel impossible to engage in self-care right now, it is truly imperative as stress can easily rise to traumatic and toxic levels and this biochemical reaction can cause a range of physical and mental health problems.

Read on for some tips that can easily be worked into your day – and can make a big difference.

Common stress responses

First, it’s important to understand what happens to our bodies when we experience overwhelming stress. Humans often respond in these four characteristic ways:

  • Flight: We may feel trapped, fidgety, tense in our bodies, numb in our extremities, or experience urges to leave work or cancel patients.

  • Fight: We may feel irritable or agitated. Our jaw can tighten. We may grind our teeth. We can glare, show anger in our voice, or feel a burning sensation in our chest or stomach.
  • Freeze: We often experience a sense of dread, hoping for cancellations, difficulty making decisions, feel our heart pounding, or notice ourselves checking out.
  • Avoidance: We may feel calm and composed, but anxiety manifests through impatience, irritability, short-temper, tense muscles, changes in sleep or eating patterns, and/or increased use of substances.

Tips to help in the short term

To remove yourself from the fight/flight/freeze/avoidance response, try to focus your mind and body to the present moment. Grounding exercises can help. Here are a few exercises to try:

  1. 5-4-3-2-1: Name to yourself five things you see, four things you feel, three sounds you hear, two things you smell and one thing you taste.
  2. Box breathing: Breathe in counting to four with each inhalation and count backward from four with each exhalation. Do this 4 times.
  3. Get moving: Take a quick walk before starting your next task.

These exercises can be helpful when you notice yourself reacting from a stressed place, or when you notice patients, families or other health professionals responding to you in ways that feel unhelpful or stress-inducing.

Tips to build  wellness

While no one will ever be completely stress-proof, building wellness can strengthen our ability to withstand stress.

One way to do this is by focusing on the meaning behind our work. When things seem uncontrollable or stressful, it often helps to reflect on our values and why our work is important to us.

Practicing consistent self-care is another way to build wellness. Self-care is actually patient care. Here are a few ideas to try:

  • Take deep breaths.
  • Maintain regular meals and snacks, as possible.
  • Try to get as much sleep as is possible.
  • Engage in regular physical activity.
  • Practice mindfulness.
  • Stay connected with loved ones.
  • Reduce consumption of news and social media: Studies from previous epidemics find a link between time spent on social media and increased anxiety/stress. Try to consume news at a set time from a reliable source and then try to leave it until that time the next day.
  • Try technology: Headspace, a mindfulness app, is free until the end of 2020 for anyone with a national provider number.