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Article 27

Culture-Specific Psychoeducational Induction Talk as an Intervention to Increase Service Utilization Among Minority Populations

The Case of Korean Americans

Josephine M. Kim

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The colossal influx of immigrants from diverse countries has restructured the nature of ethnic dynamics in American society. In the 2000 Census, the estimated foreign-born population of the United States was 31.1 million —the largest in U.S. history. Counseling literature has long-established the tendency of minority populations to underutilize mental health services; their symptomology warranting assistance; and the underlying reasons behind their lack of seeking counseling. The field also has researched productive ways of working with these populations, once they enter the therapeutic relationship. Factors such as being aware of personal biases and not automatically ascribing to stereotypes are important aspects that serve as a foundation in counselors’ work with minority clients. However, despite the growing attention given to multicultural counseling, there still exists an apparent missing link.

A question of “How do we elevate minority populations’ utilization of mental health services?” remains unanswered. The field has neglected to pinpoint interventions that will potentially change attitudes of minority populations toward seeking counseling, thereby encouraging service utilization. Without filling this gap, multicultural efforts put forth by the field in accommodating the growing multiethnic populations become futile. After all, what good is an increased repertoire of techniques that bring about positive change in minority clients, if they do not ever enter a counseling room? A culturally specific psychoeducational induction talk may be an intervention that influences attitudes toward utilization of services by minority populations, thereby bridging this apparent fissure between their known tendency to underutilize services and identified ways of counseling them.

A culturally specific psychoeducational induction talk that focuses on (1) culture-bound vulnerabilities that place a given minority population at risk for various emotional distress; (2) information regarding professional counseling, including benefits of receiving help versus the consequences of delaying assistance; and (3) the multiculturalism movement as it relates to a particular minority population may bring about a clearer and more personal meaning to a cognitive set attitudes and their emotional implications. Such a talk may have an ameliorating effect in terms of knowledge acquisition, attitudinal change toward behaviors, and other psychological dimensions.

The increased emphasis on education in counseling during recent years reflects many factors, including the consumer movement in mental health, with its advocacy for clients’ rights; new understanding regarding the basis of pathology; an increase in research deeming education as an effective component in a comprehensive treatment approach; and its effectiveness as a preventive apparatus for averting the progression of disorders (Landsverk & Kane, 1998). Interventions that use educational methods to disseminate information increase one’s ability to recognize symptoms and signs of illness. It can be growth producing, especially when the following three distinct ideas are combined into one modality of intervention:

1. cultural-specificity;

2. psychoeducation; and

3. induction talk.

A culturally specific psychoeducational induction talk implements an educational modality with a culture- specific content to orient minority populations to professional counseling as a viable coping resource. Psychoeducation, premised on the idea that education is treatment not only because of the knowledge acquired in the process but also because of the perceptions that may be changed as a result, is combined with an induction talk, which is synonymous to an orientation or an introduction. This unification creates an educational channel that can be used to orient specific populations to aspects of mental health that pertain exclusively to them, increasing their consciousness of mental health issues that they would not otherwise have an initiative to explore.

Given the heterogeneity among minority populations, subgroups should not be combined in such an intervention. Instead, a spectrum of psychological matters should be presented to a targeted group of people, addressing mental health issues that are acutely specific to that cohort. Cultural specificity ensures the dissemination of information on the culture-bound vulnerabilities that place specific populations at risk for various emotional distresses; this full knowledge of risk factors is a necessary prerequisite for primary and secondary interventions. Thus, without a clear acknowledgment of such risk factors, it is unlikely that one would seek professional counseling services, let alone benefit from primary and secondary interventions.

Case Example of Korean Americans

The fastest growing racial group in the U.S. has been the Asian American population, and Korean Americans constitute one of the fastest growing subgroups, comprising approximately 11% of the Asian American community (U. S. Bureau of the Census, 2000). Contrary to popular opinion, rates of psychopathology among Korean Americans have been underestimated, and their infrequent use of mental health services is not an indication of a lack of psychological problems. Rather, it is an indication of how the salience of shame and guilt — two core values by which Korean Americans are raised — dictates social behaviors including the usage of counseling services. Culture-bound factors threaten the mental health of Korean Americans, placing them at risk for psychological difficulties.

Korean American service utilization rates are amongst the lowest of all ethnic groups, and a general lack of information regarding mental health is a primary concern. A Korean-American-specific psychoeducational induction talk that includes the following may be an intervention that combats underutilization rates amongst this population: (1) culture-bound vulnerabilities that threaten the mental health of Korean Americans; (2) counseling as an ideal coping resource; and (3) the multicultural movement.

Culture-Bound Vulnerabilities

Research shows that Korean Americans demonstrate higher levels of psychiatric disorders and greater mental health needs and are more prone to suffer from psychological symptoms than other Asian American groups and the general population. A psychoeducational induction talk that targets this population should include information about the following risk factors.

Acculturative stress. Korean Americans experience acculturative stress, which is stress originating from the acculturation process (Hovey & King, 1996). Common problems associated with acculturative stress are perceived discrimination, cultural incompatibilities, and intergenerational conflicts. Positive correlations among acculturative stress, depression, and suicidal ideation have been found. Symptoms of acculturative stress include anxiety, hypersensitivity, and heightened psychosomatic symptoms (Berry & Annis, 1974).

Intergenerational conflicts. The Korean culture emphasizes filial piety, which is the value of utmost respect for parents. This value is reflected in the rituals and propriety of the Korean people, as children are expected to comply with parental wishes. The majority cultural values are seen as being in opposition to traditional Korean values because they encourage autonomy and individuality while considering separation from the family as healthy and necessary. Due to this conflict in values, intergenerational conflicts occur between parents and children.

Perfectionism. Korean parents consider their children as an extension of themselves, fulfilling their own dreams vicariously through their children. Education has been the only avenue to climb up the social ladder in Korea; thus, scholastic achievement is highly revered while other venues of achievement are ignored, disregarded, and deemed futile. The orientation toward academic attainment creates unwarranted demands for success, instilling an instinctive need for approval through performance and perfectionism.

Anxiety. Internalized pressures associated with the image of model minority leave Korean Americans feeling as if they must live up to inordinately high expectations. Many researchers have found associations between perfectionism and a number of problems, including anxiety, suicidal ideation, and poor adjustment (Chang, 2000). Korean American students have more doubts about their actions and more anxiety about making mistakes while perceiving more criticism from their parents than Caucasian students.

Body image and eating disorders. Asian American females are more concerned about their body shape, have more body dissatisfaction, and possess a stronger drive for thinness than Whites. They are more likely to binge and vomit than their White counterparts, and approximately 30% of Korean women in their 20s undergo voluntary cosmetic surgery yearly in attempts to improve their self-esteem through physical alterations. Feelings of lacking control, compounded by oppression of women in a male-dominant culture, multiplied by perfectionistic tendencies appear to be a detrimental combination as Korean American women equate physical beauty with personhood.

Depression. The prevalence of depression is higher among Korean Americans compared with other Asian subgroups, with more Korean males diagnosed with major depression than any other group of Asian males. With the entrenched belief that psychological distress is a manifestation of organic discourse, Koreans perceive a person who is depressed as either being physically sick or simply lacking motivation (Kleinman & Good, 1985). Korean Americans attempt to overcome emotional difficulties by utilizing willpower and self- discipline.

Alcoholism. High rates of alcohol consumption and alcoholism have been found among Koreans (Helzer et al., 1990). A large cross-national study found that the lifetime prevalence of alcohol abuse, dependence, or both was 23% for Koreans. Rates of binge drinking were more than four times greater in Koreans than in Chinese, and higher than rates reported for other undifferentiated samples of Asians (Wechsler, Dowdall, Maenner, Gledhill-Hoyt, & Lee, 1998).

Suicidality. Suicide is the fifth leading cause of death in Korean Americans in the U.S. Seventy-six percent of Asian youths who received emergency medical attention for suicide attempts reported “cultural conflicts with parents” as a major contributing factor to their suicide attempt. There is a 30-fold increase in suicidal risk with high levels of intergenerational conflict within the family (Jernewall, Lau, Myers, & Zane, 2002).

Counseling as a Viable Coping Resource

Korean Americans in general have knowledge deficits regarding resources that are available to them, including mental health services. Knowledge acquisition on the nonstigmatizing nature of counseling and its focus on situational problems of everyday life may encourage utilization rates. Endorsing information on the various types and modalities of services, the role of a counselor, and the assurance of client confidentiality may promote a positive outlook on counseling as a viable coping resource. Empirical research that provides clear evidence of the health benefits of counseling (i.e., benefits of self-disclosing distress) should be acknowledged in the induction talk.

The Multicultural Movement

The field of counseling has taken the lead among applied mental health disciplines in incorporating multicultural diversity issues into its academic curricula and training experiences. Multicultural strides have been made within the academic realm of counseling as institutions are incorporating diversity issues into their academic curricula, requiring demonstration of multicultural competence, and combating cultural malpractice. On a wider spectrum, multicultural competence has been added into the codes of ethics for professional conduct, and expectations are being made of counselors to be aware of their own cultural values and biases and how they affect minority clients.

On an even larger scale, the field of human services has acknowledged that culture has much to do with the presentation of mental disorders, validating this acknowledgment by dedicating an appendix in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatruc Association,1994) to culture-bound syndromes.

The inclusion of the Glossary of Culture-Bound Syndromes in the DSM-IV increases the manual’s cross- cultural usefulness, and the formalization of culture- bound syndromes speaks to the efforts being made by the majority culture to serve ethnic clientele. This multicultural step recapitulates the time and energy devoted to the lives of ethnic minorities and is highly persuasive as an agent of attitude change.

Although great strides are being made to accommodate a growing multiethnic clientele, there is reason to doubt that this effort is being promoted to the minority public to decrease their generally skeptical views of western mental health services and to boost their confidence in the profession. One can hypothesize that this effort of inclusion exercised by the majority culture will bring about an increased appreciation from minority populations, positively influencing their attitudes toward counseling. Acquisition of information on the multicultural movement may be especially crucial in encouraging utilization of services from non- ethnically-matched counselors, optimally increasing overall utilization of mental health services.

Summary

A culturally specific psychoeducational induction talk addresses the following deficiencies in the field of counseling: (1) the lack of focus on individual ethnic groups and (2) the lack of interventions that address the underutilization of counseling services by minority populations. An induction talk that uses an educational method to increase knowledge acquisition of culture- specific risk factors, counseling services, and multicultural strides in the field may be an intervention that encourages minority populations to utilize mental health services.