Mental Health Service Adherence Among Asian American Adolescents: Asian Clinician Perspectives of Facilitators and Barriers

Background and Purpose: Numerous studies indicate the mental health needs of Asian American (AA) youth remain largely unmet. Even when barriers like linguistic compatibility, affordability, or initial stigma are overcome, AA youth are still reported to have significantly higher drop-out rates compared to their white counterparts. Thus far, research investigating barriers and facilitators to greater adherence to mental health services from perspectives of clinicians working with AA youth and families has been limited. This study aims to fill this critical research gap to explicate a granular understanding of individual-, service-, and social-level factors that either promote or deter adherence to mental healthcare for AA youth and families.

Methods: Between November 2017 to August 2018, 5 focus group discussions and 2 individual interviews were conducted with 16 clinicians in an outpatient mental health clinic in Queens, NY. Clinicians were predominantly female (80%), Chinese (60%), Korean (27%) or Bangladeshi Americans (13%) who have provided bilingual services to AA families for an average of 8.4 years. During the focus group interviews, clinicians shared their experiences serving AA families, their perceived factors influencing AA youth mental health service use, as well as suggestions on improving treatment engagement for AA youth.

Results: Clinicians identified a plethora of factors at different socioecological levels that can influence mental health treatment adherence among AA youths and families. At the clinician level, reported barriers included difficulties managing cultural boundaries and norms while following agency protocol; a significant facilitator was being a cultural broker for families. Adolescent level barriers included internalized stigma, lack of perceived service need, academic pressures, and confidentiality concerns; a salient facilitator was having good clinician rapport. Parent level barriers included stigma, perceived irrelevance of services, fear of consequences from diagnostic labels, unrealistic expectations of treatment, and lack of time; connection between academic performance and mental health was a significant facilitator. A salient family level barrier was communication problems due to unavailability of working parents and generational/cultural gaps between parents and adolescents; seeing progress was a salient facilitator. At the therapy intervention level, lack of cultural reflexivity in existing service models and confusion in navigating the system were major barriers, whereas availability of integrated care and framing interventions in culturally reflexive ways were identified as facilitators. At the social level, structural racism embedded in mental health and school systems posed problems; culturally reflexive bridges between schools and families was a facilitator.

Conclusions and Implications: The findings suggest that with pervasive stigma around existing service delivery and framing of mental illness, there is an urgent need to develop culturally reflexive models of care such as more integrated primary care or one-stop social service centers that provide case management, parenting workshops, and medication management to normalize mental healthcare in non-stigmatizing settings. Additional research is needed to further explore mental health needs and preferences of specific ethnic groups from adolescent and parent perspectives. Practice implications of these initial findings underscore the need for structural innovation in alternative concepts of mental healthcare.