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Article 27

Culture-Specific Psychoeducational Induction Talk as an Interventionto Increase Service Utilization Among Minority Populations:

The Case of Korean Americans

Josephine M. Kim

The colossal influx of immigrants from diversecountries has restructured the nature of ethnic dynamicsin American society. In the 2000 Census, the estimatedforeign-born population of the United States was 31.1million —the largest in U.S. history. Counselingliterature has long-established the tendency of minoritypopulations to underutilize mental health services; theirsymptomology warranting assistance; and theunderlying reasons behind their lack of seekingcounseling. The field also has researched productiveways of working with these populations, once they enterthe therapeutic relationship. Factors such as being awareof personal biases and not automatically ascribing tostereotypes are important aspects that serve as afoundation in counselors’ work with minority clients.However, despite the growing attention given tomulticultural counseling, there still exists an apparentmissing link.

A question of “How do we elevate minoritypopulations’ utilization of mental health services?”remains unanswered. The field has neglected to pinpointinterventions that will potentially change attitudes ofminority populations toward seeking counseling,thereby encouraging service utilization. Without fillingthis gap, multicultural efforts put forth by the field inaccommodating the growing multiethnic populationsbecome futile. After all, what good is an increasedrepertoire of techniques that bring about positive changein minority clients, if they do not ever enter a counselingroom? A culturally specific psychoeducationalinduction talk may be an intervention that influencesattitudes toward utilization of services by minoritypopulations, thereby bridging this apparent fissurebetween their known tendency to underutilize servicesand identified ways of counseling them.

A culturally specific psychoeducational inductiontalk that focuses on (1) culture-bound vulnerabilitiesthat place a given minority population at risk for variousemotional distress; (2) information regardingprofessional counseling, including benefits ofreceiving help versus the consequences of delaying

assistance; and (3) the multiculturalism movement asit relates to a particular minority population may bringabout a clearer and more personal meaning to acognitive set attitudes and their emotional implications.Such a talk may have an ameliorating effect in terms ofknowledge acquisition, attitudinal change towardbehaviors, and other psychological dimensions.

The increased emphasis on education incounseling during recent years reflects many factors,including the consumer movement in mental health,with its advocacy for clients’ rights; new understandingregarding the basis of pathology; an increase in researchdeeming education as an effective component ina comprehensive treatment approach; and itseffectiveness as a preventive apparatus for averting theprogression of disorders (Landsverk & Kane, 1998).Interventions that use educational methods todisseminate information increase one’s ability torecognize symptoms and signs of illness. It can begrowth producing, especially when the following threedistinct ideas are combined into one modality ofintervention:

1. cultural-specificity;2. psychoeducation; and3. induction talk.

A culturally specific psychoeducational inductiontalk implements an educational modality with a culture-specific content to orient minority populations toprofessional counseling as a viable coping resource.Psychoeducation, premised on the idea that educationis treatment not only because of the knowledge acquiredin the process but also because of the perceptions thatmay be changed as a result, is combined with aninduction talk, which is synonymous to an orientationor an introduction. This unification creates aneducational channel that can be used to orient specificpopulations to aspects of mental health that pertainexclusively to them, increasing their consciousness ofmental health issues that they would not otherwise havean initiative to explore.

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Given the heterogeneity among minoritypopulations, subgroups should not be combined in suchan intervention. Instead, a spectrum of psychologicalmatters should be presented to a targeted group ofpeople, addressing mental health issues that are acutelyspecific to that cohort. Cultural specificity ensures thedissemination of information on the culture-boundvulnerabilities that place specific populations at riskfor various emotional distresses; this full knowledgeof risk factors is a necessary prerequisite for primaryand secondary interventions. Thus, without a clearacknowledgment of such risk factors, it is unlikely thatone would seek professional counseling services, letalone benefit from primary and secondary interventions.

Case Example of Korean Americans

The fastest growing racial group in the U.S. hasbeen the Asian American population, and KoreanAmericans constitute one of the fastest growingsubgroups, comprising approximately 11% of the AsianAmerican community (U. S. Bureau of the Census,2000). Contrary to popular opinion, rates ofpsychopathology among Korean Americans have beenunderestimated, and their infrequent use of mentalhealth services is not an indication of a lack ofpsychological problems. Rather, it is an indication ofhow the salience of shame and guilt — two core valuesby which Korean Americans are raised — dictatessocial behaviors including the usage of counselingservices. Culture-bound factors threaten the mentalhealth of Korean Americans, placing them at risk forpsychological difficulties.

Korean American service utilization rates areamongst the lowest of all ethnic groups, and a generallack of information regarding mental health is aprimary concern. A Korean-American-specificpsychoeducational induction talk that includes thefollowing may be an intervention that combatsunderutilization rates amongst this population:(1) culture-bound vulnerabilities that threaten themental health of Korean Americans; (2) counseling asan ideal coping resource; and (3) the multiculturalmovement.

Culture-Bound VulnerabilitiesResearch shows that Korean Americans

demonstrate higher levels of psychiatric disorders andgreater mental health needs and are more prone to sufferfrom psychological symptoms than other AsianAmerican groups and the general population. Apsychoeducational induction talk that targets thispopulation should include information about thefollowing risk factors.

Acculturative stress. Korean Americansexperience acculturative stress, which is stressoriginating from the acculturation process (Hovey &King, 1996). Common problems associated withacculturative stress are perceived discrimination,cultural incompatibilities, and intergenerationalconflicts. Positive correlations among acculturativestress, depression, and suicidal ideation have beenfound. Symptoms of acculturative stress includeanxiety, hypersensitivity, and heightened psychosomaticsymptoms (Berry & Annis, 1974).

Intergenerational conflicts. The Korean cultureemphasizes filial piety, which is the value of utmostrespect for parents. This value is reflected in the ritualsand propriety of the Korean people, as children areexpected to comply with parental wishes. The majoritycultural values are seen as being in opposition totraditional Korean values because they encourageautonomy and individuality while consideringseparation from the family as healthy and necessary.Due to this conflict in values, intergenerational conflictsoccur between parents and children.

Perfectionism. Korean parents consider theirchildren as an extension of themselves, fulfilling theirown dreams vicariously through their children.Education has been the only avenue to climb up thesocial ladder in Korea; thus, scholastic achievement ishighly revered while other venues of achievement areignored, disregarded, and deemed futile. The orientationtoward academic attainment creates unwarranteddemands for success, instilling an instinctive need forapproval through performance and perfectionism.

Anxiety. Internalized pressures associated with theimage of model minority leave Korean Americansfeeling as if they must live up to inordinately highexpectations. Many researchers have found associationsbetween perfectionism and a number of problems,including anxiety, suicidal ideation, and pooradjustment (Chang, 2000). Korean American studentshave more doubts about their actions and more anxietyabout making mistakes while perceiving more criticismfrom their parents than Caucasian students.

Body image and eating disorders. Asian Americanfemales are more concerned about their body shape,have more body dissatisfaction, and possess a strongerdrive for thinness than Whites. They are more likely tobinge and vomit than their White counterparts, andapproximately 30% of Korean women in their 20sundergo voluntary cosmetic surgery yearly in attemptsto improve their self-esteem through physical

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alterations. Feelings of lacking control, compoundedby oppression of women in a male-dominant culture,multiplied by perfectionistic tendencies appear to be adetrimental combination as Korean American womenequate physical beauty with personhood.

Depression. The prevalence of depression ishigher among Korean Americans compared with otherAsian subgroups, with more Korean males diagnosedwith major depression than any other group of Asianmales. With the entrenched belief that psychologicaldistress is a manifestation of organic discourse, Koreansperceive a person who is depressed as either beingphysically sick or simply lacking motivation (Kleinman& Good, 1985). Korean Americans attempt to overcomeemotional difficulties by utilizing willpower and self-discipline.

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

Suicidality. Suicide is the fifth leading cause ofdeath in Korean Americans in the U.S. Seventy-sixpercent of Asian youths who received emergencymedical attention for suicide attempts reported “culturalconflicts with parents” as a major contributing factorto their suicide attempt. There is a 30-fold increase insuicidal risk with high levels of intergenerationalconflict within the family (Jernewall, Lau, Myers, &Zane, 2002).

Counseling as a Viable Coping ResourceKorean Americans in general have knowledge

deficits regarding resources that are available to them,including mental health services. Knowledgeacquisition on the nonstigmatizing nature of counselingand its focus on situational problems of everyday lifemay encourage utilization rates. Endorsing informationon the various types and modalities of services, the roleof a counselor, and the assurance of clientconfidentiality may promote a positive outlook oncounseling as a viable coping resource. Empiricalresearch that provides clear evidence of the healthbenefits of counseling (i.e., benefits of self-disclosingdistress) should be acknowledged in the induction talk.

The Multicultural MovementThe field of counseling has taken the lead among

applied mental health disciplines in incorporatingmulticultural diversity issues into its academic curriculaand training experiences. Multicultural strides havebeen made within the academic realm of counseling asinstitutions are incorporating diversity issues into theiracademic curricula, requiring demonstration ofmulticultural competence, and combating culturalmalpractice. On a wider spectrum, multiculturalcompetence has been added into the codes of ethics forprofessional conduct, and expectations are being madeof counselors to be aware of their own cultural valuesand biases and how they affect minority clients.

On an even larger scale, the field of humanservices has acknowledged that culture has much to dowith the presentation of mental disorders, validatingthis acknowledgment by dedicating an appendix in thefourth edition of the Diagnostic and Statistical Manualof Mental Disorders (DSM-IV; American PsychiatrucAssociation,1994) to culture-bound syndromes.

The inclusion of the Glossary of Culture-BoundSyndromes in the DSM-IV increases the manual’s cross-cultural usefulness, and the formalization of culture-bound syndromes speaks to the efforts being made bythe majority culture to serve ethnic clientele. Thismulticultural step recapitulates the time and energydevoted to the lives of ethnic minorities and is highlypersuasive as an agent of attitude change.

Although great strides are being made toaccommodate a growing multiethnic clientele, there isreason to doubt that this effort is being promoted to theminority public to decrease their generally skepticalviews of western mental health services and to boosttheir confidence in the profession. One can hypothesizethat this effort of inclusion exercised by the majorityculture will bring about an increased appreciation fromminority populations, positively influencing theirattitudes toward counseling. Acquisition of informationon the multicultural movement may be especiallycrucial in encouraging utilization of services from non-ethnically-matched counselors, optimally increasingoverall utilization of mental health services.

Summary

A culturally specific psychoeducational inductiontalk addresses the following deficiencies in the field ofcounseling: (1) the lack of focus on individual ethnicgroups and (2) the lack of interventions that addressthe underutilization of counseling services by minoritypopulations. An induction talk that uses an educationalmethod to increase knowledge acquisition of culture-specific risk factors, counseling services, and

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multicultural strides in the field may be an interventionthat encourages minority populations to utilize mentalhealth services.

References

American Psychiatric Association. (1994). Diagosticand statistical manual of mental disorders (4th ed.).Washington, DC: Author.

Berry, J. W., & Annis, R. C. (1974). Acculturative stress:The role of ecology, culture, and differentiation.Journal of Cross-Cultural Psychology, 5, 382-406.

Chang, E. C. (2000). Perfectionism as a predictor ofpositive and negative psychological outcomes:Examining a mediation model in younger and olderadults. Journal of Counseling Psychology, 47, 18-26.

Helzer, J. E., Canino, G. J., Yeh, E. K., Bland, R. C.,Lee, C. K., Hwu, H. G., & Newman, S. (1990).Alcoholism—North American and Asia. Archives ofGeneral Psychiatry, 47, 313-319.

Hovey, J. D., & King, C. A. (1996). Accultrative stress,depression, and suicidal ideation among immigrantand second-generation Latino adolescents. Journalof the American Academy of Child and AdolescentPsychiatry, 35, 1183-1192.

Jernewall, N. M., Lau, A. S., Myers, H. F., & Zane, N.(2002). Correlates of suicidal behaviors among AsianAmerican outpatient youths. Cultural Diversity andEthnic Minority Psychology, 8, 199-213.

Kleinman, A., & Good, B. (1985). Culture anddepression. Berkeley: University of California Press.

Landsverk, S. S., & Kane, C. F. (1998). Antonovsky’ssense of coherence: Theoretical basis ofpsychoeducation in schizophrenia. Issues in MentalHealth Nursing, 19, 419-431.

U. S. Bureau of the Census. (2000). Census brief:Current population survey. Retrieved August 1, 2004,from http://www.census.gov/prod/2002pubs/c2kbr01-16.pdf

Wechsler, H., Dowdall, G. W., Maenner, G., Gledhill-Hoyt, J., & Lee, H. (1998). Changes in binge drinkingand related problems among American collegestudents between 1993 and 1997. Journal ofAmerican College Health, 47, 57-68.