BY EDWARD K. S. WANG, M.S., PSY.D.
This piece was published in the 29th print volume of the Asian American Policy Review.
Among AAPIs who use services, the severity of their mental illness and the length of suffering is longer. The shame and stigma of mental illness continues to be a major deterrent to seeking care. Language barriers and the lack of bilingual providers further impacted the availability of treatment for AAPIs.
A Journey of Public Stewardship on Asian American and Pacific Islander Mental Health: Massachusetts’ Approach to Addressing Disparities
Specific game-changing events, messages, blueprints, standards and action plans have transformed mental health care for Asian American and Pacific Islander (AAPI) communities across the country. In 2000, the Department of Mental Health, Commonwealth of Massachusetts State Mental Health Authority, established the Office of Multicultural Affairs which has the structural and functional responsibility as well as accountability for reducing mental health disparities among underserved, diverse populations, including the AAPI community. The office utilized these game-changers as catalysts to improve the 3 A’s of the mental health service delivery system: access, availability, and appropriateness of care–specific to the AAPI community. This article documents the outcomes, lessons learned and strategies in AAPI mental health policy, program and practice in the Commonwealth of Massachusetts over the past 18 years given the impact of these game-changers.
“Too many Americans who struggle with mental health illnesses are still suffering in silence rather than seeking help, and we need to see it that men and women who would never hesitate to go see a doctor if they had a broken arm or came down with the flu, that they have that same attitude when it comes to their mental health.” – President Barack Obama, The National Conference on Mental Health 2013.
Mental illness and the shadow of stigma in crisis consumed a young, high-achieving Chinese American college student. He was my brother, David, who died by suicide. He suffered from depression in silence. He did not seek help until the burden of his mental illness was so severe that others took notice. His academic advisor persuaded him to seek treatment in the hospital, where the acute symptoms were resolved without addressing the deeper issues. He quickly signed himself out of inpatient care. He was too ashamed by the shadow of stigma to follow through with his care. His invisible wound of mental illness and the shadow of stigma continued to the end.
There is no question that my brother’s mental illness influenced my interest in becoming a psychologist. My migration to the United States during the Vietnam War and my formative years as an adolescent, a time when others called me “Gook” or “Chink,” further contributed to my interest in the “American” experience and Asian American Pacific Islander (AAPI) mental health, later influencing my decision to take on the role of the Director of the Office of Multicultural Affairs (OMCA), Department of Mental Health, Commonwealth of Massachusetts.
Fast forward 45 years later to today, where a documentary called “Looking for Luke” is screening nationwide, igniting a critical conversation about AAPI mental health. The film focuses on a bright Chinese American sophomore studying at Harvard who died by suicide. It follows his parents as they read through his journals, talk to his high school and college friends, and come to an understanding of his mental illness[i]. Their journey of reflection and sharing is touching as it discusses the psychological pain that Luke and those who survive him suffered. The film is raising awareness on the importance of breaking the shadow of stigma to encourage AAPIs with mental illness to seek help.
According to the Center for Disease Control and Prevention, Asian Americans generally report fewer mental health concerns than do white Americans. However, when breaking down the data further by age and gender, the prevalence of depression looks very different. Nearly nineteen percent of Asian American high school students reported considering suicide, versus 15.5 percent of whites. Nearly eleven percent of Asian American high school students reported having attempted suicide, versus six percent of whites. Asian American high school females are twice as likely (15 percent) to have attempted suicide than males (7 percent). Suicide death rates are 30 percent higher for 15-24-year-old Asian American females than they are for white females. Suicide death rates for Asian American females over the age of 65 are higher than they are for white females[ii]. The AAPI community must challenge the social stigma that is associated with mental illness to reduce the burden on those struggling.
In 2008, Massachusetts and other state mental health authorities participated in the national survey, “The Unclaimed Children Revisited: The Status of Children’s Mental Health Policy in the United States”. The national survey confirmed the top 3 factors creating a gap in mental health access for AAPI are stigma, language barriers, and poor provider cultural competence[iii]. Francis Lu, M.D., a professor in cultural psychiatry at the University of California-Davis, has dedicated his career to teaching about cultural formulation and culturally competent care. In the training video entitled “Saving Face: Recognizing and Managing the Stigma of Mental Illness in Asian Americans”, he defined “stigma is a complex phenomenon related to loss of status and disrupted identity, associated with labeling, negative stereotypes in the media, language, distorted expectations, and simple lack of knowledge, misunderstanding, or lack of awareness of mental illness[iv].”
Interestingly, over a century ago, persons with cancers carried the stigma of the disease that was associated with death. Doctors did not tell their patients about their diagnosis, because telling them was cruel and took away their hope. The fatalistic attitude of society set cancer patients apart in social isolation, shame and discrimination[v]. By the 1930s, physicians learned to remove cancerous tumors by surgery. The surgery became a game-changing innovation that offered hope to patients. With promising research, effective treatment, and active public education, cancer carries much less social stigma now than nearly a century ago.
Similarly, people with mental illness also carry the stigma of negative stereotypes that suggest they are unstable, violent or have or weak character. “Just pick yourself up by your bootstraps and you will be fine” is the frequent dismissal to individuals with mental illness. With the broader narrative of rugged individualism in this country and the lack of knowledge and misunderstanding of mental illness in AAPI community, the illness comes with unintentional and subtle discrimination.
The Community Mental Health Act of 1963 was among the first game-changing developments in mental health, leading to patients being treated in the less restrictive setting rather being warehoused in state hospitals. The Act raised awareness of the people’s capacity to live productive lives with mental illness and helped to slowly destigmatize mental illness. Not all of the game-changing moments in mental health care have been new laws or medical advances. An opportunity to destigmatize mental illness came as a result of the terrorist attack on September 11, 2001 by prompting widespread conversations about trauma and mental health. In my own experience, government agencies can also play a game-changing role. Crisis counseling was established immediately across Massachusetts for anyone affected as a result of the September 11 attacks.
As the Director of the OMCA, I sought to understand how many racially and ethnically diverse individual sought crisis counseling at these mental health clinics. The informal report was “few” in comparison to Caucasians. OMCA quickly organized phone-in focus groups with diverse community gatekeepers of mental health and human services organizations to find out from their vantage point how the September 11 attacks impacted members of their communities, what barriers existed not only to seek crisis counseling but mental health services in general and how the Department of Mental Health could meet their community mental health needs.
Ten out of thirty-two community gatekeepers who participated were directly involved in AAPI communities across the state. They all agreed that the first priority was to raise awareness of the mental health status in their communities and destigmatize mental illness. Second, it was critical to increase the accessibility and availability of services that are culturally competent. OMCA of the Massachusetts Department of Mental (DMH) which has responsibility and accountability for reducing mental health disparities among underserved, diverse populations, organized the first AAPI community conversation about mental health. Since then, there have been other game-changing events, messages, blueprints, standards of care and action plans that served as catalysts to reduce stigma and improve AAPI mental health care.
In this article, I use my own experiences leading the OMCA to discuss some key, game-changing moments in the struggle to improve mental health in AAPI communities, drawing on key moments that helped shape the conversation in Massachusetts, but also across the United States. These game-changing moments can come in many different forms. Over the last few years, AAPIs with mental illness have courageously shared their stories and shift the negative stereotypes of stigma to positive images of strength, hope and recovery. In 2001, OMCA used a game-changing report from Surgeon General Satcher report to highlight the status of AAPI mental health and to replace a one-size-fit-all mental health care system with a population-specific care planning blueprint. OMCA also applied game-changing cultural and linguistic competence standards to AAPI population to ensure access and availability of culturally and linguistically appropriate care. These moments have all contributed to real and lasting progress in addressing mental health challenges in the AAPI community.
On September 11, 2001 terrorists hijacked four commercial planes. Two, flying from Boston, crashed into the Twin Towers of the World Trade Center. Another hit the Pentagon and the fourth went down in a field in Pennsylvania. The attack rocked the country’s sense of security. All Americans felt vulnerable, unsafe and helpless as individuals. The experience of AAPIs was no different. No one who sees a disaster is untouched by it. The 9/11 attacks were a huge event in American history, but at the time they also provided mental health professionals with an unusual opportunity to reduce stigma and initiate groundbreaking conversations about mental health.
In response to the disaster OMCA teamed up with the state Office for Refugees and Immigrants to reach out to diverse communities. “Coping with Post 9-11 Stress” brought out large groups of Chinese, Vietnamese, Cambodians and Asian Indians to converse on mental health issues in their communities. The community conversation ultimately increased awareness of mental health and lessened some of the stigma for those directly or indirectly affected by the human atrocity of September 11.
During the community conversations, people began to open up about their stresses and struggles. Hourly wage earners from Chinatown restaurants and nearby hotels reported a loss of income because fewer people were traveling and eating out. “We worked for restaurants and hospitality industries and have been laid-off after September 11” said one. Vietnamese and Cambodian refugees were re-traumatized with a heightened sense of fear and coping strategies. They said things like: “I began to stock water and food after September 11.” “I microwaved letters or not open them at all.” “I stopped taking the subway.” “I imposed my own isolation at home.” “My nightmares and flashbacks of the war increased.” Indian Americans and Southeast Asian Americans reported their fear of personal safety as a result of verbal threats, harassment, and discrimination that they received due to mistaken ethnic identity: “You are the one. You are the enemy of this country.” “We felt unsafe in our countries. Now we feel unsafe in this country”.
The shared feelings of vulnerability opened individuals to talk further about their mental and emotional distress in daily life before September 11. Parents felt concerned about their parenting, setting expectations and fear of losing control of their children. Adolescents and young adults talked about the difficulty of communicating with their parents and coping with the parents’ high expectations. Elderly people reported barriers to care due to language, culture and affordability. Immigrants experienced language and cultural barriers, isolation, exploitation, economic hardship and the fear of being a “foreigner” in this country. The community conversation was cathartic, knowing that they were not alone in their experience and being heard without judgement. Many of them wanted to find ways to cope with their mental distress. The openness to talking and sharing reduced some of the social stigma of mental illness.
The event also served as an informal needs assessment of the mental health of AAPI community that led to “Project Be Prepared,” which trained primary care practitioners who provide care for AAPI refugees about how to work with re-traumatized patients. The informal needs assessment also led to the development of community rehabilitation programs with bilingual and bicultural workers providing support to Vietnamese and Cambodian refugees as well as residential programs for Chinese and Vietnamese. In addition, the development of a training curriculum, “Integrating Culture into Practice,” was developed for the training of providers who work with AAPIs.
The conversations in the wake of the 9/11 attacks triggered cathartic discussions and new programs, but they were supplemented by other game-changing programs that were helping to improve mental health in AAPI communities. In 2001, the release of the “Mental Health: Culture, race and ethnicity. A supplement to mental health: A report of the Surgeon General” put the consideration of history, culture, socio-economic status, and race front and center for mental health care policies affecting Asian American and Pacific Islanders, African Americans, Hispanic Americans and American Indians and Alaskan Natives. The report was a game-changer that helped move the country from a one-size-fits-all approach to mental health care to a population-specific model. Surgeon General Satcher was an early supporter of mental health support that considered culture, race, and ethnicity and tried to eliminate disparities. For the AAPI community, the report highlighted the underutilization of services compared to other racial ethnic groups and the need for more outpatient mental health services. Among AAPIs who use services, the severity of their mental illness and the length of suffering is longer. The shame and stigma of mental illness continues to be a major deterrent to seeking care. Language barriers and the lack of bilingual providers further impacted the availability of treatment for AAPIs[vi].
Not all Americans have equal access to quality mental health services. Surgeon General Satcher called for the elimination of racial and ethnic disparities by improving the accessibility, availability and quality of mental health services. OMCA drew upon the findings of the Surgeon General Report to highlight the mental health needs of AAPIs. A few years later, Surgeon General Vivek Murphy, the first Asian American Surgeon General, released the National Prevention Strategy which aims to shift the nation’s focus from sickness and disease to prevention and wellness[vii]. The prevention strategy takes a lifespan approach to the social determinants of health. OMCA added a public mental health focus in designing the blueprint to address AAPI mental health disparities in Massachusetts.
Two year before the Surgeon General Satcher’s Report, the “Cultural Competence Standards in Managed Mental Health Care Services: Four Underserved/Underrepresented Racial/Ethnic Groups[viii]”report provided guidance about providing rapidly growing racial demographic with specific standards for mental health managed care.
OMCA used the language assistance and service standards from the National CLAS Standards to develop the Language Assistance Policy that all mental health care providers are responsible for providing competent language assistance for their Limited English Proficient (“LEP”) and Deaf and Hard of Hearing clients. When a direct care provider and client cannot communicate clearly with each other, the quality of care is compromised. Clients must be allowed to self-identify their preferred language for verbal and written communication, even if they can speak and read English, and ask whether interpreters and translated materials are needed. OMCA considers mental health interpretation and translation a highly technical skill and the use of language volunteers to provide interpretation is highly discouraged unless they have formal mental health interpretation training.
Both reports ultimately laid the groundwork for major improvements in mental health care for AAPI communities. The work done in the early 2000s did not stop there. In August 2011, the Office of Minority Health of the US Department of Health and Human Services and the National Asian American Pacific Islander Mental Health Association (NAAPIMHA) brought together AAPI consumers, providers, researchers, policy makers, health information technologists and community leaders to develop the “Integrated Care for Asian American, Native Hawaiian, Pacific Islander Communities: A Blueprint for Action[ix].” I chaired the Committee of Community-Based Participatory Research and later developed the multicultural research agenda at our Commonwealth Research Centers in Massachusetts.
The knowledge and wisdom behind past and present reports like Surgeon General Satcher’s and the “Blueprint for Action” provided a complete framework for OMCA to improve services for AAPI population in Massachusetts. These national blueprints focused on the role of culture, race and ethnicity in mental health, social determinants of health and mental health, integrated care shift the one-size-fit-all mental health care to AAPI specific programming and practice. Eventually all of this work in building community conversations and creating better policies behind the scenes received a huge boost from President Obama.
President Obama and Vice President Biden hosted The National Conference on Mental Health in 2013 at the White House as a part of the Administration’s effort to launch a national conversation to increase understanding and awareness about mental health. President Obama’s opening remarks addressed the prevalence of mental illness in our country.
“The truth is, in any given year, one in five adults experience a mental illness — one in five. Forty-five million Americans suffer from things like depression or anxiety, schizophrenia or PTSD. Young people are affected at a similar rate. So we all know somebody — a family member, a friend, a neighbor — who has struggled or will struggle with mental health issues at some point in their lives. Michelle and I have both known people who have battled severe depression over the years, people we love. And oftentimes, those who seek treatment go on to lead happy, healthy, productive lives[x].”
He also encouraged us to talk about mental illness and reach out to those who have the illness,
“The brain is a body part too; we just know less about it. And there should be no shame in discussing or seeking help for treatable illnesses that affect too many people that we love. We’ve got to get rid of that embarrassment; we’ve got to get rid of that stigma.” “If you know somebody who is struggling, help them reach out. Remember the family members who shoulder their own burdens and need our support as well. And more than anything, let people who are suffering in silence know that recovery is possible. They’re not alone. There’s hope. There’s possibility.”
The President’s message brought mental illness out of the shadows and empowered those with mental illness and families to share their stories of struggle and recovery. His message is a game-changer that brought AAPIs to talk about their fear of social stigma and share their recovery stories in many community forums in Massachusetts.
As the Board President of the National Asian American Pacific Islander Mental Health Association and the Director of OMCA, I had the opportunity to attend the conference. The national conference attendees included advocates, providers of care, faith leaders, members of Congress, representatives from local governments, individuals who have struggled with mental illness. We explored how the country can work together to reduce stigma and help the millions of Americans struggling with mental health problems recognize the importance of reaching out for. MentalHealth.gov was launched to provide information and resources for those suffering from mental illness and share success stories from those who have received treatment as well as a “Toolkit for Community Conversations about Mental Health” to facilitate local conversations[xi].
The OMCA went to work to use the lessons from the national conference, hosting two Boston community conversations afterwards. Both conversations were also timely because of the psychological vulnerabilities that individuals and the community experienced after the Boston Marathon Bombing on April 13, 2013. Again, no one who sees a disaster is untouched by it. AAPIs were involved with the planning and implementation of the two community conversations, “Many faces of mental health: sharing our stories” and “Many faces of mental health: mind, body and spirit.”
The community-driven conversations focused on the impact of race experience, social determinants of mental health, direct and indirect trauma have on individual mental health and well-being. African Americans, Hispanic Americans, Asian Americans made up the largest participants in the two-year citywide events in Boston. Among them was a new generation of Asian American advocates with lived mental health experience. They spoke with strength, clarity and effectiveness about their fear of social stigma and the dismissive reactions to their illness by families and friends. Their disclosure and sharing of hope and recovery were a game-changer to the reduction of stigma of mental illness. Since then, I have seen them in many community forums sharing their stories and raising awareness. We all embraced the message of “Prevention works. Treatment is effective and People recover[xii].”
President Obama’s message and community conversations brought out new energy and commitment. I also learned that a powerful message can be lost with the passage of time when community conversations happen infrequently. Making small grants available for community organizations to have ongoing community conversations is the most cost-effective way to reduce stigma, promote good mental health and prevent mental illness.
Game-changing actions at the state level
Much of my work in mental health has come through the state of Massachusetts. State mental health authorities are poised to address issues in serving culturally and linguistically diverse populations; however, there are currently only a limited number of dedicated offices across the country that have taken steps to implement cultural and linguistic competence strategies with the goal of reducing mental health disparities in status and care[xiii].
The establishment of the Office of Multicultural Affairs by the Massachusetts Department of Mental Health (DMH) was an important step to institutionalize cultural and linguistic competence (CLC) as a structural priority within the State Mental Health Authority. The office also served as an integrated focal point for increasing the access, availability and appropriateness of care for diverse populations, including the AAPI community. This was accomplished by the annual Cultural and Linguistic Competence Action Plan that operationalizes six integrated areas of focus of DMH. They are: community partnership, leadership development, services, training and education, data collection, research and evaluation and information dissemination. The office, for instance has led initiatives to increase cultural competency and improve and built analyses of mental health care disparities into the Department’s quality improvement activities.
The most affirmation of what OMCA achieved is when a Vietnamese-Chinese resident who suffered from chronic mental illness shared his appreciation with me when he moved from his regular residential program to a specialized Asian community residential program that provides cultural activities along with Chinese and Vietnamese meals that residents and staff prepare together. He felt the wholeness of who he is rather than being defined merely by his mental illness. During Vietnamese and Cambodian New Years, clients and bilingual, bicultural staff at the specialized Asian community rehabilitation programs celebrate the holidays with a religious ceremony with invited monks, traditional music and festive activities. Their mental health and well-being are supported by their invaluable cultural re-connection as a key part of the program. These specialized services integrate the science of treatment with culturally and linguistically appropriate recovery experience.
OMCA has continued to develop new initiatives since its founding to institutionalize cultural and linguistic competence through the Multicultural Advisory Committee of the Department. The goal of the advisory committee is to strengthen engagement and partnership with the community. Committee members including AAPI consumers who provide input into the planning and implementation of the Department’s Cultural and Linguistic Competence Action Plans as well as closely monitor the progress and results. Through partnering with community organizations, the OMCA has also worked to promote peer leadership and empowerment programs for AAPIs. The office developed a training curriculum to integrate the AAPI client’s culture into the assessment and treatment for direct care staff. It continues to partner with the AAPI community on the annual Asian American Mental Health Forums, which brings together people with lived experiences of mental health challenges, researchers, policy-makers and practitioners as equals to learn from each other.
On the policy front, OMCA led a major data policy initiative to eliminate mental health care disparities across state children’s services. The interagency team developed the standard of a uniform data collection of client’s race, granular ethnicity and language need based on federal requirements and recommendations on ethnic data collection in the Institute of Medicine report on “Race, Ethnicity and Language: Standardization for Health Care Quality Improvement[xiv].” As a result, AAPI data collection today include subgroups of different ancestries or countries of origin. Altogether, the OMCA has institutionalized the applications and improvement of the national game-changing developments in mental health care in the Massachusetts Department of Mental Health.
Accountability by deliverables and not mere rhetoric is essential in moving to towards equity. The public stewardship of underfunded mental health care and redistribution of already limited resources to underserved groups is challenging. Moreover, it is even more difficult to redistribute already limited resources to underserved groups. It is thus critical to highlight disparities by data and stories and identify achievable action steps as an integral part of an organization’s quality improvement.
Cultural and linguistic competency is an important part of organizational development. True commitment to inclusion of staff and client diversity is a driver for change. Building the organizational scaffolding in cultural and linguistic competence policy, programming and practice requires top-down and bottom-up employee engagement. The transformation of the mental health service delivery system is gradual.
For those who have the public stewardship role of the mental health service delivery system, the transformative change is hard work and takes a long time. We need to sustain our enthusiasm and self-care to avoid burnout. By looking back for the past 18 years of planning and implementation, I have seen a continuity of policy, program and practice on AAPI mental health care. Local and national game-changers and the collective efforts of champions have made a difference toward the reduction of mental health status and care disparities.
The reduction of mental health disparities status and care takes the effort of many. It is difficult to acknowledge all the contributors who have done excellent work in policy, program and practice. I want to acknowledge several colleagues that I worked closely with for many years. Because of their skills and knowledge, they have made significant impact on my work.
Biography: Dr. Ed K.S. Wang retired as the former Director of the Office of Multicultural Affairs, Massachusetts Department of Mental Health and received the 2015 Community Hero Award of the Massachusetts Asian American Commission. He is the Director of Policy and Planning, Division of Global Psychiatry, Massachusetts General Hospital and Assistant Professor of Psychology in the Department of Psychiatry, Harvard Medical School. His domestic and international work focuses on improving the social and emotional well-being of youth, adolescents and young adults, strengthening families and community wellness through the investment of social justice, evidence-based and community-driven evidence, informatics, networks and sustainability. He was the first Asian American psychologist appointed to the National Advisory Council, Substance Abuse Mental Health Services Administration, an invitee to the White House National Conference on Mental Health and the White House Asian American Pacific Islander Commission on Depression and Suicide Prevention. Born in Hong Kong, Dr. Wang is currently the President of the National Asian American Pacific Islander Mental Health Association that developed the blue print for integrated care for AAPI Communities. He was appointed by Massachusetts Governor Baker to be a member of his Advisory Council on Refugees and Immigrants. Dr. Wang bases his policy and program development on humility and respect displayed by the practice of his wife, Kathleen, a cross-cultural psychotherapist.
Dr. Larke Huang, Director of the Office of Behavioral Health Equity Substance Abuse and Mental Health Services Administration, is a “must meet” person to understand disparities, current initiatives across the country, and future ideas towards the reduction of disparities. Her office provides AAPI behavioral health and in-language resources, national survey data, and reports on federal initiatives.
The “Integrated Care for Asian American, Native Hawaiian, Pacific Islander Communities: A Blueprint for Action” is the brain child of Dr. DJ Ida who is the Executive Director of the National Asian American Pacific Islander Mental Health. She has been a true a champion of improving Asian mental health care across the country for over three decades with a current focus on AAPI women’s wellness.
Elisa Choi, M.D., Massachusetts Chapter Governor of the American College of Physicians, Past Chairperson, Commonwealth of MA Asian American Commission, has always put the spotlight on the importance of AAPI mental health among other AAPI issues in Massachusetts.
Chien-Chi Huang, the Executive Director of Asian Women of Health and a cancer survivor, founded the Annual Asian American Mental Health Forum which continues to be annual event for the past 10 years.
[i] Ahn, H. E. (2017). Films that heal: “Looking for Luke” explores mental health. Retrieved from https://www.thecrimson.com/article/2017/4/13/looking-for-luke-conversations/
[ii] Office of Minority Health. Mental Health and Asian Americans. (2016). Retrieved from http://minorityhealth.hhs.gov/templates/content.aspx?ID=6476
[iii] Cooper, J.L., Aratani, Y., Knitzer, J., Douglas-Hall, A., Masi, R., Banghart, P. and Dababnah, S. (2008). Unclaimed children revisited: The status of children’s mental health policy in the United States. Retrieved from: http://www.nccp.org/publications/pub_853.html
[iv] Kramer, E.J. and Lu, F.G. (2008). Recognizing and managing the stigma of mental illness in Asian Americans-video. Retrieved from: http://ethnomed.org/clinical/mental-health/SavingFace.flv/view?searchterm=saving%20face
[v] Knapp, S., Marziliano, A. and Moyer (2014). Identify threat and stigma in cancer patients. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5193175/
[vi] U.S. Department of Health and Human Service. (2001). Mental Health: Culture race and ethnicity. A supplement to mental health: A report of the Surgeon General. Rockville, MD: Author.
[vii] Murthy, V.H. Surgeon General’s perspectives. Public Health Reports, 2015 May-Jun; 130(3): 193–195. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388212/
[viii] Center for Mental Health Services. (2000). Cultural competence standards in managed mental health care services: Four underserved/underrepresented racial/ethnic groups. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.
[ix] Substance Abuse and Mental Health Service Administration (SAMHSA). (2012) Integrated care for Asian American Native Hawaiian and Pacific Islander communities. Retrieved from: https://www.integration.samhsa.gov/workforce/Integrated_Care_for_AANHPI_Communities_1_23_12_Blue_II.pdf
[x] The National Conference on Mental Health. (2013). Retrieved from: https://obamawhitehouse.archives.gov/blog/2013/06/03/national-conference-mental-health
[xi] Substance Abuse and Mental Health Service Administration (SAMHSA). (2013). Community conversations. Retrieved from: https://store.samhsa.gov/product/Community-Conversations-About-Mental-Health-Discussion-Guide/SMA13-4764.html
[xii] Substance Abuse and Mental Health Service Administration (SAMHSA). (2017). Prevention works, treatment is effective, people do recover. Retrieved from: https://www.facebook.com/samhsa/posts/prevention-works-treatment-is-effective-and-people-do-recover-the-surgeon-general/10154642275752507/
[xiii] Issacs, M.R., Jackson, V.H., Hicks, R. and Wang, E.K. Cultural and linguistic competence and eliminating disparities. In Stroul, B.A. and Blau, G.M. eds. System of Care Handbook: Transforming mental health services for children, youth and families. Baltimore, MD: Paul H. Brookes Publishing Co., Inc., 2008: 301-328.
[xiv] Institute of Medicine (IOM). (2009). Race, ethnicity, and language data: Standardization for health care quality improvement. Washington, DC: The National Academies Press.