Clients, therapists say culture plays key role in mental health treatment

First of three parts

Ale Bugaro is listening to her new client's uncertainty about seeking therapy for her depression and anxiety.

The client just isn't sure it will work.

Besides, the woman tells Bugaro, she's already paid a witch doctor $500 to chase the devil out of her.

Bugaro doesn't bat an eyelash. “That is good. You took action,” she tells the woman. “Now let's see what else we can do for you.”

A Uruguyan-born senior therapist at the Lake County Health Department and Community Center, Bugaro is keenly aware of cultural issues at play among her primarily Mexican clients, many from small towns where “curanderas” commonly prescribe herbal remedies to treat ailments of the body and mind.

“I always utilize whatever works for them,” she said. “If they say, 'I go to church twice a week' or 'I put a candle to the Virgin of Guadalupe,' I say, 'Absolutely.' It's not about taking what they believe from them. It's about adding the Western culture to that. If you don't do that, you lose the patient automatically.”

There are nearly 8.4 million people in Cook, DuPage, Kane, Lake, McHenry and Will counties, and they have more than 100 different ancestries, according to the U.S. Census Bureau. National averages say half of them will have a diagnosable mental health condition in their lifetimes, and one in five adults face such issues in any given year.

Understanding culture and the role it plays in the experience and expression of mental health is key to providing an accurate diagnosis and appropriate treatment, experts say.

And it seems every culture encounters and perpetuates its own hesitation to discuss mental turmoil, typically out of fear it makes those affected seem weak, crazy, or simply imperfect.

The best way to address these fears, psychologists say, is to seek treatment from someone who “gets it” — someone who shares your cultural background, or someone who is trained to understand.

Cultural avoidance

Issam Smeir, a trauma counselor for World Relief refugee resettlement agency in Wheaton, says some Asian, Indian and Middle Eastern cultures are more likely to look at the world through a lens of what will bring honor and what will bring shame.

Like Bugaro, Smeir says it's not his job to change a client's cultural framework, but to work within it. Understanding cultural modes of thinking, for example, allows him to help clients overcome triggers that bring back traumatic memories of violence or abuse.

The collectivist nature of some cultures can deter people from seeking treatment, says Sandra Yu Rueger, a psychologist and professor in Wheaton College's clinical psychology doctoral program who is researching mental health among Korean Americans.

People think, “If I were to seek out help, not only does that mean there's something wrong with me, but there's something wrong with my family — or my parents didn't do their job,” Yu Rueger said.

Indians, meanwhile, tend to avoid treatment because of cultural pressure to be a “model minority” with a successful professional career, says Soji Thomas, a counselor at Amita Health Alexian Brothers Center for Mental Health in Arlington Heights.

Many Indian clients request non-Indian therapists to remain more anonymous. And they want quick results.

“They say 'I need to be cured in three to four sessions. Do whatever you need to do to get me to that point,'” she said. “It's difficult to accept that this is not going away.”

In the Lao community, the lack of value placed on mental health leads to a dearth of providers, said May Saengpraseuth, who grew up in Elgin and works as a school social worker in Chicago.

“Human services and counseling, for lack of a better term, is not 'sexy' in the Laotian community, because you are not making a lot of money,” she said. “Parents push their children to be doctors, lawyers, pharmacists, ophthalmologists, and the ones that succeed get there. But nobody pushes their children to be a mental health professional.”

Her community especially needs trained providers, she said, because many Lao immigrants suffer from undiagnosed depression and post-traumatic stress disorder from fleeing war and a Communist regime in the 1970s.

When feelings of depression are expressed through physical symptoms, it's more socially acceptable, says Leila Azarbad, a first-generation Iranian American and associate professor of psychology at North Central College in Naperville.

“A lot of times a person doesn't even recognize this is anxiety,” Azarbad said. “It's manifesting itself in physical symptoms.”

In the Polish community, people often seek out therapists as a last resort, after they've talked to doctors, priests and teachers, said Joanna Huk, a psychologist in Hoffman Estates.

By the time they come to her, their conditions are more acute. “If you wait too long and the symptoms continue to persist, ultimately at the end you're going to have more to deal with,” she said.


Mental illness can carry such a stigma in Mexican culture that often family members won't discuss it with anyone. It's not uncommon among small-town families to care for “the crazy uncle” in private, isolated from society, said Raquel Doyle, a bilingual therapist with Ecker Center for Mental Health in Elgin.

“They try to resolve it within the family, because you don't air your dirty laundry,” she said.

Latino immigrants are under particular duress these days because of increased fears of immigration enforcement, Torres said.

Anna Matyja, director of mental health at Hamdard Healthcare in Addison, said she's also seeing large numbers of stressed-out Southeast Asian and Bosnian immigrants “with a lot of fear about their future.”

Even having a psychologist in the family sometimes isn't enough to dispel misconceptions.

Mount Prospect bilingual psychologist Edgar Ramos, who grew up in Chicago, says many in his inner circle still can't grasp the reality of mental illness.

“My parents still have no idea what it is that I do,” said Ramos, director of psychological services for Family Behavioral Health Clinic at Maryville Academy in Des Plaines and an assistant professor at Concordia University in Chicago. “They still think it's a choice to be mentally ill. They don't believe in medications.”

People must be taught to recognize symptoms of mental conditions, especially common ones like depression and anxiety, and to know help is available, said Yahaira Torres, a counselor with the Lake County Health Department. “It's about educating and empowering them,” she said.

Marcos Bostho, outreach and prevention coordinator at Open Door Health Center of Illinois in Elgin, has found Spanish-speaking clients in an unorthodox way — by walking into bars. There, people are more likely to open up about their depression and anxiety about language difficulties and raising families in a foreign culture, he said.

“There's a lot of stigma still around mental health services,” Bostho said. “People say, 'Oh, I'm not crazy. I don't need those services.' They imagine someone in a white coat and being out of their mind, walking with no destiny, inside a mental hospital.”

Mental illness is real

Relatives can perpetuate misconceptions about mental health, even when their loved one seeks treatment. This creates a new layer of shame and can hamper the process, says Margot Smith, director of counseling services at 360 Youth Services in Naperville.

“We have a lot of kids coming in who maybe have a parent at home who won't participate because they don't believe in family counseling,” Smith said. “They say 'It won't be helpful,' or 'That stuff doesn't work,' or 'It's not helpful to talk about your feelings.'”

For Itzayana Uribe of Mundelein, getting mental health treatment meant losing her relationship with her husband's parents.

Uribe's first experience with therapy was in her native Mexico, after she was raped and became pregnant with her eldest daughter. She moved to Illinois about 17 years ago, and sought treatment when her second pregnancy triggered her trauma symptoms. Now, she sees a therapist every two weeks or so, but never visits her in-laws.

“They don't understand. Because I'm seeing a psychiatrist or a psychologist, they think I am crazy,” she said. “That's a big issue in the Hispanic culture. They need to learn about the medical help. It's an illness, it's like the flu — you have to take medication.”

Even those trying to break cultural silences around suicide prevention can be called into question.

That's what happened to Dimple Patel, 29, of West Chicago, a psychology student whose mother died by suicide. She's been speaking out about the topic, especially among the South Asian community, by writing essays and participating in walks.

But some don't get it, she said. “Why won't she let her mother's soul rest in peace?” Patel remembers someone asking. “I got so mad hearing that because that's exactly why I'm doing this. I want to break down the lack of knowledge around the importance of education and prevention efforts.”

Patel said she might start an outreach effort to shed light on suicide warning signs. “Somebody has to take that step and do something for the South Asian community.”

Simply providing a willing ear can put people on a path to healing, said Promila Kumar of Buffalo Grove, who started a website called, or “A Helping Hand for You,” in Sanskrit.

The site lists resources and a hotline for South Asian suburbanites staffed by volunteers who connect callers with psychiatrists or psychologists in their area and offer cultural understanding. “They don't feel that they are being judged,” Kumar said.

Encouragingly, North Central's Azarbad says, students' views about mental illness seem to be shifting.

Pop culture has helped, with reality TV portrayals of people with obsessive-compulsive disorder or identity issues, while more student groups are geared toward mental health awareness.

“Young adults over time have become increasingly more open to this idea that, 'Mental illness is real. It does not reflect weakness. And we're going to view it like we view any other medical illness,'” Azarbad said.

Integrated approach

People often turn to physical ailments to express emotional distress, experts say.

Instead of talking about their depression, for example, “They might be saying 'My stomach hurts,' or 'I'm having trouble sleeping,'” said Angela Forfia, program director for the Asian Health Coalition.

That's why it's important to connect physical and mental care to fully address clients' needs, some providers say.

Linden Oaks Behavioral Health in Naperville, for example, places psychologists and social workers in primary care offices at 11 locations.

“People feel comfortable with their doctors, so they tend to bring a lot of issues there,” said Marc Browning, a nurse and psychologist who directs counseling services for Linden Oaks Medical Group.

The program dampens the stigma around mental health, builds coping skills, and helps patients improve well-being.

Ultimately, he says, this decreases health care costs.

Similarly, the Lake County Health Department offers primary and behavioral care at its nine federally qualified health centers where clients, no matter the reason for their visit, are eligible for a comprehensive physical and mental health assessment, said Nick Caputa, the health department's associate director of clinical operations.

That's especially effective, therapist Bugaro said, among Hispanic immigrants often reluctant to see therapists.

“We want to make sure that their head and their body are taken care of,” she said. “It's a holistic approach.”

Monday: A shortage of bilingual mental health providers finds patients struggling to convey feelings in their second language.

Organizations that offer mental health assistance

  AT DAILYHERALD.COM/MORE: Being active in the community, such as attending a CPR training session in Mundelein, helps Itzayana Uribe cope with her mental health issues. She is estranged from her in-laws because of the stigma in the Latino community of seeing a psychiatrist or psychologist. Gilbert R. Boucher II/
  Joanna Huk, a psychologist in Hoffman Estates, says people in the Polish community often seek out therapists as a last resort, after they've talked to doctors, priests and teachers. Bob Chwedyk/
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