The relevant literature is limited, even with regard to difficulties faced by Koreans in accessing child and adolescent mental health services in their own country. One survey identified a lack of information about available services, prejudice about mental illness, and misconceptions regarding severity being the main obstacles to accessing services (10). Our results show similar problems as well as additional difficulties related to immigration from a traditional Asian culture to a Western, English-speaking country.
Our analysis identified two groups of barriers, attitudinal and structural/systemic. The most prominent attitudinal barriers included perceived shame, embarrassment and guilt in having children with emotional and/or behavioural problems. These were generally considered a parental responsibility, and helps explain why parents avoid service referral and attempt to solve problems by themselves or within their own immigrant community.
Shame plays a key role in social control and underlies the enforcement of rules in Confucius philosophy-influenced Asian countries, including Korea (11). The shame of losing face for the individual is shared by the wider family and community itself. Accordingly, the disturbed behaviour that accompanies mental illness tends to cause shame and embarrassment in the family and wider community. As a result, mental illness is often kept hidden and secret.
Despite being given the explanation that our two scenarios reflected treatable mental illness, instead of experiencing relief from what might be seen as a face-saving alternative, most parents objected to this explanation and actively disputed the illness model. This attitude appears related to both mental health literacy and stigma. Thus, when stigma is perceived as too high a price to pay, parents disregard illness as a model for explaining children’s behavioural and emotional problems.
In Korea, both mental and physical illnesses were traditionally attributed to superstitious belief systems until contact with Western concepts following the Korean War in 1950. After this, and subsequent rapid industrialisation, belief systems regarding mental illness have evolved. Koreans have been integrating Western models of both physical and mental illness. Child and adolescent mental health is no longer a taboo subject in Korea and is now commonly discussed in the media, including television programs such as “Live Good Morning” that include discussion of common cases by mental health professionals.
In our focus group discussions, there was very little attribution of mental illness to superstitious or ancestral curses, unlike findings among Chinese immigrants to Australia (12). This difference may relate, in part, to the high educational attainment of the Korean parents in our sample.
There has been a misconception based on cultural stereotypes that Asians are model citizens and therefore experience lower rates of mental illness. However this hypothesis has been challenged, and it pointed out that Asians with mental illness often suffer in silence until the family and community are unable to cope, leading to delayed and ambivalent engagement with mainstream service providers (13).
Korean immigrants who have been less integrated into their host culture tend to adhere to beliefs in attitudes prevalent at the time they left Korea. Such individuals, as parents, appear to avoid contact with mental health services for their children. It was evident in focus groups that those with experience of child mental health services in Korea were more positive toward such services in NZ. Additionally, recent immigrants or parents of international students appeared to show better levels of mental health literacy compared to Korean immigrants who had lived in NZ for longer.
Structural barriers included lack of information about service providers and how to access them, and concerns regarding service providers’ cultural competency, specifically regarding non-Koreans’ ability to understand the nuances and underlying meaning of the family problems. Remarkably, none of our participants was aware regional child and adolescent mental health services or how to access these. Likewise, they were unaware of the Health and Disability Code of Patient Rights and the free provision of translators.
In addition to language barriers, differences in mental health service organisation may add to difficulties in access. For example, Korea has universal mandatory public health insurance, and citizens can seek the opinion of any doctor of their choice. Specialist or hospital based services do not require formal referral, and healthcare access and choice are thus very much consumer based. Our findings suggest that this systemic difference added to Korean immigrant parents’ fear of losing control in managing mental disorder in their children.
The majority of our participants preferred opting out of public mental health services in favour of alternatives, such as seeking help through family networks and community organisations, notably Korean churches. Most agreed that they would, if necessary, go back to Korea to seek an opinion from a Korean child psychiatrist or mental health service. Our findings are similar to those described by Oh (2014) in terms of the importance of culture and language barriers and also the perceived lack of accessible information regarding mental health services.
In 2002 the NZ Mental Health Commission recommended promoting mental health in Asian communities by increasing public support for cultural diversity, providing information, English language education, developing community support programmes and increasing service providers’ awareness of Asian cultural issues (8). Unfortunately, after 15 years there is little evidence to indicate effective nationwide implementation of these recommendations or indeed changes in the way Asian populations tend to view and access mental health services. Thus, although these results were derived from one region (Waikato), they are likely to reflect more general barriers to clinical service access in NZ.
On the other hand, some regional initiatives are relevant, including a Korean mental health and addiction awareness group (Like Minds, Like Mine, 2016). Asian mental health support groups have also developed in Auckland (Independent Living Services, 2013), New Zealand’s largest city and one with a proportionately higher Asian population than elsewhere in the country. Similarly, the Mental Health Foundation, a charitable trust, has developed Kai Xin Xing Dong, a public education program to reduce stigma for Asian youth experiencing mental illness (Mental Health Foundation, 2017). The impact of these initiatives is as yet uncertain.