Perceptions of Mental Health Service Utilization Among Ethnic Communities
All participants discussed the negative and stigmatized perceptions of mental health. Participants consistently talked about the perception that individuals who seek MHS are “crazy”; This label related to what all participants discussed as a taboo in seeking mental health care among their communities. Taboos were related very strongly to participants disinclination to seek mental health services or their desire to keep their mental health needs secret. One reason given for these perceptions was a lack of knowledge and old-fashioned perceptions about mental health care and institutions.
“Um, yes I think it's still a bit taboo and um just not enough knowledge of it. Or that they think yes psychiatry, psychologist, psychiatrist, that's where you go when you're crazy. And um have a very different view of psychiatry than it actually is.” (Participant 7, Provider)
Some participants also reported differing responses from their immediate families. These experiences varied depending on the existing relationship with parents and the participant’s age. Some participants reported that individuals in their social support network wanted to be supportive but did not understand mental health. Additionally, participants discussed strong cultural norms around not discussing personal issues outside of the home setting.
“My mother was open that I was going, but she was sceptical about it herself. You go to a psychologist if you are crazy in quotation marks, and they have that very much in their head even if you feel a little worse or less comfortable in your skin that you can talk to someone…And you shouldn't discuss your business from home with the outside, that's a big deal.” (Participant 3, Client)
Mismatch between Providers and Clients
A common complaint through all interviews was the homogeneity of health practitioners in the Dutch mental health system. All participants shared the views or experiences that the Dutch health system comprised mostly of Dutch-speaking practitioners with Dutch backgrounds, this lack of diversity affected the perception of care. One major way in which this influenced the perception of care was regarding language. Language mismatches were sometimes due to the client being unable to speak Dutch and the practitioner not speaking the client’s language. However, it was also related to participants feeling unable to properly express themselves and their complex thoughts and emotions in Dutch.
“a Dutch psychiatrist is less able to empathize with an Antillean client, for example. Yes, you see that very often there is and remains a language barrier and if [Dutch] is not your mother tongue, for example, then it is difficult to express yourself in that language.” (Participant 7, Provider)
While the cultural match was important, it also appeared that what was necessary was not a direct match between cultures. However, an individual with some understanding of minority cultures was perceived as being more understanding of the cultural considerations. This is illustrated by a Turkish clients (participants) discussion of her Cape Verdean psychologist
“.. a Cape Verdean man and in terms of culture he knows quite a lot and I like that too, because yes you don't take me wrong, because I was also just born and raised Dutch, and I am also just Dutch for my feelings. But of course, I have a background of culture and what's just nice, um yes, he understands” (Participant 9, Client)
The third aspect of cultural mismatch was expressed by two participants who began utilizing mental health services as minors. They expressed a frustration as the inability of health care professionals to understand the constraints of their culture, acceptable behaviour and the rules that governed their lives.
“Um, it's not necessarily that she did it consciously or anything... I was 17 at the time so I was with a child psychologist at the time, …you noticed that there were differences in their thinking and my way of thinking. For example, they said you're almost 18 so you can do this and this. And that doesn't quite work in the culture and then she did try to come up with other solutions or some things I thought of that is not entirely realistic in my situation so in that area it sometimes clashed.” (Participant 3, Client)
Availability of Services
In relation to the access and availability all clients of mental health services had positive experiences and did not experience any barriers with regards to gatekeepers or finances. Clients and practitioners did not discuss any ethnic or sociodemographic health system barriers to accessing mental health services. However, a commonly discussed problem was the presence of waiting lists, while the client participants themselves had not experiences this, they all knew of individuals who had experienced significant delays in receiving care. This was collaborated by health providers who discussed long waiting lists, limited mental health service providers, insufficient training of new mental health workers and limited finance.
“Very long waiting times, uh from locker to wall. And the larger the mental health institution the worse. A lot of expiration days, then you hear from patients of mine had to wait three four months before I could see the psychologist. After an intake, a next intake comes and then they get a note of maternity leave, check it out. I will be here in 6 months and my colleague will guide you further and that colleague is sick, and you name it. That kind of crap.” (Participant 6, Provider)
In such a system with long waiting lists, participants discussed the importance of understanding the Dutch healthcare system, including insurances and referral system. Some participants also discussed that non-ethnic Dutch population often had limited knowledge related to navigating the health system which could also affect their experiences of seeking care and ultimately mental health outcomes.