"Mental health is a Western concept," she says. Many people from minority and immigrant groups look at mental distress in totally different ways from the way most majority white people do, she has found in her research.

"Among some immigrant and refugee families, discussions of mental health problems or mental illness is taboo, due to a cultural perspective that mental illnesses signify being 'crazy' or 'mad,' thereby preventing families from seeking help because of fear of bringing shame on the family," she says.

Studies also suggest that communities of color and immigrant populations are more likely to display physical rather than psychological symptoms in response to their mental health problems.

A mental health professional could mistakenly send a person with chest pain to a medical doctor, for instance, not recognizing that chest pain is an expression in some cultures of mental distress. 

These and other factors call for a new understanding of mental health among marginalized groups and immigrant children and families. "There is an urgency for a paradigm shift in the conceptualization of engagement in mental health treatment—from the current approaches that limit engagement to a process of treatment and participation, to a broader conceptualization that begins from problem recognition and runs through participation in treatment services," says Yasui.

In a new paper, published in the journal Clinical Child and Family Psychology Review, she and co-author Kathleen Pottick call the new approach "Culturally Infused Engagement." This is a process of looking at mental health through a definition of culture as an intergenerationally transmitted system of meanings that encompasses values, beliefs, and expectations, including traditions, customs, and practices shared by a group.

"This approach bridges the gap between clinical practice and mental health services research," says Pottick, Professor at Rutgers University School of Social Work. "Through this new conceptualization, which is theoretically based, we can use new information to reduce disparities and help those families who need mental health services."

Yun Chen, AM '15, a member of the research team at SSA being trained by Yasui, is the third author on the paper.

Yasui and Pottick began their work together when Pottick was a visiting scholar at SSA in 2015. The bulk of her research has focused on better understanding the barriers to the provision of effective mental health services for children and adolescents, and disadvantaged populations, and on developing strategies for removing the barriers. One line of research investigates racial and ethnic disparities in mental health service use for youth with serious emotional disorders in the United States. Another line targets clinicians' attributions of youths' emotional problems and the correlates of biased perceptions.

Pottick is co-author of The Parents' Perspective: Delinquency, Aggression and Mental Health with Paul Lerman. The book is an analysis of urban minority adolescents receiving outpatient mental health services in Newark, NJ. She publishes in the fields of social work, psychology, and psychiatry. Because the two shared an interest in ethnic minorities, immigrant children, and families with mental health challenges, they decided to collaborate.

In the paper, Yasui and Pottick review existing measures of engagement that intersect with Culturally Infused Engagement (CIE) and suggest the need for mental health research based on a greater appreciation for culture. They also say CIE can benefit clinicians by helping them better assess the perspectives of their clients. The approach could help social service agencies be more in tune with the role that culture plays in mental health and help guide policy makers in advocating for more mental health services in areas where many ethnic and racial minority people live.

Understanding the role of culture in mental health has been a passion for Yasui since her days in graduate school at the University of Oregon, where she received a PhD in Clinical Psychology. She completed a clinical internship at the University of Illinois at Chicago, Department of Psychiatry, Institute for Juvenile Research. Prior to joining SSA, Professor Yasui completed a National Institute of Mental Health Postdoctoral National Research Service Award Individual Fellowship.

She also knows first-hand what it's like to be a minority member in another culture. Her father was an executive with an international Japanese company, and she moved with her family as a child to the United Kingdom, Hawaii, and Singapore, where she finished high school. She returned to Japan to attend college and found herself something of an outsider in her own culture, an experience that gave her an opportunity to view her homeland "through two lenses," she says.

The experience of living around the world and developing an ability to view cultures from different perspectives underlines her interest in diversity.

As a postdoctoral student, Yasui's interests in diversity, culture, and mental health came together when she helped develop a new intervention that was intended to improve communication and trust between therapists and clients from different cultures, the two-part Culturally Enhanced Videofeedback Engagement (CEVE). The program helps therapists begin their conversations with clients from the point of view of the client's culture. It was intended to provide a way to help parents whose children were experiencing disruptive behavior.

To start the CEVE, the therapist asks parents to choose influences or barriers that affect them from a cultural ecogram, an interactive activity Yasui created that uses cards depicting factors such as "my family," "education," and "spirituality/religion," as well as blank cards for parents who wanted to name other influences.

The second aspect of the approach uses integrated videofeedback, in which the therapist and parents jointly observe a videotaped interaction of parents doing a puzzle together or working in a situation that illustrates a point of stress.

"The value of this approach to access culture came through when I worked with an African American grandmother whose granddaughter was disruptive in school, and they were referred to us," Yasui recalls. "The granddaughter was asked to pick up some toys, which she did, except that she threw them into a box while she rolled her eyes at her grandmother. That angered the grandmother."

Yasui had thought that they had been making progress because the girl was following instructions. But from the grandmother's point of view, no progress was being made. Following instructions, to her mind, was a secondary issue. "The grandmother expected to have respect. She needed that because she had to know her granddaughter would follow her instructions as she dealt in the future with situations at school and potential dangers in their neighborhood. Having the video to watch and discuss made all the difference," Yasui says.

Yasui developed the Culturally Enhanced Videofeedback Engagement platform as an innovative application of another video tool, the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS), that was developed by her mentor, Lauren Wakschlag, now Professor and Vice Chair of Medical Social Sciences at Northwestern. Yasui worked with Wakschlag first during her pre-doctoral internship at the Institute for Juvenile Research at University of Illinois at Chicago, and then as the postdoctoral mentor on her National Research Service Award at Northwestern.

Wakschlag’s group had developed the DB-DOS as a videotape observation tool for clinical identification of preschool children with disruptive behavior. It includes a standardized interaction between parents and children.

Wakschlag recalls: “When Miwa saw the DB-DOS paradigm in use, a light went off for her. She had an inspiration about how she could use the DB-DOS in an entirely novel way as a clinical engagement tool for therapists and clients who are racially or ethnically dissimilar." This idea built on Miwa's longstanding theory that shared observations would have power to bridge cultural divides by providing a common framework for discussion, she says.

"This is an example of her creativity, passion, and commitment," says Wakschlag. By bridging a number of disciplines, Yasui is able to make breakthroughs, she points out.

Wakschlag says that Yasui's research is particularly important because much of the work mental health clinicians do is based on an ethnocentric perspective that is different from that of ethnic and racial minorities. "Even the concept of a barrier to treatment might not be applicable" to people from groups with another understanding of mental health problems that differ from the traditional Western model, she explains.

The shared understanding that develops from Culturally Infused Engagement paradigms and procedures is intended to create a mutual understanding and strengthen the alliance between the clinician, the parent (who is the client), and the child, Wakschlag explains. By putting the emphasis on the needs of clients and giving them a voice, the model provides a way to make them the focus of attention and increases the likelihood that they will become  engaged and continue to receive treatment, while at the same time providing a window for the clinician on the clients’ perspectives in real time, she adds.

Providing mental health services to racially and ethnically diverse youth becomes increasingly important as the United States population changes. The US Census reports that in 2014 there were 52 million white children under the age of 18, a number that will fall to 35.6 million by 2060. There were 48 million minority children in 2014, a number that will increase to 64.4 million by 2060. By 2020, white children will no longer make up the majority of births in the United States.

Studies estimate that racial and ethnic minority children and youth are one-third as likely to receive mental health services as whites, despite comparable rates of emotional or behavioral disturbances across groups, Yasui points out. The studies show that 6.6 percent of ethnic minority children and youth receive services, compared to 20 percent of white children.

The implications on health outcomes are serious. Those children who need and don't receive services are more likely to have increased depression and/or anxiety, engage with deviant peers, or become involved in violent crime. They are also more likely to have poor academic performance, experience drug and alcohol abuse, or become unemployed.

The problems communities of color and immigrant children and families face can be particularly troubling if violence and dislocation are part of their background. That has been the experience of Cambodians in Illinois, who came to the US as refugees, fleeing civil war and the genocide of the late 1970s, and their children and grandchildren who have been born here.

Many are still dealing with the trauma of that time, and Yasui is working with the Cambodian Association of Illinois/National Cambodian Heritage Museum and Killing Fields Memorial on ways to deal with their experiences.

The association seeks to address the needs of its community in a holistic way, providing cultural programs as well as activities for youth and care for seniors. It serves the original refugees and generations that have followed.

Yasui is meeting with focus groups to learn more about their experiences and the cultural aspects of their mental health challenges, says Kaoru Watanabe, associate director of the association.

"There is very little research on mental health and the Asian community and very few models that can help us," Watanabe says. "Our community has the additional problem of being traumatized by civil war, genocide, and relocation.

"She has interviewed people to explore what might be a more appropriate way for us to deal with this trauma. Research likes hers really opens our eyes and helps us discover things we didn't know. It's been a wonderful experience working with her," says Watanabe.

Yasui says she has helped the community understand their feelings of stigma toward mental health treatment and helped them realize the need for care, as many members suffer from Post Traumatic Stress Syndrome and other conditions. "They also did not realize that this trauma can continue for several generations," she says.

The literature review for the paper on Culturally Infused Engagement found ways in which culture was accommodated during treatment. The review also pointed to a primary focus on the attitudes and behaviors of clients when they began getting counseling. During their sessions little attention was paid to the process leading up to engagement.

The delivery system follows the biomedical/biopsychosocial framework that is the basis for the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which classifies mental distress as psychological, behavioral, and biophysical dysfunctions or abnormalities.

That definition and the related treatment often are not useful for minority families. Culture shapes the illness experience through various beliefs, values, practices, and norms, which means there can be significant variations in how illness is characterized and how individuals understand the illness and its treatment, research has shown.

Understanding those values is critical to a successful treatment, Yasui and Pottick contend, in proposing CIE. Just as Yasui learned that she couldn't suggest a remedy for the grandmother and granddaughter in conflict over the child's misbehavior without understanding where the grandmother was coming from, clinicians cannot be totally effective with minority families seeking help unless they understand first what values
those families bring to the treatment.

"The new paradigm can provide a wide lens that will help clinicians, program planners, and policymakers with information to improve the delivery of mental health services and treatment through innovations in community education and outreach, as well as in clinical work," they add.

The problems faced by ethnic minorities in accessing healthcare are specific and varied, the review of the literature showed.

Eighty-three percent of the 119 measures the research team studied used DSM diagnostic criteria or conventional mental health terms to define "illness," reflecting the implicit assumption that current Western mental health concepts were understood equally by all people. Yet cultures vary in their illness expressions. Of the 31 measures that assess the CIE model's dimensions of illness expressions, for example, nearly 60 percent showed that people with mental illness were more likely to report a physical symptom as an indicator of distress if they were from a minority group. That research also showed that the physical symptoms were culturally specific. As part of their mental health conditions, Cambodians, for instance, reported feeling sputum (phlegm) moving upward and causing sensations of a cardiac arrest or inability to breathe.

"Among cultures that view health holistically, interpretations of distress are viewed as stemming from the body, spirit, mind, and human relationships, resulting in expressions that link emotional and behavioral states to physical sensations," the researchers point out in the paper. There also can be a historical connection to pain and trauma.

Distressed Cambodians, for instance, report neck soreness in connection with trauma as they were engaged in slave labor and forced to carry heavy loads of dirt on a pole balanced at the neck.

Traditional Chinese medicine and Indian Ayurveda medicine also hold a holistic approach to health. Illness is considered to be the result of an imbalance or disruption of harmony in the body. Spirituality and religious beliefs can also play a role in minority and immigrant groups' conception of mental health.

Those cultural beliefs must be acknowledged for treatment to be effective, the authors contend. "The findings highlight the importance of addressing supernatural beliefs in mental healthcare practice, as misconstruing culturally unique conceptualizations of mental distress and illness are likely to overlook ethnic minority and immigrant children and families' existing help seeking beliefs, resources, and behaviors as well as deter their engagement in professional mental health services," the authors write.

As a clinical psychologist, Yasui has learned that establishing trust is an important aspect of treatment, something that was underlined in the research review. "Unlike Caucasian clients, ethnic minority and immigrant clients have been found to suspend trust of providers who are ethnically dissimilar from them until they are proven credible and trustworthy," Yasui and Pottick report.

In addition to their exposure to the problems arising from mental health difficulties, ethnic minority families face hindrances of poverty, lack of insurance, inadequate transportation, and geographic isolation that make it difficult to receive successful treatment. Dealing with those access issues is part of the package of dealing with the problem of poor mental health care among ethnic minorities.

The Culturally Infused Engagement Model suggests other remedies for the situation, Yasui and Pottick point out.

The implications for policymakers are clear. "Investing in community-based and clinical research that theoretically tests Culturally Infused Engagement interventions could develop an instrumental knowledge base for improvements in working with ethnic minority and immigrant children and families."

That research could lead to better understanding of the role of families and communities in shaping engagement in mental health services. The research could also benefit from using vignette methodologies, in which participants' responses reveal their perceptions, values, social norms, or impressions of events. "Compared to other social scientific methods, controlled experimentation has a better chance of uncovering specific mechanisms that lead to disparities in mental health detection and service use, and, thus, it can speed up scientific discovery," the authors write.

The Culturally Infused Engagement model also provides a way for social service agencies to improve their work. It can provide groundwork for educational public health messages that help ethnic minorities and immigrant children and families understand mental distress better and encourage ways that family networks can respond. Outreach programs could also be directed at pediatricians and other primary care providers to help them better understand the role of culture in mental health.

At the clinical level, the framework that CIE provides is particularly practical. CIE may help clinicians understand, for instance, that mainstream notions of depression or anxiety may not correspond to minority and immigrants' understanding of distress. That could help the clinician look for clues in the families' cultural background as a way to engage in treatment.

The model also underscores the important role clinicians play in mental health. "Clinicians are the canaries in the coal mine," Pottick says. "They can recognize problems long before they come to the attention of the public." Clinicians can help inform policymakers and others about critical changes that need to be made in the mental health system, she adds, by recognizing how important culture is in treating people with mental health challenges.