Joshua Blum grew up in a mixed European / Taiwanese household.  He was educated at Princeton University and earned a medical degree from Penn State College of Medicine, then did residencies in adult psychiatry at the University of Massachusetts and child and adolescent psychiatry at Brown.  He then worked some evenings and weekends in a freelance position for the department of pediatrics at a stand alone children's hospital in Providence that allowed him to stay home to raise his daughter.  He currently lives in central PA with his family and works in college mental health.

Dr. Blum shares more of his personal experiences and insights in EFPA Ep. 207: Mixed-White/Asian Perspectives On Mental Health.

Everyone is ambivalent about everything, to some degree.  Nowhere are things less black and white than when it comes to the inner workings of the human mind.  If you’re reading this and considering whether it applies to you, then congratulations on venturing into those murky waters.

“Hold up,” you might say.  “It’s not like I want professional help.  I just want to learn what my options are.”

And that’s exactly the point of this article.  My goal is to provide information to help you make a better informed choice, even if that choice is to do nothing.  And, as we will see, that’s still a choice.

If you are living in a country that has a primarily Western style of medicine (where there is a long history of separation between the mind and body), then “mental health” will likely be thought of as distinct from “physical health.”  Even though the nervous system is a body system like all the others, there is an artificial schism in Western medicine and many societies that exists but isn’t there biologically.  This division is artificial, but it’s important because it’s part of a reality that anyone who looks for mental health services must deal with on some level.

For reasons traditional, societal, and amorphous, mental health services are unfortunately not always easy to find within the confines of medical practices.  The next time you see a large medical complex, look to see if you can find mental health services among the gastroenterology, cardiology, and dermatology practices.  Chances are, you won’t.  The next time you pull out your insurance card, see if there is a separate number to call for mental health services.  At the time of this writing, many insurances still cover mental health differently than general medical services, even though most mental health conditions are chronic ones not unlike high blood pressure or diabetes mellitus.  

Imagine being told that, as a diabetic, your insurance company would only pay for you to see your doctor a certain number of times.  If you needed more visits since your blood sugars weren’t under control yet, you were on your own.  Even though the Mental Health Parity and Addictions Equity Act passed in the US in 1996, supposedly limiting large insurance plans from imposing limits on mental health services, a decade and a half later, patients still often have to fight for equitable coverage for mental health treatment (3).

If this sounds like discrimination, you wouldn’t be wrong.  In many places in the world, including the US, there are varying levels of stigma for mental health disorders that affect patients and their health care providers alike.  Though the reasons why are beyond the scope of this article, you don’t have to look much further than how therapists, therapy, psychiatrists, and psychiatric inpatient units are often portrayed on television and in film.  The examples are often hardly encouraging and sometimes frightening or barbaric.  It’s no wonder patients may be reluctant to seek out services if that has been their only exposure to mental health treatment.

That said, at least here in the US, there are many people who function as unofficial mental health providers, including those who do not have formal training in the area.  Even if you see a therapist once a week, the majority of your life will be lived elsewhere.  

One of the main roles of a mental health provider is to first listen nonjudgmentally.   Clergy, teachers, guidance counselors, coaches, athletic trainers, barbers, bartenders, the police – these are examples of service professions that have some element of mental health work built in.  To paraphrase a quote from Mister Rogers about what to do in times of trouble: “look for the helpers.”  It’s never a bad idea to look for the helpers in your community when you are trying to build your support network.  It’s possible you may find exactly what you are looking for.

Speaking of which, what about family?  Family members can be a source of great support, and if that’s the case for you, terrific.  While I always encourage patients to discuss their concerns with supportive family members, supportive is the operative word.  In some cases, as much as we’d like family to be supportive, it isn’t realistic.  In some cases, family may be the source of your mental health struggles, and sharing anything with them (or even the fact you are seeking help) may just add to your problems.  

I’m not saying you should give up on family members that have their own hang-ups on your seeking help.  Just because family isn’t supportive now, doesn’t necessarily mean they’ll be that way forever.  People can change.  But they have to want to.  So don’t wait on them.  Be the change you want for your life, and don’t let your progress depend on others who may not necessarily have your best interests in mind right now.  Often, the reason for their resistance has nothing at all to do with you and everything to do with their own ideas and biases.

Although you already know this, keep in mind that there is a cost to everything in life.  By pursuing mental health treatment, you will have to spend time and money.  That will take away from other aspects of your life.  You will need to attend appointments, do a certain amount of mental and behavioral work outside of them, and perhaps allot a certain amount of money for sessions.  Even if your insurance company covers your visits, getting to that point sometimes does not go smoothly, requiring you to fill out paperwork or make sometimes frustrating phone calls.  

As great as it would be if we could all be open about getting mental health treatment, the reality is murkier.  You may need to consider what you will say to others about why you are unavailable each time you have an appointment, perhaps manufacturing a reason for those you don’t wish to fully be up front with, like an employer.  There may also be side effects to deal with, such as from medications you choose to try, coming to grips with the aftermath of past trauma, or a newfound, greater understanding of yourself that shifts how you think of your past.  

I don’t say this to discourage you.  I’d rather you think about these things up front and be able to figure out if now is the right time to start this journey.  I’d also like you to think about what would happen if you did nothing different.  That, too, is a choice.  Is the status quo worth maintaining?  How bad would things need to be in order for you to take action?

what we are looking for is not so much someone who looks like us but someone who will listen nonjudgementally, validate us when we need to be validated, challenge us when we need to be challenged, and provide empathy and a supportive place to look at aspects of ourselves that we rarely discuss with others.

If you’ve decided that the status quo is worth changing, let’s turn our attention to mental health providers themselves.  I’m using the term “mental health provider” since there are a wide range of professionals that work in mental health.  While, at the end of the day, the relationship you form with that person is much more important than their degree, it can be very helpful to know a bit about the fields that provide mental health services simply because there are so many, and it can be confusing.

Providers will typically have an advanced degree or certification of some kind – e.g. a master’s degree, a certification as a licensed social worker or mental health counselor, a doctorate (e.g. PhD or PsyD), an advanced nursing degree (e.g. APRN), or a medical doctor’s degree (e.g. MD or DO).  

While it is not your responsibility to know what the letters behind someone’s name mean, ask if it is important to you.  Anyone worth his or her salt should be able to explain what kind of training they had and what that qualifies them to do.  In some cases, as we’ll discuss below, some providers who are, for example, still in training (e.g. psychiatric residents) or do not yet have a full US state license may be supervised by someone else.  

In some US states, physician assistants and nurse practitioners can practice independently of physician oversight.  In some cases, that’s fine.  In others, it may not, so again, if you are wondering or uncomfortable, ask.  The lengths of time for training vary considerably between all these different specialties.  

In general, the longer the training, the more comprehensive and holistic an evaluation someone is theoretically capable of doing.   However, just because someone has a certain kind of training doesn’t necessarily mean it will always be used effectively, so it is still important to get a sense of the person behind the degree (either on the phone or in person) to see if you can work together.

Before you start scouring google, know that you may already have someone that can help manage your mental health.  Primary care physicians (e.g. pediatricians, internists) tend to do the majority of mental health care in the medical system since there are not enough psychiatrists to go around, so it may be worth asking about their comfort level with mental health conditions.  

While not all primary care providers may be comfortable prescribing psychiatric medications, they often need to manage day to day issues that are critical to good mental health, such as problems with sleep, metabolism (e.g. obesity), substances (e.g. problems with alcohol, tobacco, and other drugs), and other medical conditions that overlap significantly with mental health (like headaches and irritable bowel syndrome).

Although the terms “psychiatrist” and “psychologist” are often confused for each other, psychiatrists are medical doctors that specialize in the treatment of mental health disorders.  Because of their training, they look at the interface between the mind and the body.  As such, they may also consider alternative medical causes for common mental health conditions.  

Some psychiatrists may have done extra training to gain expertise in working with certain populations (such as children or the elderly).  There are also psychiatrists that have done residencies in other fields, such as family medicine, internal medicine, pediatrics, neurology, and so forth, and may bring the expertise they gained from those fields to their work.  While all psychiatrists are trained in various forms of psychotherapy, in some settings, they primarily prescribe medications, though they may still be using aspects of their therapy training in those visits.  

Medications, by the way, are just tools, just like the various schools of psychotherapy.  Both can affect the brain on a structural level, though the way they do it differs.  Although there are often debates between the different mental health specialties about which tools are best, guild loyalties aside, patients tend to do best when they have access to both therapy and medical interventions.  As a patient, though, it’s ultimately your decision.  There are no absolute right or wrongs, just different tools for different jobs.  It’s part of the job of the professionals you see to help you pick the right tools for the right situations.

Before you start actual treatment, it can be helpful to have some idea what you’d like to work on.  While it is not your job to create your own treatment plan, having some initial goals, however ill-formed, can really save some time.  I’d encourage you to spend a few minutes jotting down some things you’d like to see different in your life and why.  The more specific, the better.  For example, while having a goal of “I’d like to feel less tired” is nice, it’s going to need a lot of clarification in order to be usable.  

Notice the difference in specificity if you change the statement to “I’d like to be able to sleep a consistent 6 hours through the night so I feel more awake the next day,” since now, interventions can be focused on helping you sleep better and can be more easily measured.   Don’t worry if the goal doesn’t seem attainable at this point; think of it more as a compass pointing the way as you stand at the crossroads of a series of densely covered, overgrown trails.

That said, how do you actually find mental health professionals?

• If you are a student at a university, the first place to look is to see if there is a student counseling center.  Many universities have very robust mental health services for their undergraduate and graduate students, in some cases with much better access, fees, and familiarity with student life than you’d find in the community.  Generally all you need to do is search google for “X university + counseling center.”
• Check with your insurance company to see what kind of mental health coverage you have.  All insurance companies are now supposed to cover behavioral and medical health interventions equally, but, in reality, it can still be state and company specific.  You can usually find a list of covered mental health professionals by geographic location on the insurance company’s website or by calling them (there is usually a number and/or website on your insurance card).
• Googling “Psychology Today therapist finder,” will lead you to a database of mental health professionals maintained by the magazine Psychology Today.  You will see a list of providers, each of which will have biographic information like training, areas of specialization, and insurances accepted.  You can also search who conducts visits online through televideomedicine platforms (at this point in the pandemic, that should be most people).
• Start searching here: https://www.psychologytoday.com/us/therapists
• There is a separate search engine on the same site for psychiatrists: https://www.psychologytoday.com/us/psychiatrists

A few caveats:

1) Between your insurance company and Psychology Today, you can usually find someone, though you may still have to call around, as those lists don’t necessarily tell you if those providers are accepting new patients or not.  It is not unusual for wait times for a first visit with a general adult psychiatrist in the community to be a month or more.  So if you are looking for psychiatrists, don’t forget to check first with your primary care doctor; if you are already on a medication and just need refills, they may be able to provide refills, make adjustments depending on their comfort level, and/or ultimately refer you to a psychiatrist they are familiar with.  Most primary care doctors keep a list of mental health resources at their disposal to be able to refer patients to, so it’s worth checking.

2) Keep in mind that even if someone does not accept your insurance or does not take insurance at all, it does not necessarily mean you can’t go to see that person.  In some places, particularly larger cities, providers don’t need to take insurance.  However, you can contact your insurance company first and see if they will cover part of the cost of the visit.  You would then pay cash upfront but submit the bill back to your insurance company for reimbursement.  Although they won’t cover an out-of-network provider 100%, they often will reimburse some percentage, so it’s worth asking about.

3) The next suggestion is not a secret, but it is underutilized.  Some cities may have one or more psychiatry residencies - i.e. training programs for physicians who have already graduated from medical school but are doing the practical training needed to be full-fledged psychiatrists.  As part of their training, they often see outpatients for therapy and/or medication visits.  In many cases, the treatment you get there can be just as good as with someone who is out practicing in the community.  

There are a couple reasons why seeing a resident isn’t something you should dismiss right off the bat.  First off, if you’re a young adult, you may be able to find someone closer to your own age (having a provider who is close in age is not a necessity, of course, but can be nice if that is something you are looking for).  In some cases, a resident may be able to take more time with you and/or be more thorough in his or her evaluations.  

Residents still need to be supervised by more senior physicians, though you may not necessarily meet the supervisor at the visit.  However, they’ll generally be discussing their work with their supervisor, so you technically get two doctors for the price of one.  In some cases, they may be able to take you on as an individual therapy patient as well (whereas in the community, psychiatrists often are shuttled into practices where they mainly prescribe medications).  

Lastly, because a lot of people don’t choose this method, it is sometimes quicker to find a psychiatrist this way than the methods detailed above.  On the site https://www.residentswap.org/Psychiatry/, you can find a list of residencies with contact info for the secretaries and program directors of these programs.  Start by calling or emailing them and asking where the residents do their outpatient clinics.  Often, you can get appointments a little sooner in those clinics as well, which also tend to be less stringent in their insurance requirements, sometimes accepting patients who do not have insurance.

If you’ve read this far, you may be wondering if there is anything specific to know about finding a mental health professional if you’re a person of Asian descent.  (I’m intentionally using the term “Asian,” as nonspecific as it is because when racial data is collected, it is similarly vague.)  I’ve encountered these challenges both personally, when looking for my own therapist years ago, and professionally, when trying to help patients find new mental health professionals when they’ve moved.  

According to member data from the American Psychological Association, the majority of US psychologists are female and white.  Asians accounted for only 4% of 94,048 total members surveyed in 2016 (2).  US Census data from 2010-2012 suggests that of 301,744 social workers with a master’s or higher degree, only 3.2% identified as Asian (4).  It may actually be easier to find an Asian psychiatrist.   According to data collected by the American Psychiatric Association in 2017, of 5,594 psychiatry residents surveyed, 22.5% identified as Asian (1).  

So, if finding someone that shares your background is important, know that while it can be hard to find Asian mental health professionals, it’s not impossible.   Especially in the era of telemedicine, you may very well be able to work with someone located in a different location where there is more diversity.  So if it’s important to you, don’t give up.

Of course, not everyone who looks a certain way is going to ascribe to the same values as you do, even if you’re technically from the same culture.  So often, what we are looking for is not so much someone who looks like us (since, after all, physical appearance goes only so far) but someone who will listen nonjudgementally, validate us when we need to be validated, challenge us when we need to be challenged, and provide empathy and a supportive place to look at aspects of ourselves that we rarely discuss with others.  

Although the space in which that occurs needs to be a special one, any mental health professional should be able to do that, at least in theory.  All mental health professionals should also be trained in how to not let personal feelings and biases (we all have them) get in the way of professional work.  Because we are all human, that is, at best, an ideal.  However, the ability of providers to recognize potential rifts between themselves and patients, bring those topics up, and attempt to repair them is an important task in a lot of therapeutic work.  

In fact, some therapists would say that those experiences are not only important but some of the most critical and healing pieces of therapy.  Since the relationship you develop with your therapist may parallel relationships you have in other parts of your life, being able to apply those insights more broadly can be life changing in some cases.

As much as your provider is assessing you, you are also evaluating their openness and ability to work with you.

As someone of mixed race ethnicity, I didn’t even attempt to look for a professional who had a similar ethnic background since I’d met so few mixed race folks in my life up to that point.  I did look for a therapist of Asian descent but did not find one.  Instead, I ended up finding a wonderful therapist, who though not Asian, had experience working with a diverse group of folks and felt comfortable helping me explore this aspect of my heritage in our sessions.  

On the occasion I needed to explain something that someone of the same background might have just “gotten,” it forced me to distill the idea or conflict down to a way that I could explain it.  That alone helped me gain distance and a better understanding of what I was grappling with since I had to put it into words.  It also felt validating in some ways to have an entirely neutral third party hear what I had to say without judgment.  

I have had patients confess that they were concerned that if they went to someone of the same race, they might be judged negatively or there would be certain assumptions made that would cause the provider to miss or dismiss their concerns.  Every family has its own culture, so again, there’s no guarantee that a shared race means anything other than you share geographically similar ancestors.

So when you are reaching out to potential providers, make an initial assessment of your own before you start working together.  If you are communicating with the same person you’ll be working with (as may be the case with some private practitioners), ask questions upfront that introduce the topic of race and see what happens.  

This can be both easier and sometimes more awkward to do in person since so much of our communication is nonverbal.  You may need to be more direct on the phone and specifically ask if he or she has had experience working with folks with your particular concerns and/or racial background.  If the provider is able to discuss more on the topic and create a space where you feel comfortable, that’s a good sign.  If he or she seems closed off or invalidating, note that.  

Again, in some cases, actually meeting people in person or through video erases a lot of the issues that can arise through text or voice-only communication.  But also, if race is an important part of what you want to discuss in your mental health treatment, I wouldn’t hesitate to bring it up again when you meet for the initial assessment.  As much as your provider is assessing you, you are also evaluating their openness and ability to work with you.  

In cases where you are calling a large clinic and can’t speak to an actual provider, you may want to ask the front desk staff some questions, such as which providers tend to work with certain kinds of patients.  Don’t dismiss their experience simply because they are not providing clinical care.  The front desk staff see patients before visits, after, and deals with all manner of complaints from patients and families.  They see what providers are like behind the scenes and can often be valuable resources in helping you find the right person in a practice that has multiple providers to choose from.

As I mentioned at the start of this article, a lot of this comes down to choice.  Recognize that although they are not always easy to see, you almost always have choices in life, and mental health treatment is no exception.  Deciding to get this area of your life handled is one of the most obvious ones, but know, too, that there may be factors out of your control that limit your freedom of choice.  

For example, you or your family may have gone through difficult financial times the past half year due to the effects of COVID-19.  You may have lost a job and/or your insurance.  You may have had to take on additional work, like caring for children or other family members.  You may be located in an area that has long wait lists for mental health professionals or may not have the money for broadband internet access even if you could see someone remotely.  There are a whole host of reasons why now may not be the best time.  However, as I mentioned before, not being able to act in the exact way you want does not mean you are powerless.  

If anything, if you use that time wisely, it may ultimately help you later on, since you won’t have to spend as much time working on basic skills or ideas that may be necessary for you to make the kind of progress you want.  If now is not the right time to pursue mental health treatment in a formal sense, remember that there are plenty of informal (but no less important) ways of getting started that will help you build a strong foundation of support for your life.  

Look for helpers in your community.  Look for organizations (see some below) that may help guide you.  Look after your overall health.  Read, learn, and talk to other people online or in person who may be dealing with the same things.  Write down what you would like to accomplish and save it, so when the right time arrives (and it will), you can capitalize on the opportunity.  

Most importantly, don’t lose sight of your hopes and aspirations.  At the end of the day, investments you make in your own mental health are investments in your future.  Although I am probably biased as someone who does this for a living, as long as you are alive, there is hope for a better tomorrow.    

Best of luck in your search.

Resources

• Finding a therapist
• Finding a psychiatrist
• Finding a psychiatry resident by state: https://www.residentswap.org/Psychiatry (from there, you would need to contact the programs individually to find the names of the clinics the residents train at when they see outpatients)

Advocacy, support, and education on mental health conditions:

• The National Institute of Mental Health
• National Alliance on Mental Illness – a patient and family run support and advocacy group with chapters around the country

References

1.)   American Psychiatric Association. 2019. 2018 Resident / Fellow Census.  Psychiatry.org.  Accessed Sept. 2020.

2.)   American Psychological Avocation. 2016. Table 7: Number of Active Psychologists by Race/Ethnicity, 2007-2016. https://www.apa.org/workforce/publications/16-demographics?tab=4.  Accessed Sept 2020.

3.)   CMS. 2020.  The Mental Health Parity and Addiction Equity Act (MHPAEA). https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet.  Accessed Sept 2020.

4.)   Salsberg E et al. 2017. Profile of the Social Work Workforce. The George Washington University Health Workforce Institute. www.cswe.org.  Accessed Sept 2020.