AJAs Working in Public Health, Hospitals and Religion Talk About Mental Wellness
A Pleasant Meal Followed by Mild PTSD
We are clothed in business casual and downtown alohawear, as we sit together in the air-conditioned Ala Moana Hotel conference room, after a pleasant meal. This type of workshop should seem comfortable, almost soporific, to me as a college instructor. But instead of wanting a post-meal nap, I feel a wave of numbness and panic wash over me.
I re-read the instructions in our packet; the copy of the form I have already signed trembles between my fingers. Its words say something to the effect of, “If you have been the witness to, or survivor of, a recent attempt to self-harm, you might want to reconsider attending this safeTALK session. It could trigger traumatic memories.”
I feel triggered — remembering in the near past my “talking down” of a close friend who had tried to hurt himself — but want to push on despite the minor PTSD shaking me up.
The workshop training in “Suicide Alertness for Everyone” ends up being exactly what I need. As the safeTALK card I keep in my wallet to this day says on its cover, it has helped me — when someone seems to be thinking or feeling “suicide” — to respond with actions or words to the effect of “you can talk to me.”
My participation in this half-day workshop — in which people like educators, social-service providers and other professionals who are in regular contact with populations whose members may want to hurt themselves, due to mental-health issues — was perhaps done too soon, months after my own trauma. But it proved invaluable in learning how to get help for those who are exhibiting signs of suicidal ideation.
Trainees are not mental-health professionals, but they learn to keep the person who is in crisis alive and/or able to talk with a professional, while seeking support from those trained in psychology, psychiatry or the mental-help sciences for that person.
In my wallet, the safeTALK card breaks down TALK into a set of reminders from the workshop, abbreviations of guidelines the trainers had shared with us that day:
• Tell – as clearly and directly as possible
• Ask – … Are you thinking about suicide?
• Listen – Let’s TALK about this. I am listening. This is important.
• KeepSafe – We need extra help. I want to connect you with someone who can help you KeepSafe.
This is the first of many steps in my long journey to understand mental-wellness and -health issues. I am someone who has been surrounded by depressive people among my family and loved ones with personality disorders, as well as friends with memories of abuse and trauma.
The Big Picture: COVID-19 and the Suicide-Prevention Spectrum
The safeTALK workshop came to me by email from Dr. Jeanelle Sugimoto-Matsuda, associate professor at the Office of Public Health Studies at the University of Hawai‘i-Mānoa. At UHM, we had belonged to the Compassion Hui of students, faculty and staff who advocated for a compassionate communication policy through which the campus should report suicide and other deaths in our community to its members, led by Prof. Susan Schultz, my poetry mentor.
A well-known advocate of preventive measures to lessen the societal likelihood of suicide and to bolster community support so as to optimize mental wellness, Dr. Sugimoto-Matsuda has led the way in suicide-prevention efforts statewide.
Adopted as a South Korean child into a Hawai‘i Japanese family, Sugimoto-Matsuda is sharply aware of cultural variables when it comes to mental-health issues. However, she is at heart a “policy” person looking at the larger picture, especially in the coronavirus era.
“Since my background is in public health,” she explains of this big-picture view, “ … (I) look at health and social issues on the full-prevention spectrum – that is, primary prevention (stop things even before they occur), secondary prevention (detect and intervene early) and tertiary prevention (reduce impact for those already affected).
“Like many issues, people don’t see mental/behavioral health until it’s super visible … so usually at the tertiary end. Lawmakers often think that the sole answer to our mental health crisis is creating more hospital beds.”
While she is concerned with those suffering from acute mental-health needs (that is, those with SMI or severe mental illness), the public-health advocate says that “…there are many others in our state that may be at risk for mental health issues and suicide, but the need isn’t as visible. However, because of the reactionary nature of our healthcare system and policymaking process, we often focus on those already exhibiting challenges. Programs and strategies that can help in the primary and secondary prevention realms are often cut or mandated without funding/resources.”
What is an example of the state or local government not prioritizing the primary and secondary levels of prevention? “(D)uring the 2019 Legislative Session, a law was passed mandating all Dept. of Education teachers, counselors and administrators to receive annual suicide prevention training.” Sugimoto-Matsuda praises this attempt but criticizes the methods. “While this was a great step forward for our state, there were no resources allocated to support this new mandate. Therefore, the [state’s Prevent Suicide Hawaiʻi} Taskforce [which Dr. Sugimoto-Matsuda had at the time co-chaired] ended up bearing the brunt of the time and resources needed to help the DOE establish the infrastructure to implement the mandate.”
This lack of funding support matters especially now when the whole state is in crisis due to the coronavirus. “In the context of COVID-19 (and you can think of other examples, such as a hurricane or the Kilauea eruptions),” the mental-health researcher continues, “a new group of individuals/families becomes of concern for us. These are folks who, during ‘normal’ (non-pandemic) times, their coping skills and protective factors are sufficient to help them deal with life’s stressors. However, now with the economic downturn, job losses, added roles of home-schooling and care-giving, etc., those coping skills are not enough. And the protective factors that we rely on (e.g., our workplace, going out with friends, engaging in activities, just getting out of the house) are no longer available to us in the same way.
“So while there has been discussion about shoring up mental-health services at places like our Community Mental Health Centers, those consumers are already connected to services. We’re concerned about those who are finding themselves unable to cope for the first time, and perhaps less aware of the fact that they need help, and less aware of what services exist.”
What can be done, then? I ask. “Hm … ” she answers, “I always go back to the prevention spectrum. As you know, tertiary care is important, but it’s expensive and after-the-fact. What can we support that’s more in the primary/secondary realm? Awareness-building is “cheaper,” but not free! It takes time, resources, infrastructure, etc. The DOE mandate was also a great start, but with no resources, it’s hard to say that there really is all-around support for the issue.”
Transition-Stage Stressors; Cultural v. Universal Variables
Sugimoto-Matsuda, principal investigator of the Hawai‘i State Dept. of Health’s suicide-prevention gatekeeper-training initiative, sees the risk of suicide as higher during key transitions in people’s life stages. For instance, when people go from middle school to high school; or graduate from high school; or first go into the work force; or finally leave the work force; or retire, they risk losing connections with other people which they once had, she says.
But particular to Japanese Americans, we need to watch for the cultural angle of working hard in order to live and support our families, of staying at our company or organization for a long time before retiring. Many who leave their jobs thus do not know what to do at that point, Sugimoto-Matsuda notes.
Especially during retirement, it is important that people find new connections as well as a purpose. For instance, joining senior clubs or doing volunteer work. Others help with grandkids, she offers as examples.
Also, some families in our Hawai‘i JA or local Asian communities might have the tendency to not talk about mental-health issues. “Fights happen, then there is a cooling-off period, then people go back to ‘normal,’” Sugimoto-Matsuda identifies as one of the many patterns she has observed.
Because of these transition stages and patterns, it’s important that families start early in getting loved ones to talk about their feelings. Also, for sons and daughters of retirees, or for those who care for other elderly family members, there are various signs to watch for. Sugimoto-Matsuda has provided for Herald readers the National Suicide Prevention Lifeline list of warning signs and what to do if you suspect someone might hurt her- or himself (see sidebar). She advises concerned family or loved ones, to show this list of warning signs to whoever is worrying them, saying, “This might not be you, but take it just in case you need it” or “This might not be for you, but …” so that the person knows you care.
Also critical is mental-health upkeep. Sugimoto-Matsuda says, “My parents are religious about going to the dentist, but we all need to also maintain our mental health in the same way.” For some local Japanese, it’s not uncommon to be ashamed to see a therapist. They might feel “nobody else in the family is getting psychotherapy” and thus if they do get help, they are weird or will be stigmatized. For others, it could be even “pre-stigma,” she says, explaining that they do not even think something might be wrong with them or their family members. “They see it as normal to be this tired and stressed out; this is viewed as working hard under these cultural expectations.”
The doctor of public health has some thoughtful points about cultures and how they comparatively promote or discourage talking about feelings. As someone raised as a fourth-generation Asian American, “Western society says I don’t talk enough, while Asian culture says I talk too much,” she expresses. But worse, the irony for not just young Asian Americans but others in Western society is that “we have come to the point where we pay a stranger for an hour to listen to us, because we are not doing it [talking about our feelings and mental health] in our own families.”
“People of my generation realize, ‘Gee, I can’t talk to my parents about this stuff.’ Their families do not know that they are seeing a therapist.” She advises to parents and grandparents, just bring it out, “Be open to the conversation or support and be open to what your child says they need. They may or may not articulate, ‘This is what I need,’ as everyone processes differently, so support them, help them explore their options.”
What Sugimoto-Matsuda has said about Japanese values, assimilation into U.S. culture and mental health strikes home with me. But Director of Business Development and Public Relations at Sutter Health Kahi Mohala, Trisha Kajimura, is more conflicted about culture when it comes to addressing connections between the nikkei community and suicide prevention. With ancestors from Hiroshima and Kumamoto, the sansei/yonsei has lived in Japan where she worked at the JET English-teaching program in Saitama; she can analyze cultural variables with the best of them. Previously executive director of Mental Health America of Hawai‘i, she now works at this freestanding psychiatric hospital that focuses on patients in SMI situations, mostly children and adolescents with acute mental-health situations.
Though culturally proficient, Kajimura resists thinking broadly of Japanese or Asian Americans and mental health only in terms of socioethnic factors such as shame, silence and stigma. “Our challenges in everyday life are like everyone else’s. We do not have data on how [specific] ethnicities in Hawai‘i are responding to mental-health issues.
“What I would say in terms of Japanese American or Okinawan American communities is that they are the same as other communities; that we all have the mental-health conditions such as depression, bipolar disorder, schizophrenia (this also includes addiction). I meet people with those things who are dealing with those family members who have it. I want to push back against the myths that we do not have those conditions. We have all of those — if we look at our families before we knew what these conditions were, before we called it depression or post-partum depression or addiction, we had suicide in our families, we had people who were out of work, because they could not function due to depression, we had alcoholics. The problems were always there before we labeled it.”
However, Kajimura sees some cultural values as getting in the way of mental-health literacy, when taken too far. “From what I have seen or experienced, the term ‘gaman’ is emblematic of our cultural values, but it is also a factor in dealing with mental health. What I try to do in my work, what I have come to understand, is that we need to increase the mental-health literacy of communities and leaders. They do not have the language, don’t recognize or understand what’s a mental-health issue. This means that the mental-health literacy is not there; the consequence is that mental-health problems are not recognized early.
“And early intervention is key; people need to act earlier. You are not seeking help soon enough; people are not going to identify it as a situation where they need help. If we increase mental-health literacy first, people will seek treatment and benefit from it in their personal and family relationships, in their work lives. It leads to better well-being and productivity. But if you choose to gaman, bear it, it can become a chronic condition, escalate, result in suicide attempts, harmful behaviors that negatively affect families and the community, not to mention your personal self,” she advises.
Kajimura emphasizes the importance of self-care for everyone generally but for those with mental-health challenges especially. She says, if you need to take care of yourself in specific ways, and you do so, you can recover even with long-term conditions. Self-care is not always a cultural priority for Japanese Americans; she says, “Traditional cultural practices emphasize the value of the family and the family unit, so putting the family first in everything, working for the benefit of the family, is important. Definitely it seems for parents and grandparents, they still have ‘kodomo no tame ni’ as a value — and we [yonsei etc.] are beneficiaries of that without a doubt. They did not know what self-care is; not that they did not do it, but it was not valued, labeled or discussed as we are discussing it now. It is so critical for mental health. It is not superficial things like eating chocolate and taking bubble baths, but things that impact our long-term health and well-being — physical activity, paying attention to important relationships, saying no when you need to. The focus on the individual needed for mental health does not line up with Japanese American cultural values.”
The mental-healthcare policy advocate advises on how to update our values; we can still treasure family, but in a more contemporary, less self-sacrificing, way (see the photo of her and her grandfather). “My other reflections on Japanese American families and mental health, goes back to the idea of putting your family first, behaving in ways that honor your family and achieve expectations that your family has of you — and that is to try to have a more open mind to treat your family members with empathy and not with rigid expectations. It is those rigid expectations that can exacerbate problems when young people particularly do not feel accepted. For example, with men and gender roles — if we expect men to be strong and silent all the time, they’re not going to seek help. Understanding that there is not a single way to be a successful Japanese American person — there are so many options available to use in terms of lifestyle and how we choose to live our lives now, that we need to be there for our family members.”
Kajimura shares that she has personally benefited from individual psychotherapy when she “just needed to get through a couple of difficult periods in my life. The first time was for relationship issues, for getting through my divorce. It is not a powerful story, because there was not a particular diagnosis [it was situational]. But as a result of my positive experience, I recommend therapy to people all the time.”
Since then, she has advised other yonsei women and men (along with young members of other local groups) to seek psychotherapy, but they often do not go. One pattern she has observed is that they are hesitant to follow her advice, because they feel they do not have the time (especially in the case of mothers). Or they are scared to share personal details with someone else, she guesses.
Finally, Kajimura wonders how traditional support structures for JA mental health have changed. “You have to wonder about the Japanese American context; we are not utilizing the same support context we used to have–notably the temples and shrines,” she notes. “Those participants have really thinned out; younger generations are not choosing to be Buddhist like they used to be, not continuing in the tradition. It is important to develop support systems as things change with the generations.”
Interfaith and Religious Supports: Community in New and Old Forms
A month or so ago for the Herald, I was proud to report and write about how my family temple, Honpa Hongwanji Betsuin on Pali Hwy., had won a Samaritan Counseling Center Hawaii award for community mental-health support. Honpa Hongwanji has donated to the Center’s fund to help those who lacked the right insurance or income level to get necessary mental-health counseling and also has given the Center an office in which to offer this counseling support to the community. Over Zoom, I tell Rachelle Chang, executive director of SCCH, how wonderful this recognition is.
“It’s a long time coming; they have supported us for 20 years with office space that we can use for counseling, and also they have supported our Client Assistance Fund,” Chang says. The multiracial director (Japanese, Chinese, Korean, Hawaiian) of this faith-based counseling service which offers, by request, therapy at different community religious sites including that Pali Hongwanji, knows how important affordable mental-health help is for local people.
In her own family — for instance, her dad’s side which has been in Hawai‘i for generations — they do not talk about mental-health things openly, admits Chang. However, they are more open to talk about their feelings when there are conflicts in relationships. In the case of her in-laws who are Chinese from Asia, she cannot imagine them seeing a counselor for therapy; there is the sense among many new immigrants that they do not want to talk to anyone, that mental health is not a problem. “Surprisingly, I’ve found that sometimes when I speak to my parents, I look at it from a more modern point of view. I try to put into practice what I learned at the Center [in my trainings], such as use ‘I’ statements [instead of ‘you’ ones like ‘You make me angry’],” she admits.
Though her background is marketing, not public health, Chang has used it to become a strong and innovative supporter of community-health programs. Her Center has partnered with Honpa Hongwanji and other faith-based community organizations across religious traditions. “The clergy, the pastors are among the first people that I have turned to on this issue of interfaith efforts at supporting mental-health awareness,” she recalls. “Clergy need to be comfortable with having these conversations; people will come to talk to them, so they have to be not afraid and listen. They also need to know when to refer people to professionals with more training.” Buddhist leaders such as Honpa’s Bishop Matsumoto have been supportive of the Center’s efforts, Chang states.
Churches and religious organizations, Chang believes, are key to mental-health outreach. “We need to let people (congregants) get knowledgeable in comfortable settings, reaching out to adolescents and teens as well,” she says, having read that suicide is one of the three leading causes of death among adolescents ages 15-19 (a CDC statistic), and also that the state’s Emergency Medical Services and Injury Prevention branch just announced that there were 52 suicides among Hawai‘i residents ages 10-19 between 2015-2019.
She also recently heard from a Center board member that in the member’s school community in urban O‘ahu, there was a recent attempted suicide by a student, news which “just hits home,” she admits. “This is alarming and breaks my heart,” Chang reflects about these trends. “We need to be able to talk to our kids; listen to them, don’t talk at them, do not rush to judge or say what their thoughts are, or rush to try to fix something.” She finds, however, hope in teen-led efforts such as Malama Us and Hawai‘i Teen Link which use social media to talk about mental health.
In terms of how the government can aid in such efforts, she is hoping for more support at the federal level, in terms of funding, so that more healthcare providers can see clients. Most private-practice providers cannot afford to see clients who can’t pay and thus have to turn away the uninsured. “It would be great to have more money for Medicare reimbursements, to open up these reimbursements so that more healthcare providers can seek clients,” she reflects. “…(H)ealthcare providers cannot afford to do this; Medicare will not reimburse marriage and family therapists or mental-health counseling. They will reimburse psychologists and social workers and psychiatrists. This means Medicare plans in Hawaiʻi won’t reimburse — for example, Kaiser will not reimburse marriage and family counseling outside of the Kaiser network. This has a ripple effect on the state level.”
My monkey-like brain has a hard time processing all this information, so I am glad to talk to a calm, centered, spiritual person who can help put all these facts and ideas together. Rev. Blayne Higa, the resident minister of Kona Hongwanji Buddhist Temple, is the perfect candidate to help me settle my mind. He earned a Master of Divinity degree from the Institute of Buddhist Studies at Berkeley, California, after going to seminary for three years. Before then, he had spent years at Mō‘ili‘ili Hongwanji where he performed a part-time ministry there, and also received an initial ordination by Nishi Hongwanji.
The born-and-raised Hilo boy, half-Okinawan and half-Japanese, has thought seriously about the mental health of his small congregation since COVID-19 broke out. The virus, he analyzes, plays “a big factor in the increase in depression, loneliness and isolation that people are experiencing. One of the nice things about being part of a sangha, a temple community, is its relationships which bring human interaction important to our well-being. Especially when times are tough, difficult, sangha help us persevere, to help us realize we are not alone.”
One of the things Rev. Higa did when COVID-19 began was begin a “sangha phone ministry program.” “Lay volunteers began calling our membership, especially seniors who had no access to our technology or to Zoom,” he remembered. “Just a phone call, to hear a friendly voice. That simple act of being able to have a connection was so important for people to feel they’re not alone and to feel connected.”
“Along with just checking in with people, we were doing a food distribution, food box, giveaway for the first part of the pandemic,” the minister describes. “Especially for seniors who had a hard time getting out, so they could be safe. We asked people if they wanted to participate, then got them the food boxes through pick-up or delivery. We kept them safe, connecting them to us and to each other.”
Food boxes included frozen chicken, bread, fruits and vegetables, and many food items made by members such as baked goods, tsukemono, pickled cabbage and onions, and so on. He smiles, saying, “Some made hundreds of cookies or pieces of manju. It was a nice type of event or way to support our members — physically, emotionally, spiritually, the connection to the temple was important.”
Of those helped by the food distribution, some had been seniors living alone, but others were seniors whose kids live in town or live away from the island. Through this experience, Higa, his volunteers and the congregation learned that “It is by looking back at our rich tradition and our rich history, that we learn the ways we can support each other as a sangha, a temple, from the past.
“How do we care for each other? It is important to go back to what was and recapturing that sense of relationship, connection, being in community. Finding ways to maintain connectedness contributes to our mental health, our wellness.”
As I leave you with this message which we will continue to explore in our next issue, the Buddhist minister’s conclusion echoes in my mind: “Back in the day, temples were also community centers, a place where people had their friends, their social networks, their clubs — how important that was. We are rediscovering this in this pandemic, and by exploring our spirituality, we have realized how resilient we really are, because we have these spiritual foundations and support.”
Part 2 to be continued in the March 5, 2021 issue.