Attitudes the Korean Missionary Community has on ¡°In-the-Office¡± Psychological Services HaYoung Jung (kriM, MK) Abstract Despite the explosive quantitative growth Korean missions experienced in the past thirty years, many components that adhere to the qualitative holistic care for the community – including the biological, psychological, sociological, and spiritual care – has been largely neglected. In this study the premise of missionary care is limited to the psychological aspect. Additionally, assuming that ¡°in-the-office¡± mental health services (e.g., therapy and counseling) is representative of psychological care attitudes Korean missionaries (KM) and Korean missionary kids (MK) have of ¡°in-the-office¡± psychological services have been examined via a questionnaire targeted toward these two populations. By analyzing data contrived from this measure, combined with information derived from informal interviews with therapists/counselors with basis both within the Republic of Korea (ROK) and outside the ROK that are currently working with KM and MKs that were conducted post-survey, an appraisal of where the community stands in relation with mental health services was made. Based on these observations, ways to strengthen ongoing services along with creative methods in which the community can be better served are suggested. Introduction The author is a Korean MK and has training in clinical psychology in the North American context. During training, the author had opportunities to experience provision of mental health services for diverse populations including KMs, MKs, and minorities. This exposure resulted in dissatisfaction due to inconsistency between therapeutic theories learned in class and the actual efficacy of implementing these methods to clients of diverse cultures. Subsequently, the author along with a colleague had an opportunity to create and collect a questionnaire targeted towards KMs and MKs in order to assess attitudes and needs on mental health services. The purpose of this study is to procure an objective view on how Korean missionaries and MKs view psychological services, which then will be a predictor of the effectiveness of in-the-office psychological services. Based on these observations, possibilities on how clinical psychology could be effectively communicated to non-western cultures, particularly the Korean missionary population will be discussed. Literature Review Though the 30-year history of Korean mission is relatively short compared to the several-hundred-year history of western mission, it has undergone rapid expansion in the past few years, becoming the third largest overseas-missionary sending country in the world following the US and India. (Moon 2009) Though the sharp increase of KM numbers has been encouraged within the international mission arena, expedited growth has also accompanied many structural issues that have been overlooked. At this point the lack of member care support for missionaries has become a rather serious obstacle for healthy evangelical mission development for various reasons. (Moon 2009) First of all, the fact that the ROK is now the 3rd largest overseas missionary sending country in the world clearly indicates that the inchoate stage of Korean mission has long expired. Nonetheless, many Korean missionaries still rely on non-Korean member care resources (Moon 2009), a characteristic that seems to be in disaccord with the ¡°successful¡± 30-year-history of Korean mission. Second, psychological service for missionaries, commonly labeled under the premise of missionary member care may not be an efficacious option for diverse communities. Member Care represents ongoing preparation, equipping, and empowering of missionaries for effective and sustainable life, ministry, and work. Member care includes spiritual, emotional, relational, physical and economic matters pertaining to all missionary personnel. (O¡¯Donnell, 2002) Vast cultural difference extant among various cultures, especially between the East and West, would require slight-to-drastic difference in member care models that cater specifically to meet the needs of the community. For example, studies show that perspective Asians have on the cause of mental illness is more likely to be viewed as organic rather than situational. (Sue et al. 1976) Not only would utilization and enhancement of psychological services be influenced by such beliefs, effective member care model for communities that hold this belief would have to be molded with this characteristic in mind. Additionally, due to the unique mono-cultural and mono-ethnic characteristic of the KM population, there is tendency to dichotomize persons with calling ¡°directly¡± from God (e.g., missionaries and pastors) vs. those who are not. Thus, missionaries are highly spiritualized by society and unrealistic expectations are imbued on KM by Korean Christian community and themselves. This may lead to limited awareness of perceived stress levels (Kim E. 2009) and mental health care issues may be seen as more of a threat than an issue that needs immediate attention. Consequently, the voice to articulate mental health care needs may be reduced, resulting in fewer mental health services available to the community. The field of Clinical Psychology integrates science, theory, and practice to understand, predict, and alleviate maladjustment, disability, and discomfort as well as to promote human adaptation, adjustment, and personal development. Clinical Psychology focuses on the intellectual, emotional, biological, psychological, social, and behavioral aspects of human functioning across the life span, in varying cultures, and at all socioeconomic levels. In this study ¡°mental health service¡± was limited to in-the-office service postulating that this is most commonly offered and conjured up when psychological member care for missionaries is mentioned. In traditional one-on-one therapy, therapists and clients work together to understand problems and to come up with plans for fixing them. (Encyclopedia of Psychology) Therapy is offered for individuals, couples, groups, and families. Much research in the past confirming the efficacy of in-the-office psychological services has been based on the majority population of the US. Even within the Asian-American population, those who are acculturated to the mainstream western culture are more favorable towards therapy and discussing their problems with psychologists. (Atkinson and Gim 1989) Recent studies clearly show that seeking in-the-office treatment relates to cultural determinants that carry potent weight in how the community perceives mental-illness. (Littlewood and Lipsedge 1997) Asian-Americans (and other ethnic minorities) tend to underutilize psychological services in comparison to their European American counterparts (B. Kim 2007), and have historically responded poorly to traditional in-the-office psychological services. Yet they are frequently overlooked when measuring the effectiveness of mental health services. (Wong, et al. 2007) Treatment credibility, which refers to whether a client believes that the service will be effective in solving his or her problem (Kazdin and Wilcoxon 1976), has proven to be an important factor for successful in-the-office treatment. Failure to establish treatment credibility at the onset of therapy may result in many negative results in therapy, such as early termination of therapy, noncompliance with treatment procedures, and dissatisfactory outcome of therapy. (Wong, et al. 2007) However, credibility can easily be compromised for KMs receiving therapy. Psychology is a western derived theory implemented on the field mostly by non-Koreans. Thereby the interpretation of the client¡¯s experience from a solely western cultural vantage point is a common reason for failed credibility. Even if a therapist of same heritage were to apply a Western-derived concept of psychology with the absence of a culturally sensitive filter, the client would likely feel misunderstood, and if sufficiently frustrated, may drop out of therapy. (Yi 1995) Thus, subsequent opportunities to seek therapy will have already been tainted. For Asian-Americans lack of familiarity with dominant U.S. culture (i.e., European American), particularly in the area of psychological services, and traditional Asian cultural norms that may discourage Asian Americans from seeking help from professional psychological service providers also are key factors that discourage therapy. (Kim, B. 2007) Kim also suggests that Asian Americans' attitudes toward help-seeking may have less to do with accumulation of western culture, and more to do with loss of traditional Asian cultural norms. The reason for poor mental health structure in Korean missions may be related to such matters. The ill-fitting mental health services extend to other areas of psychology such as psychological testing (e.g., measures that give expected results when given to North American missionaries may not give lucid results when given to the KM population), psychological theories (e.g., attachment theories have shown to show less pertinence with the KM population), and so on. (E. Kim, 2009) The need for a more rigorous examination of specific culture-based factors is becoming apparent given the faults that result in using only certain ethnicities when studying the effects of mental health services. (Betancourt and Lopez 1993) Variation that exists within any given ethnic group must be acknowledged at all times. Assumptions pertaining to ethnicity and therapeutic preferences are based on a crude analysis of ethnicity, which enables categorization but has the danger of being highly inaccurate. The makeup of a KM or MKs identity can be especially complex. The individual may have to go through the process of maintaining or deemphasizing aspects of their ethnic heritage while adopting or not accepting aspects of the new host culture. Gender and generational gap within a family usually complicates the situation. (Wong et al. 2007) Though in many cases Asians see the role as a therapist as a mentor providing helpful advice and offering guidance on issues concerning education, career choices, time management, practical guidance on relationship issues, and so on (Yi 1995), thus expecting directive therapy and tend to view the therapist authority figure, clearly, there will be differences depending on various Asian cultures and individuals. (Wong, Beutler, and Zane 2007). Findings suggest that Asian-Americans' initial responses may be particularly influenced by how well they are oriented to the counseling process. (Wong, Beutler, and Zane 2007) This finding is hopeful for the future acquisition of member care. Though psychological service has been a foreign notion for eastern-Asia, including the ROK, currently the ROK is inviting therapy into various venues. Nuclear families with working parents leave much of the younger Korean generation in need of guidance. Hence, need for structured systems to provide professional counseling within schools is growing. (Jang 2008) Group therapy that focuses on problem-solving and cognitive methods has proven to be an effective solution to mediate some of the immediate needs of schools. (Ga 2007) Group therapy not only alleviates the cost and number of therapists needed, but also allows space for the participants to normalize their issues, practice leadership skills, teamwork, and social skills. Characteristics germane to Korean culture such as humility and collectivist orientation stand in stark contrast to individualistic values of the West. Ho (1984) suggests that in communities that hold the prior values, disclosure of personal problems can be shame-inducing for family members and the community. In order to ¡°keep face¡± Koreans communicate in a very intricate and subtle manner with each other (Leong, Wagner, and Kim 1995) and asserting personal feelings and directive communication methods may be interpreted as unwise. (Yi 1995) However, once within the ¡°collective¡± group, such as a safe therapy group, Asians tend to be more open. Education and mere exposure to psychological services also prove to be a key factor that enhances attitude, stabilizes, and creates expectations for therapeutic experience. (Kang 2003) Education on common stress factors that lead to burnout and recognizing these factors would reduce stress that occurs even in the case of an actual burnout occurrence. (Lee, Y. 2001) Education on in-the-office services may lead to proactive stance in dealing with personal issues, which in turn naturally leads to a healthier empowering outlook in ones¡¯ life. (Kim, Y. 2004) This is especially pertinent for the lives of KMs and MKs who often deal with unexpected situations due to the nature of their work. The need to address KMs and MKs separately rose from the fact that many MKs grow in a cultural setting disparate from their parents¡¯ and wishing to look at how this may have influence on how the two groups view the needs for psychological service. In many cases cultural differences within a single family is the cause of mental stress. (Kim S.) Communication problem is core issue within familial conflict thus cannot and should not be ignored. Utilizing exterior resources such as group therapy, if needed in order to amplify it, is highly desirable. (Jeon 2002) Research shows that people have a tendency to comfort themselves by looking to significant people in their lives (Kim, E. 2009, Kwon 2006) which also emphasizes the need to assess effective methods and ineffective methods in which KM and MK issues are being addressed or bypassed. Measures Participants Participants in the study consist of 119 Korean Missionaries (47 female and 70 male) and 63 Missionary Kids (24 female and 39 male). The average age of the Korean missionaries was 49.8 years ranging from 29-70. The average age of Korean MKs was 21.8 years ranging from 17-34. All of the participants were of Korean heritage and drawn from the Korean World Mission Conference (KWMC) 2008 and Korean MK ¡°Ignite¡± 2008. Data Collection The survey on ¡°attitudes towards mental health¡± was conducted to the participants on the first day of the KWMC 2008 and Korean MK ¡°Ignite¡± 2008. The survey was distributed to participants who were in line to register and immediately collected upon completion by several surveyors. Survey Instrument The survey was created based on Fischer and Turner's (1970) 29-item measure of Attitudes Toward Seeking Professional Psychological Help, which measures recognition of need for psychotherapeutic help, stigma tolerance, interpersonal openness, and confidence in mental health practitioner. This assessment was modified by the author and a colleague in order to fit the object of the article. Items on culture, such as the question ¡®Psychology is western derived, therefore it is irrelevant to Korean culture,¡¯ and on spirituality, such as the question ¡®Emotional problems such as depression can be dealt with scriptural reading and prayer¡¯ were incorporated, and the items were divided into four parts. 1. Attitude and Need Towards Counseling/Therapy 2. Cultural Factors 3. Spiritual Factors 4. Utilization of and Exposure to Counseling/Therapy The completed survey was handed out in bilingual form. A form for KM and a form for MK were constructed. The items in the survey are rated using a 5-scale-score from 1 (strongly disagree) to 5 (strongly agree). Data Analysis 1. Attitude and Need Towards Counseling/Therapy The need of mental health services was evaluated through questions such as, ¡®While on the mission field I have had a need to see a counselor/therapist¡¯ (Q18, KM 50% & MK 41% Agree) and importance of talking about our emotions and feelings (Q17, KMs 90% & MKs 92% Agree). Question18. While on the mission field I have had a need to see a counselor/therapist. Question17. It is important to talk about our experiences and emotions. Results show that both groups show a high degree of felt need for some type of emotional support for missionary families on the mission field (Q1, KM69% & MK 56% Agree), and nearly 75% of both groups agree that counseling/therapy is not for people who are weak or inadequate. However, when asked if they would personally consider counseling/therapy, 62% of KMs and 47% of MKs agreed, which is a slightly lower rate compared to perceived needs of counseling/therapy. Additionally, while 41% of KM responded that they would keep counseling/therapy a secret while only half that ratio, 19% of MKs responded that they would keep counseling/therapy a secret to others upon receiving the services (Q14). Question13. I would consider getting getting individual counseling/therapy at some point. It is interesting to note that participants showed a relatively higher rate for need of mental health services for ¡°others¡± as opposed to personal needs for mental health services. This is seen in results shown for parents desiring counseling/therapy for their children (MKs) which is at the rate of 65% which is higher than the need rate MKs perceive for themselves (46%). Additionally, though only 46% of the MKs felt therapeutic needs for themselves, when asked about needs for the mission field in general the numbers jump to 89%. The KM¡¯s perception on needs of mental health services shows a steady trend throughout the items that rate mental health needs. Question1. Counseling/therapy is needed in the mission field for missionary families. 2. Spiritual Factors The strength of spiritual factors in dealing with mental issues was high for both groups. Interestingly, the degree to which spiritual medium is implemented in dealing with emotional/mental problems was relatively higher for MKs compared to KMs. 78% of KMs and 84% of MKs agreed that they could find relief in God when faced with emotional crisis; however, only 38% of KM and 50% of MKs believed that faith alone could be the relief factor when faced with mental issues. Results suggest that religious coping mechanisms such as praying and reading the Holy Bible, are more frequently used by MKs than KMs. Question15. If I were having a severe emotional crisis, I would be confident that I could find relief in God. Question16. Faith in God alone is sufficient to heal emotional/mental problems. Question5. Emotional problems such as depression can be dealth with scriptrual reading and prayer 3. Utilization of and Exposure to Counseling/Therapy Only 26% out of all the participants had exposure to counseling/therapy services before. This outcome isn¡¯t surprising when looking at the population¡¯s attitude towards mental health services and its accessibility. Only 31% of KMs and 20% of MKs answered that such service was accessible on the mission field where they resided. Question12. In my experience, counseling/therapy was accessible on the mission field. Research Findings and Future Implications Structured Psychological Care Overall, the need for space to talk about mental and emotional problems was high for both groups. However, this need did not necessarily extend to strong desire for traditional in-the-office therapy. Given the characteristics that the many hierarchical Asian cultures hold, and the dichotomization of missionaries vs. ¡°others,¡± a highly structured model of psychological member care seems to be a possibly effective method in order to cater to KM and MK as a community. This seems pertinent particularly in the inchoate stages of missionary member care establishment, whereas perhaps a more lenient model of psychological member care may be more desirable once psychological member care is normalized. Normalized Psychological Care The somewhat arcane attitude towards individual use of mental health services, especially among the KM population, suggests shame in utilizing mental health services. This also suggests that though there is a clear need and desire for mental health care, there may be a personal or cultural block as to how these services are viewed. In lieu of ¡®throwing the baby out with the bathwater,¡¯ many may choose to forgo care in order to ¡°keep face¡± as a ¡°spiritual¡± missionary. Educating mass on mental health care in methods and language familiar to more people within the community and perhaps less offensive to the community would be helpful. Past studies show that understanding traits of the community in need of service via extensive research and studies is imperative for effective execution of methods and less trial-and-error. Professional Collaborative Psychological Care Blatant need for more mental health care providers cannot be circumvented. Results show the dearth of accessibility of mental health services on the mission field. However, history in Korean missions has already shown that sharp increase in numbers may not be the best response in answer to desperate needs. A few strategies may prevent possible pitfalls. First of all, mental health providers must have substantial training in the right clinical, cultural, professional context and clearly acknowledge the boundaries of her professional limit. Many KMs and MKs will be dealing with dynamics of an eastern cultural, national, religious background compounded with life within a cross-cultural international group. Some may be struggling with serious clinical symptoms or traumatic issues depending on the political status quo of host country, thus possibly in need of psychiatric attention. As Body of Christ we are not called as lone rangers, but to collaborate and form a whole. If member care is the heart that enhances Body¡¯s function, the heart can only be whole when its biological, psychological, social, and spiritual components are present. Once this ¡°wholeness¡± is acknowledged, a closer look into the heart will reveal that individual blood vessels exist within the heart that each pump blood into different parts of the body. The distinction of such roles and boundaries takes time, and is a process that cannot be accelerated. In fact, at this point, member care may not be at the stage to be able to differentiate the roles of the different ¡°blood vessels.¡± The distinction then lies in the hands of member caregivers to come. ¡°Spiritualized¡± Psychological Care (Pastoral Care): Results show that spirituality is clearly an important factor for both KMs and MKs. Clear understanding of the importance of spirituality must take place especially when dealing with missionary mental health issues. A balanced view of understanding and accepting the need to incorporate spiritual needs with mental services is essential due to the fact that missionaries do in fact face many spiritual attacks. Furnham et al (1999) found that the supernatural factor plays a big role in both health and illness, and that Asians tend to have more positive attitudes toward treatment other than western medicinal methods. (Sheikh and Furnham 2000) Pastoral care provider can utilize these traits to provide ¡°holistic care focused on the soul.¡± (Lee, Y. 2001) Additional research in this area in order to utilize spirituality in ways conducive for the KM and MK community should be a continuous effort. Radically Customized Psychological Care Community Psychology, an active collaboration among researchers, practitioners, and community members that uses multiple methodologies, also seems like a viable option in providing effective psychological service for this population. Community psychological research and action not only strives to serve community members directly concerned, but is also strongly guided by the current needs and preferences of community members and asks for active participation of community members. Community research and action requires explicit attention to and respect for diversity among peoples and settings. Community psychology stands with the belief that human competencies and problems are best understood by viewing people within their social, cultural, economic, geographic, and historical contexts. Those implementing community psychology methods are encouraged to be "social change agents," "political activists," and "participant conceptualizers" of the community. (Rickel 1987) This would ensure that populations receive customized psychological tools that best fit the needs of their particular population. For example, KMs are known to be diffused around the globe with little to no regional focus, which makes member care accessibility more of a problem. (Moon, 2009) Thus, taking studies done by professional researchers such as Moon, and strategically placing member care resources according to these numbers would be a vital community psychological factor that promises future growth of missionary member care. Limitations 1. KWMC, founded in 1988 and has been held every 4 years, is one of the biggest Korean mission conferences worldwide, which warrants certain amount of diversity and range within Korean missions. However, considering the huge number (18,035+) of Korean missionaries worldwide (Moon, 2008) a survey distributed only to participants in a single conference cannot ensure accurate representation of the population. 2. The survey implemented for this article was based on orientations to seeking professional help: Development and research utility of an attitude scale (Fischer and Turner 1970), a questionnaire widely used to acquire attitudes on therapy. However, for the purpose of acquiring information associated to goals of the article, a slightly altered version of the questionnaire was implemented. The additional items may have affected the validity of the questionnaire. In the course of translation of survey from English to Korean, there may have been further obstruction of questionnaire validity. Additionally, there was little information available for the reliability and validity of questionnaire use for diverse population. 3. Much of the background research was done on populations that are of Asian heritage but reside in the US. Though the Korean missionary population may have similar qualities to this population because of their East-Asian and cross-cultural background, there are unknown variables due to the fact that most Korean missionaries that participated in this survey do not reside in North America. Additionally, there were limitations in contriving peer reviewed articles in Korean. 4. Studies show that there are additional factors that contribute to difference in attitudes towards therapy such as gender differences, (Sheikh and Furnham 2000, Dadfar and Friedlander 1982) and that change in psychological domains such as cultural values and cultural identity may not occur until the fourth generation (Kim et al., 1999). Thus, the restricted range in generation, age, and stage of life may have limited the range of responses on the culturally based variables. 5. Lastly, lack of training and experience the author has in coherent areas resulted in several limitations of process and conclusion of study. Bibliography 1. Wong, E. C., Kim, B. S. K., Zane, N., Kim, I., and Huang, J. (2003). Examining Culturally Based Variables Associated With Ethnicity : Influences on Credibility Perceptions of Empirically Supported Interventions. Cultural Diversity and Ethnic Minority Psychology, 9, 88-86. 2. O'Donnell, K., Editor. 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