Dally Sanchez spent her adolescence getting "treatment" - and the memories still sting: As a traumatized incest survivor, she recalls dealing with a social worker who couldn't talk to her Spanish-speaking mother, being restrained by staff at a youth psychiatric facility and a threadbare education in special-education classes that offered no hope of going to college.
"The reality is that in the mental health system, once you fall in there, you're not a person anymore," said Sanchez, now 27. "Somehow, having a label or having some sort of emotional problem or trauma removes your civil and human rights."
Sanchez's experiences are echoed throughout the city. In classrooms, clinics and emergency rooms, youth are labeled "crazy," "disturbed," "defiant," "loco" - indelibly marking their lives and futures. Among immigrants, people of color and the poor, advocates say, the mental health system is especially prone to misunderstanding and to overlooking youth in crisis. In marginalized neighborhoods, the system's shortcomings are compounded by the challenge of responding to the needs of different ethnic groups. The question of "cultural competency" has emerged as a major flashpoint in the debate over equity in mental health.
"There's a huge lack of cultural competency all across the board," said Sanchez, who today is YOUTH POWER! program coordinator with Families Together, a statewide mental health advocacy group. "There are huge amounts of people who are not getting the right services and who are being labeled with diagnoses that really aren't fitting."
"It's beyond disparities," she said. "It's called discrimination and racism."
In communities with high concentrations of immigrants, people of color and low-income families, youth with mental health needs must negotiate a chronically weak social-service infrastructure. Local service providers strain under tight budgets, most public schools have no comprehensive on-site health clinics, and families lacking health insurance may find psychotherapy financially out of reach.
A 2003 government survey of child outpatient clinics in the Bronx counted about 6,500 youth enrolled in services, mostly for behavioral issues like hyperactivity and anxiety disorders. More than 90 percent were black or Latino, with many from Spanish-speaking households.
According to the survey, the vast majority of the Bronx clinics were unable to meet clients' needs for day treatment. And with a six-week average waiting period, some 60 percent of people referred for services never actually entered treatment, suggesting that many thousands of city children with major mental health needs never make it to a clinic.
On a typical day at the Queens-based Child Center of New York, the multilingual staff of social workers and psychiatrists is stretched paper-thin, ready to field calls for help in Punjabi, Spanish, Haitian Creole, Russian or Cantonese.
"The biggest challenge that we face as practitioners is the waiting list," said assistant project director Reshma Shah. "Each one of us has so much of a caseload. And yet we have more and more of a population that really needs the services."
Language and Cultural Barriers
Immigrant families may struggle just to get help in the right language. In many cases, when bilingual staff members are unavailable, children of immigrants must take on the role of ad-hoc translator.
Cultural barriers, though, can be equally alienating. Adolescent emotional issues may fester silently beneath the social stigma surrounding mental illness.
In A's family, emotional suffering spanned two generations before she reached out for support. The Chinese-American teen, who asked to remain anonymous, wrestled with the scars of her father's suicide for two years until her own persistent sadness became debilitating.
A. initially resisted acknowledging her problems, as she feared she might be "mirroring" her father's actions. But eventually, a guidance counselor and others in her community persuaded her to seek a therapist through the Chinatown-based B. Wang Community Health Center. While she does not consider herself fully "recovered," she said, she has at least begun opening up about problems she previously tried to banish.
"In the Asian community especially," she said, "it is very hard to accept the idea of mental illness, since it is not often talked about."
As teens face alienation within their communities, social distance stretches between them and the people who are supposed to help.
Wanda Greene, a parent advocate with the Mental Health Association of New York City, recalled that her son, as a black youth, needed a clinician he could relate to. But in his early teens, when intervention was most crucial, he never had a therapist he truly felt comfortable with.
"A lot of my son's issues were: 'How can you tell me not to be afraid when you leave your office and you go home, and I have to return to my block?'" she said. "He may see drug deals going down on the corner, he may see gang fights - and that affects you."
Her son, now 26, is still dealing with his emotional problems, serving a long prison sentence that Greene sees as evidence that "the system failed him."
To encourage dialogue on mental health in the city's Latino community, the housing and social-service organization Comunilife is collaborating with state and city officials on a suicide-prevention campaign targeting Latina teens. Young Latinas are at higher risk of attempting suicide than white, Asian or black youth, according to government data.
The initiative, which centers on educational outreach posters, is just one step toward addressing vast, longstanding needs for culturally appropriate treatment programs. Comunilife President Rosa Gil noted that in focus groups used to develop outreach efforts, Latina girls talked about stress tied to community problems, like gang violence and unwanted pregnancy, and voiced fears that clinicians would not be able to understand them.
"The adolescents feel that the current mental health agencies do not help them," Gil said, "because they feel they're going to be blamed for these feelings. They don't believe that they should be on medication. They don't believe that the school system is supporting them. These adolescents feel very isolated."
Troubled Teens, Troubled Neighborhoods
Mental health advocates point to social and economic hardships that breed instability. For teens living in tough environments, treatment involves addressing not only physiological problems like chemical imbalances, but also the psychological affects of growing up in troubled circumstances.
Howard Raiten, director of mental health with the social-service agency AsociaciĂłn Comunal de Dominicanos Progresistas (Community Association of Progressive Dominicans), said that while mainstream clinicians tend to prioritize medication, mental health issues may be "rooted more in environmental situations than in biology," though biological factors can play a contributing role.
Raiten pointed to a corrosive, ingrained sense of hopelessness in the low-income immigrant neighborhoods his organization serves. "For years and years," he said, "people in these communities have not gotten recognition. They haven't been affirmed. They've been, and still are, very much invisible."
Shah said the social dislocation of immigration itself can push some people over the edge. "You lose your natural support system once you come into this country," she said. "So we have had cases where there might not have been depression or anything like that before. But once they move here - and due to inadequate social-support structure and services - the symptoms really come out."
The shortage of mental health resources in some communities means that many youth do not get help until a crisis hits. That can lead to inappropriate care or even deeper problems.
"If you don't get them the right services, they start consuming the wrong services," said Greg Greicius, vice president of educational initiatives with Turnaround for Children, a group that helps public schools develop preventative mental health programs. "So they wind up accessing special-education services, they wind up going out of schools in an ambulance for a behavioral crisis and get seen in a hospital. This is often the worst way to try to get a child mental health support."
In New York's special-education system, Black and Latino youth are overrepresented, with blacks more likely than whites to be labeled "emotionally disturbed." Generally, students of color with disabilities are disproportionately placed in more isolated settings than their white peers, spending less than 40 percent of their school time in a regular classroom.
Black and Latino youth are also more prone to winding up in residential treatment facilities, housed under detention-type conditions, far removed from their communities.
Ethnic disparities in mental health, along with a growing recognition of cultural issues in treatment, have spawned alternative approaches that integrate psychological health with community identity.
Ruchika Bajaj, health policy coordinator at the Coalition for Asian American Children and Families, a pan-Asian children's rights group, said traditional psychiatric treatment can overlook the importance of family and culture in addressing adolescent mental health issues.
"The Western model targets individual youth, with family involvement being supplementary treatment," she said. "But for Asian American youth, this 'one size fits all' treatment model is not effective, because family dynamics and culture play an important role within Asian families. Effective treatment must incorporate cultural aspects as well as the family."
At the Child Center in Queens, for example, family members participate directly in a youth's treatment sessions. This fosters emotional communication within the household and helps build an intimate support network for the young person.
Comunilife, which serves low-income black and Latino communities, is developing a youth program offering regular psychiatric care along with holistic initiatives like peer-support networks, tutoring and arts enrichment programs. The project aims to engage the whole family - for instance, peer groups for fathers provide both concrete social supports, like job assistance, as well as a space to talk.
The Department of Health and Mental Hygiene has tried to target underserved youth through the Coordinated Children's Services Initiative. Backed by a six-year federal grant, the program has linked hundreds of families to teams of community representatives and social-service providers. Together, they create community-based, "wraparound" treatment plans that keep families intact during the recovery process.
Beyond enhancing services, some advocates look toward systemic reforms that can tackle the social factors driving psychological issues. In Sanchez's view, promoting mental health is not about clinics or hotlines, but more fundamentally, improving lives and communities.
"We need to build communities and communities' ability to take care of themselves," she said, by strengthening schools, social-service groups, and other community institutions.
That grassroots approach has resonance in Sanchez's own recovery. The turning point came when her "wraparound team" introduced her to a local peer-support group. After years of medication, institutionalization and counseling, what helped most was simply connecting with other youth going through similar struggles.
"Traditionally, historically, naturally - peer support is what helps people," she said. "Having the support from your family, from your friends, from your neighbors, from your community, helps people get over things and heal - in any culture, in any community."
Michelle Chen is a freelance reporter in Manhattan and a native New Yorker. Â