Content warning: This story contains references to suicide.
If Khara Timsina showed signs of a mental health struggle in his country of origin, he could be called a “mad person.”
“And people would fear talking to me, coming near me, and they would point fingers,” he said. “The type of stigma the community has, comes with the culture we had back in our country.”
While negative perceptions of those struggling with mental health exist everywhere, the stigma is particularly sharp for Bhutanese refugees, suggested Timsina, executive director of the Bhutanese Community Association of Pittsburgh [BCAP].
“People don’t like to be called, having mental health issues, so with that social taboo they are not open,” Timsina said.
He’s hoping Mental Health First Aid training might be a step toward addressing a problem that has sometimes manifested in suicides, especially among the men of the community.
BCAP offered the training last month, for the third time in eight years. Members of the Bhutanese community are hoping it has ripple effects, as the attendees share what they’ve learned with family and friends and slowly counter perceptions that make mental health challenges so hard to address, especially in a population that has had to overcome so many hardships.
A familiar problem for the community
Pittsburgh’s Bhutanese community are ethnic Nepalese who, starting in the 1990s, were forced out of their homeland after Bhutan’s government adopted stringent nationalist policies. Some spent as much as 20 years in refugee camps in Nepal after fleeing discrimination and violence in Bhutan. Refugees began arriving in Pittsburgh in 2008, and have since become one of the city’s largest immigrant groups.
While Bhutanese immigrants in Pittsburgh have developed strong roots in areas along the Route 51 corridor in Carrick, Brentwood and Baldwin, their community has been facing mental health challenges consistent with findings that show a higher suicide rate in Bhutanese refugees across the United States. A 2012 report by the CDC shows that in the U.S., Bhutanese refugees have a suicide rate of 20.3 per 100,000, which is almost double that of the national suicide rate of 12.4 per 100,000. The study found the highest suicides rates in unemployed men who were not family providers.
A 2019 study into the reasons behind their higher suicide rate found that societal pressures related to resettlement in a new country — including trouble finding employment — language barriers and financial stress, all contributed to feelings of distress in Bhutanese refugees. A community-wide tendency to avoid talking about mental health worsened feelings of distress, the study found.
In Timsina’s opinion, stigma around mental health in the Bhutanese community comes from deep-rooted cultural beliefs about people who exhibit signs of mental illness. This can make it hard for members of the Bhutanese community to seek help or verbalize their distress, which can worsen the problem.
“The type of stigma the community has comes with the culture we had back in our country,” Timsina said. “There weren’t any categories of mental health.”
Timsina continued: “The community still thinks that [mental health] is not an illness. It’s because of some superstitions, like something bad is acting on you.”
In his experience, Timsina has seen that when men fall victim to mental health stigma, they turn to destructive behaviors that not only cause further hurt to themselves, but to their families and wives, too.
“It’s men’s inability to cope, or less capacity to cope with stress, and sometimes it begins from them, but the silent suffering is more on the women’s side. They bear it. They think they have to live for their kids,” Timsina said.
Benu Rijal, BCAP’s health coordinator, said that she’s noticed the severity of the problem through her experiences leading a women’s group at BCAP. Whereas Rijal believes Bhutanese men often feel societal pressure to keep their emotional struggles to themselves, she has seen women be more comfortable expressing their problems.
“I think men think they are more the boss of the family and they normally don’t come to share with us problems,” Rijal said. “I think the women are more open, and they cry and they talk to people. They want to feel relief and they share.”
Communication, transportation and mental health
Language challenges — most acute for adults — can make it harder to acclimate and to verbalize mental health struggles.
Not understanding English “is making someone homebound all the time,” Timsina said.
Sabitra Kadariya, a Bhutanese mother living in Brentwood since 2010, added that many members of the community are further isolated because they can’t drive.
“I think they have not enough financial support to buy a car, or to support their families and because of that, it’s the first thing that leads them to commit suicide,” said Kadariya.
In recent years, however, Kadariya has noticed a change: As more members of the Bhutanese community receive help accessing public resources, they help out others in turn.
“I noticed that my family members or friends like to help other members of the family or close friends,” Kadariya said. “They pick them up and drop them from work to home, and then they know how to use public resources, like the buses. … So that will minimize, I think, the mental [health] issues.”
The combined power of peer-support and greater community resources is something that Timsina hopes to harness through Mental Health First Aid training. To help alleviate mental health crises, Mental Health First Aid training teaches ordinary people how to help those around them.
Mental Health First Aid training
For the third time since 2015, The Bhutanese Community Association of Pittsburgh hosted Mental Health First Aid training for their community members on Oct. 14. About 30 men and women from the Bhutanese community gathered from early morning to late afternoon with coffee and snacks at the Intra-National Homecare building in Whitehall to learn what they could do to help their friends and family who are struggling with their mental health.
“We are a large community here in Pittsburgh, and like suicidal thoughts, like people dying by suicide — we heard that every day in the news,” Kadariya said. “Because of that, I like to attend Mental Health First Aid training … and then export knowledge to my community.”
Mental Health First Aid Training [MHFA] teaches individuals how to help people struggling with mental illness or mental health crises. The point is not to make a community member into a clinician. Rather, MHFA teaches people how to be an informal, but vital, support for people struggling with mental health or experiencing a mental health crisis.
The 8-hour course, first introduced in the U.S. in 2008, has been proven to help immigrant and refugee populations like the Bhutanese community increase mental health literacy, reduce stigma and feel better equipped to notice signs of a mental health crisis and be a first line of support.
5 steps of MHFA, often known by the acronym ALGEE:
- assess the risk of harm or suicide
- listen non-judgmentally
- give reassurance and information
- encourage appropriate professional help
- encourage self-help and other support strategies.
MHFA training includes an introduction to different mental health terms, lessons on how to recognize risk factors and warning signs of a mental health crisis, with video and text-based scenarios. Participants are also taught a step-by-step action plan for how they can help someone experiencing a mental health crisis.
Through open group discussions, Bhutanese community members brainstormed how they could use strategies like non-judgmental listening, creating safe spaces, being aware of body language and avoiding dismissive statements when approaching a person about their mental health.
Following the training, attendees shared that they wanted to see additional MHFA training offered in the Bhutanese community so that more people can support mental health awareness.
Tulashi Adhikari, of South Park, said he heard about the MHFA training on BCAP’s Facebook page and thought it would be a valuable way to learn more about a problem he sees affecting many of his friends and neighbors.
“Today our trainer did the training for more than 30 people, so at least 30 people can tell at least one or two people, then it will increase day by day,” Adhikari said.
“This is a great opportunity to have this kind of training in our community so that we can know what is going on, what the causes are and how we can solve the problem,” Adhikari added.
For Tika Sapkota, a Jefferson Hills resident and a peer support specialist for the Squirrel Hill Health Center, the recent MHFA training was not his first, but he noted that it was for a lot of attendees. While Sapkota said he felt this training will help community members start more conversations around mental health, he hopes for more.
“We have a big community … so getting this much training is not enough,” Sapkota said. “If there can be more of these trainings regularly, [community members] may understand more and help more.”
Timsina said one of the goals of doing the MHFA training is to reduce the cultural stigmas around people who struggle with mental health. While many community members do notice those around them struggling, lack of education on mental health and negative cultural perceptions make it difficult for them to know where to begin when it comes to helping, or even speaking out.
Through MHFA training, Timsina said he hopes his community will begin to see mental health as an important piece of overall health.
“The kind of education we want to provide is that it’s okay to feel bad. It’s okay to feel some kind of mental pressure — everybody else feels it,” Timsina said. “But like you have a stomach ache or a headache, you tend to go to a doctor. There is treatment for how you feel, too.”
BCAP staff can only do so much
Sapkota notes that one of the greatest impacts of mental health education in the Bhutanese community is simply giving mental health language to community members that can help them verbalize their struggles.
“Culturally, our people don’t want to express even to the family members,” Sapkota said. “We don’t express bad things.”
“When it gets too bad, and they see their primary doctor, the doctor will ask how long this has been going on, and they’ll say a long time,” Sapkota continued.
Bishnu Timsina, a former BCAP board member and the wife of Khara Timsina, who has provided support to parents and families in the Bhutanese community since 2010, said in her experience, stigma plays a large role in these communication issues.
“Where we come from, traditionally mental health was not really seen as mental health — it was seen as like a different planet thing,” she said. “So, it was not easy to work with any families or parents.”
In a 2015 study done on the effectiveness of MHFA training for the Bhutanese community at Temple University, researchers found that participants in Pittsburgh, Philadelphia and Harrisburg scored higher on their ability to recognize signs of depression and provide first aid responses based on the “ALGEE” plan after the training.
The study did not find a significant change in the part of the assessment that screened for “stigmatizing attitudes.” The authors, however, noted that might have been caused by the MHFA training instructors not being from the Bhutanese community, and suggested the training could be culturally adapted.
At the training BCAP hosted this October, the instructor was a member of the Bhutanese community and the instruction and conversations were done primarily in Nepali, allowing community members and the instructor to joke around and talk freely in their first language.
In Kadariya’s opinion, adapting mental health education to the language needs of the Bhutanese community, especially for elders, can help bridge this gap.
“Our moms, our dads – they don’t speak English — but we can explain them in Nepali what is mental health, how it disrupts the families, and how we have to help each other in our communities,” Kadariya said.
Kadariya said this education can catalyze the way she believes the community members already lean on one another.
“They definitely support one another, but due to lack of some knowledge, some people are not helpful,” Kadariya said. “But we can talk to them about what mental health is, so we can educate the people about this, and then definitely, they can help each other.”
“Where we come from, traditionally mental health was not really seen as mental health — it was seen as like a different planet thing.”
For Bishnu Timisina, the eagerness community members have begun to express for more MHFA training and to start spreading what they’ve learned is an exciting prospect — both for the future health of the community and for the reach of Bhutanese community workers.
“If we do this to more people … I think there will be less victims, because there will be more people to get help from,” Timsina said.
Katie Mirr, BCAP’s youth and families coordinator, said the organization’s five staff can only do so much. “Those people that may have been on the fence are, when they’re seeing their friends or family members talk about [MHFA] and promote it, that might help them as well because they’re seeing like, ‘It’s coming from BCAP, but it’s also coming from my brother and my cousin,’” Mirr said. “Building it up that way, I think, is the only way that it’s going to work.”
A model for community mental health
The power that peer support can have on community mental health is something that Joni Schwager, executive director of the Staunton Farm Foundation*, one of the funders of BCAP’s MHFA training, sees as a great lift for the Bhutanese community.
“We believe that they [the Bhutanese community] are the best equipped to offer and train people from their community as opposed to anybody else because they know their community,” Schwager said.
Schwager believes that the type of peer support MHFA providers do will work well for the Bhutanese community because those in it understand the nuances in culture, attitudes toward mental health and the experiences of immigrants and refugees that all play into the mental health experiences of Bhutanese people living in the U.S.
“It’s a lot easier to talk to somebody who you know has had that experience as opposed to somebody who has a degree next to their name,” Schwager said.
To Schwager, MHFA in the Bhutanese community represents a significant shift in the way communities can address public mental health.
“I think that we are in a period now where we’re realizing the power of communities and things like Mental Health First Aid equip a community to be able to reach out to their own friends, neighbors and loved ones in a way that if you don’t have the right training, you wouldn’t feel as comfortable doing.”
The greater level of comfort — both to be vulnerable in sharing and in learning — that peer support models like MHFA create, is something that Bishnu Timsina said she has noticed take root in the Bhutanese community.
“I have seen more people coming out and seeking help. Families used to keep it within the family in the past, but they’re coming out now, and seeking help,” Timsina said. “This stigma is loosening.”
* PublicSource receives support from the Staunton Farm Foundation.
Tanya Babbar is an editorial intern at PublicSource and a junior at the University of Pittsburgh. She can be reached at tanya@publicsource.org.
This story was fact-checked by Erin Yudt.
The Jewish Healthcare Foundation has contributed funding to PublicSource’s healthcare reporting.
