“I am very stupid because I don’t know anything here.” This deprecating statement from Foua in The Spirit Catches You and You Fall Down is a sentiment that many Asian immigrants share in their struggle to adapt to the American culture. Although the majority of foreign-born U.S. residents are Latin Americans, immigrants are most likely to arrive from Asia. In 2014, there were more than 12 million Asian immigrants in the U.S. alone. Asian immigration started with the Chinese in the 1850s during the California Gold Rush. This marked the beginning of the Asian American Dream, where freedom from intolerance, economic opportunities, and the promise of wealth show that hope is on the horizon. Yet, the best things in life are the hardest to obtain. Language barriers and racial discrimination often bar Asian immigrants from working in established trades. Additionally, many Asian immigrants, despite their long history in America, are still considered outsiders. Culturally, American ideology often opposes Asian beliefs. With so many obstacles in life, Asian immigrants are often faced with mental health issues. To alleviate these problems, three approaches should be taken. First, cultural brokering is necessary to bridge disconnects between different cultures. Second, Asian American mental health should be discussed openly to overcome the stigma regarding this issue. Lastly, mental healthcare providers should create a culturally responsive framework to identify potential barriers to proper care.
Asian Americans’ mental health has been studied extensively over the years. The National Latino and Asian American Study or NLASS was the first national epidemiological survey of Asian Americans in the United States that better represents the Asian community when compared to other epidemiological studies (Alegria et al., 2004; Heeringa et al., 2004). In their study, the NLASS recruited 2,095 Asian Americans 18 years or older who lived in any of the 50 states. Their sample mainly included Chinese, Filipinos, Vietnamese, and other Asian ethnic groups. 75% of the sample was foreign-born, which aligns with the focus on Asian immigrants. The results of their study showed that the overall lifetime prevalence of psychiatric disorders among Asian Americans was 17.3% (Sue et al., 2012). Compared to other nationalities, such as the 28.1% to 30.2% lifetime prevalence rate of any psychiatric disorder reported by Latinos and the 30.5% rate among African Americans, the rate of prevalence of psychiatric disorders in Asian Americans is lower. Even though comparing data such as these can be inaccurate due to variations in methodology, assumptions, disorder examined, and sampling that went into each study, Asian Americans have consistently reported lower rates of mental disorders (Sue et al., 2012). Before looking at the accessibility of mental healthcare for Asian Americans, it is important to ask: where did these mental disorders come from and how did they manifest in Asian Americans?
When talking about mental health issues, it is impossible to identify a single factor. However, one of the major factors that can cause mental disorders in Asian Americans is racism and discrimination. In a Hmong mental health needs assessment, the elders reported that “many had experienced discrimination in Eau Claire, making them very reluctant to fully integrate with non-Hmong” (Collier et al., 2011). This lack of integration can cause social isolation, which leads to social anxiety and stress. Asian elders are already vulnerable to a plethora of mental disorders such as PTSD, depression, anxiety, and stress, from their experience in their homeland. With the addition of societal prejudice, Asian elders experienced further mental health issues. Racism and discrimination also affect other age groups in Asian Americans. In a paper published by the Johns Hopkins Bloomberg School of Public Health, they compiled numerous reputable studies and found “positive associations between discrimination and marijuana, inhalants, crack/cocaine, or other drug use” (Gee et al., 2009). Correlation does not imply causation, but the relationship between the two is clear. The study measured this relationship by collecting a sample of 2,305 students from 4 high schools in Seattle. There were a total of 493 Asian students in those 4 schools. Two items, unfair treatment in the neighborhood and at school because of ethnicity, were used to measure discrimination. It is plausible to say substance abuse is connected to mental issues, as things like drugs and alcohol, in many cases, provide a sense of escape or ecstasy for the user from the depressing reality that they are in. Asian American immigrants, unfortunately, are not only affected by racism and discrimination, but they are also vulnerable to the stressful process of assimilating to an entirely different culture.
Imagine. You live in Wyoming, the smallest state with a population of fewer than 600,000 residents and a negative growth rate. Life is peaceful and slow. All of sudden, your family packs their bags and moves to Manhattan, New York, a densely populated borough with skyscrapers, tall buildings, and an entirely different lifestyle. Wouldn’t it be shocking? In the case of many Asian immigrants, that is their reality. They are not moving from state to state, but from one country to another. Assimilation, in most Asian immigrants’ cases, is more of a euphemism for acculturation. Acculturation occurs when the cultural system of one group displaces that of another. American culture dominates Asian culture in many ways, as seen in The Spirit Catches You and You Fall Down. The cultural clash between Hmong and American healthcare professionals highlights the tension that continues throughout the book. Dr. Neil Ernst
strongly expresses that American doctors have more advanced Western knowledge of medicine than the Hmong and that the Hmong people have to follow rules with their kids’ lives. He also adds, “I wanted the word to get out in the community that if they deviated from that, it was not acceptable behavior”. Dr. Neil Ernst, from a doctor’s perspective, means well. However, his message also conveys that American culture dominates the Hmong culture. In 1987, a Hmong family refused to allow their son to continue chemotherapy due to cultural reasons, resulting in a SWAT team being summoned. Out of stress, the mother threatened to kill her family unless they brought her son back (Fadiman). This traumatic event shows the extreme mental stress that can occur when assimilation is forced and coerced. In elders, acculturation is even more difficult. Since many elders did not receive formal education along experienced postwar emotional distress, “the elderly […] also reported a strong sense of helplessness, loss of competency and uselessness.” (Collier et al., 2011) These traits point to depression.
Additionally, acculturation can even cause a loss of identity in American-born Asians. A Japanese woman revealed how she tried to fit in by learning different American accents so that “someone can pick up the phone, they’re not going to be able to tell what [her] race is” (Pius 2012). This reveals the strong societal push for the woman to fit in instead of allowing her culture to flourish. The domination of the American culture weakens her own as she lives in a predominantly white community. She even explained “That came from my first-generation immigrant parents who have very thick accents … I think that’s the biggest part” (Pius 2012). The woman’s embarrassment at her immigrant parents exposes the harmful side of American cultural domination; she had to lose her Asian identity to survive. Despite her internal turmoil, the woman never sought help.
Asian Americans with mental health problems tended to not seek help due to stigmas surrounding mental therapy. In a panel exploring mental health and Asian American culture, Sunny Zhang, a student at Harvard Graduate School of Education, said, “For [her father], culturally, you don’t air dirty laundry” (Duehren 2014). In other words, Asian people tend to keep private things to themselves so that they are not judged. Research has shown that “the maintenance of traditional stigmatizing attitudes can persist despite general adaptation … can continue into the second and even third generation (Na et al., 2016). Many factors contribute to
the survival of this belief, which includes family mediating instead of allowing for professional help. With so many components affecting Asian Americans and Asian immigrants’ mental health, healthcare professionals and researchers have found ways to mend these problems.
Cultural brokering, the act of bridging, linking, or mediating between groups or persons of different cultural backgrounds to reduce conflict or produce change, is necessary to bridge disconnects between the Asian culture and the American culture. As emphasized by the participants in the Hmong mental assessment, “future Hmong mental health programs would do well to develop culturally-sensitive treatment services” (Collier et al., 2011). Cultural brokers can effectively utilize their translational skills by using appropriate terms and respecting patients’ confidentiality, as well as lowering anxiety by teaching patients how to meet their primary needs. A cultural broker closes the gaps that separate American healthcare professionals from their patients. Their cultural and linguistic competency is a fundamental requirement to eliminate racial and ethnic differences (Collier et al., 2011). Not only should healthcare providers utilize a cultural broker, but they also need to learn about Asian culture.
To identify barriers to proper mental health care for Asian Americans and immigrants, mental healthcare providers should create a culturally responsive framework. In the case of a Laotian patient, a nurse was able to incorporate the cultural meaning of the patient’s symptoms and work out an effective solution. The Laotian patient showed what a normal American person would call “psychotic” symptoms and would be admitted to a psychiatric ward. However, the nurse consulted with her colleagues about Laotian beliefs and invited a shaman to work with the Laotian patient. The patient eventually recovered (M. Park et al., 2011). This situation demonstrates that the ability to first understand and interpret cultural norms and practices, then cooperate with a network of competent healthcare providers allows providers to effectively diagnose and treat the patients. Mental health providers’ cross-cultural skills are essential in building trust with the patients as well as educating Asian Americans effectively. In a 2007 study, the possibility for Chinese, Korean, and Vietnamese immigrant and refugee women in Toronto to access culturally and linguistically sensitive services positively affected their mental health help-seeking attitude (Na et al., 2016). This result further proves the importance for mental healthcare providers to be culturally flexible for their Asian patients.
Asian Americans must also overcome the stigma regarding mental health to properly seek help. In the Hmong study, “The lack of mental health literacy was seen as the cause of the lack of awareness about how and when to seek professional help” (Collier et al). Not just the Hmong people, but many Asian ethnic groups also do not have proper terminology for depression, PTSD, or even mental health. By developing mental health literacy programs for all Asian Americans and utilizing cultural brokers, Asian Americans can come to accept that mental health is not something to be ashamed of. As stated in Duehren’s article, “ an open dialogue about mental health issues will help combat the stigma all students affected by mental illness feel.” Change will happen when Asian Americans open themselves up, personally and publicly, about the topic of mental health.
Mental health is an integral part of human lives. It encompasses the psychological, emotional, and social aspects of a person’s well-being. The ability for a person to cope with stress and adversity, to adapt to changes, and to relate to others all depend on mental health. Knowing the importance of mental health is crucial to lead a meaningful life. Asian immigrants have come a long way since the California Gold Rush. American culture, despite its many flaws, strives to adapt like its many immigrants. The ideas of cultural brokering and culturally responsive framework in healthcare show how far America has changed when compared to its early days. However, with the current Coronavirus pandemic, Asian Americans are once again vulnerable to mental health problems due to racist attacks and financial burdens. Nevertheless, the development of responsive and flexible mental healthcare will go a long way in supporting the Asian community properly.
Works Cited
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