I had a friend who approached me one day and told me that she had been dealing with anxiety and depression for quite some time. This was shocking news because she had always been the bright, energetic friend who seemed to enjoy being around others. She was a social butterfly who enjoyed her weekends and was not overly concerned about grades or schoolwork. I was struck that she had not discussed what she was experiencing with anyone, including her parents. In fact, her parents were the last people she wanted to tell. When I asked her why she did not seek any support from her friends or family members, she told me that she was afraid that her problems would be dismissed, and she would be mislabeled as someone who was crazy or dangerous. She didn’t want to be perceived as abnormal.
My friend’s concerns weren’t completely foreign to me. Growing up with parents who immigrated from Korea, I was constantly told to smile and socialize even at times when I preferred to avoid these things. Blending in and doing what was expected of me were more important than how I felt as an individual. Consequently, I found it hard to openly express my thoughts to my friends and family members. I internalized my emotions and preferred dealing with problems on my own because it was easier.
Asian-Americans are often seen as model minorities. We are expected to excel in all areas regardless of our backgrounds creating a high-stress environment with a relative lack of support. Patients often choose to prioritize their physical health over their mental health, often dismissing the latter as something to overcome on their own. Furthermore, they prefer to keep their mental illnesses private due to shame and embarrassment. This shame stems from the stigma associated with mental health issues within the Asian community. Poor mental health is perceived as a sign of weakness.
Patients may also be bound by inherent cultural values such as honor and refrain from discussing their psychological states as “it reflects poorly on family lineage.” In fact, only about 8.6% of Asian-American patients seek help for mental health-related problems compared to 17.9% of patients in the general population. This reluctance of Asian-Americans to share mental health information may pose a challenge when it comes to providing treatment and care. Lack of sensitivity to cultural cues may lead to health care providers who overlook an important problem.
Likewise, silence can easily be mistaken for an absence of an underlying issue or concern. In clinical encounters with Asian-American patients, I observe a tendency for most patients to discuss the topic only when directly asked. Even though mental health is an equally important component of a patient’s overall well-being, it is uncommon for Asian-American patients to initiate a conversation about it. Because only a small percentage of Asian-American patients seeking mental health care, there are several issues that health care providers should be aware of in order to better serve and provide for the patients’ needs:
Language: Some Asian-Americans, particularly the elderly, may not speak English. This can be complicated by linguistic isolation, meaning that they live in households where nobody can speak English well. A recent study found that poor English proficiency, a measure for acculturative stress, was a major risk factor for depression. Such language conflicts may hinder successful acculturation and lead to greater perceived discrimination and social isolation. Patients may feel more comfortable talking to health care providers who speak their native language especially when regarding sensitive topics such as mental health. Furthermore, since patients may be unfamiliar with various therapies and medications, additional time may be needed to translate and thoroughly explain treatment options.
Gender: It is important to understand that there may be gender differences in the rate of acculturation. This is partially due to the presence of traditional gender roles and expectations that may oppose the fluidity of Western nonconformity. Additionally, women must meet unrealistic standards to maintain harmony within the family. These challenges further contribute to low self-esteem and poor mental health outcomes. Research suggests that Asian-American women are more depressed and are less involved in physical activities than their male counterparts.
Unfortunately, there is very little research specifically targeting Asian-American women. Recently, Harvard University launched a program called Asian Women’s Action for Resilience and Empowerment (AWARE), which “aims to fulfill a need for mental health care for an under-researched demographic.” The purpose of the program is to facilitate understanding and discussion among individuals experiencing similar challenges.
Religion and Traditional Beliefs: Faith often plays an integral role in Asian culture. Patients’ perceptions of mental illness may be heavily influenced by their religion or traditional beliefs encompassed by their culture. For example, mental illness may be perceived as a sin or a lack of spiritual harmony leading to feelings of shame and hopelessness. Interestingly, faith also seems to play a protective role in the mental health of Asian-Americans. A study found that religious service attendance, but not religious coping, was associated with reduced likelihood of major depression. The positive effects of religion and perceived social support suggest that faith is a valuable route to healing for mental health patients.
Culture: Additionally, there are culture-bound syndromes that are pertinent and specific to certain countries. For example, neurasthenia, a condition characterized by physical and mental exhaustion, is often cited in Chinese patients. Korean patients experience another condition called Hwa-byung which involves fatigue, panic and gastrointestinal disturbances resulting from anger suppression. Being cognizant of such culture-specific mental health conditions that may manifest as physical symptoms may be helpful in understanding the patient as a trinity of mind, body and spirit.
Obtaining a detailed patient history and recognizing nonverbal cues are essential when interviewing and counseling Asian-American patients. Asking about cultural practices, values, beliefs and coping patterns as they pertain to the patient is equally important. While there is an emphasis on the physician-patient relationship as a partnership, Asian-American patients may still see their physicians as authority figures and only share information they are asked to give. Furthermore, feelings of shame, embarrassment and guilt may preclude them from sharing critical information regarding their mental health. Therefore, in order to better serve the Asian-American community, it is important for health care providers to pay attention to cultural nuances, approach patients with a non-judgmental attitude, validate their concerns and encourage them to directly confront their mental health problems.