Checking In With CMH
A Crisis of Cultural Competency in the Context of Asian-American Depression
- November 1, 2021
- Posted by: ss4555
- Category: Autism Children & Youth Research Services
By Sonam Saxena
Efforts to stop Asian-American hate are far from over.
On November 30, hundreds of Philadelphians rallied to demand “justice and safety” for Asian-Americans. This comes in response to increasing violence, with the recent example of an 18-year old girl assaulted by four teenagers on the SEPTA in a racially-charged attack. Events like these are tragic, but not uncommon.
Stop AAPI Hate also recently reported that traumatic and harmful attacks on Asian Americans are increasing. Stories of workplace discrimination, vandalism of personal property, and physical attacks are increasingly common. These culturally-based traumatic events have negative effects on physical, mental, and even spiritual health. In one study of the “perpetual foreigner stereotype,” researchers found that awareness of the stereotype was associated with lower self-reported hope and life satisfaction among Asian Americans.
To be most effective, care to address the sequelae of these events must take these harmful experiences into consideration. Trauma-informed care is one way to address past this trauma and its consequences, but different cultural lenses can result in different interpretations of trauma. So, when trauma is culturally based, therapists with shared lived experiences may be best suited to provide care. In this case, however, only about 5% of the mental health workforce is Asian, making it difficult to easily find therapists who understand these lived experiences.
One patient explained, “It can be a burden to feel like you need to explain your culture, or explain your experience as a person of color, to a therapist.” Asian Americans looking for mental health treatment often face difficulty in finding local therapists who can relate to their culture and struggles.
Understanding symptoms across cultures
Asian Americans are less likely than any other racial or ethnic group to get mental health treatment, and are least likely to see themselves as needing treatment. Unwillingness to seek care may relate to cultural stigmas surrounding poor mental health or the cultural tendency to somaticize mental health conditions. We don’t even have a great understanding of the need for mental health care in Asian-American communities because most studies include very few Asian Americans and aren’t conducted in languages commonly spoken in Asia. Compounding our poor understanding of mental health in Asian American communities is our tendency to group Asian Americans into a single monolith irrespective of the diversity of ethnicities and cultures (20+, according to the U.S. Census Bureau).
Separate from sampling and language issues, most studies may miss important nuances in how Asian Americans view mental health and associated treatment. For example, most research on depression takes a decidedly Euro-American approach. While the PHQ-9 does refer to symptoms involving sleep, energy levels, and appetite, some studies examining depression ask participants to report symptoms that are more feelings based, like anger and sadness. Researchers suggest that one cause of observed diagnostic and treatment disparities may relate to Asian Americans underrecognizing mental health conditions. For example, Eastern ideas about depression may include more “integration of body and mind,” focusing on physical symptoms rather than emotions. In practice, this might lead to Asian Americans underreporting symptoms of their depression. One study of clinical depression in Asian Americans found that they tended to present with physical symptoms (headaches, dizziness, pain) and did not discuss psychological symptoms until prodded.
Asian American patient may also misattribute their symptoms based on cultural norms, like the concept of “meng fu,” which can mask symptoms of worthlessness or guilt. “Meng fu” is a Chinese saying that means to “just grin and bear it.” Similarly, the consequences of the “model minority” stereotype may reinforce this idea, setting an expectation that they don’t have a right or the legitimacy to complain when these things happen. Kanazawa et al. found that Japanese Americans demonstrated less positive affect on average than European Americans, which was attributed to cultural standards of lower expressivity rather than lower clinical depression. Lacking a comprehensive and inclusive battery of culturally specific symptoms can lead to under-diagnosis of depression and other mental health disorders.
Consideration of culture in mental health diagnosis
Research suggests that these experiences are not uncommon amongst fellow Asian Americans. Efforts such as the Masala Study have explored how cultural nuances unique to South Asian Americans affect their physical and mental well-being. One study from Lee et al. examined factors contributing to Asian Americans’ low mental health service use; responses revealed differing perceptions over what mental health means and levels of “control” over it, parental or familial pressure to succeed and potentially ignore mental health issues, difficulty communicating with family about it, family obligations, and racial or cultural discrimination. Recognizing these differences further clarifies the need for cultural awareness when treating mental health conditions, because cultural factors can bleed into the presentation of mental health symptoms.
Many people of other minority races, as we as genders and sexual orientations, also have reported negative experiences with mental health services due to lack of understanding about the “relevance of their identities to their presenting concerns.” Immigrant populations experience unique risk factors for mental illness as well, such as the process of adapting to a new culture, racial discrimination, and interpersonal violence.
To help clinicians become more competent in someone else’s culture—and if we truly want to understand the different experiences of depression and other mental health conditions—we need to invest more in understanding the influence of culture and identities on symptoms and response to treatment. Incentivizing researchers to include this broader array of symptoms will increase the accuracy of our estimates of the prevalence and manifestations of mental health condition, and will help therapists that deliver high-quality care to patients. Let’s start by initiating the disaggregation of the Asian American monolith in research.