Cultural factors influencing the mental health of Asian Americans

Summary points

• Cultural factors, such as language, age, gender, and others, can influencethe mental health of Asians, particularly immigrants

• Traditional (adhering to native values) Asians place great value on thefamily as a unit. Each individual has a clearly defined role and position inthe family hierarchy and is expected to function within that role, submittingto the larger needs of the family

• Social stigma, shame, and saving face often prevent Asians from seekingbehavioral health care

• Asian patients are likely to express psychological distress as physicalcomplaints

Asian Americans are the fastest growing racial group in the United States.They are also one of the most diverse, including at least 43 different ethnicgroups who speak more than 100 languages and dialects(box 1). The Asian Americanpopulation in the United States has grown from fewer than 1 million (0.5% ofthe total US population) in 1960 to 7.2 million (2.9%) in 1990, to 10,242,998(3.7%) in 2000. This number is expected to double by 2025. Approximately 7.2million (70.7%) Asian Americans are foreign born, and Asian immigrants accountfor 2.6% of the total USpopulation.³

Box 1.

Distribution of the Asian American/Pacific Islander population bysubgroup reporting only one race in2000^*

According to the 2000 census, the distribution of the Asian American andPacific Islander population in the United States is as follows (Census Bureau2001a):

Chinese (25.4%) Filipino (19.3%) Asian Indian (17.6%) Vietnamese (11.7%) Japanese (8.3%) Korean (8.3%) Other Asian (13.4%) Pacific Islander (4.2%)

^*From US Bureau of theCensus.¹

KEY CULTURAL FACTORS THAT INFLUENCE MENTAL HEALTH

Culture influences the Asian health belief system and has an effect on thediagnosis and treatment of mental disorders. Several key cultural factors thatare relevant to this process are described below. However, there is tremendouscultural variability among groups and heterogeneity within groups. Thesefactors will have differing effects, depending on the individual's degree ofacculturation, socioeconomic status, and immigration status. Our emphasis hereis on new immigrants, who comprise 1% of the USpopulation,¹ andthose who are more traditionally oriented. We have chosen this focus becauseit is these patients who experience the greatest barriers to receiving mentalhealth care. Key cultural factors are:

• Language Knowledge of English is one of the most important factorsinfluencing access to care. Asian languages and dialects usually are notwidely spoken outside the individual's ethnic group and, depending on degreeof acculturation, even within it. According to the President's AdvisoryCommission on Asian Americans and Pacific Islanders, 42% of VietnameseAmerican, 41% of Korean American, and 40% of Chinese American households are“linguistically isolated.” This designation means that no one inthe household age 14 years or older speaks English “verywell.”⁴

• Level of acculturation Typically, it takes three generations forimmigrants to fully adopt the lifestyle of the dominant culture. This intervalis about the amount of time it takes to accept Western medical care morereadily than traditionalcare.⁵

• Age In general, the younger people are when they migrate, the morereadily they adapt to living in a country in the West.

• Gender Historically, men have acculturated more rapidly than women.This standard may be changing, however, as women enter the work force.

• Occupational issues Especially among undocumented immigrants,professionals and highly skilled technicians often cannot access pathways totheir previous careers because of language or license verification issues.Some are forced to accept low level jobs as is the case with white-collarworkers who become piece-goods workers in garment factories and dishwashers orline cooks in restaurants where they earn minimum wage or less. Sometimes,women earn more than men, thereby disrupting family expectations andtraditionalvalues.⁶

• Family structure and intergenerational issues (see below).

• Religious beliefs and spirituality The predominant religions ofAsians who do not practice some form of Christianity or Muslim religion are:Buddhism, which promotes spiritual understanding of disease causation;Confucianism, an ethical belief system that stresses respect for authority,filial piety, justice, benevolence, fidelity, scholarship, andself-development; Taoism, which is the basis for yin andyang theory; and animism, which is the belief that human beings,animals, and inanimate objects possess souls andspirits.

• Traditional beliefs about mental health In the traditional beliefsystem, mental illnesses are caused by a lack of harmony of emotions or,sometimes, by evil spirits. Mental wellness occurs when psychological andphysiologic functions are integrated. Some elderly Asian Americans share theBuddhist belief that problems in this life are most likely related totransgressions committed in a past life. In addition, our previous life andour future life are as much a part of the life cycle as our present life.

Table 2.

Traditional beliefs and behaviors relating to mental health

Culture	Beliefs	Coping behaviors and treatments
Chinese	Mental illness caused by lack of harmony of emotions or by evil spirits	Often try traditional herbs and acupuncture first; healers may be usedconcurrently to get rid of evil spirits
Japanese	Mental illness caused by evil spirits; often thought not to be real illness	Delay or avoid seeking professional help; many will use traditional sources ofcare
Korean	Mental illness caused by disruption of harmony within individual or byancestral spirit coming back to haunt patient because of past bad behavior;result of bad luck or misfortune; payback for something done wrong in thepast; is considered shameful	May deny problems, resulting in helplessness and depression; not likely toreveal the problem unless asked; may show signs through nonverbalcommunication and posture; may use shamanism
Vietnamese	Depression is sadness	Not readily acknowledged because of stigma; usually try home remedies,spiritual consultations, or Chinese herbs before seeking Western medical care;some use of exorcists; seek help only when problems become acute or obvious;family members try to cheer up or distract the patient

Source: Lipson JG, Dibble SL, Minarik PA. Culture and Nursing Care: APocket Guide. San Francisco, CA: UCSF Nursing Press; 1996.

Health beliefs and behaviors of Chinese, Japanese, Korean, and Vietnamesecultures are briefly summarized in the Table.

Culture shapes the expression and recognition of psychiatric problems. Theinfluence of the teachings and philosophies of a Confucian, collectivisttradition discourages open displays of emotions in order to maintain socialand familial harmony or to avoid exposure of personal weakness. Savingface—the ability to preserve the public appearance of the patient andfamily for the sake of community propriety—is extremely important tomost Asian groups. Patients may not be willing to discuss their moods orpsychological states because of fears of social stigma and shame. In manyAsian cultures, mental illness is stigmatizing; it reflects poorly on familylineage and can influence others' beliefs about the suitability of anindividual for marriage. It is more acceptable for psychological distress tobe expressed through the body than through themind.^{1,7,8,9,10,11}

The Asian American family

Traditional (adhering to native values) Asians place great value on thefamily as a unit. Each individual has a clearly defined role and position inthe family hierarchy, which is determined by age, gender, and social class.Each person is expected to function within that role, submitting to the largerneeds of the family. Rituals and customs such as ancestor worship, familycelebrations, funeral rites, and the maintenance of genealogy recordsreinforce this concept. To achieve peaceful coexistence with the family andothers, harmonious interpersonal relationships and interdependence areemphasized. Mutual obligations and shame are the mechanisms that help toreinforce societal expectations and proper behavior.

Extended families are common among Asian Americans, and two or threegenerations often live in the same household. In traditional Asian Americanfamilies, major decision-making is the purview of the father, followed by theoldest son who receives preferential treatment on the assumption that he willaccept greater responsibility in the care of the family. The mother's job isto nurture and care for her husband and children. Female children have a lowerstatus than male children within the family. In some cultures, such as theChinese, the wife is expected to become part of her husband's family.

Gender

Traditional roles for men and women prevail among the Vietnamese. Womenusually maintain that their husbands have a legitimate right to make finaldecisions, and they usually will withdraw from spousal conflict to maintainharmony within the family.

Women are at particularly high risk for the development of psychiatricdisorders during their lifetimes. Most major mood and anxiety disorders, withthe exception of obsessive compulsive disorder, occur more frequently in womenthan in men.¹²Various biologic, social, and cultural hypotheses have been advanced toexplain this phenomenon.

Unfortunately, the value placed on males manifests in sex-specificinfanticide and a disproportionate number of females in orphanages andavailable for adoption in China.

In the United States, traditional Asian expectations of women can severelyconflict with ideals that emphasize independent thinking, achievement, andself-sufficiency, even at the expense of others' feelings and needs. Theseconflicting values can play out in several ways:

• Stress and conflict in teenagers lead to isolation and withdrawal or actingout behaviors that in turn can lead to depression

• Spousal conflict can occur as women work in and interact with a culture inwhich their status is compared to that of their husband

• Resistance to or refusal of psychiatric treatment resulting from chroniclow self-esteem can lead to a sense of fatalism

Among persons aged 15 to 24 and older than 65, Asian females are at thegreatest risk of suicide compared with women of all other racialgroups.¹³

Health practitioners must be sensitive and attuned to these issues so theycan enhance the therapeutic alliance and do not miss opportunities fordiagnosis and treatment.

The life cycle

Asian society has specific expectations of each age group that differgreatly from those in American society. Because of this difference, all agegroups are exposed to conflicts or clashes that may increase the risk fordevelopment of mental illness.

Children and adolescents

Children are highly valued in Asian American families. They are taught tobe polite, quiet, shy, humble, and deferential. Conformity to expectations isemphasized, and emotional outbursts are discouraged. Failure to meet thefamily's expectations brings shame and loss of face to both the children andtheir parents. Parents are seldom forthcoming with affection and praisebecause of fear that such demonstrations will encourage laziness. Education isimportant and children who do not do well in school bring shame to theirfamilies. Positive reinforcement and discussion of personal achievements areuncommon.

Adolescence has limited meaning in most Asian cultures becauseindividuation carries little value and seeking a definition of self outsidethe family is not encouraged.

Children usually acculturate more readily than their parents and otherelders. Members of older generations benefit from this rapid acculturation bythe children serving as interpreters and negotiators for them in the newculture. Although parents expect their children to acquire the language andskills that will enable them to be successful in their new country, they oftenare reluctant to have them fully embrace most aspects of American culture forfear that they will abandon their native culture. For example, parents mayencourage their children to learn English in order to succeed in Americansociety but may refuse to allow them to speak English at home. Such confusingmessages to the child lead to transgenerational conflict.

Young adults

For many Asians, young adulthood means achieving for the family. However,with increased exposure to or immersion in Western cultures and values, andconflict between peer pressure and family expectations, many young AsianAmerican adults begin to question their family values. Interpersonalrelationships become more of a challenge. Interracial relationships may causeserious conflicts because of parental fears that biracial children willdiffuse the family lineage and culture. Asian men may feel pressured to dateonly women from their specific ethnic group.

Many Asian adults may misunderstand the meaning of the often brief andtransient personal relationships that are common in urban settings in theWest. Young adults also face such dilemmas as deciding the group with whichthey want to be identified and having one identity at home and another whenout in public, a phenomenon known as dual identity.

Often the obligation to parents takes precedence over the individual'schoice of career. Choice of a career that is different from that chosen by hisor her parents can result in loss of emotional and financial support.

Other stresses facing Asian young adults are shown inbox 2.

Box 2.

Stresses facing Asian young adults

Peer pressure to smoke, drink, and have sex Pressure to conform to societal norms of individuation, which oftenconflict with traditional family expectations Common traditional Asian modes of communication (eg, being indirect,avoiding direct conflict, respect for authority through verbal and nonverbalbehavior, and deference toward authority figures) often are not understoodwithin the majority culture New immigrants face severe and sudden challenges to cope with the cultureand demands of a new country Anti-Asian sentiment

The elderly

Whereas elderly Americans emphasize independence as a means to maintaintheir self-esteem and to avoid becoming burdens to their children, elderlyAsians look forward to having their grown children care for them. TraditionalAsian elders tend to have full control over family and financial decisionswhether or not they live with their children. Most elderly Chinese immigrantsprefer to have their children move in with them rather than moving in withtheir children. They are not inclined to value independence and, when theylive separately, it is to avoid conflict over family roles.

Elders are highly respected and honored by all Asian cultures. In extendedChinese families, grandparents often are responsible for the care ofgrandchildren. Families are expected to care for their children and elders.Japanese Americans frequently maintain separate households from their childrenand grandchildren. Korean and Vietnamese elders are welcomed to live withtheir children for the rest of their lives. Those who reside with children andgrandchildren are viewed as having been rewarded for everything they haveprovided to younger generations.

ELICITING PATIENTS' VIEWS ABOUT THEIR ILLNESS

Culturally competent assessment and treatment of mental health problems inAsian Americans requires that health professionals ask patients and theirfamily members to share their cultural views on the cause of the problem, pastcoping patterns, health care-seeking behaviors, and treatmentexpectations.¹⁴ Inthe context of health care, the physician-patient relationship is not seen asa partnership; rather, the physician is considered the authority. Asianpatients will answer questions but are not likely to raise issues, and theywill tell the physician what they think he or she wants to hear. The healthcare provider must reassure patients that they may talk about their problemsand no judgments about them or their family will be made.

Kleinman's seminal work in the development of a health explanatory beliefmodel has led to a series of questions that can be used to elicit informationfrom patients and their families (box3).¹⁵Specifically, these questions draw out patients' understanding of the causesof illness. The explanatory model is critical to successful patient engagementbecause it provides a context for diagnosis and treatment negotiation.

Box 3.

Questions from the Patient's Cultural Health BeliefsQuestionnaire

What brought you to the doctor today? What do you think caused your problem? Why do you think it started when it did? What do you think your sickness does to your body? How does it work? How bad is your sickness? Has this difficulty interfered with your normal daily routines? If yes, how? How long do you think it will last? Do you know others who have had this problem? What did they do to treat it? Did you discuss the problem with any of your relatives or friends? What did they say? What kinds of medicines, home remedies, or other treatments have you triedfor this sickness? (Include quantity, dosage, frequency, how treatmentsprepared) Did they help? Are you still using them? What type of treatment do you think you need from the doctor today? What do you hope the treatment will do for you? Do you think there is any way to prevent this problem in the future?

Adapted from: Kleinman A, Eisenberg L, Good B. Culture, illness and care:Clinical lessons from anthropologic and cross-cultural research. AnnIntern Med 1978;88:251-258.

Another important step for the practitioner is to identify sources ofsupport and strength to the individual, family, and community network in pastadaptation, coping, and problemsolving.¹⁶ In Asianculture, strength lies in the Confucian teaching of the “middleway,” the Buddhist teaching of compassion, the strong focus on theimportance of family harmony and interpersonal relationships, and the highvalue of education and hard work. Asian cultures emphasize family, friends,and ethnic community. During a crisis, Asian families can usually count onsupport from extended family members, friends/villagers, and community networkand organizations. We find it helpful to explore, recognize, and make use ofthese support systems in the treatment process.

Successful assessment of mental health problems in the Asian Americanpatient is based on:

• Practitioner awareness of individual patient demography

• The patient's beliefs about health and mental health

• Eliciting an explanatory model from the patient

• Negotiation around acceptable diagnosis and treatment

• Use of the family support system to increase adherence to treatmentregimens and to reduce barriers

Figure 1.

UNICEF

Many Chinese girls who are abandoned by their parents grow up inorphanages

Figure 2.

UNICEF

Elders are honored and respected and often play a key role in raising theirgrandchildren