Migration, Socio-cultural Factors, and Local Cultural Worlds among Fuzhounese Chinese Immigrants: Implications for Mental Health Interventions

Abstract

The last two decades have seen a rapid increase of Fuzhounese immigrants (from Fujian Province, China) to the U.S. This group spurred the interest of researchers because of their new immigrant status and their demographic and sociocultural background that places them at a significant disadvantage compared with the majority of already-established Chinese immigrants. This paper synthesizes existing research on the Fuzhounese’s historical/cultural and migration experiences and examines ways in which socio-cultural forces interact with post-migration stressors to impact the onset, manifestation, diagnosis, and treatment of symptoms in this group. From prior ethnographic work, we suggest that the pursuit of four core social goals plays a key role in interfering with psychiatric treatment adherence: 1) To pay off their smuggling debt (often >$80,000); 2) To send money to their natal families to improve social standing; 3) To save money for a dowry to perpetuate the familial lineage by marrying and producing offspring; and 4) To attain legal status. To offer more insight on how these core social motivations impact psychiatric disability, we present a case vignette of a Fuzhounese man diagnosed with schizophrenia. We relate his treatment issues to specific fundamental values that infuse both the lived experience of mental illness and inform clinical and community treatment strategies for this group. We also extend relevant treatment recommendations to migratory workers from other ethnic groups.

Immigration patterns to the United States have greatly shifted during the past 40 years. With a slowdown of immigrants from European countries, there has been an increase in the migration of non-European groups such as Asian and Latino immigrants (Pumariega, Rothe & Pumariega, 2005). While research on risk factors and mental health access for Latino immigrants exists, there is less research on Asian populations (Iwamoto, Liao & Liu, 2010; Lee, Lei & Sue, 2001). We address this disparity by highlighting the at-risk status of a Chinese sub-group, the Fuzhounese. While Fuzhounese individuals share many characteristics with other Chinese subgroups, we highlight this group because of their recent growth and the extraordinarily disadvantaged context in which they experience migration and mental illness. Because limited research has been conducted with this subgroup, our paper conceptualizes the core social motivations of this group by drawing upon the authors’ in-depth clinical knowledge gained from over a decade of combined experience with this group and is informed by deep ethnographic writings and sociological research on this and other Chinese groups.

Chinese Americans, the largest Asian American subgroup, consist of 3.6 million people (U.S. Census Bureau, 2008). The majority of early Chinese immigrants came from Guangdong province and spoke Toishanese and/or Cantonese. Since the early 1980s, a rapidly growing and mostly undocumented group of immigrants from the Fuzhou area of Fujian province changed the diversity of the Chinese immigrant population (Guest, 2004; Liang & Ye, 2001). Older estimates from the U.S. State Department (Wu, 2003) estimated that 100,000 Fuzhounese individuals resided in the Greater New York area in 1994, and that this group constituted nearly 85% of undocumented Chinese in the 1990s (Zhang, 2008). More recent estimates indicated that 30,000 Fuzhounese people enter the U.S. each year (Zhang, 2008). Law, Hutton and Chan (2003) provided an updated estimate of 300,000 Fuzhounese individuals having left China in recent decades, with these numbers almost certainly being an underestimate due to this group’s illegal migration status.

While various reasons have stimulated the increase of emigration from the Fuzhou area (e.g., economic and political forces), we suggest that one influential reason is the core lived values shared by Chinese that fundamentally motivate this migration. We examine how these shared cultural orientations become transformed via the impoverished and disadvantaged context by which Fuzhounese immigrate to the U.S. In addition, we discuss reasons for their rapid upsurge including discussing Fuzhounese individuals’ social motivations and their impact on adjustment after arrival. We describe how certain stressors and risk factors may adversely impact this group’s psychological wellbeing. For example, their perilous migration journey and the social pressure to pay back migration costs may exacerbate an underlying psychiatric condition. We utilize a case vignette of a Fuzhounese man to illustrate how such migration difficulties and the core social motivations of this group impact the onset, expression, diagnosis, and treatment of symptoms among Fuzhounese immigrants. Lastly, clinical treatment recommendations on how to better serve this new group are presented, and implications are drawn for other migratory groups (i.e., specific Latino groups).

Migratory Workers in the U.S

Many ethnic groups immigrate in search of better economic opportunities for themselves and future generations (Cavazos-Rehg, Zayas & Spitznagel, 2007). Due to multiple risk factors, some immigrants experience mental health problems after arrival (Cavazos-Rehg, Zayas & Spitznagel, 2007; Coffman & Norton, 2010). Migratory workers, such as those from Central and South America, experience even poorer medical and mental health outcomes (Anthony, Williams & Avery, 2008). Approximately one million migrant workers travel around the U.S. or between their native country and the U.S. to work in the agricultural industry (Hovey & Magaña, 2000). The bulk of health research in this group has been conducted with seasonal migratory farm workers who primarily consist of monolingual Spanish-speaking Latinos (Anthony, Williams & Avery, 2008; Arcury & Quandt, 2007) and endure multiple pre- and post-migration stressors (e.g., poverty, acculturation, fear of deportation) and hazardous occupational exposures (Cavazos-Rehg, Zayas & Spitznagel, 2007; Coffman & Norton, 2010; Pumariega, Rothe & Pumariega, 2005). These occupational and lifestyle exposures also predispose migrant workers to a higher risk for skin diseases, pesticide exposure, physical injuries, and mental health issues (Arcury & Quandt, 2007). Limited social support, restricted social mobility, poor housing conditions, and experienced racism further exacerbate their vulnerable position (Hiott, Grzywacz, Davis, Quandt & Arcury, 2008; Magaña & Hovey, 2003). Thirty-to-forty percent of farm workers reported experiencing anxiety and depression (Hovey and Magaña, 2000). Yet despite this high prevalence, multiple barriers—a transient lifestyle, long workdays, limited English proficiency, a lack of health insurance—prevent access to needed care (Anthony, Williams & Avery, 2008).

Fuzhounese immigrants share many commonalities with such migrant workers. Many travel from state-to-state to work in Chinese restaurants, and experience social isolation, discrimination, demanding job environments, and deplorable living conditions that may impact mental health. Their transitory nature, lack of health insurance, and limited English proficiency likely contribute to underutilization of mental health services. However, we propose that the Fuzhounese’s unique cultural background and tremendous pressure to repay debts to international smuggling gangs provide a distinctly different context to their migration and mental health experiences. Unlike some migrant workers like those from Central and South America who travel between the US and their home country, the Fuzhounese predominantly remain in the U.S. This is because of the distance between China and the U.S., and the arduous immigration journey many embark upon. Instead, their travel between states to seek work and the barriers in returning to China set into motion particular social and cultural dynamics, resulting in further stressors and barriers to effective mental health utilization.

Geographic, Economic, and Political Contributors to Fuzhounese Migration

Fujian province is situated in southeastern China, across from the Taiwan Straits. Its capital city, Fuzhou, is located in Fujian’s northeastern part (Fujian Provincial Tourism Information Center, 2006). Residents of southern Fujian speak Fujianhua, while those living in the Fuzhou area have their own dialect, Fuzhouhua, both of which are distinct from Mandarin, the official Chinese language. Due to Fujian’s coastal location, prosperous fishing industry, and close proximity to different countries, an extensive history of emigration from the area exists since the mid-15^th century (Liang & Ye, 2001). In the 1970s, Chinese government’s experimentation with a market-oriented economy in Fujian popularized independent businesses, which further encouraged migration (Chin, 1999). As income inequality among the Chinese widened, it created a sense of relative deprivation for those unable to prosper in their communities. Their proximity to Hong Kong, Taiwan, and other prosperous Asian cities exposed the Fuzhounese to higher standards of living, thus contributing to the exponential increase in emigration (Liang & Ye, 2001).

In addition to geographic and economic factors, surveys indicated other practical reasons that stimulated migration (Guest, 2003): desire to reunify with family; availability of unskilled labor; and availability of social support from already-existing immigrant Chinese enclaves. Religious persecution by the Chinese government, who has a history of arresting, detaining, or abusing members of Falun Gong (Leung, 2002) and Christian churches (Bhattacharji, 2008), further motivated migration. Other Fuzhounese immigrants have also sought asylum to escape China’s restrictive one-child policy, under which many women pregnant with a second child (especially those without the resources to pay a fine for having additional children) face coerced abortion or sterilization by their local governments. These geopolitical conditions provide a powerful motivation and form a crucial context by which the fundamental social motivations (described below) of the Fuzhounese take place.

Sociocultural Contributors: Extension of Family Lineage in U.S

Although economic and political forces encourage Fuzhounese migration patterns, we suggest that the deeply ingrained, lived values of filial reciprocity, ‘face’, and the building of guanxi (social exchange networks) among the Fuzhounese contribute significantly to their migration. While these social norms have been identified by extensive ethnographic texts as common among Chinese social groups (see Yang & Kleinman, 2008 for review), here we present critical ways in which these ‘core lived values’ become transformed among the Fuzhounese due to particular contextual factors, which in turn might adversely impact mental health. We suggest that these social motivations give rise to four goals that guide much of their social interaction, which will be discussed later in this paper.

Filial reciprocity, a Confucian tenet, emphasizes that an individual is foremost expected to fulfill obligations to provide for one’s parents in return for their early care as a child. Not only does this obligation extend materially (i.e., providing sustenance and money), one must also perpetuate the familial lineage by producing offspring, and accruing wealth and social status. Another fundamental obligation is to preserve one’s ‘face’ (lian) by upholding one’s reputation as a good or ‘moral’ human being in one’s local social world, which is also a prerequisite to participating in social exchange networks or guanxi. The building of guanxi enables one to access and mobilize social capital, or network resources, which in turn symbolizes social status within one’s local community. These values are constantly reinforced and are so deeply held that to not participate is to be denied of “personhood” (Yang et al., 2007).

In order to enact these engagements, many young Fuzhounese face the potentially hazardous and often illicit journey to leave China to elevate their social status. Almost 90% of young adults in some Fujian villages have gone overseas, leaving behind the elderly and children (Ye, 1995). Increased earning power and obtaining of a foreign passport due to working abroad enhances a family’s social status. Themes of enhanced social standing for the family are evident among anecdotal statements from Fuzhounese immigrants as elicited by one researcher in New York City in the 1990’s: “Since I left, everybody in my family has been full of hope for the future,” while another reported, “I am sacrificing myself to bring happiness to my family” (Chin, 1999, p.18). In contrast, those who do not go abroad are considered mei chu xi (have no great future; Liang & Ye, 2001).

Fuzhounese Migration Pathways

Motivated by these sociocultural factors, Fuzhounese immigrants utilize a variety of means to arrive to the U.S. A fortunate few migrate legally, e.g., through family- or employer-sponsored visas. Others must utilize alternate means including fraudulent marriages that are arranged with U.S. residents/citizens (Zhang & Chin, 2002). One prominent illegal method is via transnational human smuggling. Human smugglers or “snakeheads (she tou)” coordinate individuals’ travels within an international network. “Snake people (ren she)” are smuggled via land, sea, air, or a combination of the three. Sea travel—or hiding as stowaways in cargo containers on freighters-- has become less common because of high detection rates and is mostly reserved for peasantry (Zhang & Chin, 2002). Snake people usually land in Central American or Mexican coasts and then cross the border on land (Kwong, 2002). In recent years, most urban Fuzhounese with more financial resources prefer air travel (Kwong, 2002), although it is slower due to the need to obtain reliable travel documents and pass through more transit points (Chin, 1999; Kwong, 2002).

Due to multiple players facilitating this transnational network, costs have risen exponentially. Recent anecdotal reports suggest costs of >$80,000 (Zhang, 2008). Prior to departure, one pays or “snakeheads ” $1,500 for initial transportation, which is borrowed from family in the U.S. or through a mutual aid system of co-villagers or friends. Upon arrival, relatives in the U.S. pay the remaining costs or the immigrant must borrow from the snakeheads at a 30% interest rate (Kwong, 2002). When payments are not received, debt collectors resort to intimation and violence (Zhang & Chin, 2002) or threaten relatives with the new immigrant’s execution (Kwong, 2002). Since these immigrants do not possess legal status, these assaults generally remain unreported to police. However, Zhang (2008) indicated that repayment is typically not an issue because “relatives usually find ways to pay off the fees quickly” (p. 87). These pressures thus cause the new immigrant to work even longer hours to prevent snakeheads from harming himself or his relatives back home.

Manifestation of ‘Core Social Motivations’ in the U.S

Immediately after the Fuzhounese arrive to the U.S., in order to participate in their group’s core lived values, many strive to broaden their traditional guanxi networks within the Fuzhounese community, which helps to increase social capital and status for their family. For example, religious communities in New York’s Chinatown re-create guanxi among the Fuzhounese and expand exchange networks. Isolated by their unique dialect within a primarily Cantonese-speaking Chinatown, Fuzhounese immigrants re-form networks through church-going activities with former co-villagers. Fuzhounese religious communities thus operate as a primary base by which to reconstitute guanxi networks. Distributing a portion of one’s social networks to the U.S. adds considerable social and material benefit, thereby engaging in a core engagement shared by many Chinese social groups (Yang et al., 2007).

We offer an analysis based upon over ten years of combined clinical experience with this group that extends prior writings about Chinese immigrants. While awaiting further empirical validation, we provisionally formulate via our interactions with this group and prior empirical writings that these core motivations manifest in the pursuit of four goals shared by those within the Fuzhounese local immigrant world. An initial goal is to pay off their smuggling debt. Because many Fuzhounese pay large sums of money (Zhang, 2008) to be smuggled into the U.S., this might require working up to 70-hour weeks of unskilled labor for four years to repay this debt (Chin, 1999). A common means of enhancing social and material status is to open small businesses such as “take-out” restaurants, as evidenced by nearly 90% of take-out restaurants in the Northeast being owned by the Fuzhounese (Chin).

As a manifestation of filial reciprocity, a possible second goal is to send money to their natal families in China to improve their living conditions (e.g., build more modern households) and social standing. In the past decade, as much as $100 million per year has been sent to Fuzhou from U.S.-based relatives (Zhang, 2008). Since many working-age adults have emigrated, those remaining behind—mostly elderly and children—primarily depend on their U.S.-based family members.

A third potential goal is to perpetuate the familial lineage by marrying and producing offspring. Male Fuzhounese commonly strive to save money for a dowry. Lam et al. (2009) suggest that Fuzhounese men, in addition to paying off their wives’ smuggling fees, are obligated to pay a dowry of $33,000. Accordingly, many Fuzhounese men have tremendous pressure to earn money to fulfill these familial obligations and to achieve full “personhood”. Many female immigrants also find a spouse through matchmaking services, thus providing relief from their debt and providing financial resources for their family in China. A fourth possible goal is to attain legal status in the U.S., which is an important marker for increased social standing. Critically, this also allows sponsorship of other relatives to the U.S.

Collectively, we provisionally identify these four goals as constituting the core social motivations of this immigrant group. While we are currently undertaking research to empirically validate this initial formulation, clarifying these goals enables mental health researchers to better understand obstacles to mental health delivery for this group.

Impact of Migration and Cultural Factors on Symptom Onset, Expression and Diagnosis

Due to these migration stressors and cultural factors, many Fuzhounese immigrants express psychiatric distress which then may subsequently lead to development of disorders such as depression, anxiety, and psychosis. Onset of psychiatric symptoms may have roots during the typically arduous and dangerous migration journey itself, with some immigrants being stored in cargo ships, traveling along rugged terrain and barbed wire barriers, or being detained in “safe houses” with minimal sustenance before relocation to another transit point (Zhang, 2008). Physically, these individuals often become malnourished or sick. They also risk detection and deportation to China, and physical abuse by snakeheads. Women face additional risks of sexual abuse (Lagdameo, 2008), which may have both physical and psychiatric consequences.

Onset of psychiatric symptoms may also take root after immigration to the U.S. After arrival, other stressors include the financial costs for smuggling and the pressure to repay snakeheads as rapidly as possible. As a result, most Fuzhounese individuals travel to other states to work in affiliated restaurants for six or seven days a week, >12 hours a day, at an average hourly wage of <$3.75 without healthcare benefits (Kwong, 2002). From the authors’ clinical encounters, many Fuzhounese clients expressed a feeling of being trapped in their demanding work arrangements and impoverished living conditions. Many are also forced to live in squalid, crowded buildings on the Lower East Side of Manhattan. Three to five immigrants may share a small bedroom and bathroom in apartments that have been described as “pigsties: small, filthy, and overcrowded” (Chin, 1999, p. 113).

As a reaction to these psychosocial stressors during or post-migration, some Fuzhounese immigrants manifest psychiatric distress that may further develop into mental disorders. Exposure to violent or life-threatening situations in their travels likely impedes the individuals’ psychological adjustment after arrival and may contribute to the onset of post-trauma reactions that include post-traumatic stress disorder, anxiety, or depression. The emergence of these symptoms may impair their ability to work and fulfill core social goals and further contribute to feelings of guilt, shame, and incompetency. For those who have already immigrated, subjective expressions of excessive work pressure, social isolation, and homesickness also emerge as frequent complaints (e.g., Chin, 1999). These manifestations of psychiatric distress can contribute to development of disorders such as depression, and might act as precursors to even more severe disorders (e.g. psychosis).

Although exact rates of those developing mental disorders among the Fuzhounese are unknown due to an uncertain number of total Fuzhounese immigrants, records from the Asian Bicultural Clinic at Gouverneur Healthcare Services (an outpatient mental health clinic servicing Chinese immigrants) in New York City documented that the proportion of Fuzhounese clients entering mental health services has increased in recent years (Law et al., 2003). Possible explanations for this trend include increased Fuzhounese migration and expanding bilingual treatment services. However, increased mental health service use by this group does not appear to equate with earlier detection of mental disorders, as undocumented Fuzhounese infrequently use community and rehabilitative services and are more likely to initially enter mental health treatment via inpatient hospital settings than other Chinese groups. Later access to treatment is likely to contribute to more severe psychiatric symptoms when treatment is finally sought, and consequently more severe diagnoses for this group (Yang et al, 2008). Accordingly, one study showed that undocumented Fuzhounese patients tended to be diagnosed more often with a psychotic disorder (69%) when compared with the non-Fuzhounese Chinese group (55%). Conversely, the non-Fuzhounese tended to be diagnosed with less severe disorders (e.g., depression--34%) relatively more frequently than the Fuzhounese group (22%; Law et al, 2003). This study also found that undocumented Fuzhounese exhibited less insight into illness and a nonsignificant trend towards prior history of suicide in this group when compared with other Chinese groups. While the precise causal relationships still require clarification, migration and cultural factors appear to powerfully influence the particular pattern of onset, manifestation, and diagnoses assigned to psychiatric symptoms experienced by the Fuzhounese group.

Impacts of Culture and ‘Core Social Goals’ on Continued Treatment

Once treatment has been initiated, several factors common to other immigrant groups, such as alternative explanatory models of illness (Kung, 2004); limited understanding of Western psychiatry; limited English proficiency (Yang et al, 2010a); and a lack of family in the US to monitor the individual’s treatment adherence are likely to contribute to poor adherence to treatment among Fuzhounese immigrants. Furthermore, psychiatric stigma has an immense effect on continued help-seeking behaviors of Chinese immigrants attributable to concerns about preserving ‘face’ (Shea & Yeh, 2008; Yang & Kleinman, 2008; Yang, Phelan, & Link, 2008). However, Fuzhounese immigrants demonstrate even poorer treatment adherence than the larger Chinese immigrant community. For example, Law et al. showed that 41% of undocumented Fuzhounese patients attended less than half of their outpatient mental health appointments, in comparison to only 11% of the non-Fuzhounese Chinese patients. Because many Fuzhounese patients terminate treatment and stop taking their medications soon after their psychiatric symptoms abate, sustained remission is made more difficult (Opler et al, 2007).

We propose that one primary explanation for these high treatment dropout rates is the particular way in which the core social motivations of the Fuzhounese manifest within their difficult immigration circumstances. That is, their urgency to pursue the engagements associated with the aforementioned goals, in combination with their disadvantaged conditions, result in greater obstacles to effectively access mental health services. Based on our clinical experiences, we have repeatedly observed that once discharged from inpatient units, these individuals are compelled to return to paid work. After locating a job (usually outside New York City), they return only once a month or less, thus frequently leading to medication non-adherence. Additionally, since most Fuzhounese individuals are not eligible for government-subsidized health insurance due to their illegal status, their ability to stay in mental health treatment is further compromised (Kung, 2004). Although New York City offers emergency Medicaid which makes inpatient psychiatric hospitalization and continuing outpatient treatment free (New York State Department of Health, 2004), this group fears perceived expensive treatment costs, further adding to help-seeking delay. Thus, we have observed a typical treatment pattern of seeking treatment only for a short period when symptoms exacerbate followed by treatment withdrawal once symptoms remit.

We use a case vignette to illustrate how this complex interrelationship of sociocultural, economic, and political forces exerts profound effects on the lived experience of mental illness in this group and challenges effective treatment. This case vignette illustrates how the cultural and migration factors described above impact the onset, symptoms, diagnosis, and treatment of a Fuzhounese man with schizophrenia. We utilize a case vignette because of its clear relevance for practitioners and its ability to illustrate how the social forces and core social motivations described earlier intersect with culturally-appropriate assessment, engagement, and treatment (Shea, Yang, & Leong, 2010).

Clinical Case Vignette

Mr. X¹ is a patient at the Asian Bi-cultural Clinic at Gouverneur Healthcare Services where the first and fourth authors worked. Gouverneur Healthcare Services is located on the Lower East Side of Manhattan, with a large surrounding immigrant population. Because it is a public city hospital, it also provides no- to low-cost services to undocumented immigrants.

Mr. X is a 35-year-old single male from Fuzhou. His father worked as a blue-collar worker in China, while his mother was a homemaker. Mr. X has two brothers and is the middle child and is the only one to complete high school. Mr. X came to the U.S. in 1993 at 17 and was smuggled out of China with hopes of improving his family’s financial and social status. Mr. X obtained a student visa to travel to the Netherlands where his brothers resided (where one brother, after being smuggled, obtained legal status). Mr. X then journeyed to the U.S. where most of his fellow villagers settled. He entered the U.S. utilizing a visitor’s visa and settled in Manhattan’s Chinatown, where he shared a room in a tenement building with five Fuzhounese men. To repay his smuggling fees, Mr. X worked in different states (e.g., Connecticut, Massachusetts, North Carolina and Ohio) in Chinese take-out restaurants. He hoped to legalize his status and applied for political asylum based on his involvement in the 1989 student movements in China.

For four years, Mr. X worked up to 13 hours a day, six days a week. He experienced daily stressors including economic hardship and crowded living conditions. In 1997 at age 22, Mr. X began experiencing frequent paranoid ideation, auditory hallucinations, disorganized speech and behavior, and social withdrawal, which led to his first psychiatric hospitalization in New York City with a schizophrenia diagnosis. According to Mr. X, he had no prior personal or family psychiatric history. Upon discharge in 1997, he was referred to an outpatient community mental health clinic for follow-up, but after a few initial sessions, he dropped out. This pattern continued from 1997 to 2002, during which Mr. X’s symptoms would exacerbate, leading to inpatient psychiatric care, referral to outpatient treatment, drop out and then eventual relapse. During this period, the treatment team advised Mr. X not to leave New York City to engage in his treatment. He developed hand tremors and drowsiness from his antipsychotic medications, affecting his work as a restaurant helper. Mr. X regarded the team as working against his desire to work, or to fulfill a core social motivation. Furthermore, the stigma associated with mental illness adversely affected his willingness to continue treatment. Because of the close-knit Fuzhounese community, he did not wish to be seen attending a mental health clinic, which would threaten his employment opportunities. Mr. X subsequently dropped out of treatment. During these five years, Mr. X was often frustrated and discouraged with his frequent hospitalizations and inability to maintain employment.

Five years after illness onset, Mr. X was mandated by court to participate in Assisted Outpatient Treatment program (Office of Mental Health, 2006), which supports those with a severe mental illness and unable to remain safe in the community without supervision. Medication non-adherence would result in an emergency room visit and possible re-hospitalization that would hinder Mr. X’s ability to work. To avoid further hospitalizations, Mr. X agreed to attend weekly clinic appointments.

To ease Mr. X’s frustration with his frequent relapses, the outpatient treatment team built a therapeutic alliance with Mr. X, and established treatment goals that facilitated actions that ‘mattered most’ within the context of Mr. X’s community: to prevent re-hospitalizations and to secure employment. The team discussed with Mr. X the importance of medication in maintaining functioning, common side effects, and signs that predispose relapse. Mr. X subsequently adhered to treatment for several months. Eventually, he located a job in Connecticut, but agreed to weekly phone contact and for monthly medication visits to the clinic. Mr. X did so for a few months until stopping medications due to severe side effects. He soon became mute, unable to perform at his job, and was fired shortly afterwards. He was rehospitalized in New York City due to his severe symptoms and non-adherence to his court-mandated treatment. On an outpatient basis, the team continued to work with him by negotiating his ensuing treatment plan to include a choice in his medications and appointment times to facilitate his finding employment. Soon thereafter, Mr. X began to realize the severity of his condition and the necessity of treatment adherence to remain stable, and he thus formed an even stronger alliance with the treatment team.

With his pending political asylum case from 1993 to 2007, Mr. X received temporary employment authorization from the Federal government. Owing to a unique employment program for mentally ill individuals with basic English proficiency, Mr. X obtained a factory job in New York City with the treatment team’s assistance. This job not only eased Mr. X’s financial concerns, but also significantly facilitated adherence to psychotherapy and medication appointments because he was able to work locally. Mr. X also felt that the treatment team intended to support his recovery process instead of working against his core social goals as he had previously thought. Rather than focusing solely on symptom stabilization, Mr. X started to discuss obstacles to his recovery in psychotherapy. Reflecting on his grief over not being able to fulfill Confucian obligations, he lamented his inability to earn large sums of money to support his family in China. He also expressed sadness that he could not find a wife due to his illness and financial limitations. Mr. X described how losing the capacity to extend his family lineage deprived him of social standing and led to conflicts with his family. He was eventually able to develop better insight and to more effectively utilize treatment. He became an active volunteer in an Asian psychiatric inpatient unit where he shared his struggles and encouraged other patients to adhere to both psychosocial and medication treatments.

Implications for Clinical and Community Services

After arrival, immigrants typically encounter multiple stressors such as language barriers, acculturation difficulties, discrimination, and a sudden loss of social support (Perreira, Chapman & Stein, 2006). Many Fuzhounese face traumatic migration journeys and extreme social isolation, which often precipitate mental health problems. We have utilized an extensive literature review and clinical case vignette to formulate how core social motivations of the Fuzhounese occur within a particular sociocultural, economic, and political context, which is further transformed by the disability brought on by severe mental illness. For the Fuzhounese, as among other Chinese groups, we propose that these include fulfilling familial obligations of reciprocity, enhancing one’s guanxi and face, and perpetuating the family lineage. However, the case vignette represents how among the Fuzhounese these fundamental lived values become transformed within particular disadvantaged conditions that lead to a poorer course of illness. This vignette also illustrates how integration of these core engagements into treatment might in some cases facilitate treatment.

In working with Fuzhounese, clinicians should be aware of the complexities posed by immigration and the cultural forces that motivate individual’s behaviors (Schouler-Ocak, Reiske, Rapp & Heinz, 2008). To help this group better cope with stressors related to immigration, targets for psychotherapy include alienation, loneliness and exhaustion brought on by living and work conditions. For those who endure traumatic migration experiences, post-traumatic stress disorder might constitute a focus of treatment. Further, consideration of core social engagements should be incorporated into any therapeutic approach. As illustrated above, attaining financial stability to pay off debt and to eventually provide for family might be integrated into initial treatment plans to more effectively engage this group. Incorporating psychoeducation about adjustment stressors and mental health, effective use of psychotherapy and/or medications, and the importance of consistent outpatient visits in forestalling relapse ought to occur while simultaneously maximizing the client’s vocational functioning. While not directly illustrated by our case vignette, psychoeducation might also address the proclivity for this group to use traditional remedies such as Traditional Chinese Medicine, tai-chi practice, or ancestor or folk god worship rather than Western psychiatric treatments as a way to resolve emotional or mental health concerns (Chen, Kazanjian & Wong, 2009; Ho, Hunt & Li, 2008; Sue, 1994). Culturally sensitive psychoeducational approaches might be implemented by presenting this group with information regarding the Western psychiatric model without dismissing or directly challenging traditional beliefs, which may disrupt the therapeutic alliance (Yang and Singla, 2011).

Community-level interventions might consist of improving outreach to provide information linking migration and other stressors to their effects on mental health. Accurate psychoeducation may also gradually improve the ‘mental health literacy’ of this community and to dispel specific common stereotypes of people with mental illness, e.g., dangerousness and work incompetence (Tsang, Tam, Chan & Cheung, 2003). Further, community psychoeducation might also address any threat that accessing psychiatric treatment poses to what we have identified as Fuzhounese immigrants’ core social motivations. For example, making specific treatment options, including low cost services without regard to immigrant status, available might decrease help-seeking fears related to the costs of treatment or illegal status. For example, attempts might be made to convey that mental health treatment in New York City is not contingent on citizenship status, and that many city hospitals offer sliding-scale or free services to low-income, as well as undocumented individuals. It is also critical to communicate that treatment providers will not report clients’ immigration status to government officials. Addressing these perceived dangers to these core social motivations in accessing services promises to substantially lower treatment barriers for this group.

Finally, institutional-level interventions might enable this group to adhere to psychiatric treatment while participating in fundamental lived engagements. One government-level intervention might be to increase job-training programs for Fuzhounese immigrants with mental illness, as current programs require English proficiency to participate. Employment further improves the individuals’ social standing within the community which is critical for individuals to be seen as ‘full status adults’, and provides motivation for individuals to engage in ongoing treatment. Such job-training programs would relieve the tremendous pressure of finding employment, thus lessening one major contributor to relapse. Further, allowing individuals to work within New York City (as we observed with Mr. X) would increase the likelihood of treatment adherence.

Although our recommendations are meant for the Fuzhounese specifically, it is possible to extract several principles to apply to at-risk migratory workers from other ethnic groups. First, psychoeducation is critical to connect migration stress and the genesis of mental disorders, thus emphasizing the importance of seeking treatment when needed (Hovey & Magaña, 2000). Due to the generally low level of education among migrant workers, these alternative education programs might take place via verbal presentation and video format (Anthony, Williams & Avery, 2008; Hovey & Magaña, 2000). Second, due to these groups’ migratory nature, psychological services should be embedded within other frequently utilized social, vocational and health services. For example, locating support groups near medical clinics and community centers facilitates opportunities for farmworkers to discuss feelings regarding leaving families and other acculturation issues (Anthony, Williams & Avery, 2008; Hovey & Magaña, 2000). Lastly, treatment might be focused and short-term initially to accommodate this group’s frequent need to migrate for work, for example in the areas of agriculture or food industries (Hovey & Magaña, 2000).

In this paper, we have provided a comprehensive literature review to explore the unique historical, cultural, and sociopolitical background of one of the largest subgroups of Chinese immigrants. Using prior ethnographic writings and a detailed case vignette, we formulated the psychosocial, economic and deeply-ingrained cultural dynamics that challenge mental health provision for this population. Although future research might further elaborate upon these core social motivations via qualitative and quantitative methods, we offer provisional recommendations concerning how to better integrate treatment at the clinical and community level for this group. We also suggest ways in which lessons learned from this group might apply to other migratory working ethnic groups. We hope that our analyses will spur systematic qualitative and quantitative research (Yang & Fox, 1999) that eventually lead to implementation of culturally-appropriate interventions for this growing and at-risk population.