Silently Screaming in the Dark: Gender-Based Dynamics of Distress in Japanese Migrants

Abstract

Prior literature has shown the female Japanese population experiences higher susceptibility to mental health disorders. The causal influences of help-seeking for distressed women were investigated through analysis of 24 interviews of Japanese immigrant women in the Detroit Metropolitan Area. The Clinical Ethnographic Narrative Interview (CENI) was utilized as the interviewing technique, investigating Japanese culture as a determinant of personal wellness. This study was a grounded theory examination of the interactions among gender, social context, cultural displacement, and a causal model for Japanese women’s distress experiences. The resulting theoretical model revealed the familial and social dynamics traditional to Japanese culture developed feelings of poor self-worth common amongst study participants. This negative perception of self was exacerbated by gendered challenges of expatriation and intense pressures within this region’s Japanese migrant community. These findings show the need for increased contact with at-risk populations to understand their causal models and help-seeking behaviors and expectations.

“It was as if I was locked in a dark place where nobody hears me no matter how hard I try… It was like nobody hears me even though I was screaming for help.”

Introduction

Among all United States ethnic groups, Asians are the most quickly growing, yet East Asian immigrant women exhibit the lowest rates of mental health service usage (US Department of Health and Human Services 2001; Garland et al. 2005; Humes & Mckinnon 1999; Saint Arnault & Shimabukuro, 2012). There is a significant subgroup of Japanese immigrant women in the Detroit Metropolitan Area, drawn to the region due to their husbands’ employment within the automotive industry. Research has shown that despite residing in large homes in suburban areas, many of these women suffer from significant distress connected to gender-related immigration stressors (Saint Arnault, 2002). This research study aims to build upon research related to migrant health, examining the cultural and social “causes” of this distress through two lenses: the intersection of gender and immigration and the anthropological concept of causal models.

Migration experiences are influenced by gender (Pessar, 1999). Some scholars have noted that immigration research has generally focused on the males, who “tend to be seen as behaving according to the gender norm of mobile family breadwinner while women [are] transgressing the norm unless they followed as dependents” (Morokvasic, 2015, 57). Little research has documented the specific mental health risks faced by female immigrants, which include stigma based on social expectations of roles, gender-based violence, and financial dependency due to emigrational employment laws (Saint Arnault & Roels, 2011). These risk variables have been cited as accounting for the fact that East Asian Immigrant women have the highest levels of distress of any immigrant group (Takeuchi et al., 2007; Williams, 2008; Yeung et al., 2008). Qualitative research has shown that difficulties navigating the immigration environment are exacerbated by a lack of emotional support within the nuclear and extended family. This difficulty may be due to historical and cultural perceptions of marriage (Iwao, 1998; Saint Arnault & Roels, 2011). As such, the experience of emotional distress of the Japanese immigrant women is culturally specific, and their causal models can be explored to help situate their distress outcomes within the context of their gendered immigration experiences.

Culture, the illness experience, and causal models

Causal models are an anthropological conceptual domain of inquiry that seeks to understand “notions of causation, theories of underlying mechanisms, the expectation for outcome or prognosis, and recommended or appropriate treatment” (Kirmayer & Bhugra, 2009, 30). The clinical application of these relies on a strategy of open inquiry into the patient’s life experience and worldview. This exploration, while deemed critical by the American Psychiatric Association (American Psychiatric Association, 2000, 2013; Lewis-Fernández et al., 2014; J E Mezzich et al., 1999; Juan E. Mezzich, Caracci, Fabrega, & Kirmayer, 2009), conflicts with the dominant model of care which focuses on clinical diagnosis and subsequent development of a course of treatment (Bhui & Bhugra, 2002).

Causal models serve to elucidate perceptions about the social cause of illness across a variety of cultures. Causal models were explored by a 2010 Melbourne study focusing on the mental health care of East Timorese and Vietnamese refugees. Both the patient and provider perspectives were included, with participation from 24 patients and five providers (Kokanovic et al., 2010). The East Timorese group understood the course of the illness as a family phenomenon rather than an individual one and feared the repercussions on the family’s status and the ability of children to marry. These participants also exhibited extreme resistance to receiving support from individuals close to them due to the cultural perception that sharing their struggles would place a significant burden on others. In another study, forty Chinese American women were shown a vignette that portrayed major depression and asked to identify the cause of the distress and the mechanism by which the subject should practice help-seeking behaviors. Three categories were provided: psychological, physical, or do not know (Ying, 1990). Thirty percent of the psychological group and 75% of the physical group responded that the professional help was needed, the rest of each group saying help should be obtained from family or friends.

These studies focus on the link between causal models and distress outcomes, such as depression, anxiety, social withdrawal and loneliness, carrying implications for clinical practice. The needs of Japanese immigrant women living in the Detroit Metropolitan Area can be better served through the knowledge and clinical usage of their causal model of distress. Understanding a causal model can enable higher patient satisfaction because providers gain a clearer picture of a patient’s goals for their care. (Bhui et al., 2015). There has been little investigation regarding this population’s exploratory process, making qualitative exploration the ideal starting point. The research question for this study is: “How does gender, social context, and cultural displacement interact to form a causal model of distress for Japanese women?”

Methods

Study Design

This research is a secondary analysis of the interview data that was gathered in a larger mixed-methods project that examined distress and help-seeking in the Japanese immigrant women living in Michigan (NIMH R01MH071307). In that study, the senior author used interviews and surveys with 25 and 209 Japanese women living in the United States (Saint Arnault & Fetters, 2011). Previous research using this interview data has described social support (Saint Arnault, 2002), finding that the Japanese model of social support was a reciprocal one, differing from the American contractual model of social exchange. Another study found that the social networks formed by the Japanese community served a function of maintaining propriety and social order (Saint Arnault & Roels, 2012). A third study illuminated the importance of concept of Ikigai (purpose in life) and quality of life perceptions for the Japanese women in our study (Saint Arnault & Shimabukuro, 2016). This present study focused on the causal model the participants had that they used to explain their distress, and adds to this body of literature understanding how culture affects distress and help seeking.

Sample.

The parent study sampled women of childbearing age who were born in Japan and living in the US for reasons other than their education. The recruitment sites included a primary care clinic, Japanese-specific Saturday schools, and women’s clubs. Two hundred nine women participated in the survey, and 128 women were deemed highly distressed (60%) using a Center for Epidemiological studies for Depression screen or 6 or more physical symptoms in the Composite Symptom Inventory (see Saint Arnault & Fetters, 2011). Forty-one highly distressed women provided contact information, and of these, 25 women agreed to be interviewed. The interview data analyzed here was from these 25 interviews.

Procedure.

All procedures and materials for this study were approved by the University of Michigan Institutional Review Board (HUM00002837) and the Community Advisory Board that consisted of key members of the Japanese community. All communication with women in this study was in the participant’s native language, including all written contact, consents, surveys, and all research materials (Saint Arnault & Fetters, 2011). Interview participants were told about the interview and signed informed consent for the interview and audiotaping. An incentive of $20 was provided. Interviews were conducted between 2006–2010 by a Japanese master’s prepared Marriage and Family therapist. All interviews were conducted in Japanese, transcribed, and verified by the interviewer. Bilingual Japanese research assistants transcribed audiotapes of the interviews using a standardized protocol.

Ethnographic Interview

The Clinical Ethnographic Narrative Interview (CENI) was used. The CENI was developed to gather culturally relevant illness experience, meaning, and help-seeking (Saint Arnault & Fetters, 2011; Saint Arnault & Shimabukuro, 2012), and has been adapted for trauma survivors (Saint Arnault, 2017). The CENI is a 90-minute semi-structured interview composed of four activities: Social network mapping, body map, lifeline, and card sort (see Figure 1). The social network mapping helps the participant describe all help-seeking behaviors within the social context. The body map elicits physical and psychological experiences (Evans, 2010). The lifeline facilitates a retrospective overview of distress and identifies linkages between experiences and actions (Frank, 1984; Gramling & Carr, 2004; Shimomura, 2011). The card sort references a low point in the lifeline and facilitates description and organization of physical and psychological feelings (Gordon, 2001; Saint Arnault & Simabukuro, 2016). Finally, the participant describes causal interpretations, social significance, and help-seeking actions, assisting them in identifying their beliefs, meanings, patterns, and processes (Gergen & Gergen, 1986; Saint Arnault, 2017).

Figure 1:

Example drawings from the CENI

Analysis

The lead author used grounded theory analysis to examine the associations between a causal model of distress and distress outcomes, where the latter is defined as depression, anxiety, loneliness, and social withdrawal. Grounded theory was chosen because causal models are the precursor to treatment-seeking and are therefore part of the overall distress psychosocial process. Because this is a secondary analysis, the theoretical sampling step of the classic grounded theory approach was not possible. Therefore, our analysis used the constant comparison method that has been described by Corbin and Strauss, and Chen, et al. First, a comprehensive code list with definitions was developed of perceptions about distress causation, specific causal statements, and the impact of these on outcomes. Next, these definitions were “constantly compared” to each other to ensure that they were, in fact, distinct concepts and processes. This study aimed to discover the causal model and their impact on distress outcomes. Hence, we used the Six C’s: Causes, Contexts, Contingencies, Consequences, Covariances, and Conditions (Charmaz, 2012). “The Six C’s” help the grounded theorist discern the relationships among causal beliefs and the resulting distress and were used for the development of the theoretical model. Low-frequency codes were collapsed into higher-frequency codes when appropriate.

Reflexivity.

The lead author approached this work with a preliminary understanding of this culture obtained through both coursework and independent research, in addition to significant training in feminist practices ideal for this analysis. The trustworthiness of the findings was ensured by the constant comparison method, as well as the numerous meetings between the authors to ensure accuracy. The rigor of the data analysis were assured through an audit trail consisting of three components: reflective, analytic, and theoretical. The reflective journal included personal experiences and beliefs that may have affected the analysis, and this method helped to “bracket” personal biases and ensured that the voices of the participants were accurately represented. The analytic journal included preliminary code lists, the final code lists, and all coding decisions along the analytic journey. The theoretical journal included developing thoughts regarding the creation of the theoretical model that relates the participant’s causal model with their psychological distress.

Findings

Sample Characteristics

The women in both samples lived in single-family homes. The average age of the women was 37.5 years, and ages ranged from 25 to 59 years old. The average length of time women had spent abroad was six years, and the range was from 1 to 14 years. About one-quarter of both samples had either no children or very young children, 40% had school-aged children, and the remainder had grown children living in Japan or going to college in the US Because the women came to the US as spouses of husbands employed in the automotive industry, two-thirds of the sample had incomes over $60,000. Because of visa restrictions, 50% were not employed. Twenty percent were employed full time through work visa status. Eight women had less than junior college, and over half of the women had some college.

Silently Screaming

The title of this work represents the overall findings of this analysis. The concept of “silent” screaming is related to the inability of these women to meaningfully reach out to those around them during their time of need. The first part of this work’s title, “Silently Screaming,” was derived from one woman’s description of her experience when she stated, “It was as if I was locked in a dark place where nobody hears me no matter how hard I try… It was like nobody hears me even though I was screaming for help” (R910). The theoretical model emerging from this work presents five concepts and sixteen subconcepts (see Figure 2).

Figure 2.

The causal model for Japanese migrant women’s distress outcomes

Familial Expectations and Pressures.

Familial Expectations and Pressures consisted of three subconcepts: Familial Tension, Negativity within Intimate Partner Relationship, and [Familial] Expectations of Others. Familial Tension was defined as quarrels between interviewees and family members, including her husband’s family. An example of scrutiny imposed by the women’s mother-in-law was evident in one woman’s account, “Both of my parents worked, so we ate a lot of ready-made foods… [My mother in-law] said that I had a miscarriage because I grew up with junk food. I felt terribly bad” (R563).

Negativity within Intimate Partner Relationship referred to the distress experienced due to the presence of relationship disagreements, emotional or sexual abuse, or physical violence between an interviewee and her partner, as well as stressors related to the nature of her marriage. For example, many women reported that it was stressful for their husbands to understand her feelings, or that she needed to neglect her well-being in the presence of her husband. This pervasive spousal misery appeared in one woman’s expression, “Everything I enjoyed was criticized by him. That was a huge damage on me. I was so down and despaired that I did not even speak to people… I thought that I became absolutely crazy” (R577).

Familial Expectations of Others referred to internalized stress stemming from the high standards of family members. One woman discussed this at length, stating, “They never approved me of anything I did… They told me that I would stop working hard if they praise me even once… I always had to work hard; otherwise, they would not love me.” (R968).

Loss of Autonomy.

Loss of Autonomy consisted of four subconcepts: Dependency on Others, Jealousy, Difficulty Coping with New Surroundings, and Loss of Sense of Purpose. Dependency on Others was defined as distress due to frustration or other negative emotions concerning the inability to live with full autonomy. One woman commented on these feelings, stating, “I am very dependent on others… the anxiety comes from not being needed by someone” (Y572). This distress also arises from language challenges related to status as Japanese immigrants. Multiple women reported frustration when unable to express themselves in English, with one woman expressing the language barrier inhibited her from maintaining a happy marriage. She said, “But even if we went [to marriage counseling], I wouldn’t be able to explain myself well in English… it wouldn’t be helpful even if we went” (B612).

Jealousy represented the complex negative emotions that interviewees expressed regarding their inability to engage in meaningful activity while in the United States. Jealousy was often expressed as envy towards those gainfully employed, as illustrated by one woman’s reverberated statement, “I envy people who have jobs. I envy people who use their time and earn money, rather than killing their time for volunteering” (B573).

Difficulty Coping with New Surroundings referred to the distress caused by difficulty acclimating to new environments. The challenges experienced by interviewees that lead to this subconcept do not include linguistic impediments accounted for in Dependency on Others. A common manifestation of this subconcept was homesickness. One woman complained, “I got terribly homesick. I was far away from [my sisters] and could not see them… I cried every time I talked with them on the phone” (R553). A second woman elaborated on the intersection between homesickness and her social life through her statement, “it’s difficult to tell my feeling of wanting to go back to Japan to my friends who are enjoying the US” (R300).

Loss of Sense of Purpose was defined as the relatively common lapse in self-identity interviewees experienced after moving to the United States. One woman explained, detailed this experience; “Up until I came here, I always belonged to somewhere, I was always in school, I was a member of a company… But I felt like I lost it since I came here” (R885).

Notions of Self and Competency.

Notions of Self and Competency consisted of three subconcepts: Self-Blame, Lack of Self-Confidence, and Dissatisfaction with Appearance. Self-Blame referred to the practice of attributing negativity in life to one’s actions or inherent personality traits. One woman described these as feelings of inferiority. Another woman echoing this idea through the statement:

When you decline people’s invitation, again and again, people will eventually stop asking you to come. Ultimately, you will not be able to catch up with people’s conversation. I would feel isolated or feel like I am being left out if that happens… I know that it is my fault for not going out” (R553).

Lack of Self-Confidence was stress that occurs due to low self-worth in interviewees and was different from Self-Blame because it did not involve the specific action of placing responsibility for negativity in life to one’s flaws. One woman expressed instability due to this phenomenon. Another woman disclosed, “[I had suicidal thoughts] … I lost a lot of confidence… [my family] couldn’t understand why” (R717).

Dissatisfaction with Appearance was the personal insecurity and subsequent distressing actions relating to an interviewee’s perception of their physical traits. One woman disclosed, “I felt I needed to be thinner… I became anorexic and then bulimic” (Y572). Another woman expressed the concept in this manner, “I gained a lot of weight… I was so ugly” (B573).

External Expectations and Pressures.

External Expectations and Pressures had three subconcepts: Social Adversity, Work Commitments, and [Non-Familial] Expectations of Others. Social Adversity referred to distress resulting from social situations such as bullying and disagreements between friends. One woman’s explained, “I started having problems with my friends, so I went down” (Y572). Another woman discussed isolation from Japanese mothers, saying, “I had a hard time socializing with mothers of other children. They are all from Nagoya, and they had treated me as an outsider, like, ‘Oh, you are from Tokyo…’” (R553).

Work Commitments was distress from interviewees’ responsibilities to their daily occupation, such as job, student, or a volunteer commitment. One common manifestation of this distress was an explicit form of expectation or pressure directly linked to academic performance. One woman expressed that her job often had her working during holidays, which prevented her from joining clubs or seeing friends. (R717). Another woman said, “I worked too much, and needed an ambulance to be taken to the hospital” (R563).

Non-Familial Expectations of Others referred to the stress felt from the pressure imposed on interviewees by Japanese societal ideals. One woman’s said, “If you were not married in your late thirties, you were very aware of the way the society saw you in Japan… People would imagine strange things about you. It was very annoying, and there was a period I was feeling depressed because of it” (B612). Another woman expressed similar sentiments, stating, “I told myself that I should kill myself if our marriage did not work. I felt people’s expectation and anticipation that our marriage could fail” (B573).

Social Hesitancy.

Social Hesitancy included three subconcepts: Distance from Others, Gossip, and Nuances of Japanese Communication. Distance from Others was intrapersonal negativity felt related to an unspoken gap between an interviewee and another individual, and the subsequent inability for the interviewee to reach out. One woman explained, “For example, just because your kids play together doesn’t necessarily mean you talk about private things with them. And besides, normally, friends, the people you just met, it’s hard to gauge the distance” (R717). A second woman elaborated, “I distance myself from people… This kind of characteristic gets in the way of making friends… It is very hard to change myself” (Y525).

Gossip referred to the distress interviewees experience when they are afraid to share information or emotions with others out of fear that more individuals will become aware of the knowledge. One woman complained about her inability to speak freely, stating, “If I say something, it’ll be repeated somewhere…” (B111). Another woman agreed, commenting on the size of the Japanese community through the statement, “It’s so hard when things don’t go well because the Japanese society is so small. [People] would spread the words…” (R300).

Nuances of Japanese Communication was defined as how Japanese individuals communicate expressively using verbal pauses, vocal intonation, and body language. Americans do not utilize this same form of intricate communication, which can cause distress in the interviewees during interpersonal interactions. One woman explained this phenomenon at length, declaring,

We pick up cues in facial expressions, attitudes, manners of responding… Using common sense, I can guess the person’s character from their face, atmosphere, and how to reply… if I meet people who are different in race, or culture… I don’t know what they are thinking and how they take what I say, so I cannot communicate well (Y525).

Theoretical Model

The theoretical model that emerged from the grounded theory approach, shown in Figure 2, illustrates the emotionally suffocating internal dialogue described by women in this sample. Looking at the model, one can see that the subconcepts interact to ultimately create an outcome of distress, defined in this work as depression, anxiety, social withdrawal and loneliness. Within the model, Familial and External Expectations and Pressures both caused the emergence of Notions of Self and Competency. These feelings of (in)competency gave rise to intense feelings of pressure and social expectations, causing feelings of low self-esteem and self-worth. Social Hesitancy further cemented these feelings, creating a social environment perceived as riddled with gossip, ultimately inhibiting the formation of positive relationships that could counteract the effects of low self-worth. Loss of Autonomy stimulated Notions of Self and Competency. The damaging, poor self-worth at the core of Notions of Self and Competency was made worse by feelings of helplessness resulting from cultural displacement. The opposition between Loss of Autonomy and Social Hesitancy was noted, as the former seems to naturally necessitate more significant reliance on the views on others, which acts in contradiction with strong feelings to distance oneself.

Discussion

This study yielded the identification of a causal model revealing that Japanese women’s cultural ideals, social world, and migration experience interact to shape their sense of self and capability. We found that cultural ideals prompt the Japanese women to engage in a cyclic thought pattern saturated by negative self-talk when confronted with weakness (Heine, Kitayama, & Lehman, 2001). Japanese women may elicit negative feedback as part of a cultural pattern of acute focus on personal shortcomings to improve themselves (Saint Arnault, Sakamoto, & Moriwaki, 2005). The crux of this work’s causal model being Notions of Self and Competency suggests that this individual self-evaluation may relate to both familial and external pressures in addition to social hesitancy within the community.

This complex social hesitancy is itself a causal model of the Japanese immigrant woman’s interpersonal experience. This study is novel in that it revealed how social hesitancy fits into the overarching causal model encompassing this group’s mental health. We found that social hesitancy governed help-seeking behavior, and this was consistent with the prior observations that these women were expected to exhibit increased traditional cultural norms and roles, which was enforced through scrutiny, gossip, and the possibility of ostracism (Saint Arnault & Roels, 2011).

In the case of Japanese immigrant women, culturally-based gender norms include ways to function as a member of a social group. Inherent in this dynamic is the sense that individual shame is also shared across all members. Thus, any alleged, “disgraceful action of one [woman] causes a collective loss of face” for the entire group (Lebra, 1976, 36). As such, feelings of pressure and fear are part of the pursuit of maintaining harmony and consensus among her peers (Lebra, 1976). This focus on the social group is, in part, compounded by her having “fewer opportunities than men in which [she] can be evaluated on [her] own merits and abilities” (Iwao, 1998, 10). Because drawing attention to herself (as in the case of asking for help) might be perceived of as interrupting social harmony, the Japanese immigrant woman may find herself unable to engage in meaningful help-seeking, wordlessly experiencing the emotional consequences of the culturally-expected social hesitancy. This dynamic is not unique to the Japanese, shared in various forms across others in Asian cultures. Clinical intervention to promote help-seeking must account for cultural expressions of need, culturally adapting, and creating spaces and frames within which women and men can express needs.

Also, this study revealed a culturally distinct internal dynamic that is created by the combination of Loss of Autonomy and Social Hesitancy. The women involved in this study each underwent migration, which “involves three major sets of transitions: changes in personal ties and the reconstruction of social networks, the move from one socio-economic system to another, and the shift from one cultural system to another” (Kirmayer et al., 2011, p. E961). Such an experience naturally renders one in the position of requiring significant assistance from those around them. Yet, these women find themselves in a social situation that they perceive is characterized by gossip and rumors, to the point that asking for help does not feel like an option (Saint Arnault & Roels, 2011). This evaluation of the availability of social support is consistent with current literature on immigrant mental health, for example, research has shown that immigrant women face particular barriers to help-seeking due to social stigma, fears that disclosure will disgrace the family reputation, and perceptions of mental illness as a psychosocial issue (Kirmayer et al., 2011; O’Mahony & Donnelly, 2007). This knowledge must be incorporated into psychological understandings about help-seeking, and researchers and clinicians should work with communities to create culturally informed intervention methods.

Gender plays a crucial role in immigrant adjustment, and research has supported the relationship between Jealousy and Negativity within the Intimate Partner Relationship (Morokvasic, 2015). The women in our research were legally unable to pursue their careers and consequently described feelings of anger and jealousy towards those with the freedom to engage in employment. This distinctive social position and related expectations create a unique worldview in which it may be difficult for their husbands to see through their eyes, leading to a rift between the spouses that may create a lack of emotional support needed by the women in their attempt to adjust to a new society. This perspective is interesting to investigate, and a potential avenue to explore interventions aimed at providing support and information for all members of the immigrant family.

Implications for Clinical Practice

This research has highlighted the central importance of causal models in the experience of psychosocial suffering. Unfortunately, not all psychiatric and mental health nurses understand or routinely assess for this information or incorporate it into their care planning. In general, psychiatric mental health nurses should routinely assess cultural beliefs about illness, and simple culturally-relevant assessment guides should be incorporated into routine assessment plans. One such guide is the ETHNICS interview guide, in which the acronym stands for Explanation, Treatment, Healers, Negotiate, Intervention, Collaborate, and Spirituality (Kobylarz, Heath, & Like, 2002), although there are dozens of such guides. For instance, understanding this causal model helps us understand that the population may have concerns about social scrutiny and gossip, as well as the fears that help-seeking violates expected group norms. Therefore, individuals involved in direct patient contact (i.e., counselors or translators) should not be members of the community or otherwise intimately involved with community matters. Understanding causal models also helps the provider see that it is essential to accurately assess whether their patients receive sufficient emotional support from spouses, parents, or fellow community members, and the social and cultural beliefs and values that regulate this exchange. Understanding causal models can help the psychiatric mental health nurse recognize that individuals may not always match their methods of treatment with their causal model, and that providers should be aware that it is common for individuals to hold multiple causal models, and may use multiple strategies to cope with distress based on perceived outcomes (Chrisman, 1977). Examples of the latter in our sample was speaking with friends and utilizing prescribed medicines or folk remedies. The final nursing implication is the necessity of increased contact with at-risk populations to understand their causal models and their help-seeking behaviors and expectations (Ying, 1990). These methods may include increased and long-term community engagement with social service agencies dedicated to providing a range of services to this population.

The causal model discovered in this research may not be transferable to other Asian immigrant women. Continued research should be done to examine Japanese women’s causal models and those of other Asian immigrant women residing in the Detroit Metropolitan Area, as well as Japanese immigrant men’s causal models of distress.

In aggregate, the causal model discovered in this research contributes to the growing body of migrant health research. Our work helps move forward this body of knowledge by shedding light on how this particular migrant community perpetuates culturally specific mental health challenges, despite their residing within the context of an entirely different healthcare system and overarching social world. In researching migrant health, we have the unique opportunity to increase mutual understanding as people are increasingly coming together from all parts of the world. Further, it is our responsibility as the healthcare providers caring for these vulnerable migrant populations to think critically regarding how their culture shapes their beliefs about illness and their expectations for their health. In doing so, we can contribute to a world in which all people feel respected in their communities, fundamentally accepted by all providers, and ultimately honored in the bettering of their health.