Also In This Special Report
Frank A. Clark, MD
María José Lisotto, MD; Andrés Martin, MD, MPH
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The rise in anti-Asian violence will likely lead to a rise in Asian Americans presenting for psychiatric care. Here is how best to address the longer-term problems they face...
SPECIAL REPORT: MINORITY MENTAL HEALTH PART 1
The shocking Atlanta mass shooting in March 2021 that resulted in the deaths of 6 Asian American women brought the nation’s attention to the rise in anti-Asian violence since the advent of the COVID-19 pandemic. The increase in hate speech, property damage, and brutal attacks, coupled with the negative mental health impact of quarantine isolation, has led to an increase in feelings of anxiety and distress among Asian Americans.1-3 With this confluence of stressors, we anticipate more Asian Americans will present for psychiatric care. Given the shortage of psychiatrists with expertise in working with Asian American patients,4 it seems timely for us to share some insights on both acute and longer-term issues facing Asian Americans.
Frank A. Clark, MD
María José Lisotto, MD; Andrés Martin, MD, MPH
Before we begin, a caveat: Asian Americans are an incredibly diverse group, representing more than 20 countries of origin and hundreds of languages and cultures. The needs of immigrants differ from those of American-born Asians. There are wide differences in socioeconomic status, insurance status, educational background, age, and degree of acculturation. Although 3 case presentations are inadequate to capture the diversity of this population, the cases are used to illustrate some of the issues with enhanced nuance and depth.
“Ms Cho” is a 37-year-old married professional Korean American woman with a history of major depressive disorder (MDD) and generalized anxiety disorder (GAD). Although she has been on a long-term stable dose of sertraline, her mood and anxiety have gradually worsened in recent months, and she reports feeling inexplicably “overwhelmed.” She finds herself struggling to keep up with work demands. Her psychiatrist, “Dr Williams,” who is not Asian, asks if this feeling has anything to do with the recent rise of anti-Asian violence. Ms Cho thinks for a moment, then nods. She discloses that she is constantly worried about the physical safety of her parents and her 2 school-aged children. She is also having intense memories of being bullied when she was in grade school. She finds herself thinking about these incidents, now with an adult’s perspective, and realizing the long-term impact these incidents have had on her life.
Anti-Asian racism in the United States began with the arrival of the first Asian immigrants in the 1850s. Frequently seen by Whites as “uncivilized, unclean, filthy beyond all conception,”5 Asians were labeled the “Yellow Peril” and “perpetual foreigners.” Over the subsequent 75 years, legislation such as the Exclusion Act (1882), Immigration Act (1917), and Johnson-Reed Act (1924) was passed to severely restrict immigration from Asian countries and to make those who did immigrate ineligible for citizenship.
In 1965, the United States relaxed immigration restrictions from Asia, and a second wave of more affluent, highly skilled Asians immigrated to this country. Perception of Asian Americans shifted from revulsion to admiration, as Asian immigrants attained educational and professional success. Asian Americans came to be known as a model minority, with success attributed to aspects of Asian culture, as compared with that of other ethnic minorities.
The recent rise in anti-Asian attacks reveals the fragility of the model minority myth. In the wake of COVID-19, Asians are no longer seen as educated hard workers worthy of admiration, but instead as carriers of disease, harkening back to the first racist insults. Furthermore, the attacks, which often take place in broad daylight with bystanders around, leave many Asian Americans feeling vulnerable and needing to be vigilant. One Asian American author eloquently describes the feeling of vulnerability: “I’m seen for my race above anything else,” she said. “I can be a Brown University student or a professor, but if I walk out onto the street, I will first and foremost be seen as an Asian and could still be attacked for that.”6
There has been a recent recognition that the strife associated with racism can rise to the level of traumatic stress,7,8 which can cause symptoms characteristic of posttraumatic stress disorder (PTSD): intrusive thoughts and memories, anxiety, and feelings of being unsafe, as experienced by Ms Cho. Thus, we could consider Ms Cho’s current symptoms to be products of vicarious trauma, triggering memories of earlier childhood racial trauma. While Ms Cho’s symptoms may not rise to the threshold level of PTSD (Dr Williams would need to perform a more comprehensive evaluation to say so definitively), subthreshold traumatic stress symptoms can exacerbate preexisting comorbid conditions, such as MDD and GAD.
While no empirically validated treatment models exist yet for managing symptoms associated with ethnoracial trauma, experts do recommend a few ground rules (Table 1).9
In addition to the above general principles, consider some of the interventions described in Table 2.
“Mr Sok” is a 58-year-old Cambodian American man referred by his primary care doctor to psychiatrist “Dr Smith” for chest pain with unremarkable cardiac workup. Because the clinic is without a Khmer translator, Dr Smith asks the accompanying daughter to provide translation.
The patient describes that he is worried that his chest pain could mean that he is developing, in his words, a “weak heart.” He also worries about tension in his body, which he takes to be a sign that his body is “falling apart.” Dr Smith, believing Mr Sok to be suffering from somatic symptom disorder, prescribes escitalopram. She explains the neurobiology of anxiety disorders; she notes the medication will help with his anxiety and suggests he return in several weeks. Mr Sok looks visibly puzzled but agrees to the treatment plan. Mr Sok does not fill the medication and is lost to follow-up.
Many Asian American immigrants have spent more time outside of the United States than in it. Consequently, a patient’s experience of their illness—their beliefs about its cause, its treatment, its meaning—is more likely informed by their culture of origin than by Western concepts like psychiatric diagnosis. Clinicians would do well to mind the gap between the psychiatric explanation and their patient’s. Ignoring this gap can lead to problems such as misdiagnosis, medication nonadherence, or early treatment rupture, as in Mr Sok’s case.
We recommend explicitly soliciting the patient’s cultural understanding of their illness using the DSM-5 Cultural Formulation Interview (CFI)10,11 or the Engagement Interview Protocol (EIP).12 The CFI operationalizes the process of elaborating a cultural narrative of the patient’s illness by reframing the query: “Sometimes people have different ways of describing their problem to their family, friends, or others in their community. How would you describe your problem to them?” In our experience, the CFI or EIP opens new opportunities for building a patient-clinician alliance and improves patient trust in the treatment.
It is also important to provide a culturally sensitive disclosure of diagnosis. Dr Smith could begin the discussion by relaying her understanding of the patient’s concern about a wind imbalance, and then wonder with him whether a medication might help bring his wind back into balance.
Asian American immigrants, particularly elders, vary in their degree of English language proficiency. Access to mental health care conducted in a patient’s primary language is limited in the United States and represents a serious barrier to care. Use of family members as translators, while necessary in limited resource settings, has considerable drawbacks ranging from omission of information to traumatizing the family member acting as translator.13 For this reason, we recommend the use of professional staff to perform translation.
“Ms Elizabeth Chen” is a 17-year-old Chinese American high school senior who presents following a brief inpatient stay for self-harm by cutting; her mother, who discovered the cutting, arranged for emergency evaluation. Elizabeth angrily relays the episode: “I’m so embarrassed. It’s actually her fault that I’m cutting. If she didn’t put so much pressure on me to succeed and if she took the time to understand my emotions, none of this would have happened.”
Elizabeth was born in the United States after her parents immigrated from China 20 years ago. Elizabeth describes the challenges of never feeling like she fits in. She describes one instance when she brought lunch from home and how some of her classmates teased her and said her food had “odd smells.” From that point on, she bought her lunch from the cafeteria.
“Dr Santos” speaks with Elizabeth’s mother, who describes her view of the problem: “Elizabeth tries to do too many things at once. She studies hard, but also wants an active social life—I always tell Elizabeth that she will feel better if she doesn’t spend so much time around her friends, but she never listens to my advice and then gets so mad.”
Many American-born Asians struggle navigating 2 cultures: They strive for acceptance from the host culture on the one hand, and they strive for acceptance from their family and the culture of origin on the other. This added conflict can complicate the already onerous process of identity formation in adolescence, setting the groundwork for psychiatric symptoms and problematic behaviors.
Furthermore, Asian American immigrant parents tend to judge their child’s behavior and actions by the cultural standards of the country of origin and are apt to make suggestions that may miss the bicultural nature of the conflict. For example, Mrs Chen’s suggestion to minimize socializing and focus on schoolwork may be well-received by a student who grew up in China, but to Elizabeth, this suggestion is likely to feel invalidating of her desire to acculturate, fueling further frustrations that her mother does not understand.
What can a treating psychiatrist do to help the situation? In addition to recommending standard behavioral treatments for problematic behaviors such as cutting, Dr Santos might also suggest a family intervention, using the Bicultural Effectiveness Training framework as an approach.14,15 Specifically, Dr Santos could gently reframe the problem as a conflict of cultural perspectives rather than a conflict of individual personalities and reflect with both parent and child on the advantages and disadvantages of each cultural perspective. For example, Dr Santos might ask Elizabeth and Mrs Chen to reflect on situations when spending less time with friends might be a good solution to stress and when it might not be a good solution.
Elizabeth’s case also illustrates the damaging effects of the model minority stereotype on the individual. Asian Americans like Elizabeth can feel immense pressure to live up to an image of success, exacerbating academic stress and leading to concealment of mental health symptoms. Of all US racial groups, Asian Americans are the least likely to seek mental health care, and while the reasons for this inequity are complex, the perpetuation of the model minority myth likely contributes to this disparity.16,17
By presenting these 3 cases with patients of varying ages, national origins, language proficiencies, and presenting problems, we hoped to capture a fragment of the diversity and showcase some of the main issues facing this population. The techniques highlighted might be helpful not only for Asian American patients, but across cultures as well. In fact, we might think about these techniques as ways for clinicians to assume a general attitude of cultural humility—a position of openness, self-awareness, and curiosity—that is useful in all encounters with patients, regardless of race or cultural background (Table 3).18
We hope that some of the strategies in this article may help in that effort to treat Asian American patients. However, when it comes to treating symptoms that are produced by systemic forces like racism and alienation from mainstream American culture, bearing witness to a patient’s experience of racism is like treating the symptoms without addressing the underlying cause. A truly comprehensive treatment plan for Asian American patients ultimately requires us to address the root cause by participating in advocacy for systemic change outside the consultation room.
Dr Liu is an assistant psychiatrist at the Behavioral Health Partial Hospital Program at McLean Hospital, a supervising psychiatrist to residents in the Adult Outpatient Services, and a member of the faculty at the Massachusetts General Hospital Center for Cross-Cultural Student Emotional Wellness. Dr Tuttle is a psychiatrist at Massachusetts General Hospital.
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19. Learning for Justice staff. How to respond to coronavirus racism. Learning for Justice. March 20, 2020. Accessed June 2, 2021. https://www.learningforjustice.org/magazine/how-to-respond-to-coronavirus-racism
20. Cultural Formulation Interview. American Psychiatric Association. 2013. Accessed June 2, 2021. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Cultural-Formulation-Interview.pdf ❒