Going Alone: How COVID-19 and Racism Are Exposing Gaps in AAPI Mental Health Care

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COMMENTARY

A year in pandemic lockdown and relentless, racially-motivated attacks revealed a reality for Asian Americans. For starters, Asians across the world were collectively blamed for the spread of COVID-19. After enduring the mental stress of the pandemic, Asian American and Pacific Islanders (AAPI) individuals are facing a new threat: unprovoked attacks that are casting a harsh light on long-simmering hatred toward AAPIs. The Atlanta spa shootings left 8 people dead, 6 of them Asian. Elderly Asian ladies are being shoved to the ground. Racial slurs are hurled from slowed cars as Asian families push strollers down the street. No less than 81% of all AAPI say violence against them is increasing, compared to 56% of all adults in the United States.¹ AAPI individuals watch their backs, exchange whispered stories about attacks, and reconsider walking through their favorite neighborhood parks. In broad daylight.

And yet, despite these harrowing experiences, AAPI communities have the lowest mental help-seeking rate when compared with other ethnic groups. Certainly, cultural and generational differences play a huge role in this, but there are other barriers keeping AAPIs from receiving care, one of which might be that they do not see themselves visually represented in the mental health care system.

Young individuals, in particular, are often caught between the pull of family traditions and open discussions about mental health in American culture. Suicide is the leading cause of death for AAPI aged 15 to 24 years old, a unique distinction among every other racial/ethnic group in the United States.²

With heightened fears becoming the new normal, now is the time to address a mental health care industry that needs to do more to reach this vulnerable population. At the very least, there is an urgent need to develop a cultural competence that shows patience, bridges gaps, and respects differences.

The Challenges of Assimilation

Since they first immigrated in the late 1800s, AAPI communities have endured the sting of racism, which is defined as “the belief that a particular race is either superior or inferior to another [that] can be direct and obvious or more subtle and indirect.”³ At the time, critics warned of the supposed yellow peril sweeping California. Then, for 3 years during World War II, 120,000 Japanese Americans were rounded up and held in internment camps.

After WWII, AAPI individuals settled into modern American society. Quickly setting to work creating a life for their families, they earned the title of model minority, a term that implied they were productive, quiet, and law-abiding.³ But this also held racist undertones, simultaneously serving as an example to all minorities that they should keep their heads down and not complain—in short, to remain invisible.

Today, more than 20 million Asians live in the United States, with 85% tracing their roots to China, India, the Philippines, Vietnam, Korea, and Japan. AAPI represent the fastest-growing major racial or ethnic group in the United States.⁴

Anger and fear during the COVID-19 pandemic needed a scapegoat and found one among AAPI communities. In fact, AAPI individuals said the racism they experienced during COVID-19 was greater than the stress of the pandemic itself. Many strongly associated symptoms from their experiences with those of post traumatic stress disorder.⁵ Reported hate incidents jumped from 3795 in March 2020 to 6603 during March 2021, according to Stop AAPI’s Hate Mental Health report from May. Verbal harassment (65%) and shunning (18%) were the 2 most common types of incidents, with physical assault being the third.⁵

Almost 65% of the incident reports were made by women, followed by youth (11%), and seniors (6.6%). Interestingly, the report indicated that AAPI individuals who made a report after experiencing racism had lower race-based traumatic stress.⁵ And yet, these same communities are the least likely to seek help for mental conditions, with just 23.3% adult AAPIs receiving mental illness treatment in 2019.⁶ There are myriad reasons why this is, but the conversation usually starts with cultural differences.

Mental Health and Cultural Divides

It would be a mistake to regard and treat all AAPI communities as singular. About 50 ethnic groups and more than 100 languages comprise the AAPI community. In fact, this broad diversity often makes it difficult to conduct research about AAPI mental health care needs. At best, research studies paint an incomplete or inaccurate picture.

Source: National Alliance on Mental Illness

In general terms, however, AAPI communities are tight-knit and family-oriented. Often, the need of the individual runs second to the needs of the family. Many families came to the United States, sacrificing their pasts in the hopes of finding a better future. Many struggle to make a living, with 11.1% of Asian Americans and 15.4% of Pacific Islanders living at the poverty level, compared with 9.6% of non-Hispanic whites.⁷ This family ideal creates a dilemma: The idea of sharing your struggles with a complete stranger seems unfathomable when your whole family is right there for you.

Historically in Asian cultures, mental health services were provided by family members under the guidance of religious leaders and healers.⁸ As a result, mental health issues are often interpreted and explained as karma, disrupted energy flow, or physical imbalance.⁶ Admitting you are suffering from a mental condition or illness is often seen as a sign of weakness and indulgence in traditional Asian cultures. This stigma can extend to bring shame on the entire family, causing some to hide problems or even refuse to acknowledge they exist.

As a result, it is not uncommon for AAPIs to refuse mental health care services because they do not want others finding out, they have concerns about confidentiality, or they fear neighbors’ opinions.6 Repressing mental health issues, however, has deadly consequences. In a 2011 study, Asian countries represented about 60% of the world’s suicides.⁹

A popular assumption is that if a man in a suit appears at the beach in an Asian country, chances are he is there to kill himself. The Nanjing Yangtze River Bridge in China and Aokigahara forest in Japan are among the world’s most popular suicide sites. San Francisco’s Golden Gate Bridge is also on that list.

Diverse religious and medical approaches also play a role in shaping a culture’s approach to mental health. AAPI communities are comprised of Buddhist, Hindu, Muslim, and many other belief systems. They practice a wide range of medicine, including Ayurveda, guided meditation, acupuncture, and herbal medicine. Many of these practices run counter with the American approach to mental health care, which leans on pharmaceuticals. For young individuals caught in the middle, this adds a unique pressure.

Bridging the Generation Gap

“My parents don’t believe in depression,” said Anna Akana, an AAPI actress and mental health advocate who was just 17 years old when her younger sister committed suicide. “There is a lot of shame, there is a lot of silence. To ignore that is to have honor.”¹⁰

In 2019, only 23.3% of AAPI adults received treatment for a mental illness. This is the lowest help-seeking rate for any racial/ethnic group in the US.⁶ Furthermore, in a 2020 study, while Chinese immigrant parents understood Western approaches to mental health issues, they did not easily note suicidality. Social anxiety was not considered a major mental health issue. Instead, this was often attributed to personality or cultural differences.¹¹

AAPI youth often experience conflicted cultural identity. The traditions of immigrant parents often clash with the openness of American culture, which emphasizes individualism and self care. Plus, there are cultural differences on how conditions are regarded, such as anxiety and depression. While many Americans can tick off every mental condition in their family for 2 generations or more, some AAPI individuals may never know this history.

Many Asian parents balk at the idea of doctor-patient confidentiality for their children. This hesitancy to expose the family may cause some parents to restrict access to mental health services for their children. White patients, for example, were more likely than AAPI patients to be diagnosed and treated for a mental health condition, such as anxiety or depression.¹¹ In many cases, AAPI youths have to fight to get the care they need. Left with few tools to grapple with their mental health issues, many AAPI youth turn to suicide.² Acculturation stress—the struggle for an individualto adopt another culture that conflicts with their own—can be a major suicide risk factor.¹²

Stressors like these are significantly compounded when racial attacks are targeting every member of the family. This has many health care providers worried that AAPI communities will be unequipped to deal with the pressure and strain.

When they do seek care, AAPI individuals often have to navigate a whole host of barriers. For many, this is unfamiliar territory, filled with providers who often do not look like them.

Barriers to Care

For any patient, finding the right mental health care provider is an intimate and vulnerable process, and this is certainly no different in the AAPI community. Meeting with a provider who gets you because they understand where you come from is often more important than knowing how many years they have practiced medicine. Unfortunately, the psychological workforce of minorities in general do not match the diversity of the United States population.

In 2016, active psychologists in the United States were 84% White, 5% Hispanic, and 4% each for Black and AAPI. At the same time, the general population was 61% White, 18% Hispanic, 12% Black, and 5% Asian.¹³ That said, the percentage of minority psychologists actually doubled between 2007 and 2016, and diversity is increasing among a younger generation of psychologists. The average age of minority psychologists is 44.7 years, while White psychologists average 51 years.¹³

The Asian American Psychological Association (AAPA), which began in 1972 with just a handful of members in California, expanded to 400 nationally by 1995, and has since grown its ranks today to 1556.

Having providers who represent the community they serve has the added bonus of overcoming the language barrier many AAPI individuals find when seeking mental health services. In 2019, almost 31% of AAPI were listed as not fluent in English, while 73.5% spoke a language other than English at home.¹⁴ It may explain why, in 2017, 13% of AAPI patients said they experienced discrimination while visiting a doctor or health clinic. Among AAPI immigrants, that rate jumped to 16%. Among AAPI women, it was even higher at 20%.¹⁵

Part of this disconnect can be explained by a lack of awareness of available resources and services in the AAPI community.¹⁶ Another disconnect can be chalked up to simple cultural misunderstandings. This is something the mental health care industry must work to correct as it embraces cultural competency in a way that is relevant, sensitive, and aware.

Bridging Acceptance and Understanding

Cultural competency is a set of behaviors, attitudes, and policies that allows systems, agencies, and professionals to work sensitively in cross-cultural situations, according to the Centers for Disease Control and Prevention.¹⁷ It requires an attitude that includes a basic understanding of one’s own culture, a willingness to learn about other cultures, and a positive attitude about those differences.¹⁸

For mental health care organizations, it is an opportunity to provide training for those interacting with the AAPI communities.

For providers, it means getting to know your patients and talking about race, even if it is challenging. It means acknowledging and respecting the difficult decision many AAPI’s make in seeking out mental health treatment. It could mean encouraging patients to be their own expert when it comes to their experiences of discrimination and hate.

A good place to start is by showing a personal interest in our patients. In the process, it could serve as an opportunity to engage in our own cultural self-reflection.

Dr Abenes is a licensed clinical psychologist for Community Psychiatry + MindPath Care Centers and an advocate for the AAPI community as a Filipino women leader.

References

1. Ruiz NG, Edwards K, Lopez MH. One-third of Asian Americans fear threats, physical attacks and most say violence against them is rising. Pew Research Center. April 21, 2021. Accessed July 13, 2021. https://www.pewresearch.org/fact-tank/2021/04/21/one-third-of-asian-americans-fear-threats-physical-attacks-and-most-say-violence-against-them-is-rising/

2. Centers for Disease Control and Prevention. Deaths, percent of total deaths, and death rates for the 15 leading causes of death in 5-year age groups, by race and Hispanic origin, and sex: United States, 2017. December 31, 2018. Accessed July 13, 2021. https://www.cdc.gov/nchs/data/dvs/lcwk/lcwk1_hr_2017-a.pdf

3. The MGH Center for Cross-Cultural Student Emotional Wellness. COVID-19 and Racism. March 11, 2021. Accessed July 13, 2021. https://static1.squarespace.com/static/5e72b7407f116a59eac10cb4/t/6001d7887b453e667b8cf67f/1610733452639/WM_COVIDRacism_EN.pdf

4. Budiman A, Ruiz NG. Key facts about Asian origin groups in the US. Pew Research Center. April 29, 2021. Accessed July 13, 2021. https://www.pewresearch.org/fact-tank/2021/04/29/key-facts-about-asian-origin-groups-in-the-u-s/

5. Saw A, Yellow Horse AJ, Jeung R. Stop AAPI hate mental health report. Stop AAPI Hate. May 27, 2021. Accessed July 13, 2021. https://stopaapihate.org/wp-content/uploads/2021/05/Stop-AAPI-Hate-Mental-Health-Report-210527.pdf

6. National Alliance on Mental Illness. Asian American and Pacific Islander. Accessed July 13, 2021. https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/Asian-American-and-Pacific-Islander

7. Americann Psychiatric Association. Mental health disparities: diverse populations. Accessed July 13, 2021. https://www.psychiatry.org/psychiatrists/cultural-competency/education/mental-health-facts

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11. Liu CH, Li H, Wu E, et al. Parent perceptions of mental illness in Chinese American youth. Asian J Psychiatr. 2020;47:101857.

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13. Lin L, Stamm K, Christidis P. Demographics of the US psychology workforce findings from the 2007-16 American Community Survey. American Psychological Association. May 2018. Accessed July 13, 2021. https://www.apa.org/workforce/publications/16-demographics/report.pdf

14. US Department of Health and Human Services Office of Minority Mental Health. Profile: Asian Americans. Updated 2020. Accessed July 13, 2021. https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=63

15. Discrimination in America: experiences and views of Asian Americans. NPR, Robert Wood Johnson Foundation, Harvard TH Chan School of Public Health. November 2017. Accessed July 13, 2021. https://legacy.npr.org/assets/news/2017/12/discriminationpoll-asian-americans.pdf

16. Spencer MS, Chen J, Gee GC, et al. Discrimination and mental health-related service use in a national study of Asian Americans. Am J Public Health. 2010;100(12):2410-2417.

17. Centers for Disease Control and Prevention. Cultural competence in health and human services. October 21, 2020. Accessed July 13, 2021. https://npin.cdc.gov/pages/cultural-competence

18. What is cultural competence? And why is it important? Preemptive Love. January 23, 2020. Accessed July 13, 2021. https://preemptivelove.org/blog/cultural-competence/