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Copyright © Copyright 2002 BMJ publishing Group Cultural factors influencing the mental health of Asian Americans 1Charles B Wang Community Health Center 125 Walker St New York, NY 10013 2Charles B Wang Community Health Center 125 Walker St New York, NY 10013 3RAMS 3626 Balboa St San Francisco, CA 94121 4Pfizer, Inc 235 E 42nd St New York, NY 10017 Correspondence to: Elizabeth Kramerekramer931/at/earthlink.net ![]() | |||||
Summary points
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Asian Americans are the fastest growing racial group in the United States.They are also one of the most diverse, including at least 43 different ethnicgroups who speak more than 100 languages and dialects(box 1). The Asian Americanpopulation in the United States has grown from fewer than 1 million (0.5% ofthe total US population) in 1960 to 7.2 million (2.9%) in 1990, to 10,242,998(3.7%) in 2000. This number is expected to double by 2025. Approximately 7.2million (70.7%) Asian Americans are foreign born, and Asian immigrants accountfor 2.6% of the total USpopulation.3
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KEY CULTURAL FACTORS THAT INFLUENCE MENTAL HEALTH Culture influences the Asian health belief system and has an effect on thediagnosis and treatment of mental disorders. Several key cultural factors thatare relevant to this process are described below. However, there is tremendouscultural variability among groups and heterogeneity within groups. Thesefactors will have differing effects, depending on the individual's degree ofacculturation, socioeconomic status, and immigration status. Our emphasis hereis on new immigrants, who comprise 1% of the USpopulation,1 andthose who are more traditionally oriented. We have chosen this focus becauseit is these patients who experience the greatest barriers to receiving mentalhealth care. Key cultural factors are:
Health beliefs and behaviors of Chinese, Japanese, Korean, and Vietnamesecultures are briefly summarized in the Table. Culture shapes the expression and recognition of psychiatric problems. Theinfluence of the teachings and philosophies of a Confucian, collectivisttradition discourages open displays of emotions in order to maintain socialand familial harmony or to avoid exposure of personal weakness. Savingface—the ability to preserve the public appearance of the patient andfamily for the sake of community propriety—is extremely important tomost Asian groups. Patients may not be willing to discuss their moods orpsychological states because of fears of social stigma and shame. In manyAsian cultures, mental illness is stigmatizing; it reflects poorly on familylineage and can influence others' beliefs about the suitability of anindividual for marriage. It is more acceptable for psychological distress tobe expressed through the body than through themind.1,7,8,9,10,11 The Asian American family Traditional (adhering to native values) Asians place great value on thefamily as a unit. Each individual has a clearly defined role and position inthe family hierarchy, which is determined by age, gender, and social class.Each person is expected to function within that role, submitting to the largerneeds of the family. Rituals and customs such as ancestor worship, familycelebrations, funeral rites, and the maintenance of genealogy recordsreinforce this concept. To achieve peaceful coexistence with the family andothers, harmonious interpersonal relationships and interdependence areemphasized. Mutual obligations and shame are the mechanisms that help toreinforce societal expectations and proper behavior. Extended families are common among Asian Americans, and two or threegenerations often live in the same household. In traditional Asian Americanfamilies, major decision-making is the purview of the father, followed by theoldest son who receives preferential treatment on the assumption that he willaccept greater responsibility in the care of the family. The mother's job isto nurture and care for her husband and children. Female children have a lowerstatus than male children within the family. In some cultures, such as theChinese, the wife is expected to become part of her husband's family. Gender Traditional roles for men and women prevail among the Vietnamese. Womenusually maintain that their husbands have a legitimate right to make finaldecisions, and they usually will withdraw from spousal conflict to maintainharmony within the family. Women are at particularly high risk for the development of psychiatricdisorders during their lifetimes. Most major mood and anxiety disorders, withthe exception of obsessive compulsive disorder, occur more frequently in womenthan in men.12Various biologic, social, and cultural hypotheses have been advanced toexplain this phenomenon. Unfortunately, the value placed on males manifests in sex-specificinfanticide and a disproportionate number of females in orphanages andavailable for adoption in China. In the United States, traditional Asian expectations of women can severelyconflict with ideals that emphasize independent thinking, achievement, andself-sufficiency, even at the expense of others' feelings and needs. Theseconflicting values can play out in several ways:
Among persons aged 15 to 24 and older than 65, Asian females are at thegreatest risk of suicide compared with women of all other racialgroups.13 Health practitioners must be sensitive and attuned to these issues so theycan enhance the therapeutic alliance and do not miss opportunities fordiagnosis and treatment. The life cycle Asian society has specific expectations of each age group that differgreatly from those in American society. Because of this difference, all agegroups are exposed to conflicts or clashes that may increase the risk fordevelopment of mental illness. Children and adolescents Children are highly valued in Asian American families. They are taught tobe polite, quiet, shy, humble, and deferential. Conformity to expectations isemphasized, and emotional outbursts are discouraged. Failure to meet thefamily's expectations brings shame and loss of face to both the children andtheir parents. Parents are seldom forthcoming with affection and praisebecause of fear that such demonstrations will encourage laziness. Education isimportant and children who do not do well in school bring shame to theirfamilies. Positive reinforcement and discussion of personal achievements areuncommon. Adolescence has limited meaning in most Asian cultures becauseindividuation carries little value and seeking a definition of self outsidethe family is not encouraged. Children usually acculturate more readily than their parents and otherelders. Members of older generations benefit from this rapid acculturation bythe children serving as interpreters and negotiators for them in the newculture. Although parents expect their children to acquire the language andskills that will enable them to be successful in their new country, they oftenare reluctant to have them fully embrace most aspects of American culture forfear that they will abandon their native culture. For example, parents mayencourage their children to learn English in order to succeed in Americansociety but may refuse to allow them to speak English at home. Such confusingmessages to the child lead to transgenerational conflict. Young adults For many Asians, young adulthood means achieving for the family. However,with increased exposure to or immersion in Western cultures and values, andconflict between peer pressure and family expectations, many young AsianAmerican adults begin to question their family values. Interpersonalrelationships become more of a challenge. Interracial relationships may causeserious conflicts because of parental fears that biracial children willdiffuse the family lineage and culture. Asian men may feel pressured to dateonly women from their specific ethnic group. Many Asian adults may misunderstand the meaning of the often brief andtransient personal relationships that are common in urban settings in theWest. Young adults also face such dilemmas as deciding the group with whichthey want to be identified and having one identity at home and another whenout in public, a phenomenon known as dual identity. Often the obligation to parents takes precedence over the individual'schoice of career. Choice of a career that is different from that chosen by hisor her parents can result in loss of emotional and financial support. Other stresses facing Asian young adults are shown inbox 2.
The elderly Whereas elderly Americans emphasize independence as a means to maintaintheir self-esteem and to avoid becoming burdens to their children, elderlyAsians look forward to having their grown children care for them. TraditionalAsian elders tend to have full control over family and financial decisionswhether or not they live with their children. Most elderly Chinese immigrantsprefer to have their children move in with them rather than moving in withtheir children. They are not inclined to value independence and, when theylive separately, it is to avoid conflict over family roles. Elders are highly respected and honored by all Asian cultures. In extendedChinese families, grandparents often are responsible for the care ofgrandchildren. Families are expected to care for their children and elders.Japanese Americans frequently maintain separate households from their childrenand grandchildren. Korean and Vietnamese elders are welcomed to live withtheir children for the rest of their lives. Those who reside with children andgrandchildren are viewed as having been rewarded for everything they haveprovided to younger generations. | |||||
ELICITING PATIENTS' VIEWS ABOUT THEIR ILLNESS Culturally competent assessment and treatment of mental health problems inAsian Americans requires that health professionals ask patients and theirfamily members to share their cultural views on the cause of the problem, pastcoping patterns, health care-seeking behaviors, and treatmentexpectations.14 Inthe context of health care, the physician-patient relationship is not seen asa partnership; rather, the physician is considered the authority. Asianpatients will answer questions but are not likely to raise issues, and theywill tell the physician what they think he or she wants to hear. The healthcare provider must reassure patients that they may talk about their problemsand no judgments about them or their family will be made. Kleinman's seminal work in the development of a health explanatory beliefmodel has led to a series of questions that can be used to elicit informationfrom patients and their families (box3).15Specifically, these questions draw out patients' understanding of the causesof illness. The explanatory model is critical to successful patient engagementbecause it provides a context for diagnosis and treatment negotiation.
Another important step for the practitioner is to identify sources ofsupport and strength to the individual, family, and community network in pastadaptation, coping, and problemsolving.16 In Asianculture, strength lies in the Confucian teaching of the “middleway,” the Buddhist teaching of compassion, the strong focus on theimportance of family harmony and interpersonal relationships, and the highvalue of education and hard work. Asian cultures emphasize family, friends,and ethnic community. During a crisis, Asian families can usually count onsupport from extended family members, friends/villagers, and community networkand organizations. We find it helpful to explore, recognize, and make use ofthese support systems in the treatment process. Successful assessment of mental health problems in the Asian Americanpatient is based on:
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Notes Competing interests: None declared | |||||
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