with Edmond Hsin T. Pi, MD, Geetha Jayaram, MD, Joan Han, DO, Francis Sanchez, MD, Dora-Linda Wang, MD, Clayton Chau, MD, Rona J. Hu, MD, Helen Lavretsky, MD

The latest rise in discrimination, harassment, and attacks on Asian Americans has led to increased attention on the plight of Asian Americans in this country. Recent high-profile attacks and grassroots campaigns have led to widespread media coverage and legislative changes. The American Psychiatric Association aimed to address mental health among this population and facilitate discussions on Asian American racism at its 2021 annual meeting, held virtually in early May.

As part of two key sessions, panelists offered an in-depth analysis of Asian American racism and historical trauma, shared poignant stories of discrimination and personal triumphs, and provided hope for the future through discussions of their ongoing work to address mental health disparities among Asian Americans.

The panels included:

  • Asian American Mental Health and Racism During and Post COVID-19, with Edmond Hsin T. Pi, MD, Geetha Jayaram, MD, Joan Han, DO, Francis Sanchez, MD, Dora-Linda Wang, MD, Clayton Chau, MD
  • Saving Which Asians? One or Many at a Time: Clinically, Legally, Through Media and Live Theatre, with Rona J. Hu, MD, Helen Lavretsky, MD

Below is a summary of the key points made and my takeaways as an Asian American third-year psychiatry resident.

Asian American Racism and Historical Trauma

The exponential rise in anti-Asian American/Pacific Islander (AAPI) hate activities has led to a renewed focus on Asian American racism in the United States. Recent hate activities likely constitute the most widespread anti-Asian American incidents since the internment of Japanese Americans during World War II. The COVID-19 pandemic created the perception that the anti-AAPI activities were fueled by hateful rhetoric from high-profile public figures, but racism has always been rooted in the founding of this country. To better understand the current state of affairs and create solutions for the future, the APA panelists recommend we look beyond recent events and reckon with our country’s long history of anti-Asian American racism.

The history of Asians in America long precedes the founding of our nation. It has been postulated that human populations from Asia emigrated to the Americas through the Bering land bridge more than 10,000 years ago. This theory is further supported by evidence showing shared genetic linkages between Native Americans and Asian Americans.

US history is notable for our institutionalized racism against AAPI, which is particularly evident in immigration and naturalization laws. In 1790, US citizenship was limited only to “white” persons and required 2 years of residence and good character. The Chinese Exclusion Act of 1882 prohibited the immigration of Chinese laborers. The inequality in the immigration and naturalization processes for Asian Americans were challenged in two landmark supreme court cases: Ozawa v. United States (1922) and United States v. Bhagat Singh Thind (1923). The court ruled against Asian Americans in both cases, and it would take decades before Asian Americans could gain citizenship to this country.

Our country also has a long history of anti-Asian American violence. The Chinese massacre of 1871, where 19 Chinese immigrants were lynched, is one of the worst mass lynchings in US history. It was followed by the San Francisco riot of 1877, and the Rock Springs Wyoming Massacre, which occurred after the Chinese Exclusion Act, in which miners at Rock Springs were either killed or driven from town. The 1982 murder of Vincent Chin by two autoworkers in Michigan is perhaps the most famous example in the modern era.

Today, the panel noted, Asian American women are twice as likely as men to be victimized. And despite the increasing public outcry and awareness of rising hate activities, hate crimes continue to be under-reported for a variety of reasons. For one, traditional Asian Americans subscribe to a collectivistic culture that may value peace-keeping and “saving face,” rather than potentially opening oneself to humiliation by reporting victimhood. Another reason may have to do with the model minority myth. Asian Americans are erroneously considered to be more well-off socioeconomically compared to other minority groups, and thus their suffering and plight are often downplayed through racial gaslighting.

There are resources for education and reporting on AAPI hate activities, including the Asian Pacific Policy & Planning Council (A3PCON) and Chinese for Affirmative Action (CAA).

Mental Health Care of Asian Americans

The Need for Cultural Humility Among Clinicians

Asian Americans, in general, suffer from mental health issues at roughly the same rate as other groups, although they are much less likely to seek mental health treatment, according to the APA panelists. For example, Asian American women have a 17% lifetime risk of developing a psychiatric disorder, but they are three times less likely to seek treatment compared to Caucasian-American women.

Within the Asian American populations, Dr. Sanchez pointed out that Filipino-Americans, in particular, are more likely to suffer from depression (20 to 34%) than Korean Americans (33%), Chinese Americans (16%), and Japanese Americans (20%). Of note, depression rates in US-born Asian Americans are higher than Asian American immigrants, although the figures are likely underreported.

It is important to understand why mental health disorders in Asian Americans are under-recognized, under-diagnosed, and under-treated, noted the panelists. Depression may be under-recognized in AAPI populations due to the different clinical presentations of depression exhibited by these individuals – “smiling depression” occurs quite often and somatization of mood symptoms may lead to mischaracterization of the patients’ diagnoses.

As noted, AAPI cultural and religious beliefs may further lead to internalized feelings of guilt and shame when an individual is suffering from mental health problems. A collectivistic and family-oriented culture may lead to stigmatization, bias, and lower engagement with mental health treatment. Lastly, the shortage of culturally-informed and linguistically-concordant mental health professionals further deters help-seeking and contributes to treatment noncompliance and drop-out.

More on the importance of cultural humility in psychiatry in our special report with Dr. Steven Starks.

From the panelists’ point of view, the existing Asian American mental health care disparities represent opportunities for improvement and growth. Clinicians often strive for mastery and knowledge, even though culture is not something to be mastered. Perhaps a more appropriate term would be cultural humility, which normalizes not knowing, values understanding of differences and development of cultural knowledge, and focuses on self-reflection and growth.

Mental health treatment for AAPI individuals should include an assessment of their cultural/ethnic background and level of acculturation. Treatment should be contextualized and incorporated with the patient’s belief systems, such as spirituality, when appropriate. It also may be important to involve family members as allies, with the goal of educating them about mental health and working toward normalization of psychiatric treatment. Finally, clinicians should always provide face-saving solutions for conflicts and allow patients and families to maintain dignity and reputation when possible.

Using the COVID Pandemic to Drive Future Directions

Several of the presenters spoke about promising initiatives and works-in-progress and suggested pathways towards improving mental health care for Asian Americans.

Dr. Chau, the Orange County Health Care Agency (OCHCA) director, discussed his agency’s ongoing efforts to provide care to AAPI elders. During the COVID pandemic, AAPIs accounted for 12% of COVID testing but 20% of mortalities. There is often a delay or avoidance in testing or treatment due to concern over bias and discrimination, and intra-familial spreading of COVID has been common due to the close-knit family structure and living arrangements. In recent vaccination efforts, Dr. Chau described particularly poignant moments, when elderly patients broke down crying after receiving the vaccines, as some of these individuals have been “stuck” at home for almost a year. These efforts illustrate the importance of community outreach through a collaborative task force.

Dr. Hu, in the Kun-Po Soo Award lecture, discussed in detail her work with the Stanford Mental Health for Asians Research and Treatment (SMHART) clinic, as well as Communication Health Interactive for Parents of Adolescents and Others (CHIPAO). The CHIPAO program, launched in 2005, was initially geared toward Asian American parents of high school students in Palo Alto, California, partially as a response to the rising suicide rate in adolescents in the area. In recent years, CHIPAO has grown to include live shows, YouTube videos, and Zoom meetings, all with the goals of addressing bias and stigma around emotional and mental health issues, cultural/identity challenges, and teenage stressors such as grades, peers, and sexuality. Dr. Hu’s work has been performed at schools and conferences such as American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP), and CHIPAO has been featured on popular media and news outlets.

At the end of her lecture, Dr. Hu offered a few words of advice and encouragement to mental health clinicians. Always start off by listening to your patients; attainment of cultural competency always require an inquisitive mindset that focuses on lifelong learning. If you have lived experience, do share; if not, you can always be an ally and an upstander. Lastly, always remember to pay it forward.

Reflections from a Psychiatry Resident

The series of APA meeting sessions on AAPI-related topics were timely and sorely needed. The presentations on both past and present racism toward Asian Americans evoked difficult conversations about race, trauma, and culture. As an Asian American, I was saddened by the history of hate events against AAPI in this country, and I could relate to the presenters’ personal accounts of xenophobia and discrimination.

However, I was inspired by the progress that the presenters have made in combating AAPI mental health disparities in their own workplaces and amazed by the ways they have embraced their Asian American heritage and uplifted the communities around them. In this tumultuous time of unrest and uncertainties, perhaps the silver lining is that the human tragedies lend themselves to opportunities for people to unite and work toward a brighter future for humankind.

I will continue to use my personal experience and my voice to advocate for my patients and support causes that will better the world for everyone.

More from Dr. Wong on being an early career psychiatrist. See also, our special series on racism and psychiatric care in the BIPOC community.

 

Last Updated: Jul 1, 2021