Gloria Huh was 26 and juggling multiple jobs while earning her master’s degree in psychology at the University of Pennsylvania when she got a persistent twitch in her eye. She had been gaining weight, and her muscles ached. She went to her doctor, hoping to get a medical diagnosis and perhaps some medication to address her ailments.
She was surprised when her doctor told her that the eye twitch was a symptom of a much larger problem. She was on the verge of a nervous breakdown. “He said, ‘I can give you some medication for the residual effects of it, but something’s got to give,’” Huh, now 32, recalled. “He said the eye twitch may not be that big of a deal, but it’s the tip of the iceberg.”
The doctor’s visit was a wake-up call for Huh, a second-generation Korean American. She had never before seriously considered seeking psychiatric help.
“I grew up in a culture and in a family where you don’t really show your issues,” she said. “You smile and you work really hard, and then you go home and cry. My parents were really hardworking and they dealt with a lot of stress, but their way of coping wasn’t talking to anyone.” Even as a student studying to become a psychologist, Huh said, “it broke a lot of norms I had for myself by going to see someone.”
She put aside her misgivings and decided to see a therapist.
Huh’s physical symptoms served as a tipoff, to her and to her doctor, that something deeper was amiss. Increasingly, these so-called “somatic” ailments — mental health issues that appear at first to be physical ailments — are providing a pathway for practitioners to address the intractable problem of untreated mental health issues in Asian-American communities. In several medical studies, Asian Americans have been found to exhibit more somatic complaints than other ethnic groups.
In New York City, the recent suicide of a bipolar Korean-American dental student, whose body was found in the Hudson River in April, has brought new attention to this old problem. In fact, Asian Americans have for some time been the least likely group to receive mental health services, no matter their age, gender, or location, according to a 2001 Surgeon Generalreport. And a 2011 CDC report found that young Asian-American women have the second-highest rate of suicide of any American ethnic group.
Mental health professionals are trying to find new ways to address the problem and overcome the cultural stigma that prevents many in the community from seeking the help they need. In New York City and beyond, mental health specialists in communities with large Asian-American populations are tailoring their approach to include an understanding of the cultural differences that have traditionally made Asian Americans less likely to seek out mental health care.
A Practical Approach to Treatment
An understanding of somatic ailments, it turns out, can be a part of the solution for health centers catering to this population. Teddy Chen, a social worker at the Charles B. Wang Community Health Center, which serves nearly 50,000 Asian-American patients annually from four locations in New York City, said a number of his patients just don’t connect the symptoms their body is experiencing – for instance, stomach problems caused by anxiety, or lethargy caused by depression – to a mental health condition.
“Mental health problems can create a lot of symptoms that are similar to other medical conditions,” Chen said. “For example, anxiety can be very similar to cardiological conditions – so palpitations, shortness of breath, these kind of symptoms can be very confusing.”
Wen-Chun Hung, a mental health professional at Henry Street Settlement who works with Chinese-American patients with severe mental illness, agrees. Hung says that culturally, Chinese Americans aren’t taught to express their emotions and feelings out loud, and are more comfortable reporting physical symptoms.
“In terms of Chinese culture, it’s not an expression that you say you are sad; you don’t say that directly,” Hung said. “You don’t say ‘I don’t feel happy, I’m sad, I’m depressed.’ So they use the things that are happening physically – they say, ‘I don’t want to eat, I don’t sleep, I cry a lot.’”
The approach of Chen, Hung, and countless other practitioners across the country to addressing mental health issues that present as physical symptoms might seem innovative — and indeed, it’s supported by a growing body of academic literature. But in a way, there’s nothing new about it: The approach is consistent with some of the tenets of traditional Chinese medicine. Where Western medicine looks at physical health and mental health as separate realms, Chinese medicine looks at body and mind as interconnected and inseparable.
That traditional culture can sometimes also include a skepticism of modern psychiatry. A 2006Psychiatric Times study notes that in Europe and North America, depression is a “well-accepted psychiatric syndrome characterized by specific affective, cognitive behavioral, and somatic symptoms,” but there are no equivalent disorders in Chinese, Japanese, and South Asian cultures.
The authors of the study argue that by “incorporating belief systems from other cultures” and understanding somatic complaints through a cultural lens, “it is possible to begin bridging the gap between care providers and their patients.”
Cultural Stigmas Remain
The other factor that makes it hard to reach Asian Americans who need mental health services is the tremendous shame many Asian Americans, particularly immigrants, feel about the effect of mental illness on their families and communities.
Pearl J. Park, a filmmaker whose documentary, “Can,” focuses on a Vietnamese American’s battles with bipolar disorder, said the stigma goes beyond the patient who receives a mental illness diagnosis. Her documentary followed not just a patient, Can, who is bipolar, but also the effect his condition had on his Vietnamese-American family.
“They don’t think of it as a personal thing, they think of it as a family thing,” Park said, “and it would be very selfish for you to come out and say something that would hurt the whole family.”
Park has seen this in her own life, also. “I have mental illness in my family and I’m one of the few Korean-American people going around telling people about that,” Park said. “It brands you — and your children, and their children.”
Kristina Wong, a comedian and performer whose one-woman show, “Wong Flew Over the Cuckoo’s Nest,” deals with the stigma of mental illness in the Asian-American community, said that growing up, emotional well-being wasn’t thought of as a priority.
“The way I was raised, there’s no such thing as self-care. You just go and go and go until you get the trophy,” Wong said.
In the seven years that she has toured her show across college campuses and beyond, Wong said she has heard from many Asian Americans who come forward with their personal stories of suffering, which initially surprised her.
“Asian people seem fine — we don’t complain, we do really well in school — so there’s this assumption that we don’t have mental health issues,” Wong said. “It persists because it is so hidden.”
In the Safety of a Crowd, Patients Blend in
Many immigrant communities — not just Asian Americans — have a harder time accessing mental health services due to language barriers, and sometimes a lack of health insurance and quality care. The strain of immigration, adopting to a new culture, and struggling to make a living in adverse circumstances can push many new immigrants to a breaking point.
As a relatively well-established immigrant community, Chinese Americans have greater access to bilingual and bicultural mental health care than many other immigrant groups. The Chinese-American population in New York City, for example, jumped 34 percent from 2000 to 2011, according to census data. “So we are very lucky,” Chen said, “compared to other smaller ethnic groups in terms of mental health care.”
But even as mental health practitioners become aware of somatic ailments as a way into treatment of psychiatric issues, the approach is not always so simple. Chen said that at the Charles B. Wang Center, it’s common for patients to refuse treatment when doctors refer them to a mental health specialist.
“There are people in the community that avoid mental health agencies because of the stigma,” Chen said. “They don’t wanna go into that building where everyone knows there are a lot of people with mental disorders coming in and out.”
Because of this, the Wang Center implemented the Bridge program, which Chen directs. “Bridge” refers to the connection between primary care, which brings the vast majority of their patients to the center, and mental health services, a program that many of their patients would choose to avoid.
When a patient gets an annual exam from their primary care physician, she or he is automatically given a standard screening for depression. In a 2006 survey conducted in part by Chen, the center gave 3,417 patients a standard three-question screening for depression as part of their primary care visits, following up with a second, nine-question screening for those who scored high. They identified 141 patients with significant depressive symptoms, and 114 of those agreed to receive treatment. Of course the goal is to help 100 percent of those with mental issues to get help, but Chen said that he considers even one visit to a mental health care provider a success.
“Our goal is to give patients as much help as we can immediately, even in just one session,” Chen said. “We give them self-care tools, so when they go they can have something to think about.”
And because almost all the medical staff are bilingual and bicultural, doctors ask careful, culturally sensitive questions that help put their patients at ease. Those who are identified as depressed are referred to a certified psychiatrist or mental health care professional in the same building, and doctors are able to easily access patients’ charts and to follow up with them.
Chen says this approach lessens the stigma for those who want to seek out mental health services. The multilevel Canal Street hub of the Wang Center has no designated “mental health” floor, and all the waiting rooms are similar, with neutral-colored walls and fluorescent lighting. From dental care to pediatrics to internal medicine, the halls and elevators are bustling, and are designed to allow those there for mental health treatment to blend in.
“It’s really a mixed setting, so it’s easy for people to ‘hide’ among other patients,” Chen said.
The Henry Street Settlement, a Lower East Side–based health and social services center, also employs “Asian bi-cultural mental health services,” an approach that has spread widely in cities with large Asian-American populations.
Hung, who runs a unit for patients with serious mental illness, said his focus is to get patients to open up and start becoming more comfortable with their emotional lives.
“Gradually we’ll work on that and help them to express their feelings, that it’s okay to feel angry and okay to feel sad,” Hung said. “It’s not that they can’t. They have to learn to do that.”
Gloria Huh, who now sees an Indian-American therapist, said that going to someone who understands her reticence to open up is important to her.
“[My therapist] is also a person of color, and for me that is amazing, because I don’t have to feel uncomfortable talking about certain things,” Huh said, adding that she sometimes avoided topics like perceived workplace discrimination or childhood memories with her previous therapist, who was white, because she didn’t think her therapist would understand.
Now, she says, her therapist can hold her accountable in certain ways she says a white therapist might be uncomfortable with. “I’m not offended because I know that he gets it,” Huh said.
Huh is now in her third year of a Ph.D. program; her goal is to become a clinical psychologist specializing in “cultural competency,” including the methods employed by Chen, Hung, and others that aim to increase access to mental health treatment for Asian Americans.
“I’m on a mission to be a resource to the Korean-American and Asian-American community,” Huh said. “We need more psychologists. There’s such a need.”