Cover Story

Asian Americans are less likely to seek help for their emotional or mental health problems than whites, according to preliminary data from the National Latino and Asian American Study (NLAAS), conducted from May 2002 though December 2003-the first national study to examine the rates of mental illness and treatment use among a national sampling of three major Asian-American groups. The study, principally funded by the National Institute of Mental Health, interviewed 2,095 participants, consisting of large samples of Chinese, Filipino and Vietnamese-as well as other Asian Americans, including among others, Japanese, Koreans and Asian Indians. Past studies have examined these groups, but with limited samples, such as treatment studies, college student samples or regional community data.

NLAAS data show that, as a group, Asian Americans have lower rates of mental illness than whites but seek treatment less often. However, investigators are still at the early stages of analyzing the study's data, which are the first to tease out on a large scale the differences between the many cultural and ethnic Asian-American groups. Investigators are exploring the ways in which these differences, along with immigration status, birthplace and age, may affect the prevalence of mental health disorders and the likelihood of seeking and getting effective treatment.

For instance, while Vietnamese Americans had similar rates of mental illness as the other Asian-American groups, they were much more likely to seek help, preliminary study data indicate. NLAAS researchers think that the disparity may be due to the trauma that many Vietnamese immigrants experienced as refugees before coming to America. Also, Asian Americans who were born in the Unites States or who immigrated at a young age had higher rates of mental illness-possibly because they are more exposed to American peer networks and institutions than are adult immigrants. Although the NLAAS participants have many different cultural and religious beliefs, researchers found some common risk factors for mental health problems-particularly those involving family and social status.

Prejudice and mental health

Social status-both real and perceived-can be significant risk factor, according to NLAAS findings. For many, income level, profession and familial respect contribute to a sense of success.

"For Asian Americans, it isn't just objective social status, but their perception of their social status in society-those who see it as low have higher rates of disorders," says David Takeuchi, PhD, a principal investigator for NLAAS and a professor of sociology and social welfare and director of the Diversity Research Institute at the University of Washington.

The negative effects of social status can reach beyond dissatisfaction with social status, NLAAS researchers have found. Takeuchi and Soo Yun Uhm, PhD, a postdoctoral fellow with the APA Minority Fellowship Program at the University of Washington, studied the relationship between perceived unfair treatment and depression among NLAAS participants. Such treatment may include both specific events and a general sense of being disrespected that may or may not be linked to racism, says Uhm.

In the study they presented at APA's 2005 Annual Convention in Washington, D.C., Uhm and Takeuchi found that 74 percent of Asian-American NLAAS participants said they had experienced some kind of unfair treatment and 63 percent attributed such instances to racial factors. NLAAS researchers asked participants whether and how often they had experienced any of nine unfair events, such as "I was treated less courteously," or "people act as if they think you are not smart," or "you are threatened or harassed." Then researchers asked them to attribute the event to racial factors, such as ethnicity, race or skin color, or nonracial factors, such as gender, age, weight or education. This unfair treatment scale was adapted from a study that appeared in the Journal of Psychology (Vol. 2, No. 4, pages 335-351).

When Uhm and Takeuchi compared these responses with the NLAAS rates of major depression, they found that participants who experienced any one of the nine items were 9 percent more likely to have had major depression in the previous 12 months.

Although recent immigrants might be expected to experience more unfair treatment, they were actually less likely to perceive such events as unfair than second- or third-generation Asian Americans, the study found. Uhm speculates that recent immigrants may have encountered circumstances that make such treatment seem relatively unimportant, or they may expect different treatment because of their accents or limited English and unfamiliar customs.

In contrast, she notes, Asian Americans who grew up in the United States are more likely to identify strongly with the mainstream culture and thus may be more attuned to suggestions that challenge their rights and identity as Americans.

Family matters

When it comes to family life, the second generation's embrace of mainstream culture can lead to confusion or conflict in the family, points out Anna Lau, PhD, a professor of psychology at the University of California at Los Angeles.

For example, immigrant parents expect their children to be obedient and perform well in school-a cultural norm that shows their appreciation of the sacrifices the family made by leaving their native country. However, children may reject this role in pursuit of independence and a place in the new culture. These changing dynamics lead to conflict between child and parent, which increases their risk for experiencing mental health problems.

Conflict can also lead to violence. Using NLAAS data, Lau has found in as-yet-unpublished research that over 30 percent of Asian-American parents reported minor parent-to-child assault, and 2 percent reported major assault. Both minor and major forms of violence further increase the risk of mental health problems-particularly for children.

"Families with issues over goals and family unity and priorities are more likely to report severe abuse," says Lau. And although statistically Asian Americans have lower rates of child abuse than other ethnic groups, Lau thinks abuse goes largely undetected because Asian Americans are reluctant to talk about personal issues and tend to deny family problems exist. In fact, reports Lau, parents from Asian cultures are often more likely to view the use of physical discipline as part of being an involved and concerned parent, and as a way to teach children duty. The children themselves may not even perceive it as abuse. However, even if children see such punitive measures as normal, studies have shown that they still show increased stress levels, says Lau.

Cultural stress

Cultural adjustment and changes in gender roles may also lead to domestic or interpersonal violence, which Asian Americans generally don't talk about or even acknowledge, says Doris Chang, PhD, a psychology professor at the New School for Social Research.

"I don't think recent immigrants see it as a huge problem in the community. It tends to be considered a private family issue," says Chang, adding that in certain Asian-American cultures, some degree of male-to-female violence-such as a man hitting his wife in certain circumstances-is considered normal.

Indeed, a distinct cultural clash is at the root of many domestic violence cases among recent immigrants, according to a study Chang conducted with Takeuchi and Biing J. Shen, PhD, and presented at the 4th Pan-Asian Pacific Conference on Mental Health in Shanghai, China. She says that even after taking into account traditional risk factors such as alcohol use and poverty, cultural conflicts related to individual versus "group" (family or couple) goals appear to increase the risk for intimate partner violence. Both spouses are trying to learn a new language and looking for work, upsetting traditional gender roles. For recent immigrants, simply the idea of the woman working can be a problem for both spouses. Suddenly, the wife is juggling working with maintaining a household and may try to negotiate a more egalitarian division of household labor. Chang says that struggles over household duties are closely tied to an increased risk of violence.

The data show that Asian Americans who are born in the United States have a higher risk of committing or being a victim of domestic violence. Chang is not sure why, but suspects that this group may become socialized to violence in ways that are similar to mainstream U.S. populations. Chang believes that friends and family may actively urge women to keep quiet. Language may also keep a woman silent-there may literally be no one to talk to, she says.

Getting help

Such barriers as language, culture and little access to care keep many Asian Americans from receiving help for mental illness.

In fact, Asian Americans as a group are unlikely to seek help for mental illness from any source, and when they do they report low levels of satisfaction, according to as-yet-unpublished research by Takeuchi and Jennifer Abe-Kim, PhD, an associate psychology professor at Loyola Marymount University. However, they found, when Asian Americans seek help from a mental health professional rather than a medical provider, the rates of satisfaction go up.

So how can the psychological community reach out to this group?

"Education," says Abe-Kim. "A lot of immigrants aren't aware of resources."

Working with medical providers is particularly important because they are usually the first or only professional seen by most immigrants and many U.S.-born Asian Americans with mental illnesses, says Abe-Kim, who stresses that interpretation services should be used whenever possible. Providers also need to be aware that many immigrants-especially those from isolated areas-have no idea what a psychologist is or what they do. Health professionals need to educate themselves about a patient's culture and how that might affect symptoms or treatment.

And, since many Asian Americans don't seek medical help, the public health and psychological communities need to be creative.

"Go where the people are," says Abe-Kim, whether that be schools, churches or community centers-wherever groups gather. For example, Cut It Out, a national program originally created by antidomestic violence groups in Alabama, is working to prevent domestic violence by reaching out to women in nail salons.

Takeuchi and Abe-Kim say many cultural and mental health issues still need to be examined. But, as for many minorities, the essential issue remains, in Takeuchi's words, "How do you fit into society? How do people from different racial and ethnic groups find a "place" or a sense of belonging in their neighborhoods, schools or workplaces?"