Mental Health and AAPI Communities

Asian Americans and Pacific Islanders (AAPI) are an integral part of the American cultural mosaic, encompassing a wide range of diversity. AAPI communities consist of approximately 50 ethnic groups speaking over 100 languages, with connections to Chinese, Indian, Japanese, Filipino, Vietnamese, Korean, Hawaiian, and other Asian and Pacific Islander ancestries.

Over 24 million Americans, or 7.3% of the U.S. population, are AAPI; however, about two-thirds of the population identify with their specific ethnicity or country of origin.

Ethnic and community identity is considered a notable protective factor to mental health for many AAPIs. The sense of communal identity, connections, belonging and family bonds is a strong predictor of resilience while facing life’s challenges. In fact, studies have shown that a strong sense of ethnic identity is linked to lower suicide risks and predicts higher resilience in the face of racial discrimination, which is, unfortunately, an issue for many in this population.

On the other hand, second-generation AAPI immigrants can face challenges in cultural identity, struggling to balance their familial ties to traditional cultural values with the pressure to assimilate to mainstream American society. Additionally, an emphasis on community identity can create a strong burden of expectations, which may increase stigma and shame if a person doesn’t meet those expectations.

Barriers To Mental Health Care 

AAPIs have the lowest help-seeking rate of any racial/ethnic group, with only 23.3% of AAPI adults with a mental illness receiving treatment in 2019. This is due to the many systemic barriers to accessing mental health care and quality treatment. It may also be driven by stigma and lack of culturally relevant and integrated care that addresses mental health in a more holistic way. These disparities can lead to worsened symptoms and poorer quality of life due to the lack of or delayed treatment.

Language Barriers 

Over 13 million U.S. residents were born in Asia, representing over 30% of the total foreign-born population in the nation. Overall, 32.6% of AAPI Americans are not fluent in English, and rates of proficiency vary within specific subgroups: 44.8% of Chinese, 20.9 % of Filipinos and 18.7% of Asian Indians are not fluent in English. Additionally, 60% of AAPIs aged 65 years and older have limited English proficiency. The disparity between the high demand and poor availability of linguistically and culturally appropriate mental health service providers is a significant gap in accessing treatment.

Stigma and Shame 

According to a recent SAMSHA survey, compared to other racial and ethnic groups, AAPIs are the most likely to quote the following reasons for not receiving mental health treatment:

• Didn’t want others to find out 
• Confidentiality concerns 
• Fear of neighbors’ negative opinions 

Lack of understanding about mental illness and stigma associated with mental health issues can lead to denial or neglect of mental health problems, especially among first-generation AAPI immigrants. The notions of shame and “loss of face” is an important factor in understanding low use of services among AAPI people.

Mental illness has often been considered a weakness or a sign of poor parenting, and a source of shame not only to the individual, but also to the entire household. The desire to protect the family’s reputation can often discourage help-seeking until there is a crisis.

The Model Minority Myth 

Asian American communities are burdened with the “model minority” stereotype, a prevalent and misleading assumption that depicts AAPIs as uniformly well-adjusted, attaining more socioeconomic success than other minority groups through strong work ethic, conforming to social norms and excelling academically. The fact is the AAPI community is highly diverse across subgroups in rates of socioeconomic, health and mental health challenges. The social and familial pressure created by this deceptive stereotype can prevent community members from seeking mental health care.

Insufficient Health Insurance Coverage 

Concerns over the high cost of mental health care also lead to lower rates in help-seeking and treatment adherence. Some groups within the AAPI community face disparities in coverage — Native Hawaiian or Other Pacific Islander (NHOPI) populations have a higher uninsured rate of 9.3%, compared to 6.8% for Asian American communities in 2018.

Immigration Status Some AAPI immigrants may not seek necessary mental health care due to fears of jeopardizing their immigration status or citizenship application process.

Faith and Spirituality 

Faith and spirituality have important influences on mental health, especially for the AAPI community where religious diversity is a distinct characteristic, and more people identify as Buddhists, Hindus, Muslims or other religious affiliations compared to the U.S. average.

Faith communities often offer a built-in social support system. However, religious communities may perpetuate stigma around mental illness that can delay treatment. For example, characterizing mental illness as divine punishment, bad karma, disturbed flow of life energy or imbalance of basic elements inside the body. This is especially true for AAPI families who turn to their religious leaders first for mental health support.

Alternatives to Treatment 

Traditional/non-western medicine or indigenous healing practices, which often emphasize the integration of mind and body in maintaining health and promoting healing, remain popular forms of mental health intervention in some AAPI communities. These practices include, but are not limited to:

• Traditional Chinese medicine 
• Ayurveda (the traditional medicine of India) 
• Japanese herbal medicine 
• Tibetan medicine 
• Acupuncture 
• Massage therapy 
• Folk nutritional therapy 
• Energy healing exercises (such as tai chi and qi gong) 
• Guided meditation 

Spiritual healing Some AAPIs, especially first-generation immigrants, consider traditional/non-western medicine their primary treatment rather than a complementary treatment. This can result in delaying or refraining from seeking mental health care.

Challenges in Research 

Insufficient research on AAPI communities often leads to an inaccurate picture of the experience and needs of these communities. Due to the broad diversity of the community overall, and the relatively small population size of specific cultural subgroups, it can be challenging to obtain adequate samples or to generalize the needs of this population.

Despite these challenges, researchers and clinicians have made progress recently in bridging the gap of quality treatment by exploring culturally relevant interventions for AAPI people. An example is the first NIH-funded study that tested a form of cognitive-behavioral therapy (CBT) adapted for Chinese American people seeking psychotherapy.

Many cultural traditions within Asian American Pacific Islander (AAPI) communities emphasize “collectivist” values, where personal identity is defined by the interconnectedness and relationships with other community members. The needs and interests of the community often take priority over the needs and wants of each person.

This culture can create a burden of high expectations and family pressure, which can worsen, or even cause, mental health issues. Additionally, having mental health issues typically does not align with the expectations a person is supposed to meet — and too often, people in the AAPI community will try to hide their symptoms from friends and family in order to avoid the cultural shame and stigma that is so closely associated with mental health issues.

Expectations 

Both internal personal motivations and external cultural values can create a high burden of expectation and pressure to succeed. Predominant stereotypes like “Asian advantage” and the “model minority” myth assume that AAPI individuals should be intelligent, affluent, obedient and living the “American dream.” Failure to live up to these stereotypes and expectations can be a source of significant stress, often creating feelings of inadequacy.

Different philosophies and religions — including Catholicism, Islam, Protestantism, Hinduism, Jainism, Sikhism, Buddhism, Taoism and Confucianism — also shape cultural values in the AAPI community. Many of these philosophies and religions include a strong emphasis on personal self-control to achieve internal balance or harmony in order to maintain peaceful and respectful relationships in the community. These traditions and practices can strongly influence community members across generations, regardless of how recently they have immigrated to the U.S., or how thoroughly they have integrated to the U.S. “mainstream” culture.

In many of these cultural and religious traditions, clearly defined roles and expectations for different family members are an important foundation for strong families and communities. For example, the concept of “filial piety” expects children to pay deep respect to their elders and parents. The interests and respectability of the family are of the utmost importance and depend on children obeying the authority of older generations and representing the family well in the broader community. To live up to this expectation, children often grow up with a strong emphasis on emotional self-control, loyalty, conformity to social norms, respect for authority and academic achievement.

AAPI individuals with mental illness may deny or hide their symptoms due to fear of rejection by their families or communities. Family-oriented interdependence and hierarchy often mean that any decision-making, including the decision to seek health care, is determined by the interests of the family as a whole. Because mental illness remains highly stigmatized, concerns about revealing a perceived flaw, failure or weakness to the community can lead to shame and avoidance for the whole family — creating a barrier for accessing timely mental health care.

Family Pressure  

Belonging to a family with strong bonds and close relationships across generations can be a significant source of personal strength, providing a reliable network of support and compassion. But it can also be a source of significant distress and trauma when something disrupts these bonds — whether by a family member breaking away from shared traditions or from a personal crisis. The pressure to uphold family expectations can manifest in various ways.

• Acculturation: AAPI youth may face a great amount of family and social stress from biculturalism, attempting to balance the expectations of belonging to two different communities at the same time without “failing” either. Traditional AAPI community and family values can often be at odds with the highly individualistic values of mainstream American culture, and individuals may feel that they face a choice between disappointing their family or remaining an “outsider” to non-AAPI friends, classmates and broader society. 
• Intergenerational cultural conflict (ICC): Intergenerational cultural conflict (ICC) is a notable stressor for AAPI youth, especially in families with wide acculturation gaps between recent immigrant parents/grandparents and U.S.-born children. Although families from any cultural background experience conflict based on behaviors and expectations changing over time, Asian American families are more likely to experience intergenerational disagreements about fundamental core cultural values. This type of conflict can also be motivated by intergenerational disagreement on religious principles. For example, Hindu Indian-American families may experience significant intergenerational conflict about commitment to dharma, which includes the duty and responsibilities to family. Because the source of this conflict is so deeply personal, affecting critical aspects of identity, it can cause serious friction between family members and worsen mental health outcomes for the younger generation. 
• Gender-related expectations: Gendered norms and expectations tied to cultural values can cause significant distress. Young women are often expected to provide care to younger siblings or elders, and experience more strictness and scrutiny of their social behaviors. This prescribed role within the family and community can be highly restrictive, leading to frustration, stress and limited options in choices of education or careers. 
• Achievement expectations: Children of AAPI immigrant parents often grow up hearing explicit or implied messages that their parents made a lot of sacrifices for them to be in this country, and that the family’s future depends on their hard work and achievements. This pressure to achieve can create a deep sense of obligation and burden, and, ultimately, significant struggles with their mental health. The past two decades have seen increasing rates of depression and suicide among AAPI high school and college students. 
• Diagnosis severity: In some AAPI families, a psychotic disorder might be taken more seriously by the family because of its more severe and less relatable manifestations, while mood disorders may be trivialized. For example, parents might make statements, such as “How can you be sad when I worked so hard to bring us here?” or “No one is anxious back in our home country because they have other things to worry about. Be grateful”). 
• Trauma: In addition to personal mental health concerns, many AAPI individuals also struggle with the lasting impacts of stress and trauma experienced by their parents and earlier generations. For those who came to the U.S. as refugees or as immigrants from areas with significant conflict, experiences of violence, war or economic and political oppression can often be manifested as post-traumatic stress disorder (PTSD). One study found that 70% of Southeast Asian refugees receiving mental health treatment were diagnosed with PTSD. Refugees’ children, who never experienced the trauma firsthand, can internalize their parents’ psychological distress — a process known as intergenerational trauma. 

How To Seek Culturally Competent Care 

Culturally competent providers understand each person’s values, experiences and personal beliefs, and strive to provide services that support their goals and are aligned with their cultural values. When a person is struggling with their mental health, it is essential to receive quality and culturally competent care in order to improve outcomes.

Given the vast diversity of AAPI groups, culturally competent providers for these communities often show a strong desire to establish a trust-based therapeutic relationship with the individuals they are treating through effective listening and willingness to learn. They may understand and work with individuals to address concerns over medication, such as fear of side effects. A culturally competent provider may also demonstrate knowledge and acknowledgement of “cultural bound syndromes,” such as:

• “Hwa-byung” – Korean syndrome similar to DSM-5 major depression 
• “Taijin kyofyusho” – Japanese disorder similar to DSM-5 social phobia 
• “Shenjing shuairuo” – Chinese term for neurasthenia 

While we recommend seeking help from a mental health professional, a primary care professional can be a great place to start for an initial assessment or to get a referral for a recommended mental health professional.

When meeting with a provider, ask questions to get a sense of their level of cultural sensitivity. Providers expect and welcome questions from their patients since this helps them better understand what is important in their treatment. Here are some questions to ask:

• Have you treated other AAPI people? 
• Have you received training in cultural competence or on AAPI mental health? 
• How do you see our cultural backgrounds influencing our communication and my treatment? 

Whether you seek help from a primary care professional or a mental health professional, you should finish your sessions with health professionals feeling heard and respected. You may want to ask yourself:

• Did my provider communicate effectively with me? 
• Is my provider willing to integrate my beliefs, practices, identity and cultural background into my treatment plan? 
• Did I feel like I was treated with respect and dignity? 
• Do I feel like my provider understands and relates well with me? 

The relationship and communication between a person and their mental health provider is a key aspect of treatment. It’s very important that a person feels their identity is understood by their provider to receive the best possible support and care.

More Information

• If finances are preventing you from finding help, contact a local health or mental health clinic or your local government to see what services you qualify for. You can find contact information online at findtreatment.samhsa.gov or by calling the National Treatment Referral Helpline at 800-662-HELP (4357). 
• If you or your loved one does not speak English, or speak it limitedly, you have the right to receive language-access services at institutions that receive funding from the federal government as well as the right to request a trained interpreter and to receive information in your language. 

NAMI Support for AAPI Community Members 

You are not alone. AAPI individuals and families contribute to NAMI’s collective wisdom in coping, healing and recovery. We are fighting to remove the systemic and cultural barriers to quality mental health care for all through awareness campaigns, education, support, outreach and advocacy.

There are many pathways to healing and the journey of recovery is individual for each person. It can be a long journey, but in an adage ascribed to Lao Tsu, “a journey of a thousand miles begins with a single step.” It is okay to reach out. Your mental health matters and there is always hope.

NAMI Family & Friends 

A free 90-minute or four-hour seminar, with an e-book available in three Asian languages: Chinese, Korean and Vietnamese.

NAMI In Our Own Voice

A stigma-busting presentation providing a model that facilitates highly individualized accounts of lived experience of mental health conditions. This video features program leaders from various racial and ethnic backgrounds.

NAMI Family-to-Family 

An 8-week psychoeducation program for families and friends. A Chinese translation with cultural adaptations, with online classes offered by NAMI Affiliates in a limited number of states, including California and New Jersey.