For Asians, Treating Our Mental Health Issues Feels Like Having To Pick A Side

To better understand what you’re about to read, there’s something you should know right off the bat: The majority of AAPIs (Asian Americans and Pacific Islanders) don’t seek help for mental health issues. According to the National Latino and Asian American Study (NLAAS), AAPIs are three times less likely to seek mental health services than white people. A staggering 2016 study by the CDC showed that half of all the suicides were committed by AAPIs in the U.S. Part of it is a holdover; in Asian countries, talk therapy is rare. Psychotherapy isn’t covered by the Korean National Health Insurance, so the access to get help in South Korea is limited. In Japan, hospitals privately set their own costly psychotherapy prices at about $100 (£80) a session. And India’s first-come, first-serve method means that people travel and wait for hours in hopes of seeing a psychiatrist for a few minutes. 

But as a US-raised Korean-American born to immigrant parents, I didn’t need research to tell me that AAPIs don’t subscribe to psychotherapy. For many of us, talk therapy isn’t part of our vocabulary — we weren’t brought up to discuss our own emotions. Instead, we’ve been conditioned to think about how our actions could affect our greater community; that others’ feelings are more important than our own, and that there's shame in airing dirty laundry. We’re taught to buck up and overcome these issues in isolation, like our parents and theirs had done before them. In turn, seeking professional help is viewed as a weakness in character, or a flaw in your upbringing. In the West, tending to our mental health is seen as courageous. In the East, it’s seen as indulgent and selfish.

In lieu of therapy, some AAPIs cope by dissociating, compartmentalising, or suppressing negative feelings — techniques that research assistants Led Camille Soriano and Tiffany Tran at The Menninger Clinic in Houston, TX, point out are classic examples of avoidance coping. Rather than seek external help, AAPIs tend to use coping sources within the family structure, which could be due to their strong culture of respect for elders and authority figures. “Research says that these kinds of coping can be adaptive in the short-term during times of intense trauma or stress,” wrote Tran in an email. “But long-term, avoidance is a dysfunctional coping style because you’re avoiding your emotions rather than facing them.” 

While in quarantine mode, I’ve been rewatching The Sopranos and I can’t help but recognise how Tony Soprano’s emotional distress, stemming from running a mafia empire, are similar to how AAPIs’ deal with mental health concerns. Like Tony and his chronic anxiety attacks, Asians may look into treatments only when they've reached a breaking point that's caused a major disruption in their lives. In the first season, Tony is reluctant to talk to his therapist, Dr. Melfi: he can’t articulate the complicated relationship he has with his mother; he relies on a Prozac prescription as a quick solution; he outright rejects Melfi’s thoughtful and sound assessments that his unresolved emotional issues drive his anxieties. Tony is also embarrassed to admit to his wife that he’s seeking help. 

The binary approach to mental health — talk therapy is correct; repression is wrong — isn’t helpful when presented so reductively, especially when you consider the many Asians who have been successfully avoidance coping for centuries. Research shows that techniques like expressive suppression can work. One 2014 study on Chinese individuals even stated that emotion regulation “might be as similarly effective as, or even more effective than, acceptance in regulating negative emotion in Chinese subjects.” And psychologists have found that repressing negative memories has proven to be an essential method in treating PTSD — and it’s gentler than forcing someone to confront their traumas head-on. In a New York Times Magazine story, psychiatrist Bessel van der Kolk raised concerns that the desensitisation process of exposure therapy can be harmful, and that trauma “[is] not something you can talk yourself out of” when it comes to cognitive behavioural therapy.

But the reality is that the majority of AAPIs don’t talk at all. When we fixate on internal struggles in isolation, depression and anxiety become exacerbated — feeling stuck between two sides can oftentimes lead to a sort of paralysis, wherein you don’t seek help in any form. The numbers prove that Asians are severely depressed. So, is there a middle path for Asian-Americans who are struggling?

Thankfully, there are an increasing number of options available. “For some, it can feel strange or even inappropriate to be telling your family business to a stranger who isn’t Asian in any sense — like, if you're feeling pissed about your parents’ somewhat patriarchal attitudes, or how they express love in a way that you don’t understand," says NYC-based clinical psychologist Marcia Liu. “Those kinds of dynamics can be quickly minimised and labeled as ‘typical Asian parenting’ by the uninformed therapist, which then can feel incredibly othering and demoralising. There’s also pressure to be loyal and speak honourably of your parents in spite of abusive or even destructive dynamics, no matter what. It's a conflict that many Asian-Americans must navigate."

Dr Liu recommends those interested in therapy to look at organisations like Asian American Psychological Association (AAPA), which works to pair potential patients with medical professionals who are culturally aligned with patients’ Asian values and identities (Dr. Liu is also a member of AAPA). For example, you can request a doctor who is LGBTQIA-friendly, based in Wisconsin, and speaks Tagalog, and the org will do its best to find a close match. Dr. Liu stresses that patients should feel entitled to finding a doctor who is a strong fit.

The number of local clinics serving Asian-American communities is also growing, like the Charles B. Wang Community Health Center in Manhattan’s Chinatown and Queens’ Flushing. “Their doors are open to everybody, but they specifically offer culturally competent services for the Asian-American community in New York City in both primary care and mental health treatments,” says Dr. Liu. Charles B. Wang has implemented a unique approach; they treat physical ailments with behavioural ones together, not separately. This integrated process caters to AAPIs, who are more likely to experience mental illness in their physical bodies, manifesting as headaches, gastrointestinal issues, or even a loss of eyesight. Physicians can also administer a depression screening as a regular part of the yearly physical. If a patient screens positive, they can then be referred to the mental health department, all within the same building. “I think of therapy as an acculturation issue,” says Dr. Liu. “It's about blending what is not the norm in one culture with what is the norm in another culture, and finding something that works in between. The step to seeing a therapist is a very bicultural move.”

Even though U.S.-based Asian patients may be more readily accepting of a hybrid approach, broaching the topic with their traditionally minded family members still requires sensitivity. TV writer and performer Hye Yun Park has been in and out of therapy since she was 15 after her first suicide attempt as a teenager. While Park’s Korean parents were supportive of her receiving mental health services, they also wanted to keep it a family secret. “Every time my mom drove me [to the clinic], it was as though she was driving me to get an abortion,” the now 36-year-old Park recalls of the experience.

Last summer, Park checked herself into a psychiatric clinic when her suicidal tendencies became more extreme. “I'm done being passively suicidal. I want to actively live,” she says of her decision. Park’s current outpatient program includes group therapy sessions that utilise dialectical behavioural therapy (DBT), which is a skills-based program that includes core mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. In these sessions, patients learn tools like how to meditate and balance priorities within their close relationships that help them cope through moments of duress.

When Park last updated her mother on her mental health status, she did it gently, telling her mother that she’s been in rigorous therapy and back on medication, but she withheld the information that she’d been hospitalised. “I wanted to save [my mom] the anxiety of worrying about me,” Park says. “[There are] mechanics of how love can work between a parent and child [in an Asian culture], and how they can be so adamantly against certain things that are actually for the wellbeing of their children. But I don't blame her for not understanding. I have a lot more compassion towards her.”

When I ask Park about representation in her group therapy sessions, Park mentions that it’s predominantly white, although that hasn’t changed her overwhelmingly positive experience of therapy. “But yes, I do crave seeing more Asian bodies in those spaces,” Park says. “I had a hard time in my 20s talking about mental health to other Asian people because nobody was talking about it. So in my adult life, I’ve made it a mission to talk candidly about my mental health, and try to hold a safe space for others to talk about theirs.” 

Two months into quarantine and a few seasons into The Sopranos, I'm seeing Tony’s relationship with Dr. Melfi at the seven-year point. The show is smart in taking Tony’s mental health journey slowly; he doesn’t even experience his first major breakthrough until the third season. It’s a reminder that therapy can be effective, but only when a patient puts in the work and time to get better. 

“There are definitely risks to therapy, too,” says Dr. Liu. “It’s a cruel fact that a lot of times, you have to get a little worse to get better. You’re going to have to look at things that are causing you stress, including how you might be contributing to the pain yourself. It can be uncomfortable. For most, therapy takes time and commitment. It’s about developing a muscle that takes time to strengthen.” She also acknowledges that there are questions surrounding whether or not therapy is the best tool for people who are collectivistic, like many Asian-Americans. “I'm careful not to say that it's the only way for people to resolve whatever they're experiencing, but it is an available, structured, and formalised way to receive instrumental support,” she says. “It’s a wonderful opportunity to get to know yourself, cope with stress, and experience joy. People usually, as a result, understand themselves better regardless of whether they're collectivistic or individualistic.”

Although the number of AAPIs receiving mental health treatments is relatively small, I’m grateful to know that thoughtfully administered AAPI-aligned options are out there, and these services are likely to grow as more Asians opt for therapy. But in the meantime, something that I and fellow AAPIs can do in the immediate is talk more openly about mental health issues. We can all agree that this topic ought to be less taboo and more normalised. Oftentimes, it’s the silence of what AAPIs don’t talk about that can be the most deafening. But, with these innovative approaches to mental health becoming increasingly prevalent within the Asian-American community, it’s a positive sign that a larger cultural shift is on the horizon.