Research has found that adults of Asian American Native Hawaiian Pacific Islander (AANHPI) descent are far less likely to seek mental health services than any other demographic group in the country.
And seniors who live in AANHPI communities are especially vulnerable: With family members out and about all day, seniors often feel isolated, anxious about anti-Asian hate crimes, and face language barriers when accessing mental health services.
But the AANHPI community is incredibly diverse. So there’s no “one size fits all” solution to this problem. What seems to work is community-led, culturally appropriate programming that meets the realities of AANHPI seniors and recognizes their diverse needs.
As part of this AANHPI miniseries on older adults and mental health, clinical psychologist Dr Helen Xu sheds light on some of the challenges facing older adults in these communities and explains what’s working to help them.
Dr. Helen H. Su is a bicultural and bilingual clinical psychologist, clinical supervisor, and educator. She Hera Mental Health Outreach Director Stanford UniversityShe is past president of the Asian American Psychological Association and the American Psychological Association Division 45 (Society for the Psychological Study of Culture, Ethnicity, and Raciality) and lives in the San Francisco Bay Area.
Lisa Ramlaika wrote this interview: USC Annenberg Center for Health Journalism‘s 2022 California Impact Fund.
Hana Baba:
Can you give us some basic reasons why you think we should be having conversations with Asian American (AAPI) seniors about their risk for mental health issues?
Helen Sue:
I think culturally sensitive care, as we know it now, will benefit everyone’s health, their mental health. This is a big problem for Asian American, Native Hawaiian and Pacific Islander communities because there are so few culturally tailored resources. This is a very large aging population, and AANHPI has a lot of multigenerational households. Seniors may be living in nuclear families, but there are very few services.
Baba:
What are some of the factors that contribute to mental health issues in AAPI communities, especially in the older adult community? When we think about the Black community, for example, one of the things that comes to mind when they come to this country is isolation.
Xu:
Loneliness and isolation, lack of transportation if you can’t drive. In a lot of our home countries, you didn’t have to drive, you had places to go, you could walk or take a bus. So here you might be in a big city or a far-flung suburb; no one speaks your language, no one gives you food, no place to go. So there’s isolation, and also, what everyone really craves is a sense of purpose and motivation. So losing your role as an elder in your community, no longer working, no longer having skills that are considered valuable, that’s certainly a factor here.
There’s a great study that the Asian American Psychological Association put out about the impact of hate crimes, especially against Asians, which, as you know, have increased dramatically during the pandemic. And that has certainly impacted seniors, because they were literally being attacked and even murdered just going about their daily lives. So, seniors have become even less independent, and now they have to fear even going to their local market or taking their morning walk.
Baba:
And then there’s the stigma. Can you also talk about the stigma that comes with talking about mental illness?
Xu:
I was actually talking to someone just this morning about customizing a mental health outreach and public health education training program specifically for Asian Americans, and she said, “I’ve noticed that in these communities, we tend to call it mental wellness, not mental health.” And I said, “Well, in a lot of our countries, we tend to think of health as a holistic thing, so it’s okay to talk about things that might be out of balance and taking care of your mind and your body.”
But when you say the words mental health or mental illness or diagnosis, sometimes there’s a real stigma that comes with it, like, there’s something permanently wrong with you, your family is something wrong, you’ve never heard of it because we don’t talk about it in our culture. So I have this misconception that someone is either in a hospital, or disabled, or normal, there’s no in-between. And, of course, the reality is that most of us are always somewhere in between. But there’s a real fear of losing face, of someone thinking there’s something wrong with you, something wrong with your family.
Baba:
I want to talk about a report from the UCLA Center for Health Policy Research that discusses culturally competent services, which argues that without knowledge of a community’s specific culture, traditions, and values, mental health professionals may misdiagnose or completely ignore signs of mental health concerns, because each individual patient’s belief and value systems have a major influence on their preferences and even their willingness to get involved.
So, from your experience, what does it take to create community-specific knowledge, as San Francisco General Hospital refers to it? Long ago, the psychiatric ward at San Francisco General Hospital had a culturally competent specialty unit, which they don’t have anymore. But that was the idea behind them. Why is this important?
Xu:
That’s life-changing, right? Whether someone gets treatment and whether they get treatment at the right time can make a difference in severity and even life or death. So cultural responsive training, the involvement of the community and community experts is fundamental to how we do that.
It’s actually not that hard. Sometimes I feel like the system says, “That’s too hard.” But there are models already out there. As you said, there was a model already in place at San Francisco General Hospital. For example, one place I talk about a lot when I teach is in the Central Valley of California. They had a program that embedded Hmong shamans in the hospital. The hospital staff could learn what spiritual and cultural practices help people feel better and heal better. The shamans themselves learned what they do in the hospital and how it works. And we can share that with the community, and it builds trust. Otherwise, they would never go to the hospital, or they would try to go home as soon as possible against medical advice.
The Waianae Coast Comprehensive Medical Center on Oahu has a hospital, dentists, mental health professionals, an advisory board of kupuna elders, traditional lomilomi massage and healing gardens, so people come here for a nonjudgmental, supportive and healing approach.
Baba:
So your new book, “Trauma Healing Workbook for Asian Americans,” blends modern psychology with ancient mind-body approaches to build resilience in the face of racism, overcome trauma and internalized oppression, reclaim mental health, and celebrate one’s heritage. Can you explain this approach in more detail and give us some examples?
Xu:
Now that I’ve been working in psychology for about 20 years, I’ve found that we have some pretty good tools, but my Asian American, Native Hawaiian, and Pacifica clients will say, “This is pretty good and it helps a little bit, but none of the resources that currently exist address the intergenerational trauma that my family has endured, and none of the microaggressions and racism that I experience every day and the impact that that has on my self-image and my identity.”
Or, “My Western therapist is suggesting something that goes against my values,” which is unfortunately quite common. A lot of times well-intentioned Western therapists don’t understand that your client probably has different, very deep values and needs to be approached in a different way. And in our traditional cultures, practices that support mental and physical health have existed for a long time. So tai chi, qigong, yoga, drumming circles, storytelling circles, elder consultations, and of course prayer, ritual, chanting, all of these things have been around and helped for thousands of years. And of course, now Western research is catching up and saying, “Singing really helps with depression,” and so on. Yea, yes, we knew that. “Hey, yoga and tai chi help.” Yea, yes, we knew that, even if we expressed it in different words.
Baba:
Meditation. Right. When meditation came out, well, it wasn’t out, but, you know, there was research and there was fads. People have been doing this for thousands of years. Are you just catching up?
Xu:
Now, research is finding that meditation changes brainwaves, dancing improves mood, art helps trauma victims integrate and process their experiences. These are all wonderful things that American, capitalist, siloed medicine has yet to figure out. How do we incorporate this into care?
Baba:
So, if someone is listening to this right now and they’re thinking about their mom or dad and they’re unwell and they want to help them, what can they do?
Xu:
So speaking to older people is a special thing in itself. But I often talk about it as something really normal, that there are things you can actively do to be healthy. And many older people think of health as a mind, body, spirit and community experience. So what can we do?
Ideally, if you can find a community with your elders, would that be the best place to normalize, be it a community center or a family gathering? Finding resources and support that are accessible in your language, for example. I work with a lot of undergraduate and graduate students, and we often find information about mental health and mental well-being, for example, in their parents’ native language, prepare that, and they actually share that with their parents. Because for people and families with two cultures, multiple cultures, oftentimes they struggle with the fact that within the same family, there isn’t enough language to talk about these things.
Baba:
Is there respect there? For example, do I go to my father and tell him something is wrong? In many cultures, that doesn’t happen.
Xu:
You know, I’m at an age now where I’m having to make some very difficult decisions about elderly care and safety. And, of course, I can go to elderly people that I respect and say, “You need to get a neuropsychological evaluation. I think you’re getting dementia. ” I mean, it’s sad that I have to acknowledge that and say that they need support to get through it.
But that’s never a good thing for your elderly, but can we talk about screening tests? I really care about you, and I want you to do this. This is just a normal thing that everybody does at this age, and it’s something that we do to protect your health for as long as possible. So instead of the focus being on diagnosing your dementia, if the test finds something abnormal, that’s so great and we’re so happy. And if there’s anything to be concerned about, we’ll know about it and we’ll start taking action to protect your strong mind for as long as possible.
But right now, not being able to have those conversations and not being able to get tested can sometimes lead to people getting sicker than they need to. There could have been a treatment that would have slowed the progression of dementia, but we just didn’t find it. There’s a growing body of research that supports and validates that these ancient treatments that people have been doing for generations all over the world do work, and it’s very promising. And then how do we apply that and, of course, evolve it to fit modern life…very slowly.
But there are many more clinicians with diverse backgrounds and experiences, and we can bring more of that to our community. One great example of a promising program is the very small, minority-serving fellowship program run by the American Psychological Association. This is an example of a program that recruits, encourages, and partially funds young people from historically marginalized or underrepresented backgrounds who want to go into medicine, and provides them with a lot of specialized training and mentoring. I feel hopeful.
Lisa Ramlaika wrote this interview: USC Annenberg Center for Health Journalism‘s 2022 California Impact Fund.
If you or someone you know is experiencing emotional distress, please call or text 988. Suicide and Crisis Lifeline.
Trauma Healing Workbook for Asian Americans: Helen H. Hsu: Recovering from Racism, Building Resilience, and Finding Strength in Identity will be published in July 2024.
