Introduction

Asian American Pacific Islanders are the fastest-growing racial group in the United States: between the years 2000 and 2019, the population grew by 81% (Budiman & Ruiz, 2021). Moreover, 58% of U.S.-born Asians are 22 years of age or younger (Budiman & Ruiz, 2021). Yet the mental health of young¹ Asian American Pacific Islanders (AAPI)² is often overlooked.

According to the Anxiety and Depression Association of America, “Asian-Americans are three times less likely to seek mental health services than other Americans” (2020). AAPI cultural values and beliefs shape how mental health is perceived, if and how care is pursued, and can influence mental health outcomes overall. These values and beliefs often translate into risk factors for adverse mental health outcomes that are unique to the AAPI experience, which can decrease the efficacy of the current mental healthcare system. This article will investigate how the cultural values and unique risk factors for adverse mental health outcomes for young AAPI people act as barriers to seeking care and/or preventing care altogether. By highlighting how their experiences are inherently mismatched with the existing mental healthcare framework, it will offer suggestions on how culturally competent care is a solution to this misalignment and the failure to consider culture in the mental health setting.

Cultural Values and Stigma Beliefs

It is important to examine AAPI cultural beliefs and values because “culture shapes the expression and recognition of psychiatric problems” (Kramer, Kwong, Lee, & Chung, 2002). Cultural beliefs and values not only construct how young AAPI people experience mental health outcomes but may also determine whether they vocalize their experiences or seek help. In many Asian cultures, there is great value placed on the family as a hierarchy and collective unit. Multiple generations may live in one household where one has an assigned role based on their age, gender, and social class in which the person “is expected to function within that role, submitting to the larger needs of the family” (Kramer et al., 2002). Younger individuals often occupy a lower position within the hierarchy. This may cause an invalidation of feelings by higher-ranking family members because “they are aware of the traditional beliefs about mental illness perceived by their parents and other family members” (Fogel & Ford, 2005). Furthermore, when beliefs about mental health conflict within the hierarchy and thus disturb coexistence, there may be a disruption of young AAPI’s ability to submit to those collective familial needs.

While it is stigmatized across many cultures, the “stigma of mental disorders is much more severe among Asians and ethnic minorities than among white Europeans or Americans” (Hsu et al., 2014). Additionally, in many AAPI cultures, it is believed stigma extends beyond the individual to impact the entire family (Kramer et al., 2002). The cultural value of “saving face” describes “the ability to preserve the public appearance of the patient and family for the sake of community propriety” (Kramer et al., 2002). This communicates to young AAPIs that they cannot discuss their experiences not only in fear that they will be stigmatized but that their entire family will suffer because of those experiences as well. The value of saving face and the low position young AAPIs occupy in the family hierarchy can result in worse mental health outcomes as they may feel the need to suppress their emotions to protect the family reputation. The desire to “save face” may also steer them away from seeking treatment altogether. It is important to note that seeking treatment involves seeking support for treatment in the first place. Ultimately, intergenerational stigma makes it inappropriate for young AAPIs to confide in or seek support from one’s parents during mental distress. TedxYouth speaker Alan Phan illustrates why the inability to confide in a parent as an AAPI youth is so damaging. Phan recalls the rejection he faced from his mother when trying to confide in her about his emotions and suicidal ideations. Phan explains the commonality he identified among his AAPI peers: their parents thought mental illness was taboo or “for the weak and losers of life,” they “lacked a trusted adult to discuss things like mental health,” and that because of this, they “bottle up emotions until they burst” (TedX Phan, 2020). Phan’s experience highlights how the absence of a parent’s support (or familial support, generally) can exacerbate mental distress and invalidating one’s experience as legitimate or worthy of attention. The role of intergenerational stigma is a powerful influence on the treatment decisions young AAPIs may make.

Within many AAPI cultures, there is an “unacceptability . . . attached to psychological expression of distress” (Grover & Ghosh, 2014). This unacceptability results in the belief that “psychological issues should not be discussed outside the family and that physicians need to be consulted only for physical symptoms” (Grover & Ghosh, 2014). This produces a somatic expression of mental illness itself in order for one’s distress to be considered acceptable. The belief that mental health is not as “legitimate” as physical health actually alters how mental distress is experienced. The somatic manifestation can make identifying mental distress more difficult as traditional diagnostic tools and mainstream understandings of mental illness do not consider somatic experiences, resulting in existing services being unsuitable for this population. Mental health services in the United States like psychotherapy operate under “assumptions that some take for granted, like ‘talking about it will make you feel better’” (McLean Hospital, 2020). There is an inherent mismatch between existing treatments and how mental illness manifests in young AAPIs; “talking about it” does not address or alleviate somatic symptoms like headache or joint pain because it fails to recognize that the experience of mental distress in this population is fundamentally different. The difference in how mental distress is experienced by this population is not commonly understood or acknowledged in existing treatment settings.

Discrimination + Acculturation: Risk Factors for Poor Mental Health Outcomes

AAPI youth experience an array of unique risk factors for adverse mental health outcomes. Racial discrimination is a known risk factor for poor mental health outcomes among racial minorities (Williams, 2018). Among AAPI youth particularly, racial discrimination is correlated with poor self-esteem, depressive symptoms, the internalization of AAPI stereotypes, and more (Lee et al., 2009). For example, the “model minority” stereotype that AAPIs are “the ones who excel in education, are diligent and responsible, and are silent rather than vocal” may be damaging to mental health due to the pressure of upholding or fitting the stereotype (Lo, 2010). Anything that does not align with the model minority stereotype may be internalized as a failure. Internalization can lead to an overwhelming fear of failure and undue pressure to succeed, which can cause stress, anxiety, etc. As shown in figure 1, this internalization may alter treatment-seeking behaviors or prevent care from occurring at all as it insinuates an unacceptability in receiving care, exacerbating symptoms further (See Figure 1). It can also be an obstacle to care as “the psychological and behavioral problems exhibited by Asian American youth are often overlooked because of the model minority stereotype and their cultural values” (Lo, 2010). Ultimately, discrimination is a powerful determinant of poor mental health, and whether an individual seeks or receives appropriate care.

Figure 1.

Figure 1.

Racial discrimination and mental health outcomes among AAPI youth.

The stress of acculturation also presents as a risk factor for adverse mental health outcomes in younger AAPIs. The experience of acculturation is marked by the “difficulty of balancing two different cultures” as one is “expected to respect the culture and values of their home country in the family and household environment while they grew up in the American culture at school with friends/colleagues” (Lee et al., 2009). Acculturative stressors include language barriers (e.g., having an accent or learning the nuances in non-native language or affectation), environmental factors (e.g., a lack of diversity or others of the same racial identity in the immediate community), and intercultural relations (e.g., opposing cultural customs) (Miller, Yang, Farrell, & Lin, 2011). While acculturative stress is a risk factor for poor mental health among AAPIs regardless of age, younger AAPIs may be more severely influenced by it because young adulthood, adolescence, and youth are all considered to be an impressionable time in life due to development and identity exploration/formation (Gwon & Jeong, 2018). Thus, having to continuously change (or choose) one’s cultural identity based on the setting they are in may create confusion and stress for younger persons, leading to negative mental health outcomes. It should also be acknowledged that acculturative stress as a risk factor may be unnoticed in treatment settings because it differs from common stressors of the general population. The unique risk factors that young AAPIs experience often result in an unmet need and delay in care. Their lived experiences demand a new, original approach to mental healthcare and encourage them to seek care.

Future Directions: Culturally Competent Care and AAPI Representation in the Mental Healthcare Workforce

As previously mentioned, Asian Americans are less likely to seek and receive mental health services compared to the general population (Anxiety and Depression Association of America, 2020). This reality coupled with the fact existing mental health services are already unsuitable with the values and unique risk factors among young AAPIs reveal possible ways to mitigate the unmet need for care and improve service provision.

First, practicing clinicians should be required to be trained in cultural competency so that they are attuned to the needs of young AAPIs. Culturally competent care describes when clinicians “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” (National Alliance on Mental Illness, 2022). Examples of culturally competent mental healthcare in the context of the AAPI population may include practices like addressing notions of shame and “saving face,” a clinician having knowledge about “cultural bound syndromes” (i.e., Hwa-byung, a Korean syndrome reflective of a DSM-V diagnosis of major depression), and providing linguistically appropriate care (National Alliance on Mental Illness, 2022). Other efforts may include the incorporation of family members to address group stigma beliefs. For example, even if destigmatization efforts prove effective for the individual, the efforts may be overpowered by the stigma beliefs of their family. There is limited evidence on the efficacy of cultural competency trainings in direct correlation with service provision improvements, health outcomes, and increasing rates of those to seek care, particularly within mental healthcare and by race/ethnicity. However, as cultural competency trainings have become more common in the general health workforce, some studies have shown improvements in measurements of practitioner knowledge and patient satisfaction in correlation to such trainings ( Jongen, McCalman, & Bainbridge, 2018). Furthermore, some patients themselves have identified a need for trainings. Ryann Tanap, author of Why Asian Americans and Pacific Islanders Don’t Go to Therapy published on NAMI’s website, reflects on her own mental health experience in young adulthood: “I didn’t know of any mental health professionals who understood my experience, culture and heritage,” and that “part of me wondered if therapy was only meant for white people” (2019). After her discussion of how Western psychotherapy is incongruent with AAPI values and experiences, she explains how she thinks the mismatch may be solved: “I have identified what I need: a mental health professional trained in cultural competency” (Tanap, 2019). Cultural competency on a broad scale may include diversifying and increasing representation in the mental healthcare workforce by striving “to recruit and train Asian American mental health professionals” (Li & Seidman, 2010). In 2015, only 5% of psychologists in the United States identified as Asian (Lin, Stamm, & Chrisitidis, 2018). A larger, prominent representation of AAPIs in the workforce may help to break down stigma beliefs. The visibility of AAPIs in the workforce may encourage people to seek care by disproving the belief that care is unacceptable or misaligned with occupying an AAPI identity. Cultural competency practices and initiatives may realign the existing care infrastructure to better support the lived mental health experiences of AAPI young people.

In order to bridge the gap of unmet mental healthcare among AAPI young people and to prevent further mental health disparities from occurring or worsening, immediate action must be taken. Culturally competent practices and AAPI representation in the mental healthcare workforce can validate the lived experiences of these young people, empower them to seek care and support, and contribute to conversations within their community that eliminate the stigma surrounding the issue and legitimize mental health as a vital component of health and well-being. These two solutions may serve as the impetus for a positive transformation in perceptions, understandings, and lived mental health experiences among young AAPIs.