Providing Culturally Competent Mental Health Care to Asian Americans and Pacific Islanders

When Asian and Pacific Islander (API) patients visit medical facilities complaining of physical problems, they usually receive physical treatments. However, Shih-Yu (Sylvia) Lee, PhD, RNC, a postdoctoral fellow at Emory University in Atlanta, knows that asking these patients a few extra questions may mean the difference between curing a minor physical ailment and treating a major mental illness.

“[API patients] tend to express their feelings through physical complaints like a headache or upset stomach,” she explains. This practice is known in psychiatry as somatization.

Research suggests that health care providers’ failure to look at non-physical causes of ailments in Asian Americans and Pacific Islanders, combined with other cultural and linguistic barriers, may mean that this population is receiving inadequate mental health care. Lee encourages nurses to actively help eliminate these barriers by adopting a culturally competent approach to assessing API patients’ symptoms. Cultural sensitivity to these patients’ unique mental health needs is also a must for communicating treatment options to API individuals, who represent the fastest-growing minority population in the United States.

According to A Provider’s Handbook on Culturally Competent Care: Asian and Pacific Islander Population, 2nd Edition, published by Kaiser Permanente, little is known about the frequency of mental disorders in APIs. Because they represent a relatively small number of patients admitted to psychiatric hospitals compared with other racial and ethnic groups, this has led to the misconception that Asian Americans simply have fewer mental health problems than other Americans.

However, the research data that is available contradicts this stereotype. The Centers for Disease Control and Prevention’s National Center for Health Statistics reports that API males and females between the ages of 15-24 consistently have the highest suicide rate of all ethnic groups in that age range. Elderly Asian Americans exhibit more instances of dementia than the general population, according to the National Asian American Pacific Islander Mental Health Association (NAAPIMHA). The association also reports higher than average suicide rates among some elderly Asian groups.

Many immigrants from Southeast Asian countries, particularly those from Vietnam, Laos and Cambodia, have survived traumatic refugee experiences. According to NAAPIMHA, 40% of these refugees suffer from depression, 35% from anxiety and 14% from post-traumatic stress disorder. And a study cited in Kaiser Permanente’s Provider’s Handbook reveals that while API patients are less likely to be admitted to psychiatric hospitals than their Caucasian counterparts, those who are admitted have a longer median length of stay than white patients.

These disturbing statistics suggest that Asian Americans and Pacific Islanders may not be receiving adequate mental health care early on and that by the time they do obtain treatment, their problems are more severe and harder to treat.

Behavior, Culture and Language

While mental illness is not an easy topic for most Americans to discuss, there is an especially strong stigma in the Asian American culture that discourages potential patients from seeking mental health services. “We tend to suppress our feelings,” says Lee, who is from Taiwan. “What happens in the family stays in the family.”

This is where the somatization comes in. Instead of seeking a mental health referral, many API patients will choose to see their primary care physician about a physical problem. Even if primary care providers are aware that their patient’s physical complaints may have an underlying emotional cause, lack of familiarity with Asian cultural norms can make it difficult for providers to determine whether a particular behavior is a common practice or a cause for concern.

For example, Lee says, in Chinese, Japanese and Korean cultures, women who have given birth take the post-partum healing period so seriously that they often remain at home on bed rest for up to a month after delivering their baby. Even if the newborn needs to be placed in the NICU, the mother might send other family members to visit the baby, while she continues to rest. If she were to visit the baby, her family may request a wheelchair for her to help conserve her energy. Nurses who are not familiar with this cultural practice may be unnecessarily alarmed that the mother is showing signs of post-partum depression.

If a nurse does have a concern about a patient’s behavior, Lee’s advice is to simply ask for more information. “You really need to talk to a family member,” she emphasizes.

Linda S. Beeber, PhD, APRN, BC, a professor of nursing at the University of North Carolina at Chapel Hill, agrees that nurses should look at each patient individually, even if they are Asian American nurses who share the patient’s ethnic background and are familiar with the culture. This is because familiarity could lead to labeling and making assumptions. “It could perpetuate biases. It is a step away from stereotyping,” says Beeber, who has studied depression in Korean, Chinese, Taiwanese and Native Hawaiian graduate students. “It does not take into account the powerful process of acculturation.”

In addition to barriers caused by cultural differences, there are often obvious language barriers that can prevent Asians and Pacific Islanders from receiving adequate mental health treatment. “New immigrants might not be able to speak English well,” says Lee.

According to the Kaiser Permanente Provider’s Handbook, about 38% of Asian Americans do not speak English fluently. The same holds true for a very large proportion of APIs over 65 years of age. And unlike most Hispanic subgroups, who all speak Spanish, API subgroups encompass a wide range of different languages, from Chinese, Japanese and Vietnamese to Tagalog, Hindi and Hmong.

While nurses are not expected to provide interpretive services, patients will rely on nurses to find well-trained translators to help communicate with them. Lee advises nurses to get to know the network of translators in their geographic area and to only recommend the professionals who have proper training. “In addition to linguistic training, they need to know the medical terms,” she says, citing an instance where a patient misunderstood a diagnosis because one of the medical terms was not communicated effectively.

Gayle Tang, MSN, RN, director of national linguistic and cultural programs at Kaiser Permanente in San Francisco, believes that linguistic competence is an important component of a health care facility’s ability to provide culturally competent care. This goes beyond simply providing translation services, she adds. “Language and culture are interchangeable,” Tang argues. “[If you can’t] speak the right words, in the right tones and with the right expressions, you’re not linguistically competent.”

Communication for Compliance

Once it has been determined that an Asian American or Pacific Islander patient is in need of mental health care, the next challenge for the nurse to overcome is often recommending treatment in a way that encourages the patient to complete his or her therapy successfully. Typically, a care provider would gather data on the symptoms of the problem, determine the cause, recommend a treatment and assume that the patient accepts the counsel.

However, an API patient might have a different explanation for the problem, based on his/her cultural beliefs. According to Tang, some patients may feel that their problem is primarily a spiritual one, or is a consequence of past behavior. If the recommended therapy does not address what the patient believes is causing the problem, the patient may choose to forego treatment.

Tang recommends using one of two culturally sensitive communication methods to increase the chances of successful treatment: the Kleinman model or the LEARN model. These methods can help nurses determine their patient’s level of acculturation and minimize the use of broad cultural stereotypes and prejudicial biases.

The Kleinman model, developed by noted psychiatrist Arthur Kleinman, is a general tool for cross-cultural communication. According to Tang, this model involves asking patients a series of questions about their complaint. “[It helps] assess a patient’s beliefs about their condition,” she says.

What do you call your problem? What name does it have? Why has it happened to you? Why now? are examples of questions Tang may ask. She would also ask patients what they believe will help make the problem go away. Using this model helps nurses understand whether or not they are seeing an issue in the same way their patient sees it.

The LEARN model, published in 1983 by E.A. Berlin and W.C. Fowkes, Jr., is geared toward letting the patient lead the discussion of his/her symptoms. It is an acronym for listen, explain, acknowledge, recommend and negotiate.

“It is an easy-to-remember model that reminds nurses to not only explain a situation but to also take time to understand how their patient sees a problem,” says Tang. “The nurse will listen to how the patient sees their own problem, then the nurse will explain his or her own perception of the problem. At that point the nurse acknowledges the differences and similarities between the two viewpoints while being nonjudgmental. The nurse would then recommend treatment or behavior change and then try to negotiate the best way to get the patient to follow through.”

Encouragement is a good way to successfully negotiate a treatment plan. “Find out what the patient is doing to help himself,” Beeber suggests. Even if a nurse has to advise a patient to stop using his current remedy in favor of a more medically effective option, the nurse can still use negotiation techniques to encourage the patient to try the recommended treatment.

For example, if a patient is treating her ailment with a traditional remedy such as a blend of herbal plants, Tang recommends saying something along the lines of: “We would like you to stop taking the herbal remedy for two weeks [and use the medicine that the doctor prescribed for you], just to make sure we know what is working and what is not working.” The patient is probably more likely to take the prescribed medicine if this approach is used–as opposed to the nurse saying, “That’s not going to work. There’s no scientific basis for [the herbal remedy].”

Even if patients accept a specific treatment regimen, they may not know how to follow it once they get home. “Ask for a return demonstration to help ensure that the information was communicated successfully,” says Tang.

Patient Advocacy

If an API patient needs to be referred to an outpatient or inpatient psychiatric care facility, it is once again important for the nurse to be a strong encourager. “[Patients] need assurance that this is the right thing to do,” says Maggie Luo, program coordinator for the Chinese American Mental Health Outreach Project (CAMHOP) in New Jersey. This may mean encouraging family members to encourage the patient. Luo suggests that nurses identify the relative who may have the most influence in the family and try to win that person’s support for the referral.

She also recommends using the term “mental health consumer” instead of “mentally ill” when referring to patients. This simple title change may help reduce the level of stigma associated with the referral.

Being a patient advocate also means proactively locating other supportive health care providers. “Try to help patients find a physician who knows about their culture,” says Lee. “You could actively make the referral for the patient, or you could just follow up with the other physician.”

Tang agrees that nurses should take a proactive approach to making sure the patient’s cultural and linguistic needs are met. “Every single nurse needs to make sure the system is in place,” she urges. “Make sure there are no gaps. Take that extra step. Make sure the interpreter is pre-scheduled for the next visit and the referral is made.”