Out of 37 evaluations, we received a median score of 8 (14 evaluations), five 10s, six 9s, one 9.5, three 6s, and three 5s. One of those who scored the film a 5, said that it was a powerful and important film, but that it made her very sad and therefore, didn't enjoy it. More than 10% of the viewers rated their enjoyment of the film a ten, much to my surprise. I wasn't expecting very high scores because the film's structure has yet to be developed.
Rough cut #53 (Fifty-Three!!! Yes, there were 52 rough cuts before this one.) was screened on March 19, 2011 at Mount Sinai School of Medicine for NY/NJ Regional conference of APA Medical Students.
In keeping with the Asian Women's Giving Circle grant, I am using the film to help educate health professionals about cultural competency. Because many medical schools do not have a cultural competency in their curriculum, I slipped some in after my presentation, offering them some insights into Asian American mental health and online training resources such as www.thinkculturalhealth.org. At the end, I also asked them to consider psychiatry as a specialty since there is a national shortage of Asian language bilingual psychiatrists. I honestly don't know if I made progress for Asian American mental health, but I did address the many issues and the root causes of these issues. I was impressed with the depth and detail of the film evaluations they filled out.
I gave a variation of the below speech at this event. I wrote it, but did not present it in this manner because of the lack of time. This is the long version, which I wish I had the time to give.
I am inordinately grateful for the National Association of State Mental Health Program Directors for sponsoring this screening and presentation. Thank you, Pat Shea, for believing in this project. Pat is an awesome and intelligent woman who understands the challenges in Asian American mental health and necessity for this film project. She understands the importance of cultural change as a means of health prevention and everything that it entails. Unfortunately, many mental health organizations do not and I am so fortunate to have their financial support for the educational outreach portion of my project.
Culture, Community and Health Thank you so much for inviting me to your conference. It’s an honor to be here and present my film to you all future doctors.
Where are we headed?
What is progress? It's doing better than previously.By 2050, minorities: Latino Americans, African Americans, and Asian Americans will become the majority, changing the way health care services will be delivered. Therein lies many challenges with this diversification of cultures and languages. Culturally and linguistically appropriate health services will likely become mandatory and very challenging, given the variety of cultures and languages that America will absorb. Can’s little story of recovery and resilience is a small fish in a large pond of millions of fish, but it’s a very important one, one that needs to be told for a myriad of reasons. Culture matters and mediates emotional expression. The culture of patient can help appease or contribute to illness and wellness. The culture of the health care provider can also help or hinder his ability to heal.
Culture Always Matters
Can I ask you how many of you could relate to Can and some of his issues? If most of you are 1.5 or second generation AAs, you can probably relate to Can’s experience of trying to relate to his parents. That intergenerational cultural gap is a source of stress and inner turmoil for many Asian Americans. Do you know the one and only major national study on Asian Americans, the National Latino and Asian American Study in 2006, found that the cultural conflicts with their immigrant parents and perceived discrimination were the two significant life stressors for second generation AAs? Second generation AAs had higher rates of MI than their immigrant parents. Can isn’t the only Asian American who is having difficulty navigating and straddling two very different cultures. We all are and there aren’t many resources for us to tap into. Asian Americans tend to encounter more cultural and linguistic barriers when seeking mental health resources, according the 2001 Surgeon General's Report and the 2003 President New Freedom Commission on Mental Health.
Some of the reasons why I made this film are very personal. I had mental illness in my family; and my family is terribly embarrassed that I’m the only Asian going around publicly disclosing that, but I believe it’s with a greater purpose in mind. Other reasons why I made this film was because of the lack of documentary films, addressing this issue in the Asian American community. In fact, there aren’t many Asian American health organizations that are addressing the mental health crisis in our community. Historically, there weren’t many films in the mainstream media, which depicted realistically the lives of Asian Americans. A part of this project is about dispelling the model minority myth and the inaccurate stereotypes of people with MI.
Media Impacts Culture
Everyone in this room has heard of Jared Loughner, the accused shooter in the Tucson, AZ massacre. Since that fatal day of shooting in December, there have been more than 5,000 news articles about him, scrutinizing every aspect of his life, reporting on minutae of his life. They interviewed his family, friends, neighbors, teachers, and former classmates. Essentially, when a person with a mental illness goes on a murder rampage, there is massive media coverage that exceeds capacity.
Had that same person, Jared Loughner, realized that he had a mental illness, sought treatment and recovered, we’d never have known of him, his family. No one would have cared that he had a mental illness, and as remarkable and extraordinary as his recovery may have been, there probably wouldn’t have been a shred of news about it. The fact is that the mass media nearly exclusively shines a spotlight on those with mental illness, who have committed violence, when in fact, it is a very small percentage of people with mental illness who are violent. There are people with mental illnesses who fought hard to overcome their mental illness and succeeded, but rarely does their story make the headlines. Representations of people with mental illnesses are very skewed in the mass media and those repetitive images of violent people with mental illnesses have an adverse impact on our culture. It basically creates a fear of people with mental illnesses; I know from having people with mental illness in my own family that some are vulnerable to being ridiculed for their different ways because of their mental illness. Often, it is the person with mental illness who needs to be protected from society and its inability to understand mental disabilities.
Based on the deluge of press focusing mass murderers with mental illness, our collective impressions of people with mental illness are violent and deranged when there are millions of harmless people with mental illness who are simply suffering silently. There are numerous health effects and consequences in society because of the stigma of mental illness. For Asian Americans, of which 50% or more are foreign-born, the stigma of mental illness is even harsher and more oppressive. All the while, the news coverage of Asian Americans in the mass media has historically focused on success stories, reinforcing the model minority myth, which has inadvertently led to lack of resource allocation in Asian American mental health.
So in telling Can’s story, I sought to respectfully and realistically express the emotional and factual truths of an human being, trying to recover from mental illness. His being Asian definitely certainly gives his story, a different set of life issues, than someone who grew up in an Euro-American culture. Because stories of heroic efforts to recover are rarely told, despite the importance of telling such stories, I felt a moral imperative to tell Can's story in a way that bears all. Media impacts culture and we must tell the stories of the millions of people like Jared Loughner who have a mental illness, but did not harm or kill anyone. It impacts our collective unconscious, which we call culture. Or we will be complicit in the conspiracy to subjugate those with a mental disability. The denial and shame surrounding mental illness in Asian American communities is very real and has deadly consequences.
Facts About Asian American Mental Health
● Asian Americans who suffer from mental illness are less likely to seek treatment than Euro-Americans, African-Americans, and Latino-Americans, typically seeking psychological care as a last resort when they can no longer conceal their illness. I’ve talked to numerous counselors and psychologists who say that they are seeing
● The 2001 Surgeon General’s report found that Asian Americans had less access to mental health services and, when they did receive treatment, they were more likely to receive lower quality care than other racial groups.
● Nearly 80% of the Southeast Asian refugee population in the US suffer from depressive, anxiety, and post-traumatic stress disorders because of the devastating experience of war in their countries of origin.1
● Asian American women ages 15 to 24 lead in the highest suicide rate amongst all ethnic groups, according to the Department of Health and Human Services.
● 30% of Asian American girls, a higher percentage than any other ethnic group, exhibit symptoms of depression according to the another.
Culture and the Root Causes of Health Disparities
About 30% of the causes of health disparities are rooted in culture, but yet health prevention efforts rarely address cultural change. In fact, most funding is channeled into clinical research, which is only responsible for 10% of the problem. Many of our lifestyle choices: diet, exercise, view of health, whom we seek to find healing, and how we think are often influenced, if not dictated by culture — the beliefs and behaviors around us. And because of culture, Asian Americans with serious and persistent mental illnesses are not receiving the care and treatment they deserve. We are more likely than other ethnic group to confront numerous cultural and linguistic barriers in finding mental health help. Instead of being supported by their neighbors, friends, and family, Asian Americans often deal with their MI in shame and isolation. Why? Culturally, many traditional Asian cultures hid their family members with mental illness. Our cultures desperately need a revolutionary change. In November 2010, a fairly comprehensive article about mental health system in China was published in the New York Times. It illustrated just how deeply the stigma disabled the health system and affected even the development of mental health resources. Only when numerous murders of children by individuals, with untreated mental illness, were they offered help and medical attention.
How many of you in this room know who Iris Chang is? She was a bit before your generation. She was a beloved and popular Chinese American historian, scholar and author. She had a mental illness and committed suicide, in part, because she and her family could not bear to tell their friends and family about her mental illness. This is the cost of living in a culture, one which denigrates a person for having a mental illness.
This film project is help dispel the taboo power around mental illness in Asian American communities and to contribute to the broader public discourse on cultural competency and mental health.
The stigma not only prevents individuals with mental illness from seeking treatment, but also prevents doctors from specializing in psychiatry so there is an actual shortage of Asian bilingual, bi-cultural mental health providers in the U.S. compounding the problems. Though about 25% of medical students are of Asian ancestry, the number of them entering psychiatry is disproportionately low. I would encourage those of you with empathetic and patient personalities to consider a career in psychiatry.
CULTURAL COMPETENCY
The second reason I made this film is because I realized through my experiences with mental health providers, that very few of them understood other cultural realities. Not surprisingly, our mental health system has been a long history of misdiagnosis and mistreatment of minorities, the President’s New Freedom Commission on Mental Health found. There is a growing movement toward culturally competent health care with about 14 states passing legislation mandating some level of education in cultural competency for physicians.
Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. 'Culture' refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. 'Competence' implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. (Adapted from Cross, 1989).
In practical terms, it means effective cross-cultural therapeutic relationships between provider and consumer or patient. In the medical anthropological approach to developing cultural competency, the health provider needs to understand his/her own culture and beliefs. The first step is awareness of one’s own culture and worldview.
For example, in Can’s family, Mr. and Mrs. Truong have an explanatory model for Can’s mental illness, which may be contrary to precepts of conventional Western medicine. Western medicine explains mental illness in scientific terms, not spiritual terms. Though if you think about it, the idea of karma does not necessarily conflict with the scientific idea of mental illness, which is that there is a biological component to it or that it is a complex interaction of nature and nurture. If a psychologist or social worker was working with Can’s family, it would be very important for them to respect their viewpoints and work within their belief systems. And it may not be easy for them to do that if they are not familiar with the culture. But it’s of critical importance to fostering provider-patient trust.
I’d like to add that just because you are Asian American does not mean that you are culturally competent with Asian Americans. Often times, many of us still harbor certain assumptions about our own ethnic, religious or cultural groups. None of us are blank slates and make assumptions and/or have formed habitual beliefs, which may interfere with being culturally competent. For example, there are some Asian Americans, like Can, who have grown up in predominantly white communities and have internalized self-hatred and may reject their own language, culture and customs. So the fact that you are Asian American and speak an Asian language does not a culturally competent health care provider make.
And why is it important?
Cultural competency is one the main ingredients in closing the disparities gap in health care.
In sum, because health care is a cultural construct, arising from beliefs about the nature of disease and the human body, cultural issues are actually central in the delivery of health services treatment and preventive interventions. Your patients are going to you because they believe they will benefit by seeing a doctor. Why they choose to go to a medical doctor, not a shaman, a Buddhist priest, a minister or a acupuncturist is often influenced by culture.
Why cultural competency is important in fighting health disparities? You have understand the culture as well as the physiology of the patient you are treating. What if the Asian woman you are treating for depression lives in a culture which has induced a great deal of shame around mental illness? You must address the shame as well as the illness, because shame can prevent the person from developing authentic relationships with people who support her emotionally. Culture matters.
Culturally and Linguistically Appropriate Services Standards (CLAS)
Culturally and Linguistically Appropriate Services Standards (CLAS) are the collective set of culturally and linguistically appropriate services (CLAS) mandates, guidelines, and recommendations issued by the U.S. Department of Health and Human Services Office of Minority Health intended to inform, guide, and facilitate required and recommended practices related to culturally and linguistically appropriate health services (National Standards for Culturally and Linguistically Appropriate Services in Health Care Final Report, OMH, 2001).
Free Online Cultural Competency Training Resources
- thinkculturalhealth.org – free physician training for which you can receive CEUs, developed by the Office of Minority Health, US Dept of Health and Human Services
- CLAS
- The Technical Assistance Partnership for Child and Family Mental
Health (TA Partnership) provides technical assistance to system of
care communities that are currently funded to operate the
Comprehensive Community Mental Health Services for Children and Their
Families Program.
http://www.tapartnership.org/COP/CLC/asianHawaiianPacificIslander.php
- Management Health Sciences http://erc.msh.org/aapi/index.html
Prescribing Psychotropic Meds for Asians
- As you saw in the film, Can had a lot of trouble with medications, which may, in part, be due to his Asian physiology.
- Asian patients may also experience side effects at lower doses than are seen in other ethnic groups.13,14,15,16
- Start with half the usual recommended starting dose because of possible side effects
- Similar to their response to antidepressants and benzodiazepines, Asian patients often respond to lower doses of antipsychotic medication.
Call to Action
I was fortunate enough to hear Dr. Cornell West, one of America’s most provocative intellectuals and champions of racial justice of our time, at the American Public Health Association Conference. Being who he is, he asked the question, What kind of a human do you want to be? The question wasn’t what kind of a professional do you want to be? What kind of a filmmaker do you want to be? Or what kind of a nurse do you want to be? The question is what kind of a human being do you want to be? It’s the fundamental, primordial question, one that will determine what kinds of choices we make in our roles as professionals, friends, family members, daughters, and sons.
Many of us grew up in households, where racism towards other ethnic groups was acceptable. Chinese are like this; Japanese people are like this; Blacks think this way; White people always do this. I know my parents, who lived in homogenous Korea, never quite understood why it was wrong to classify people based on race, gender, ethnicity or social class. They grew up with a collective sense of responsibility, which meant that individuals in a group did what their leaders told them to. They did not grow up in an individualistic, mult-ethnic society. In their generation and culture, gender-based expectations and race-based assumptions were the norms. Race, cultural and linguistic competence were non-issues in some of the homogeneous Asian societies where our parents came from. I had to unlearn some of the racist attitudes I learned from my upbringing and environment. Luckily, I am a product of a multi-cultural upbringing and had friends from many backgrounds throughout my life. One of my first childhood best friends in the U.S. was from Jamaica and I remember the first time I went over to her house, I had breadfruit and rice and peas. In the U.S., she would be misidentified as African-American, instead of Jamaican-American, which is how she would identify herself. I remember one day walking home from school with her and she was crying, like slow leak, seeping tears. Some kid at school had called her the N word.
My education, particularly the tragic chapters of American history, taught me that racism, and cultural chauvinism is unequivocally wrong. Cultural chauvinism was an acceptable part of being Korean. It was viewed as inherently being Korean. And as you saw in my film, the consequences of racism are deeply penetrating, deeply psychologically damaging. Can feels the pain of his peers taunting him with words like "chink" nearly 30 years after it has happened.
Though we cannot do much change culture and community as a whole, each of us can take responsibility for our own world view. We are all members of this culture and community. Changing ourselves is changing our community. If each one of us took responsibility for our worldview and how we treat others, the world will change. So firstly, the change has to take place within ourselves. Do you want to be a by-product of your culture or a product of truth and reason? Racism has no place in the mind of a doctor, you cannot heal and harm at the same. I had to unlearn the stigma of mental illness by meeting extraordinary people who also happened to have a mental illness. I thought I was enlightened; I thought I was educated. I was both those things, but I still harbored negative stereotypes of people with mental illnesses.
Life is a processing of unlearning and learning, depending on what kind of a human being you want to be. What kind of a human being you want to be will determine the kind of doctor you will be.
And I challenge you today to unlearn the stigma, inculcated by our culture. It will be especially important for doctors, like yourselves, to unlearn the stigma because you will be in positions of power. We’ve all internalized it through the media and those around us. Consider it a form of discrimination based on disability. We should not engage in it, but because it’s so ubiquitous, the stigma is invisible, like water to a fish.
I challenge some of you to become psychiatrists despite what your parents might tell you. Progress begins with yourself and being the change that you want to see in the world. Embrace change and differences. Thank you.
Closing thank you
IN closing, I’d like to thank the California Endowment, the Mental Health Assoc. of California, National Asian American Pacific Islander Mental Health Association, the Asian Women’s Giving Circle and the National Assoc. of State MH Program Directors.
