Beliefs about causes,symptoms,and stigma associated with severe mental illness among ‘highly acculturated’ Chinese-American patients

Abstract

Background:

Literature about experiences of mental illness among ethnic minority has tended to focus on first-generation migrants. This study fills that gap by exploring experiences among highly acculturated Chinese-American patients with mental illness.

Materials:

Twenty-nine participants completed semi-structured interviews based on Kleinman’s explanatory model, which were audio-taped, transcribed and coded for qualitative analysis.

Discussion:

Beliefs about the causes of mental illness included biological factors, head trauma and personal losses. Issues relating to stigma and shame were also discussed.

Conclusion:

Highly acculturated ethnic minority patients may ascribe to a biomedical model at the same time as ascribing to culture-specific beliefs.

Keywords

US Chinese explanatory model mental illness mental health beliefs acculturation

Introduction

Commonly cited reasons for the under-use of mental health services among Asian-Americans are lack of language proficiency, poverty and stigma (US Surgeon General, 2001). But Ying (1990) suggested that what may also deter Asian-Americans from seeking help is the incongruence between the patients’ and the clinicians’ illness conceptions.

Classical western philosophy stemmed from the traditions of Descartes’ body–mind dualism (Ryder, Yang & Heine, 2002). Biomedicine, a product of western philosophical traditions, is based on the principles of empiricism and positivism (Gordon, 1988). In contrast, Chinese thinking and philosophy are more holistic, in that the body and the mind are considered to be one and the same, with bidirectional influences (Lin, 1980). Research has documented the prevalence of somatization, or the expression of psychological distress through physical symptoms, among the Chinese (Kleinman, 1980; Parker, Chan & Tully, 2006; Ryder, Yang & Heine, 2002). Difficulty in using the western biomedical model to accurately diagnose psychological illnesses in Chinese patients might be complicated by a mismatch between cultural models of the body and mind (Kleinman, 2004; Ryder, Yang & Heine, 2002).

A few past studies have examined illness conceptions, or explanatory models, of mental illness in less acculturated Chinese-American samples (e.g. Yeung, Chang, Gresham, Nierenberg & Fava, 2004; Ying, 1990). Ying (1990) conducted research using vignettes with immigrant Chinese women (mean length of stay in the USA = 2.7 years) who experienced major depression and found that the women who primarily endorsed psychological causes were more likely to say that the best solution would be to turn to family and friends for social support, while those who primarily endorsed physical causes for depression were more likely to suggest seeking professional help. In another study, Yeung and colleagues (2004) explored illness beliefs among 40 Chinese-American women (mean length of stay in the USA = 6 years) who presented in a primary care setting with major depressive disorder. The interviewers found that the majority of the participants (94%) reported stress or psychological reasons for the cause of their condition, with magical-religious-supernatural causes (45%) as the second most common category of responses.

Most studies regarding beliefs of mental illness in minority population focus on foreign-born or first-generation individuals (e.g. Karasz, 2005; McCabe & Priebe, 2004; Ying, 1990). Studies that take acculturation into account generally find that these barriers are more prominent among recent immigrants (Barreto & Segal, 2005; Frisbie, Cho & Hummer, 1999) and that barriers become less important as the person becomes more acculturated (Ying & Miller, 1992). Beliefs about mental health among US-born individuals of ethnic descent are less documented although Chinese-Americans comprise of the largest ethnic Asian group in the USA (Reeves & Bennett, 2004).

This study used a qualitative approach to examine mental health beliefs among highly acculturated Chinese-American patients with severe mental illness and serves to fill the gap in the literature of Chinese-American mental health.

Methods

Participant recruitment

The participants were recruited from two community mental health centres (CMHCs), four rehabilitation clubhouses and one provider-of-services agency providing bilingual case management services within the public adult mental health system in the island of Oahu, in state of Hawai’i. Participants either volunteered to participate or were referred by site staff. The inclusion criteria were: (1) a client of the state public mental health system; and (2) a client who self identifies as Chinese-American. A client was excluded from the study if he or she was in imminent danger to self or others or was experiencing acute psychosis. The study was approved by the University of Hawai’i at Mānoa Institutional Review Board and the Hawai’i Department of Health, Adult Mental Health Division.

Participants

Demographic information gathered included age, gender, heritage ethnicities, primary ethnic identification, place of birth, places of birth of parents and grandparents and fluency level of languages. ‘Heritage ethnicities’ referred to all the ethnicities that the participant possessed by birth. ‘Primary ethnic identification’ was defined as the ethnicity with which participants most identified. This was especially important for those who identified more than one heritage ethnicity. Information regarding place of birth and places of birth of parents and grandparents were used to estimate participants’ generational status. Finally, participants were asked to list all languages, as well as Chinese dialects, spoken and the fluency level of each language (beginner, intermediate or fluent).

Measures

Cultural preference items (six items adapted from Suinn-Lew Asian Self-Identity Acculturation Scale, SL-ASIA; Suinn, Ahuna & Khoo, 1992) served as a quantitative index of acculturation level. The original SL-ASIA is a 21-item multiple-choice acculturation measure assessing the degree of identification among Asian populations to western or Asian cultures (Suinn et al., 1992). This study used items related to reading, writing and cultural preferences (1, 2, 10, 11, 17, 18). Only six items were included due to concerns regarding the overall length of the interview session and potential cognitive fatigue in this population. Items 1, 2, 10, 11 and 18 were identified through a factor analysis to be able to account for 41.5% of the total score variance (Suinn et al., 1992). The original wordings of the items have been changed to reflect a more homogeneous sample, changing references from ‘Asians’ to ‘Chinese’. Each statement is rated on a five-point scale (1 = in agreement with Asian values and practices, 5 = being in agreement with western values and practices). The average score of the six items was obtained for each participant as one measure of acculturation, ranging from 1 to 5 (high Asian identity to high western identity). The Cronbach’s α for the six items included in this study was .84. This six-item version of SL-ASIA has not previously been used in other studies.

The Explanatory Model Semi-Structured Interview was developed for use in this study and had not been previously used in other studies. The development of this interview schedule was based on Kleinman’s (1978) work with explanatory models with questions that focused on five areas of the explanatory model – Etiology; Pathophysiology; Onset of Symptoms; Course of Illness; and Treatment, Help-Seeking and Recovery – being adapted from papers by Lloyd and colleagues (1998) and Ying (1990). The sixth area, Culture, was an addition to the original model and devised by this author, and explored perceived cultural norms and beliefs related to the participant’s problem.

Procedure

Language used

Participants had the option of using either English or Chinese study materials. The original English versions were translated into Chinese by this paper’s author, a Masters-level clinical psychology graduate student with a Bachelors of Arts degree in Psychology, who is a native speaker of Mandarin and a fluent speaker of English. The translation was read and confirmed to retain its original meanings by two bilingual graduate student (Zhang and Li), PhD-level clinical psychology graduate students with a Masters of Education degree in Psychology and Masters of Arts and Science degree in Psychology, respectively. Both are native speakers of Mandarin and intermediate speakers of English.

Study protocol

Each participant signed consent forms to participate and to allow the investigator to access their medical records. Each participant was asked to elaborate on answers with regards to the ‘problem they are working on at the CMHC or Clubhouse’. The mental illness was initially referred to generically as a ‘problem’, and then followed by a question asking the participant what label he or she would like to use. In both Lloyd et al. (1998) and Ying’s (1990) interviews, they initially referred to the illness being discussed as a ‘problem’ to allow participants to freely talk about what their health practitioners would refer to as ‘mental illnesses’ while allowing for other potential explanations of their ‘problems’. When asked for clarification of the term ‘problem’, the researcher gave a standardized explanation: ‘Sometimes doctors and patients see things differently – doctors might call it mental illness but what do you think?’

The session lasted approximately 40– 60 minutes. Only one participant refused the audio-recording so the responses were written down verbatim. The participants received a $10 gift certificate to a supermarket as a token of appreciation. After the field data collection was completed, the primary investigator requested each participant’s clinical diagnosis/diagnoses from the public mental health system database.

Data reduction

Transcription

The English audio-recordings were transcribed by the primary investigator and two research assistants who were undergraduate psychology students. One of the interviews was conducted in both English and Mandarin and the Chinese sections were first transcribed in Chinese, translated to English by the primary investigator, and then reviewed by one of the graduate students who was previously involved in translation for this study (Zhang) before undergoing regular coding procedures. All transcripts were checked twice against the original audio-recording by the investigator.

Coding

The primary investigator derived major themes from the transcripts and established a coding scheme with inclusion and exclusion criteria for each code (Patton, 2002). The coding process was facilitated by CDC EZ-Text software (Carey et al., 1998). Each transcript was coded independently by two research assistants, both undergraduate psychology students in their final year of study, who were not involved in the transcription process. The coders were instructed to examine each transcript in its entirety and if there were discrepancies between codes, a consensus among the two coders and the investigator was required. Problematic codes were revised and the revised criteria would be applied to all transcripts. Percentage agreement between the two coders for the 19 cases that the raters coded independently was 50%–79%.

Results

Sample characteristics

Between July and December 2008, 33 people expressed interest in the study. Four cases were excluded from the analyses: one person used ZhongShan dialect during her interview and because of the language abilities of the research team, her transcript was unable to be transcribed verbatim; one person was not of Chinese ancestry; and two reported unclear ancestries. Of the 29 participants whose data were retained for analysis, 14 were female, among whom one self-identified as a male-to-female transgendered person. The average age of the participants was 51.8 years (median = 51.5, mode = 49, range = 20–75). Twenty-six participants had received a minimum of high school education. Twenty-two were diagnosed with a schizophrenia spectrum disorder (11 with schizoaffective disorder bipolar type, 10 with schizophrenia and one with psychosis not otherwise specified (NOS)); six people were diagnosed with bipolar disorder type I; and one person with major depressive disorder recurrent type. The average number of years they had received services from the public mental health system was 13.9 (median = 13, mode = 3, range = 0.5–31) (Table 1).

Table 1.

Study sample characteristics.

Demographic variable	n (%)
Total number	29
Females	14 (48)
Age range (years)	20–75
Mean	51.8
Participants with high school graduation or above	26 (90)
Participants with clinical diagnoses
Schizophrenia spectrum disorders	22 (76)
Bipolar disorder	6 (21)
Major depressive disorder	1 (3)
Average length of time in public mental health system (years)	13.9
Range	0.5–31
Participants who have attended psychoeducation class(es)	20 (69)

Acculturation factors

In Hawai’i, a large proportion of the population is multi-ethnic and this is reflected in this sample. Twenty-one out of 29 participants in this sample (72.4%) reported their ethnic backgrounds as Chinese and at least one other ethnic background (thus, multi-ethnic); the remaining eight reported ‘Chinese’ as their only ethnic background. Of the 21 multi-ethnic participants, five identified themselves as Chinese, eight identified with their other ethnic heritage group (Filipino, Korean and Hawaiian), four identified as part-Chinese (‘Samoan-Chinese’, ‘Chinese-Hawaiian’, ‘Chinese-Vietnamese’, ‘part-Chinese’), one identified as ‘Human’, and one did not respond to the question. The investigator decided to include all 29 participants in the analysis as this range of ethnic self-identification may be a reflection of a society’s acculturation process. It is debatable whether a person who was born of a Caucasian father and a Chinese mother and identifies as a Caucasian is any less ethnically Chinese than a person who was born of two Chinese parents. For the purpose of this research, all of the participants are included.

Twenty-five people were US-born and were second generation or above. Eight people spoke a Chinese dialect with fluency ranging from beginner to fluent. Twenty-eight participants were interviewed in English and one was interviewed using both English and Mandarin. A recent study (Lee, Nguyen & Tsui, 2011) showed that English fluency among foreign-born Asian Americans is a good indicator of acculturation level and foreign-born Asians who interviewed in English showed similar health status as US-born Asians. The overall mean score for the Cultural Preferences Measure was 4.47 (range = 2.67–5) and 16 of 29 people scored an average of 5, indicating high western identity. Based on these demographic variables, this sample was deemed to be highly acculturated.

Qualitative analyses

Etiology

Participants identified several causes related to their mental illness: biological/somatic; losses, interpersonal and ethnic identity issues; recreational drug use; head trauma; sexual abuse; and improper diet.

Biological/somatic

Fifteen participants (52%) referred to mental illness as hereditary, the result of neurotransmitter deficiencies, or more vaguely, brain abnormalities. For example, a 62-year-old woman and a 59-year-old woman both referred to abnormal chemical levels in the brain.

Losses, interpersonal and ethnic identity issues

There were seven participants (24%) who reported family losses and past negative interpersonal experiences as causes for their mental illnesses. For example, a 49-year-old man attributed mental illness to prior marital and family problems and a 34-year-old woman reported ethnic identity issues (i.e. referring to herself as a Chinese growing up in American culture) in addition to marital problems.

Recreational drug use

Six participants (21%) referred to past recreational drug use as a cause for their mental illnesses. For example, a 51-year-old woman who identified as part-Chinese reported that she started using cocaine and marijuana when she was 13 and experienced ‘drug-induced paranoia’ when she was 13 and 15.

Head trauma

Four participants (14%) referred to head trauma as possible etiological explanations. For example, a 56-year-old man with no previous history of schizophrenia was involved in a car accident when he was 32 years old. While he felt fine immediately after the accident, a few years later he started to experience poor concentration, auditory hallucination and increased fatigue. A 71-year-old man explained that his mother took two hours to give birth to him and perinatal brain damage may have led to the later development of psychiatric symptoms.

Sexual abuse

Three participants (10%) cited sexual abuse and resulting psychological trauma as contributors in the development of their mental illnesses. For example, a 38-year-old woman believed that her bipolar disorder stemmed from trauma resulting from being a victim of bullying and sexual abuse.

Improper diet

Two participants (7%) believed that their mental illnesses were caused by improper diet. For example, a woman who identified as part-Chinese believed that her schizophrenia was caused by the ‘physical properties of the food’ she ate. She stated that she ‘probably ate something that upset [her body] balance’ when she was in college.

Symptoms

There were some common symptoms among the participants that increased their awareness of a potential mental illness. Most often, the participants experienced mood changes, hallucinations or delusions. Fourteen participants (48%) reported perceptual disturbances including auditory and visual hallucinations, and five participants (17%) reported experiencing paranoia and delusions. Twelve participants (41%) reported affective symptoms, such as depression or hypomania, compulsive behaviour, suicidality and social withdrawal, and five participants (17%) reported cognitive problems, such as a decline in concentration or problem-solving skills. Nine participants (31%) reported a total lack of insight at the beginning of their illnesses.

Culture

Participants were encouraged to share their own experiences regarding cultural-specific experiences of mental illness; if they did not have relevant experiences or were unwilling to share them, they were asked to share experiences from other Chinese patients that they knew.

Stigma

Stigma refers to negative and discrediting markers that society attributes to people who are different, in the context of social, political, cultural factors, and standards of which individuals have little control (Goffman, 1963). Those who are stigmatized are often avoided and deprived of opportunities available to others. Sometimes stigma could also be extended to an individual who is socially associated with a discredited individual, such that larger society treats both individuals in certain respects as one (Goffman, 1963).

There were 16 participants (55%) who reported that there is a stigma attached to mental illness. For example, a man who identified as Chinese reflected: ‘The Chinese seldom… talk about those things… They accept [the patient]… if [the patient] is not violent and… they’ll take care of [the patient] at home.’ When another man who identified as Chinese was asked how being ‘officially diagnosed’ affected him, he replied that it was ‘like they branded you’ and discussed one instance where a stranger told him that his gait betrayed him as someone who is on psychiatric medication. A 71-year-old man thought people’s views on those with mental illness are conditionally based on functioning. He said: ‘If they [people with mental illness] can work their problem out, it’s alright. [Interviewer: But if they cannot?] It’s a disgrace [to the family].’

Shame

Shame is related to stigma in that it is also a negative emotional reaction; however, it is often directed towards oneself (or one’s own group) when one believes something improper had occurred. There is a value judgement placed on the behaviour or mental processes experienced, and as a result, shame may be experienced internally with or without outside influence and often not shared with other people.

Ten participants (34%) reported that they felt ashamed at some point during the course of their illness. These experiences often overlapped with increased perceived social stigma. A man who self-identified as Samoan-Chinese said that his family’s high expectations for his future were some of the reasons for his mental illness. A woman who self-identified as Chinese reflected on what it means to be Chinese: ‘I guess, just by definition of being Chinese, you [are] suppose to be in total control of your feelings, and not overreact and act out in public.’ On the other hand, a man who self-identified as Chinese-Hawaiian reported that he was not ashamed of his illness and that he would like to be a role model for his children.

Acceptance from others

Eight participants (28%) reported experiences that exemplified acceptance from other people regarding mental illness. For example, a man who self-identified as Chinese-Hawaiian talked about how telling his friends about his mental illness led him to discover that there were others among his friends who also had mental illness.

Family support

Seven participants (24%) reported some family support in their recovery process. Although a few participants endorsed family support, some did not. For example, a man who self-identified as Hawaiian also reported a sense of lack of understanding among family members. He said: ‘My kids [were] saying that dad… you [are] just putting on an act, you just want to be in the system.’

Discussion

The following discussion will focus on the notable findings of the study and discuss the reasons for convergent or divergent results in comparison with existing literature.

Etiology

Minimal reference to traditional Chinese medicine concepts

Only three out of 29 participants (10%) referred specifically to traditional Chinese medicine (TCM) concepts. Given that twenty-five out of 29 people in the current study were US-born, this finding is consistent with results from Yang, Corsini-Munt, Link and Phelan (2009) national survey that found that US-born Chinese rated TCM as less effective in treating psychiatric illnesses than foreign-born Chinese.

Head trauma reported as an etiology for mental illness

Four out of 29 participants (14%) in this study reported head trauma as a cause of their mental illnesses. According to the public mental health system database available, only one participant had an identified history of traumatic brain injury. However, it is unclear how many other cases may be undocumented. Head trauma may be a cause or maintaining factor of psychological symptoms, but according to standard diagnostic practices, medical conditions have to be ruled out prior to making Axis I diagnoses based on Diagnostic and statistical manual of mental disorders, 4th edition (APA, 1994). Chan (2004) found that among 12 patients with schizophrenia from Hong Kong, an ethnically Chinese society with prolonged western influences as a former British colony, some participants had reported generic ‘brain problems’ that did not fit into the categories of heredity or general physical problems, such as the effects of chemical exposure, as causes for mental illness. Chan (2004) theorized that when mental illness is attributed to ‘brain problems’ there are no distinctions made between western notions of physical and psychological illnesses – and an organic disorder is seen with little or no stigma attached (Chan, 2004; Ng, 1990).

No references to supernatural or spiritual causes

Moreover, there were no references to supernatural or spiritual causes of mental illness in this sample, contrary to findings from Chan’s (2004) study with Hong Kong patients. In her study, there were many examples of supernatural influences, such as ghosts and spirits, on the development of mental illness. Supernatural beliefs were cited as causes for mental illnesses by a minority of overseas Chinese patients or family members in other research (Phillips, Li, Stroup & Xin, 2000). In general, a western model of mental illness is incongruent with beliefs in supernatural causes. Based on previous research, the lack of reference to supernatural causes in this sample could be explained by their experiences with psychoeducation classes and access to public mental health services.

Recreational drug use

Six out of 29 participants (21%) cited past recreational drug use as the main cause for their illnesses. Drug use has rarely been discussed in previous literature on the beliefs regarding causes of mental illness in Chinese from Australia, China (mainland and Hong Kong), the UK and the USA (Chan, 2004; Furnham & Chan, 2004; Hsiao, Kimidis, Minas & Tan, 2005; Yeung et al., 2004; Ying, 1990). For example, Phillips and colleagues (2000) surveyed families of patients with schizophrenia in China regarding perceived causes of schizophrenia and found that drug and alcohol misuse was noted in only two of 135 patients. One possible explanation for this difference may be that this study’s sample is more acculturated to western culture than samples from previous studies, and recreational drug use is less stigmatized in western countries.

Symptoms

Limited somatizing of psychological symptoms

Despite research on the prevalence of somatization of psychological symptoms among Chinese (Kleinman, 1980; Parker et al., 2006; Ryder, Yang & Heine, 2002), there appears to be few examples of this in this study. There was little or no distinction between somatic and psychological symptoms in these narratives. The participants often explained psychological symptoms as a result of structural or functional problems in the brain. These participants often mentioned a temporal causal relationship between the trauma incident and the onset of symptoms.

Culture

Shame and stigma

Shame or stigma associated with mental illness was often reported by participants. Many participants described feelings of failure and shame when they were unable to meet the high expectations of their families. There was a common perception that mental illness is not culturally accepted or comes in conflict with the image of the Chinese. Through their own experiences as well as the experiences of others, many participants realized that their diagnoses are often incongruent with the societal stereotype of the Chinese as the model minority (Sue, 1994). As such, they often feel misunderstood.

Family involvement

Although Chinese doctrines promote family cohesion and relationships, shame and stigma were still evident among family members. In the Chinese society, the family not only consists of the immediate family members as in modern western cultures, but it also includes distant living relatives, ancestors of the past and generations of the future. When someone in the family has a mental illness, stigma not only affects the individual but it also affects the extended family because of the beliefs in the hereditary nature of mental illness or stigma by association (Goffman, 1963). In this regard, Lin and Lin (1981; cited in Chan 2004) suggested that siblings might also decrease their potential for marriage if they were found to be related to someone with a mental illness.

Despite feelings of shame, there were still family members who supported the participants. It is possible that family members are motivated to care for the ill in secret to protect the family name; however, the Chinese usually place great emphasis on the family’s basic resources for support in problematic circumstances (Tseng, Lin & Yeh, 1995).

Intergenerational conflict, cultural loss and process of assimilation

The themes of intergenerational conflict, cultural loss and process of assimilation highlighted the process of negotiation between the traditional Chinese values that the participants were raised with at home and the American/western values that they experienced outside the home. In this study, many participants regretted their lack of exposure to Chinese culture when they were growing up. Some examples included evident differences in values and beliefs between more traditional families and mainstream culture, as well as a missed opportunity to learn a Chinese language. Some questioned whether part of their problems might stem from the incongruence between Chinese and American cultures.

Conclusion

This is one of the few studies that have been conducted with a highly acculturated Chinese-American population with severe mental illnesses. Based on these results, when clinicians are working with a US-born patient, they may find that they share a biomedical framework with the patient regarding the causes and symptoms of mental illness. However, depending on the patient’s personal history, it will be important to explore whether there are specific beliefs that may not be consistent with the biomedical model. In addition, depending on the community the patient grew up with and the one that he or she is currently living in, it may also be beneficial to discuss some common conceptions of mental illness among those communities, to contextualize the patient’s experiences with shame and stigma. The culturally sensitive clinician is recommended to inquire about explanatory models to help remove barriers to treatment stemming from shame or incongruence between the clinician’s and the client’s explanatory models.

Footnotes

Acknowledgements

This study was conducted in the context of the author’s Masters thesis. The author would like to acknowledge thesis committee chair John Steffen, PhD, thesis committee members Charlene Baker, PhD and Elaine Heiby, PhD, dissertation committee chair Stephen Haynes, PhD, and colleagues Puihan Chao, PhD and Andrea Hermosura, MA for their comments on previous versions of this manuscript. This study was made possible by the assistance of colleagues Yiling Zhang, MA and Chun-I Li, PhD, as well as research assistants Timothy White, Eileen Chau, Paula Kawajiri and Yuta Sugihara. This study was supported financially and in kind by the Hawai’i State Department of Health – Adult Mental Health Division, Mental Health Services Research, Evaluation and Training Program, and the Department of Psychology of University of Hawai’i at Mānoa through the Gartley Research Award.

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