Improving nuance in South Asian immigrant mental healthcare
If there is anything the pandemic has shown us, it is that isolation is exceptionally rattling. A June 2020 survey by the Centres for Disease Control and Prevention (CDC) reported that 40.19% of adults were experiencing depression, anxiety, PTSD, or substance abuse in the United States. This was three to four times higher than the rates reported just the year prior. Thus, the need for appropriate mental health interventions is higher than ever. Neither the effects of the pandemic nor healthcare needs are uniform across populations. Yet, the diagnosis and treatments we assign to these mental health conditions often do not recognise nor appropriately address these differences. While there is some degree of universality in the human experience, there must be greater nuance and understanding in how we provide mental healthcare, especially in vulnerable and underserved populations. To illustrate this need, I will specifically be looking at how mental health is diagnosed and treated in the United States (US) and how this approach often does not work for the South Asian population here.
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“The need for appropriate mental health interventions is higher than ever. Neither the effects of the pandemic nor healthcare needs are uniform across populations.”
The medical system in the US is ascribed by the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-V). The DSM-V is a collaborative work created by mental health professionals to lay out guidelines for appropriately diagnosing someone with a mental health condition. Anxiety and depressive disorders are among the most common, annually affecting 19.1% and 10.4% of American adults respectively. For a patient suffering from anxiety, the DSM-V lays out symptoms and the level of daily impairment a patient must be experiencing to receive a diagnosis of generalised anxiety disorder (GAD). These include the duration, breadth, and content of anxiety, as well as the presence of somatic symptoms, such as fatigue or restlessness, not explained by a different physiological cause. While the treatment varies across conditions, the overarching principle remains the same: the evidence we have supports a combination of psychotherapy and pharmacotherapy. A patient diagnosed with GAD is likely to be prescribed a selective serotonin uptake inhibitor (SSRI) and is recommended for a therapy programme, such as cognitive behavioral therapy. Although this is considered standard treatment, the success rate of this regimen broadly varies. This model of mental healthcare does not consistently consider that two patients with GAD may have vastly different cultures, values, and stories, and thus may experience their disorders in very different ways. While there are many components missing in this model, I will delve into three that I have found to be largely absent.
“This model of mental healthcare does not consistently consider that two patients may have vastly different cultures, values, and stories, and thus may experience their disorders in very different ways.”
Mental health diagnosis and treatment largely rely on using the individual as the focal point. As a part of the South Asian community, I have felt caught between the Western sense of self that contrasts sharply with the more collectivist ideals that South Asian cultures hold. In South Asian cultures, there is a high degree of interconnectedness between families and communities, spanning generations. Thus, the concept of ‘the individual’ is diluted. There is a protective element here; ideally, the burdens that one person may have to carry will be bolstered by a community. However, in a dysfunctional dynamic, the diminishment of the individual sphere turns into undue burdens forcibly carried by many. This ties in with the idea of intergenerational trauma. Young South Asian Americans today are the grandchildren and great-grandchildren of those who lived to see the end of colonialism in India. Many are children of parents who immigrated to the West, facing poverty, racism, and uncertainty in a new country. These are not easy events for any generation to cope with, let alone within South Asian culture, where traumatic events are not openly spoken about. There is a profound alteration of sense of self that comes with traumatic occurrences, which can be greatly magnified when it occurs within a culture that also de-emphasises the individual. A communal notion of self can also make it difficult for a person to recognise intergenerational patterns that may be harming them. Contingently, a collectivist focus makes it difficult for many South Asians—whether they are from the era of Indian independence or they are influenced by modern-day societies—to buy into a mental healthcare system that places focus largely on the individual.
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“As a part of the South Asian community, I have felt caught between the Western sense of self that contrasts sharply with the more collectivist ideals that South Asian cultures hold.”
Language is another major barrier in providing nuanced mental healthcare. As clinicians, we use terms like “major depressive disorder” and “generalised anxiety disorder” to demystify. These labels make sense for those who work in healthcare, but what do they really mean to individuals who have never heard these terms before? What do they mean to those who do not speak English? The majority of the clinical language used to describe mental health come from a Western context and are amenable to English speakers. As seen by the portrayals in South Asian media, including cinema, a large number of South Asian languages do not use or have words that speak extensively or objectively about mental health. Thus, it becomes difficult for people to be aware of these issues, let alone act against the stigma around them, when there are barriers for communicating about them.
Finally, each community should be framed within the context of how they view the healthcare system. Like many immigrant communities, there is a degree of mistrust regarding healthcare amongst South Asians. Given the rich history of Eastern medicine within the region, there is an ongoing balance between how much trust the community will divvy up between these traditional, generational healing practices, and Western medicine. A 2016 study in BMC Endocrine Disorders looked at South Asian opinions on diabetes medicine and found a prevalent theme of scepticism. Many of those surveyed worried about drug toxicity, drug interactions, appropriateness of their therapies, and more. Doubt in the healthcare system, coupled with the underlying stigma and shame that South Asian communities hold towards mental health conditions, makes it all the more difficult to seek out help. As many South Asian languages do not have words to describe mental health conditions, negative terms end up being used in their place, increasing the shame around these conditions. According to a 2019 review, shame is deeply woven into the South Asian community and acts as a major barrier towards acceptance and treatment of mental health disorders. Stigma also creates a paradoxical problem: although South Asian cultures are largely collectivistic, the shame surrounding mental health is often so potent that any such problems become the individual’s fault. The effects of this can be devastating. Interconnectedness creates an erosion of the sense of self that is not particularly conducive to handling major stressors and mental health concerns.
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“Healthcare workers should be trained to at least seek out context regarding how a culture views the sphere of the individual, and how its people regard mental health.”
Ultimately, these are only some of the barriers facing South Asian immigrant mental healthcare. There are countless other cultures and innumerable nuances that need to be understood in caring for their mental health. It would be impossible to expect public and clinic health providers to be well versed in the struggles of every community. The idea of culturally competent care—which refers to the ability of healthcare professionals to understand, respect, and interact with patients with cultures and value systems different from their own—recognises this. The core principle here is curiosity; healthcare workers should be trained to at least seek out context regarding how a culture views the sphere of the individual, and how its people regard mental health. Care must also be framed within the context of how the culture views Western healthcare as well as the stigmas it holds regarding not only Western medicine, but mental health overall. For an arena as complex as mental health, there are no clear-cut answers. Simply put, nuance is needed to fight our myopia when it comes to sensitive care in immigrant communities.