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Explaining Away Mental Illness
Many Immigrants Face Cultural Barriers, Other Obstacles to Psychiatric Treatment

By Sandra G. Boodman
Washington Post Staff Writer
Tuesday, September 4, 2007

The parents had tried with little success to cope with their son's accelerating deterioration. Unable to concentrate, he had dropped out of college and moved back home. When he could no longer function at the job he had held briefly, his parents kept him sequestered in their house, his condition a closely guarded secret. By the time the trio arrived in the emergency room, the youth was hallucinating and had assaulted his parents.

When psychiatrist Amir Afkhami asked why the couple had waited two years to seek treatment for their son's schizophrenia, the answer was simple: "We thought he was just spoiled."

Another patient insisted his symptoms reflected a spiritual rather than a psychiatric crisis. He told Afkhami, an assistant professor at George Washington University's School of Public Health and Health Services, that the vivid images of a devil-like apparition that had kept him awake for days reflected his inadequate devotion to Allah, not bipolar disorder.

In each case, the patients were recent immigrants to the United States, the first from South Korea, the second from Africa. As the numbers of immigrants swell, they are being seen with increasing frequency in emergency rooms, clinics and physicians' offices in the Washington area and across the country. In many cases their views of the nature, origin and even existence of mental illness sharply diverge from the American mainstream.

These cultural differences, experts say, can have profound implications for their access to treatment. Psychiatrists who specialize in culturally sensitive treatment say there is a delicate balance between discussing the problems in a way that encourages those who need help to seek it and drawing unwanted attention to immigrants who already feel stigmatized and vulnerable.

Some of the obstacles facing immigrant families are reflected in the case of Seung Hui Cho, the 23-year-old Virginia Tech student who shot to death 32 people before killing himself during a campus rampage last spring. Cho's serious psychological problems were evident from the age of 8 when he emigrated from South Korea to the United States with his parents and older sister.

He was unusually silent even with his family and was later diagnosed with selective mutism, a severe anxiety disorder. His family, described as "involved and concerned," agreed to therapy and medication during his middle and high school years in Fairfax County, according to the report released last week by a blue-ribbon panel appointed by Virginia Gov. Timothy M. Kaine (D).

The panel commended Cho's parents for overcoming the "cultural barriers" that confront many immigrants. "The stigmatization of mental health problems remains a serious roadblock in seeking treatment in the United States, too, but in Korea the issue is even more relevant," the panel wrote. "Getting help for such concerns is only reluctantly acknowledged as necessary."

When Cho entered Virginia Tech in 2003, the report notes, "his multi-faceted support system then disappeared leaving a huge void."

Days after the shootings, there were reports that in the months before the April 16 tragedy Cho's mother had sought assistance from several Northern Virginia Korean churches in ridding Cho of what one pastor called the youth's "demonic power."

Seeking help from a church for a psychological problem is common practice in the Korean community, psychiatrists say, because churches play a singularly important role. It is the place many immigrants turn to as a last resort -- if they seek help at all.

"Asians don't view it as a sickness or an illness, but as a family curse," said Esther Chung, a minister and part-time counselor at the Korean Family Counseling and Research Center in Vienna. "They try to take care of it themselves."

Common Obstacles

While there are clearly differences among the dozens of immigrant groups in the Washington area, the obstacles new arrivals face obtaining mental health treatment are similar, experts say.

These include poverty, lack of health insurance, a history of trauma that often drove them to leave war-ravaged homelands, an inability to speak English, long and often inflexible work hours that make it hard to keep appointments, and a lack of practitioners who speak their language or understand their culture. Added to that are intergenerational conflicts and what one psychiatrist calls "complicated mourning" for their old lives and those left behind.

"It's not that [immigrants] have higher rates of mental illness, but they are less likely to seek services" than those born in the United States, said Joyce Y. Chung, a clinical associate professor of psychiatry at Georgetown University. (She is not related to Esther Chung.)

Among immigrant families, Joyce Chung noted, early intervention, which is known to improve long-term prognosis for mental health problems, is rare. More typical are treatment delays of months -- or years -- resulting in a long-festering problem that has spiraled into a full-blown crisis requiring immediate hospitalization, doctors say.

"Often there isn't even a concept that a problem is a mental illness," said Francis Lu, a professor of clinical psychiatry at the University of California at San Francisco who consulted with the Virginia Tech panel.

An expert on the effect of culture on psychiatry, Lu founded the pioneering Asian Focus Unit at San Francisco General Hospital. The unit's staff speaks 17 Asian languages and dialects and is designed to provide culturally sensitive treatment.

In Lu's view, the shame, stigma and silence surrounding mental health treatment among Asian immigrants appears to be greater than among other ethnic groups.

Although Koreans are among the fastest-growing groups of Asian immigrants, they are among the least likely to have medical insurance and rank among the lowest in their use of all health services, according to Hochang Benjamin Lee, an assistant professor of psychiatry at Johns Hopkins University.

In the Korean American community, Christian churches have traditionally been the most powerful institution, noted Lee, who immigrated to the United States as a child. Although doctors and lawyers are respected, pastors have unrivaled standing, even among those who are not religious or even Christian, as are an estimated 70 to 80 percent of Korean immigrants, noted Lee, a member of the Association of Korean American Psychiatrists.

Many immigrants, he noted, attend church three or four times per week. And for those working 12 hours a day seven days a week, as many Koreans do in the small businesses they own, there are few other opportunities to socialize, and language barriers often prevent assimilation.

The problem, Lee said, is that few ministers are trained to handle or even recognize psychological difficulties. A 1993 study of 50 Korean American clergymen with an average of 20 years' experience found that half regarded psychotic delusions with religious content as a spiritual, not a psychiatric problem, and many had never made a referral for mental health treatment, according to Lee.

Child psychiatrist Wun Jung Kim, a professor at the University of Pittsburgh, said that some clergy may prescribe exorcism or "other extreme measures" for psychiatric illness.

Seeking help outside the family, Kim said, "lets people know there is a defect in the gene," which could jeopardize the marriage prospects of siblings and other relatives. That belief, he said, was especially strong in Korea, where matchmakers were widely used.

"I've worked with families where the parents encouraged marriage almost as a cure for mental illness," said San Francisco's Lu.

The '1.5 Generation'

Many of those who call the Korean American Family Counseling Center refuse to give their name or phone number and are reluctant to meet with a counselor, according to Esther Chung.

Often they are married women with children. Some are victims of domestic violence; others are grappling with impending divorce or are worried about their troubled or drug-addicted children, members of the so-called "1.5 generation" born in Korea but raised in the United States.

Cho was among this group, many of whom feel an intense pressure to succeed, if not to excel, in part to justify their parents' sacrifices.

As a counselor, Chung said, she sees "a lot of people who struggle with depression, anxiety, phobias and addiction." The center provides brief counseling, typically limited to six sessions, and refers more-serious mental health problems elsewhere.

Some callers, Chung said, do not understand why more than one counseling session would be necessary, nor do they trust that what they say won't be repeated.

"Confidentiality is a new idea for a lot of immigrants," said Chung, who in 1990 arrived in the United States with her family, none of whom spoke English, to enter Robert E. Lee High School in Springfield.

Intergenerational tensions are pervasive in immigrant families, mental health workers say, compounded by the exhaustion of long work hours and constant financial worries.

"Often the parents' sense of well-being is based on how well the children are doing in school," said Pittsburgh's Kim. "As long as they move with the rest of the group and are getting A's and B's," there is an assumption that things are okay. "They don't pay attention to a child's personal growth."

Esther Chung said that her parents, who worked at a carryout in the District, frequently reminded her and her younger brother that they had left their home to provide better opportunities for them. It is a refrain, she said, that is repeated by "99 percent of Korean first-generation immigrants."

"I had to struggle and see other people struggle," Chung said. "The expectations are very high."

Physical Symptoms

The tendency for immigrants to describe psychiatric problems in physical terms is common, experts say, and can obscure diagnosis and complicate treatment.

Prominent among Koreans, Hopkins's Lee notes, is "hwa-byung," or anger syndrome -- a psychiatric disorder listed in the psychiatric Diagnostic and Statistical Manual as a "culture bound" malady. Symptoms include insomnia, fatigue, indigestion, panic and a heavy feeling in the chest. Many sufferers insist their ailments are purely physical and reject the notion that their pain may have an emotional cause.

GWU's Afkhami said that Muslim patients often express emotional distress similarly, as fatigue, dizziness, heart pain or a headache.

"There is no word for depression in Persian or Arabic," he noted. "I know several patients who've been worked up the wazoo for headaches by neurologists" when they were really suffering from depression.

Esther Chung said that while the Korean community is still coping with the fallout of the Cho case, the shootings have sparked an increase in calls to the counseling center, located in a tidy red-brick office building near Tysons Corner.

"More people are calling us for help," she said. "And they're a little bit more open." ?

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