In mid-March, a friend and I texted about what our reality will look like in the next few months, in light of the stories we’d been hearing from family and friends in China and South Korea since January. “Why are we so bad at containing this?” she asked…and we both came to the conclusion that masks had something to do with it, but still couldn’t quite get on board with the many people, mostly of Asian Pacific Islander (API) descent, wearing masks around town. At that point in the COVID-19 timeline, the stigma of wearing a mask, especially as an API person, was so strong. And despite being two strong-willed and outspoken Asian American women living in a progressive town, we were scared. Not just of signaling that we might be infected and the consequent hostile reactions so many people in our community had already experienced, but also of the shame for being “ignorant” about the lack of benefit (being promoted by health organizations at the time) of wearing masks for asymptomatic people. Because similar to so many API who grow up in predominately white spaces, our conditional sense of belonging in our communities has always rested up on the idea that we don’t make those kinds of waves — we’re expected to keep our head down, follow current civic decorum (right or wrong) so not to be perceived as un-American (classic “respectability politics” nonsense).
One of the many differences in the COVID-19 experience for API in the United States compared to our family and friends in China and South Korea has been the compounding fear of hate incidents in addition to the financial, social and physical impact of disease. In recent months, APIs around the country have experienced a rise in explicit and aggressive racism — which does not seem to care about our country of origin, citizenship, how successful we are, or how hard we are working to save lives during this pandemic. Even our children are not safe. The anti-Asian harassment in the COVID-19 era has the undermined the proximity to whiteness often associated with East Asians and unmasked the complexities of the model minority myth. We are reminded of the falsehoods of being the “right” type of minority or the “right” type of immigrant, and that our perpetual foreigner status will follow us in ways where our “Asianness” and “Americanness” will always be mutually exclusive, due to strict boundary policing of white hegemony.
The false lens of the model minority myth also perpetuates the illusion that APIs are well adjusted and thriving, and paints a deceptive picture of the state of API mental and physical health. This stereotype often contributes to API populations being overlooked in discussions about health disparities. In the COVID-19 context, Pacific Islanders are actually seeing higher rates of COVID-19 cases when compared to other ethnic groups in at least four states (Hawaii, Washington, California and Oregon) and the highest death rate from COVID-19 in California, yet these concerning trends have not received much national attention. Additionally while there has been important media attention on experiences of racism and the historical context of anti-Asian American xenophobia, there’s been limited discussion on the mental health toll on API populations.
Granted, we are anticipating a population-level increase in anxiety, depression and substance use among all Americans, but there are several reasons why APIs are an especially high risk group. There is already a substantial body of research linking racial discrimination to adverse mental health as well as lower use of formal treatment pathways. Despite the high prevalence of mental health-related issues, mental health is still commonly neglected in API communities. In past decades, API have also consistently shown more negative help seeking attitudes towards mental health services compared to their non-API counterparts. API students tend to report similar levels of depression and anxiety symptoms compared with their peers, yet underutilize service relative to their level of need. In a large study of college students with mental health symptoms, students that identitied as Asian were the least likely of all racial and ethnic groups to perceive a need for services.
My research primarily focuses on college students — an important population in general given that the traditional college age, 18–25, directly coincides with the age of onset of 75% lifetime mental illnesses. Using the last three waves of Healthy Minds Survey (HMS), the largest and most comprehensive annual national survey examining mental health, service utilization, and related factors among students in higher education, I found that the overall prevalence of mental health symptoms between API students and all students are fairly similar, with API students screening significantly higher for Eating Disorders and self-reported Suicidal Attempt.
Asian international students, in particular, report highest odds of suicidal attempt, which is significantly associated with perceived public stigma of receiving mental health treatment. When looking at specific mental health help-seeking trends in higher education students with mental health symptoms, I found across the board that API students utilize help-seeking avenues far less than students overall, including both formal (therapy, psychotropic medication) and informal pathways (family, friends, mentors, etc.)
The xenophobia, hostile racism and resulting collective trauma has likely exacerbated mental health issues among Asian Americans. The mental health repercussions are not limited to API individuals who experience direct hate incidents. Witnessing or even the knowledge of these accounts can result in hyper-vigilance, fear, and increased feelings of anxiety and depression. Preliminary findings from our HMS COVID-19 survey findings indicate that while approximately 20% of API students experienced discriminatory or hostile behavior due to their race or ethnicity as a result of the pandemic, over 65% of API students witnessed discriminatory hostile behavior or exchanges. Among API students who experienced or witnessed hate-incidents, 60% of these students screened positive for a mental health condition (depression, anxiety, eating disorder, suicidal ideation or non-suicidal self-injury), but only 36% reported seeking mental health treatment. It is now more important than ever to address this help-seeking disparity and strengthen mental health outreach and service delivery programs that support often overlooked APIs struggling with their mental health.
So what can be done? College settings present as a unique opportunity for early intervention and prevention. As part of my dissertation, I conducted focus groups with API students focused on mental health help-seeking barriers and facilitators. Several themes emerged that provides some clues into how we can address the help-seeking barriers in this population:
- One of the major discussion points was the invalidation of API mental health concerns across several different contexts. The first source often came from familial messaging surrounding the idea that mental health concerns are not authentic pain and not comparable to the immigrant burden that so many API students’ parents had carried. Another source of invalidation of mental health symptoms came from cultural messaging, and the conceptualization of the API experience compared to the historical oppression of other communities of color. As a result of this invalidation of mental health concerns, students reported the inability to identify mental health symptoms, which presented an obstacle to perceiving a need for treatment. If participants were able to perceive signs of mental illness, they were still unsure on what measures to take to address their symptoms. This points to a need for culturally-tailored psychoeducation, to de-stigmatize mental health concerns and teach students about various pathways to take to address mental health symptoms.
- The difficulty in perceiving a need for care also highlights the salience of increasing opportunities for screening and referral for API students, as well as expanding contexts for mental health gatekeeping and contact with providers. Collaborative care models may be an avenue to reach API populations, and potentially other hard-to-reach populations, by finding natural allies within campus structures, through the integration of mental health care into features of the campus infrastructure or combining campus health centers and campus counseling centers into a single space — removing that layer of stigma of going somewhere to solely seeing a therapist. This could also include reducing physical barriers by embedding mental health providers in structures frequented by students (such as departments, academic advising, or religious offices/chaplains). In the COVID-19 era, interventions involve physical spaces will be difficult if not impossible, but college campuses can be proactive through virtual or phone mediums to address mental health in combination with academics and physical health.
- Finally, my focus group participants described personal experiences with ways in which provider cultural competency served as a barrier to initiating and sustaining mental health treatment. We need more active recruitment of diverse and culturally-competent mental health providers could facilitate help-seeking, especially as mental health treatment avenues move online.
The racialization of COVID-19 has the potential to produce long-lasting effects on attitudes towards API populations. We need to recognize that APIs are not invulnerable to racism and discrimination-driven mental health problems, and that the model minority stereotype (which among many problems, aggregates and generalizes a very diverse group) upholds white supremacy by dismissing the historical and modern realities of marginalization again both amongst API populations and other people of color. Given the mental health challenges API populations are facing, it will be crucial to make an active effort towards resolving mental health treatment disparities already looming in our communities.
Sasha Zhou is a doctoral candidate in the Department of Health Management and Policy at the University of Michigan’s School of Public Health. Her research uses mixed methods to understand and address the mental health needs of emerging adults and college students of color, with particular focus on Asian Pacific Islander Desi Americans and international students. Sasha also currently serves as the Data and Analysis Manager of the Healthy Minds Network (HMN), a research-to-practice network dedicated to improving the mental and emotional wellbeing of young people through innovative, multidisciplinary scholarship. Upon graduation this summer, Sasha will join the faculty at Wayne State University as an Assistant Professor in the Department of Public Health.