Which ethnic group in the united states tends to use mental health services the least?

Even before the deadly Atlanta-area spa shootings in March, Asian Americans and Pacific Islanders (AAPI) had faced nearly 4,000 hate incidents since the pandemic began, a 149% rise over the previous year (Stop AAPI Hate National Report, 2021; Anti‐Asian Prejudice March 2020, Center for the Study of Hate & Extremism). Reported episodes range from verbal harassment, insults, and jokes—such as referring to COVID-19 as the “kung flu”—to violent attacks in schools, businesses, and other public spaces.

To meet the needs of AAPI communities, psychologists are looking beyond traditional therapy and operating outside academic and health care settings. They’re studying racist incidents, including their roots and outcomes, and designing interventions to help targets and bystanders fight back. Psychologists are even engaged at the policy level, urging cultural sensitivity in Congress and promoting legislation to tackle hate crimes.

“For the Asian American communities that are experiencing this, it just feels like an all-out assault,” said William Ming Liu, PhD, a counseling psychologist and chair of the Department of Counseling, Higher Education, and Special Education at the University of Maryland.

Early research has linked the uptick in anti-Asian discrimination to increases in anxiety, depressive symptoms, and sleep problems among those who are targeted. Getting help isn’t always straightforward. AAPI individuals are less likely to access mental health services than any other racial group, partly because of the cultural bias against it but also due to a lack of culturally relevant approaches to treatment (See more on the unmet need for mental health services in the April/May Monitor).

While psychologists are hopeful about the increased focus on the AAPI experience, they also say it won’t be easy to reverse decades of relative invisibility in the fight for racial justice.

“It’s almost as if the public just discovered that there’s anti-Asian bias, discrimination, and hatred in this country,” said Derald Wing Sue, PhD, a professor of psychology and education at Columbia University’s Teachers College. “What’s upsetting is that it took so much violence for people to take the discrimination seriously.”

Anti-Asian xenophobia in the U.S.

Anti-Asian xenophobia and bias in the United States dates back to the 19th century, when the Page and Chinese Exclusion Acts shut out would-be immigrants, and peaked during World War II with the forced incarceration of Japanese Americans. To this day, AAPI individuals face harassment rooted in that racist history, including the “perpetual foreigner” stereotype, which tags them as outsiders who will never be truly American (Armenta, B. E., et al., Cultural Diversity and Ethnic Minority Psychology, Vol. 19, No. 2, 2013).

“The notion that Asian Americans are foreigners and outsiders makes it easier for them to be seen as ‘reasonable’ targets where people can direct frustration, anger, fear, and aggression, including the spate of xenophobia and anti-Asian violence we have seen during this pandemic,” said Hsiu-Lan Cheng, PhD, an associate professor of counseling psychology at the University of San Francisco.

Another stereotype that contributes to ongoing anti-Asian bias and hate is the “model minority” myth, the idea that Asian Americans are unilaterally successful and well adapted because they are quiet, submissive, and hard-working. In fact, the stereotype was manufactured during the civil rights movement to weaponize Asian Americans against Black Americans, and it masks the diversity of the AAPI experience, said Sherry Wang, PhD, an associate professor of counseling psychology at Santa Clara University.

“It can also create the perception that Asian Americans are not considered to be people of color and that we are immune to racism,” Wang said. “Therefore, when people do speak up about it, our experiences are actually dismissed.”

In the incidents documented by Stop AAPI Hate, women were targeted more than two thirds of the time, pointing to more complex gendered stereotypes that also contribute to the current violence, said Sue, including the shooting deaths of six Asian American women in Atlanta.

“Asian American women have an image in this society as being exotic, sexually attractive, and domestically oriented,” said Sue. “It is very difficult to separate out an individual’s sexual proclivities from the way society sexualizes Asian women.”

Such stereotypes—and the discrimination and hate they fuel—cause physical and psychological distress. In a spring 2020 survey of 410 Asian Americans, 29% of participants reported an increase in discrimination. Those who faced discrimination were more likely to have problems with anxiety, depression, and sleep than those who did not. Lower levels of social support were also associated with worse physical and mental health (Lee, S. & Waters, S. F., Stigma and Health, Vol. 6, No. 1, 2021).

These problems are compounded by the fact that AAPI individuals are less likely than other racial groups to seek mental health treatment, including inpatient care, outpatient care, or prescription medications (Racial/Ethnic Differences in Mental Health Service Use Among Adults, Substance Abuse and Mental Health Services Administration, 2015).

“There’s a tendency to either underreport or not report at all and just hold onto those events, never having a chance to process them,” said Richelle Concepcion, PsyD, MPH, president of the Asian American Psychological Association (AAPA).

Current efforts to fight discrimination

Despite the barriers, psychologists are putting their expertise to work through creative research, interventions, and policy efforts.

Between May and October 2020, Wang collected data from more than 200 targets of anti-Asian harassment and hate through an open-ended survey on social media, where she asked questions about context, including who else was present, whether anyone intervened, and what sort of social support victims sought or received afterward.

“A lot of the data on anti-Asian racism tends to focus on perpetrator behavior, rather than the experience of the victim or even the witnesses,” Wang said. “By using a trauma-informed approach, we are focusing on the participant’s needs, which will hopefully reduce victim-blaming and contribute to more healing.”

So far, respondents to Wang’s survey have reported very low levels of bystander intervention—which is when a witness intercedes to thwart harassment—and social support, but Sue’s research suggests an antidote to that. After decades of studying racial microaggressions, he and his colleagues have identified four major anti-bias strategies that targets, allies, and bystanders can deploy when racist incidents occur in everyday life: educate the perpetrator, make the “invisible” visible, disarm the microaggression, or seek outside support and help.

For example, a common “invisible” microaggression is to laud an Asian American’s English proficiency—what appears to be a compliment is actually an insinuation that the target is not a true American. Sue replies: “Thank you, I hope so. I was born here,” which calls attention to the statement’s xenophobic subtext. In another instance, a target or bystander might “disarm” a racist joke by interrupting to say they do not want to hear the punchline. (American Psychologist, Vol. 74, No. 1, 2019).

“Microaggressions do not occur in isolation from others. If no one intervenes, it fosters a false consensus—that it’s OK to make racist comments or jokes,” Sue said. “It should not be the sole responsibility of targets to deal with these everyday slights.”

Sue and his colleagues also found that targets who intervened felt an increased sense of empowerment, health, and well-being, while bystanders who intervened felt that they were staying true to their moral values.

In addition to intervention by bystanders—especially White allies, who can be particularly effective because they are part of a dominant social group—other people of color can help bring awareness to the AAPI experience, says Wendi Williams, PhD, president of APA’s Div. 35 (Society for the Psychology of Women) and dean of the School of Education at Mills College in Oakland, California.

“BIPOC folks know what being targeted because of our race feels like, and we also know how empowering it is to have others join our fight,” she said. “Realizing dignity, safety, and respect for all people is our shared struggle.”

The campaign for allyship has reached the highest level of U. S. government, where Judy Chu, PhD, a psychologist and representative for California’s 27th congressional district released a toolkit to encourage culturally sensitive rhetoric around COVID-19. For instance, the toolkit recommends that lawmakers make statements about specific actions taken by the Chinese government, rather than repeating the term “Chinese virus” or other xenophobic slurs. Chu is also backing the NO HATE Act to give local law enforcement more resources to stop hate crimes and has called for a national awareness day for anti-Asian hate.

“There is so much we can do, but healing the damage will take a societal change,” she said. “We need to stop treating people of color as others and tear down the divisions between us that create isolation and mistrust.”

Opportunities for impact

To further maximize their impact with AAPI communities, psychologists should focus on interventions that may carry less stigma than one-on-one therapy, such as psychoeducational workshops and support groups, said Cheng. They can also collaborate with community leaders—peer counselors and grassroots organizers, for instance—on mental health advocacy and anti-stigma campaigns. For example, AAPA is collaborating with Asian American immigrant organizations in Northern California to provide guidance on delivering trauma-informed care and culturally adapted services.

Future research efforts should continue to explore new approaches to mental health care that may be more culturally relevant to various AAPI groups. Cheng adds that more work is needed to understand the effects of increasing incidents of online racism, particularly on youth and young adults, who are highly vulnerable to the negative effects of racism on mental health and identity development (Journal of Interdisciplinary Perspectives and Scholarship, Vol. 3, No. 3, 2020).

“The pandemic has showcased inequities—like anti-Asian racism and the racialization of infectious disease—that have existed for a long time in our country,” Wang said. “Now that we know that ‘business as usual’ is racist, what are we going to do about it?”

What is the name of the process by which an individual becomes a member of a particular culture?

What is the name of the process by which an individual becomes a member of a particular culture and takes on his values beliefs and behaviors?