Perceptions of Mental Illness and Rehabilitation Services in Chinese and Vietnamese Americans
By Hampton, Nan Zhang Yeung, Teresa; Nguyen, Courtney Hoa
Abstract – The purpose of this study was to explore perceptions of mental illness (MI) and rehabilitation services among Chinese and Vietnamese Americans. A qualitative study design (face-to-face interview) was used and 40 Chinese and Vietnamese Americans/ immigrants participated in the study. Results indicated that the participants’ views of MI were multifaceted. The major themes included: (a) MI was a treatable disease that consisted of different types and varied from mild to severe; (b) the major cause of MI was stressful circumstances such as the Vietnam War and immigration; (c) MI was not positively perceived in the participants ‘ communities; and (d) rehabilitation counseling services were almost unknown to the participants although some of them were aware of mental health services. Implications of the results for rehabilitation counselors and researchers are discussed in light of the impact of Chinese and Vietnamese cultures on the perceptions of various aspects of MI. The study of the public perception of mental illness (MI) has a long history in the field of psychiatric rehabilitation. A body of research has found that negative perceptions or stigmatizing attitudes exist towards MI (Angermeyer, 2006; Corrigan & Penn, 1999; Fabian & Edwards, 2002). According to the literature, people with psychiatric disabilities (PWPD) constituted a large proportion of the clients served by the federal-state rehabilitation system and diey had difficulties obtaining equal access to education, employment, health care, and social involvement (Diksa & Rogers, 1996; Fabian, 1990; Garke & McReynolds, 2005; Hand & Tryssennaar, 2006; Kirsch, 2000; Tsang, Lam, Ng, & Leung, 2002). Although attitudes toward PWPD are improving, the primary source of the difficulties encountered by PWPD is still the public’s negative attitudes rather than the person’s mental limitations (Fabian & Edwards, 2002; Garske & Stewart, 1999; Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999). In order to improve PWPD’s access to educational, employment, health care and rehabilitation services, it is crucial to continue investigations regarding the perceptions of MI in the public in order to foster a positive change in attitudes.
Previous studies revealed that perceptions and beliefs about MI were related to various demographic variables such as age, gender, education, and the degree of contact that people had with PWPD (Bhuga, 1989; Gill, Murphy, & Birkmann, 2005). Individuals who were younger or female, had more education about MI, and had more contact with PWPD were more likely to have positive perceptions of MI and favorable attitudes toward PWPD compared to those who were older or male and had less education and less contact with PWPD (Bhuga , 1989; Gill, Murphy, & Birkmann, 2005).
In recent years, more studies have focused on the influence of culture on perceptions of MI. Although limited, the literature suggests that, in several countries with a considerable number of immigrants, people from Western cultures tended to have more positive perceptions of MI than those from non-Western cultures (Cinnirella & Loewentiial, 1999; Fan, 1999; Furnham & Chan, 2004; Li & Browne, 2000). Within the U.S., findings of previous studies revealed that perceptions of PWPD varied from one ethnic group to another with Whites having the most favorable attitudes and Asian Americans having the least favorable attitudes (Saeteremoe, Scattone, & Kim, 2001; Shokoohi-Yekta & Retish, 1991; Whaley, 1997). For example, Asian American college students were more likely to stigmatize physical and mental disabilities and had greater desire to distance themselves from those with disabilities than African Americans, European Americans, and Latin Americans (Saetermoe et al., 2001). At the same time, Asian Americans with psychiatric disabilities were under-represented among those enrolled for services with rehabilitation and mental health agencies (Chen, Jo, & Donnell, 2004; Hampton, 2000; Lin & Cheung, 1999; Matsuoka, Breaux, & Ryujin, 1997).
Previous researchers have attributed the negative perceptions of MI and the under utilization of rehabilitation services to culture- related health beliefs and a lack of knowledge or suspicion of government services (Loo, Tong, & True, 1989; Luk & Bond, 1992; Saetermoe et al., 2001). They postulated that Asian Americans’ views of the causation of MI might be largely influenced by Eastern philosophies (e.g., Confucianism) and religions (e.g., Buddhism and Taoism). For example, Buddhists believe that the karma of past existence determines the present state as a corresponding consequence. From this perspective, having mental illness may be viewed as an indication of the past wrong-doing by the person or his or her ancestors (Loo, Tong, & True, 1989).
Despite these promising findings, in-depth knowledge of the perceptions of MI in Asian Americans is still lacking. Most of the published studies on attitudes toward MI or PWPD have used a survey method. In these studies, questionnaires were used and participants were requested to give their responses by choosing a number on a Likert scale or a rating scale. Although the survey method has many advantages, it may limit the expressions of respondents. On the other hand, a qualitative research method is a valuable approach for gaining insight into the plight of Asian Americans regarding their views of MI. A thorough search of several databases (PsycArticles, Psyclnfo, Medline, and Social Sciences Citation Index) located a few studies that investigated the meaning of MI as perceived by Asian Americans.
Tatman (2001) interviewed 19 Hmong adults with at least a college education residing in the Midwest and found two perspectives (traditional and biological) regarding their attitudes toward causation of disability. The study also found that, regardless of the acknowledgment of biological origins of disabilities, all participants were influenced by traditional belief, in which disability was perceived as a punishment by God for sins (Tatman, 200 1 ).
Using a semi-structured individual face-to-face interview method, Soonthomchaiya and Dancy (2006) investigated perceptions of depression among 20 elderly Thai immigrants (60 years old or older) in the U.S. They found that the causes of depression as reported by the participants were stress-related (e.g., family tensions, work problems, and losses). Although the symptoms of depression reported by the participants shared some similarities (e.g., social isolation, dissatisfaction, and negative thoughts about oneself) to those reported in the Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR) published by the American Psychiatric Association (2000), participants tended to somatize depression (e.g., instead of saying “I am depressed”, the participants tended to say “I feel pressure on my heart”). The investigators attributed the differences to the stigmatization of depression in Thai culture.
It seems that traditional cultural beliefs regarding MI played a role in the conceptualization of MI among the participants in these two studies. However, these studies used a small sample from two Asian ethnic groups (Hmong and Thai) in one geographic area (Midwest), and the findings of the studies may not be generalized to other Asian ethnic groups in the U.S., particularly as Asian Americans consist of many ethnic groups (Chen et al, 2004). In certain geographic areas such as California, Massachusetts, New York, and Texas, Asians constitute a considerable proportion of the total population (US Census Bureau, 2006). An examination of Asian subgroups revealed that the percentage of individuals with disabilities was as high as 1 3% among the Vietnamese population and many of them had psychiatric disabilities (Cho & Hummer, 2001). Because cultural perceptions of MI may have dramatic consequences for stigmatizing, help seeking, and rehabilitation, a vital role for rehabilitation counselors is to continue exploring perceptions of MI among different Asian American groups.
The purpose of the present study was to explore perceptions of mental illness and awareness of available rehabilitation and mental health services among Chinese and Vietnamese Americans. Specifically, data were sought on the thoughts of participants about (a) what is health, (b) what is MI, (c) what causes MI, (d) what impact does MI have on the life of the person and his or her family, (e) what strategies are used to cope with MI, and (f) what formal and informal services/support can a Chinese/Vietnamese with MI obtain. These two Asian ethnic groups were selected because (a) Chinese was the largest ethnic group among Asian Americans, (b) Vietnamese Americans had a high prevalence of MI, (c) both groups were reported as having negative attitudes toward PWPD, (d) there were relatively large Chinese and Vietnamese enclaves in the area from which the sample was drawn, and (e) each ethnic group had its unique culture.
Method
Participants Participants in this study were 40 Chinese/ Vietnamese Americans/Immigrants from the New England area in the U.S. The criteria for participation required that an individual (a) was 30 to 65 years old; (b) was a Chinese/Vietnamese American/ immigrant; (c) had lived in the U.S. for less than 20 years; and (d) did not have a disability. A purposive sampling method was used. Participants were recruited through multiple sources, including Chinese/Vietnamese organizations, English classes for immigrants in Chinese/Vietnamese communities, Buddhist temples, and churches.
Of the 20 Chinese participants, 20% were males and 80% were females. Their age ranged from 32 to 64 years old with an average age of 46 years old (SD = 8.72). All participants spoke Chinese at home. About 35% of the Chinese participants self-identified as Chinese Americans and 65% self-identified as Chinese. Of the 20 Vietnamese participants, 40% were males and 60% were females. Their age ranged from 30 to 65 years old with an average age of 46 years old (SD = 10.73). Vietnamese was the language spoken at home for all Vietnamese participants except one who spoke English with her husband at home. About 35% of the Vietnamese participants self- identified as Vietnamese Americans and 65% self-identified as Vietnamese.
Table 1 describes the background of the sample.
Instrument
A research protocol form was developed. The protocol contained (a) an introduction about the study, (b) demographic information, and (c) 10 open-ended questions. In the introduction section, we emphasized that there might be many different opinions about MI, and we asked the participants to tell us how they think or feel about the illness honestly. The demographic section yielded descriptive information such as age, gender, education, etc. (see Table 1). The 10 open-ended questions asked the participants to discuss their views of MI and they are provided in Figure 1 . The interview protocol ended with a statement that asked the participants to add anything they would like to say and thanked them for their participation in the study.
Figure 1. Open-Ended Interview Question.
Expert panel review was used to address the validity of this interview protocol. Four experts with doctoral degrees in counseling psychology or related fields reviewed the protocol and confirmed that the protocol was consistent with the purposes of this study. Suggestions from the experts were incorporated. The interview protocol was translated into Chinese and Vietnamese via a back translation method (Brislin, 1980). Initial interviews were conducted with six interviewees (three from each ethnic group). This ensured that interview questions were relevant and would elicit exactly the kind of information desired.
Procedure
After obtaining approval from the Institutional Review Board, the research team recruited participants from various sources as identified earlier. Once a participant was identified, an appointment was scheduled for a face-to-face interview at a location chosen by the participant. Snowball sampling (Polit & Hungler, 1 999) was also used as participants who were interviewed identified further potential participants.
At the beginning of the meeting, participants signed a written consent form before the interview began. The language used during the interview was determined, in advance, according to the participant’s preference. Of the 40 interviews, 20 were conducted in Chinese (Cantonese), 1 1 were conducted in English, 9 were conducted in Vietnamese. All interviews were audio-taped. Each participant received $15.00 honorarium for their participation.
Data Analysis
Audio taped interviews were transcribed verbatim. The non- English transcripts were translated into English for data analysis. To ensure that the meaning and spirit of the answers were reflected in the translation, the researchers and their assistants went through each item with back translations. Each transcript was analyzed by two investigators. First, each investigator read the transcripts line by line and word by word independently. Responses that identified attributes of a phenomenon within a sentence or paragraph were coded by categories and subcategories (Miles & Huberman, 1 994). Summary response statements were provided for each category and subcategory. After independently coding the data, the investigators compared their coding of the responses. The inter- rater reliability between the two investigators was 96% using a percent of agreement method. In addition two steps were taken to assure validity and reliability of the study. First, a data triangulation (the use of a variety of data sources such as transcripts of interview session and field notes) was used to examine the materials. Second, peer debriefing was used to test the investigators’ insights against an uninvolved peer (Lincoln &Guba, 1985).
Results
Conceptions of Health
Content analysis revealed two themes: Physical and mental/ psychological health. The physical perspective included appearance (e.g., the person looks fit), free from diseases such as pain, heart problems, high blood pressure, cancer, diabetes, etc., and being able to go to school or work. The mental/psychological perspective included: appearance (e.g., grooming and dressing oneself appropriately), being able to think clearly, free from abnormal behaviors, free from worrisome thoughts, having good memory, being socialized with others, and being happy. However, participants tended to link physical health with mental health. For example, they stated that depression could be related to chronic illnesses such as cancer. The following statement of a participant illustrates this belief: “In my opinion, health can be considered mental and physical. The physical aspect is illness free. The mental aspect is hard to define. I would first consider the person’s life style and eating habit, and then, the connections between the eating habit/ life style and emotional issues.”
Conceptions of MI
Five major themes emerged from the content analysis. First, all participants described MI as “abnormal” or “not healthy”. They stated that PWPD might have some “abnormal” behaviors such as “forgetful”, “very anxious”, “outbursts of temper”, “sudden laughter”, “crying a lot”, “having flashbacks or nightmares”, etc. Second, all participants agreed that MI was not perceived favorably in their communities and cultures. They commented: “It is not good to have MI in the Chinese culture. Chinese people are very reserved and they would take MI as a shame. They would rather hide it.”"I tend to think more about the culture… Uh… Vietnamese people in general view (MI) as shameful and they don’t want to talk about it and they are afraid of talking about it because it’s a big stigma that they have to overcome …” However, some participants noticed that there was an age difference in attitudes toward MI between younger and older generations. They reported that younger Chinese/ Vietnamese Americans had more positive attitudes toward MI. An example comment includes: “In this (young) generation, they probably understand and accept MI, but for older people, it is hard, they still deny.”
Third, many participants pointed out that in their home countries (China or Vietnam), depression would not be regarded as a type of MI but they knew it would be considered to be in the U.S. This theme was well illustrated by the following examples: “I think the definition about MI in the U.S. is different from Vietnam.”"Over here, (if a person is depressed) it counts as MI but in Vietnam, if you are depressed, that is not MI. Sometimes, they just have suicidal thoughts. People in our community do not count that as MI.”
In addition, there were some differences in the views of symptoms among participants. Some emphasized that MI was a “deficiency in the state of mind” or a type of “thought disorder”. They stated that the person who had MI could not think clearly and might be delusional or obsessive about unsolvable problems. Here is an example: “MI is the loss of control of oneself. It is about the spirit and mind … the way the brain works and distorted thoughts.” Others described MI as feelings of loneness, disappointment, sleeplessness, and suicidal thoughts. They commented: “MI means feeling sad and depressed, not wanting to go out or wanting to kill herself or end her life.”
The fourth theme reflected the fear of PWPD among the participants. On the one hand, many participants agreed that “there were different types of MI” and “mild MI would not result in violent behavior”. On the other hand, some participants believed that MI made people do violent things. They commented “MI is people doing things such as using drugs and hurting others.” Still, others had concerns about being attacked by PWPD, even though they recognized that not all PWPD would have violent behavior. The following statement of a participant illustrates this belief: “If I have to have interaction with the person, I would be very cautious. I think some people with MI are dangerous and some are not. At least I would remind myself about that because I do not want them to attack me.”
Participants also emphasized that their relationships with PWPD would make a difference in the way they respond. If the person with MI is a stranger, they would be very cautious and try to avoid the person. However, if the person is their family member or close friend, they would give a lot of love and help. They would suggest that the person see a doctor and they would get all the help they could for the person. The participants said that they might share the person’s situation with other family members, relatives, or friends if they needed help or support, but they would not tell a stranger about the person’s condition. When they tell others about the person’s situation, they would use the word “emotional problems” or “short temper” rather than mental illness. Here is an example comment: “This is a family member regardless what happened. People outside of the family may exclude him or her, but not the family.”"I would only mention that the person is not feeling well lately, but not necessary to mention what it is. It is inevitable to take care of this person if the person is in the immediate family. I would give this person more love and care, and encourage this person to confront the problem and use medications to help.” The fifth theme was about the curability of MI. All participants stated that MI was “treatable with medications” although they disagreed on whether MI was curable. Some participants believed that MI was “100% curable.” Others stated that MI “could be treated but would never be cured.” Still, others said that “some types of MI could be cured but other types would not.”
It was interesting to note that some of the participants formed their views of MI from reading or watching news in the newspapers and on the TV. They never had any direct contact with PWPD. The following comment illustrates it well: “I am sure they are different from normal people. They would be confused. You can tell they are different than normal people by their eyes, movements, and behaviors. They might beat up others, throw things around, and yell and scream. You can see it on the news that they slaughter their own family.”
Causes of MI
The causes of MI identified by the participants could be categorized as (a) stressful circumstances in a person’s life; (b) a genetic or inherited problem; (c) personality (e.g., “a tendency to drill into things”), (d) lifestyle, and (e) consequence of misdeeds in one’s previous lives. All participants identified stressful circumstance in people’s life as the main cause of MI. For the Chinese participants, the stressful circumstance included: (a) immigrating to the U.S. and having problems adjusting to a new environment due to language and cultural differences; (b) family problems such as spousal infidelity, abusive relationships, generation gaps, etc.; (c) employment or financial problems such as being unable to find decent jobs to support one’s family; (d) pressure from work such as competition among coworkers and demands from supervisors; and health problems such as having a chronic disease (e.g. cancer).
For the Vietnamese participants, the most salient stressful circumstance which separated them from the Chinese participants was having experienced the Vietnam War and its aftermath. Almost all the Vietnamese participants regardless of age and gender talked about the Vietnam War and its impact on their lives. Other stressful circumstances identified by the Vietnamese participants were similar to those identified by the Chinese participants.
Here is an example comment: “There are so many reasons, the first is the war even if we did not witness the war because of (our) age but the older generation did. The second reason is the move to another country and it’s not your country . . . everything changed. You have to try to adapt to the new lifestyle, the new living situation. This creates some distress and especially when you do not speak the language, kind of discriminate yourself from many activities and it turns you to feel like you are useless and it creates a depression …”
About 20% of Chinese participants and 25% of Vietnamese participants agreed that MI could be caused by genes inherited from parents. They commented: “It (MI) can be a hereditary … on either side of the family, on the paternal or maternal side of the family”. A few participants believed that personality, lifestyle, and punishment for past wrong-doing were causes of MI. For instance, about 15% of Chinese participants and 10% Vietnamese participants stated that some people might be prone to depression because they “think/worry” too much and “lack of a strong will”. Here is an example of the comments: “It (MI) is related to personality if the person has the tendency to drill into things, or if the person has a quiet and pessimistic personality which is more prone to depression.” About 5% Chinese participants and 10% Vietnamese participants believed that a person’s lifestyle contributes to MI (e.g., hanging out with the wrong people such as drinkers, gamblers, and drug abusers). Only one participant stated that having MI might result from mistakes made in past life.
Impact of MI on the Life of the Individual and Family
Some participants had relatives or friends with MI or had contact with PWPD through work. They discussed the impact of mental illness on PWPD and their families based on their experiences or observations. Others had no prior contact with PWPD, they talked about the impact of MI based on what they had heard from others or seen in the newspapers or on TV.
Most participants talked about the negative effects of MI and did not believe any positive effects could emerge from having a MI. A theme that frequently occurred was that having a MI would be a burden to one’s family. Almost all participants mentioned the issue of burden during the interview. Another belief that many participants held was that PWPD would not be able to work, though some of them stated that “some (people with MI) could work and get married and others cannot, depending on the severity of the illness.” Those who did not think that PWPD could work commented that “if I am a hiring agency, people with MI will be the last persons I would look for. They cannot even help themselves, what make you think that they are able to do work for the company?”
Other negative effects perceived by the participants included: being unable to pursue education and get married; losing jobs and social life; tarnishing the reputation of the family; affecting siblings’ ability to get married; and hurting the family’s relationships with neighbors. They said: “Everyone would be worrying about this person hurting himself/herself or not capable of taking care of him or her self.”"It will hurt the reputation of the family because the others will prevent their children from getting contacts with this person.”"People would criticize and gossip if they get to know there is one with MI in a particular family.”"This would result in a not-so-good relationship with the neighbors.”"No one would want to marry someone with MI. One reason is because it is hereditary.”
Several participants identified some positive influences of having MI. These included that the illness may: bring the family closer, assist the individual to develop coping strategies, help the individual obtain medical benefits such as Medicaid that otherwise would not be available, remind others to pay attention to their mental health, inspire doctors to find treatment if a lot of people have it, and raise concerns of the community to try to solve the problem. The following comments illustrate these beliefs: “It could have some positive impacts such as increasing love and care between family members.”"People compensate their suffering by finding advantages within that suffering. If the person is forgetful, the person may find a way to organize things and to make themselves improve their memories.”"Family is more aware of the potential development of MI and crisis. They would give more attention to these individuals and encourage them to get involved with healthy group activities.”
Coping Strategies
The major theme that emerged from the interviews is to get treatment. All participants reported that they would go to see a doctor for treatment if they had a family member or relative with MI because they believed that MI was a disease that needed to be treated with medications. Few of them mentioned going to see a psychologist or other mental health professional. Other coping strategies included: avoidance (“not to think about it and focus on work”), accepting the fate (“it already happened so do the best you can to help and support that person”), be patient with the person who has MI, searching for better treatment, giving a lot of support, care, and love to the person with MI, taking responsibility for getting treatment, going to church or temple for spiritual relief, keeping a positive view (“there is no irresolvable problem in the world”), and cultivating interests in music, reading, and travel.
Perceptions of Government and Community Services
Although some participants mentioned getting help from churches, temples, local ethnic organizations (e.g., the Asian Task Force and the Vietnamese Civic Association), or Goodwill Industries Inc., the majority of them were not aware of any non-governmental support or services in their communities. Those who knew the local ethnic organizations or Goodwill Industries Inc. were eitiier the employees of these organizations or their office was next to the Goodwill Industries Inc. On the other hand, about 50% of the participants indicated that PWPD could get help from state mental health hospitals or health clinics where they had bilingual staff members. Only a few of them mentioned state rehabilitation agencies as possible resources for PWPD.
The majority of participants reported a favorable attitude towards government agencies. They described government agencies as “not bad”, “pretty good”, “helpful”, and “better than in China or Vietnam.” Despite these favorable feelings about governmental agencies, participants also pointed out that there were not enough services or outreach programs for Chinese and Vietnamese Americans and the lack of culturally appropriate programs made them feel that they were abandoned by the government. Here are some examples of comments: “Most Chinese people including myself do not know what government services are available to us because of a language barrier.”"I hope the service agencies will outreach to the people in need of services and welcome them, not to wait for them to come to the door. So the community can get to learn about the services.”
Discussion
Results of this study indicated that the participants tended to have a holistic view of health. Although they distinguished physical health from mental health, they tended to link these two aspects together and believe that the former was the cause of the latter. As previous researchers pointed out that the arbitrary distinction between mind and body was lacking in many Asian cultures (Ng, 1997), the results of the present study seemed to support this statement. Findings of the study also revealed that the participants’ views of mental illness were multifaceted. Their perceptions of MI covered various aspects from the symptoms, behaviors, severity, and curability of the illness to the favorability of the illness in their communities. Although the Chinese participants differed from the Vietnamese participants in terms of gender, years of education, and years of living in the U.S., there are many commonalities in their view on MI. Many of the symptoms of MI they identified (e.g., delusion, flashbacks, insomnia, and suicidal ideation) were similar to those reported in DSM-IV-TR (American Psychiatric Association, 2000), indicating that their perceptions of symptoms of MI were in line with the diagnostic criteria of the APA. Many participants were aware that there were different types of MI and depression was one type of MI recognized in the U.S. However, some of them may not accept that depression is one type of mental illness as indicated by their definitions of MI. These findings were consistent with previous investigations that found Asian Americans possessed some knowledge of MI but tended to separate depression from other types of MI (e.g., schizophrenia) (Chang, 1985; Soonthornchaiya & Dancy, 2006)
Congruent with previous findings (Saeteremoe et al., 2001; Shokoohi-Yekta & Retish, 1991; Whaley, 1997), participants in the present study reported that MI was not positively perceived in their communities and that negative views were usually associated with a sense of shame. In the present study, the sense of shame appears to be linked to several concerns. The most frequently mentioned concern was having a mental illness would make the person a burden to the family. The second concern was that it would tarnish the reputation of the family and affect other family members’ opportunity to get married due to the hereditary nature of the illness. The third concern was related to the belief of being punished for past wrong doing of oneself or one’s ancestors.
These concerns may have their roots in the Chinese and Vietnamese cultures which emphasize in-family sharing of material and nonmaterial resources, pride and shame, and family harmony. Since everyone in the family has a responsibility to make the family proud, failures in school, work, and marriage or misbehavior in the public would be considered an embarrassment, shame, and loss of face to the entire family. On the odier hand, the participants pointed out that they would not abandon a family member with MI and would give more love, care and support to the person. These statements were in line with the principle of “Ren” which is one of the major principles of Confucian’s philosophy that guides the behaviors of many Chinese and Vietnamese. “Ren” means goodness, benevolence, humanity, and kind heartedness. Related concepts include respect and consideration, reciprocity, neighborliness, and love. Similarly, the coping strategies suggested by the participants could also be interpreted from the cultural perspective. For instance, in the eyes of many Chinese and Vietnamese Americans/immigrants, endurance and patience are considered good virtues that could enable better handling and overcoming the hardships of life and that lead one to achieve goals in life. Having MI can be seen as a test for one’s ability to endure “bitterness” or “suffering”. The way to deal with the hardship, as indicated by the participants, was to accept the fate and be patient.
With regard to the perceived causes of MI, this study found a unanimous agreement (among the participants) about the role of stressful circumstances in the development of MI. The findings are consistent with Link et al’ s (1999) study on the general population in the U.S. In contrast to Tatman’s (2001) study, only one male Vietnamese participant (61 years old) in the present study linked MI to punishment for past wrong-doing of the person or his or her family. A possible explanation for the difference between the two studies is that all the participants in the present study were immigrants and experienced many stressful situations during the process of immigration. The salience of the immigration experiences might cause them to attribute MI to stressful circumstances rather than to an internal source. For instance, the experiences during the War and its aftermath played an essential role in the Vietnamese participants’ views of the causes of MI as all of them identified the War experience as the major cause of mental illness.
Consistent with Link et al ‘s (1999) studies, the present investigation found that the stereotype of PWPD being dangerous was still popular among the participants. This stereotype is somehow related to the mass media rather than personal contact with PWPD, indicating a need to reexamine the role of mass media in fostering stigma toward mental illness and discrimination against PWPD. It should be noted that participants who had a close relationship (e.g., sibling) with PWPD or had prior contact with PWPD tended to have less concerns about violent behaviors of PWPD. This is congruent with previous research that reported direct personal contact would reduce the fear of PWPD in the public (Corrigan & Penn, 1999).
Previous studies indicated that Chinese and Vietnamese Americans/ immigrants would seek help in their communities rather than professional services to treat mental illness (Leong, 1986). However, results of the present study did not seem to support this notion. AU participants indicated that they would seek help from a doctor immediately if they had a family member with MI. Very few participants were aware of non-governmental services provided in their communities. Many of them stated that they would tell other community members about their loved one with MI only if these people were trustworthy and willing to help. Why did the participants choose professional help rather than assistance from their own community? The possible explanation is that they may feel more comfortable talking to a doctor who has no connection with their own community rather than dislosing the issue to someone from their own community due to fear that the disclosure would tarnish the reputation of their family. One participant’s comment illustrates this fear well: “The Vietnamese sometimes do not want to talk to anyone besides the doctor because in the Vietnamese community, confidentiality is nothing . . . nothing. Your business is my business. So, if something happened in your family, I have to know about it and then half an hour later, everybody in the community will know”.
It is important to note that the perception of MI in the Chinese and Vietnamese communities was gradually improving in the attitudes of the younger generation. As reported by the participants in this study, the younger Chinese/Vietnamese Americans had a better understanding of MI and were more accepting of PWPD than the older generation. This finding was in concert with the national trend and may be the result of public efforts to reduce stigma toward mental illness (Corrigan & Penn, 1999). Since younger Chinese and Vietnamese Americans have English proficiency, they may have better access than the older gen- eration to national, regional, and school educational programs on MI, which in turn, might increase their awareness of the illness. Another finding that is worthwhile to note is some participants recognized that MI might bring some positive changes at both personal and societal levels. This finding is very encouraging and is another indication that the attitude of the Chinese/Vietnamese Americans toward mental illness is gradually moving in a positive direction.
Implication for Rehabilitation Counselors
Findings of the present study have several implications for rehabilitation counselors. First, many participants seemed to have some faith that government agencies could help them if they had a family member with MI. This belief could serve as a foundation upon which a trusting relationship could be established between rehabilitation counselors and Chinese/Vietnamese clients. Rehabilitation counselors need to encourage this belief by providing appropriate services. Given that many participants were not aware of rehabilitation services, rehabilitation counselors need to inform Chinese and Vietnamese communities about rehabilitation service systems through existing social services such as English as a Second Language classes, ethnic health clinics, Buddhist temples, and churches that serve Chinese and Vietnamese Americans. This information should be available in a brochure and translated into Chinese and Vietnamese languages. In addition, rehabilitation agencies may need to hire or train more bilingual and bicultural counselors.
Second, the Chinese and Vietnamese participants identified “accepting the fate” as one of the coping strategies. This “going with the flow” or “making peace with the fate” may have both positive and negative consequences. On the one hand, this kind of belief may encourage Chinese and Vietnamese Americans to accept the illness and develop coping strategies and self-reorganization. On the other hand, the belief may prevent them from taking actions to restructure an unfavorable or injustice environment. Rehabilitation counselors may facilitate this acceptance by helping clients and their family members develop strategies and build persistence to cope with the illness. At the same time, the message on acceptance to the illness will need to be delivered with caution so passive acceptance is not encouraged. Third, the results of the present study suggest that Chinese and Vietnamese Americans might be lacking knowledge of MI and might therefore rely on mass media, which often uses stereotypes of PWPD for information. It should be noted that younger Chinese/Vietnamese Americans with English proficiency may obtain information about PWPD or MI from the mainstream mass media. However, older Chinese/Vietnamese Americans with limited English proficiency often read newspapers/magazines or watch TV programs in their native language. Whether the news or TV programs are solely for entertainment, the themes and content of the newspapers/TV programs are more likely to reflect negative views of MI and stereotyped PWPD. In order for Chinese/Vietnamese Americans to make positive changes in attitude, they must have access to accurate information on PWPD. Rehabilitation agencies and counselors may need to work on educating society about mental illness as well as the promoting awareness of how media stereotypes may negatively affect the well-being of PWPD. This can be done by continuously providing the mass media with accurate information about people with psychiatric disabilities, and by correcting mis-information when it occurs.
Also, education about MI and the benefits of professional treatment for PWPD and their family is crucial in the successful delivery of rehabilitation services. Rehabilitation agencies/ counselors may need to reach out to offer MI education workshops in the Chinese and Vietnamese communities. Given that many participants did not think PWPD could work, the education workshops may invite PWPD to talk about their employment experiences. Rehabilitation agencies may encourage their bilingual counselors to write about PWPD, and publish articles in local Chinese or Vietnamese newspapers. They may set up booths to talk about services for PWPD at the celebration ceremonies during the Lunar New Year or other Chinese/Vietnamese festivals. The MI education programs may also be broadcasted through local Chinese or Vietnamese TV or radio programs if they are available in the area.
Finally, when working with Chinese or Vietnamese clients with MI, rehabilitation counselors may want to secure consent from the clients to involve their family members in the rehabilitation process and form alliances with the family members. When possible, maximum support should be provided to the family as the participants of the current study expressed that they would do their best to help family members with MI.
Implications for Research
Turning to the implications for research, the differences in stressful circumstances found between Chinese and Vietnamese participants point to the importance of conducting investigations on specific Asian groups. Future studies may investigate how these stressful circumstances affect Chinese and Vietnamese Americans, respectively. Also, rehabilitation researchers may explore how other agencies and professionals (e.g. mental health professionals) reach out to the Chinese and Vietnamese communities, given that many participants in the present study were aware of mental health services in their communities but only a few of them were aware of rehabilitation services. In addition, the results of the present study revealed that direct personal contact might facilitate positive changes of attitudes toward PWPD. Future research may investigate the mechanism of attitudes change in this context.
Limitations
Several limitations to the present study should be acknowledged. First, this study employed a purposive sam- pling method. The participants were recruited from one geographic area and they had lived in the U.S. for an average of 10 or 13 years. Their experiences of living in a metropolitan area in the U.S. might have an impact on the views that were expressed; thus generalization of the findings is limited. Second, we used percent agreement between the two raters in the data analysis. Although this method is appropriate and frequently used in a qualitative data analysis, it tends to overestimate rater agreement. The results of the study, therefore, should be interpreted with caution.
Summary
The present study provided preliminary insights into the perception of mental illness among Chinese and Vietnamese Americans/ immigrants. Although the image of MI and PWPD perceived by the participants still reflected stigma or stereotype, there were some positive changes shown in the participants’ perceptions. The study also shed light on the Chinese/Vietnamese Americans’ perceptions of government and community services. Both positive and negative perceptions of government services were reported, suggesting that there is still a long way to go for government agencies to reach out to these populations. Rehabilitation counselors can play a major role in facilitating attitudes change through advocacy for PWPD, education for the general public, and out-reach to the local Chinese/ Vietnamese communities.
References
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4 ed.). Washington, DC: Author.
Angermeyer, M. C. (2006). Public beliefs about and attitudes towards people with mental illness: A review of population studies. ACTA Psychiatrica Scandinavica, 113, 163-179.
Bhugra, D. ( 1 989). Attitude toward mental illness: A review of the literature. ACTA Psychiatrica Scandinavica, 80, 1-12.
Brislin, R. W. (1980). Translation and content analysis of oral and written materials. In H. C. Triadis, & G. W. Berry, Handbook of cross-cultural psychology (pp.398-444). Boston: Allyn & Bacon.
Chang, W. C. (1985). A cross cultural study of depressive symptomatology. Culture, Medicine, and Psychiatry, 9, 295-315.
Chen, R. K., Jo, S., & Donnell, C. M. (2004). Enhancing the rehabilitation counseling process: Understanding the obstacles to Asian American’s utilization of services. Journal of Applied Rehabilitation Counseling, 3J(I), 29-35.
Cho, Y., & Hummer, R. A. (2001). Disability status differentials across fifteen Asian and Pacific Islander groups and the effect of nativity and duration of residence in the U.S. Social Biology, 48, 171-195.
Corrigan, P. W., & Penn, D. L. (1999). Lessons from social psychology on discrediting psychiatric stigma. American Psychologist, 54, 765-776.
Cinnirella, M., & Loewenthal, K. M. (1999). Religious and ethnic group influences on beliefs about mental illness: a qualitative interview study. British Journal of Medical Psychology, 72, 505- 524.
Diksa, E., & Rogers, E. S. (1996). Employer concerns about hiring persons with psychiatric disability: Results of the employer attitude questionnaire. Rehabilitation Counseling Bulletin, 40, 31- 44.
Fabian, E. S. ( 1 990). Quality of life: A review of theory and practice: Implications for individuals with long-term mental illness. AeAabilitation Psychology, 35, 161-170.
Fabian, E. S., & Edwards, Y. V. (2002). Psychiatric disabilities: A 20 year anthology and implications for the future. Journal of Rehabilitation Administration, 26, 73-83.
Fan, C. (1999). A comparison of attitudes towards mental illness and knowledge of mental health services between Australian and Asian students. Community Mental Health Journal, 35, 47-56.
Fumham, A., & Chan, E. (2004). Lay theories of schizophrenia: A cross cultural comparison of British and Hong Kong Chinese attitudes, attributions, and beliefs. Social Psychiatry Epidemiology. 39, 543-552.
Garske, G. G., & McReynolds, C. J. (2005). Psychiatric rehabilitation: A means of de-stigmatizing severe mental illness. Journal of Applied Rehabilitation Counseling, 36(A), 28-34.
Garske, G. G., & Stewart, J. R. ( 1 999). Stigmatic and mythical thinking: Barriers to vocational rehabilitation services for persons with severe mental illness. Journal of Rehabilitation, 65(4), 4-8.
Gill, K, Murphy, A., & Birkmann, J. (2005). Developing attitudes: The role of psychiatric rehabilitation education. American Journal of Psychiatric Rehabilitation, 8, 136-149.
Hampton, N. Z. (2000). Meeting the unique needs of Asian Americans and Pacific Islanders with disabilities: A challenge to rehabilitation counselors in the 2 1 sl century. Journal of Applied Rehabilitation Counseling, 3/(1), 40-46.
Hand, C, & Tryssennaar, J. (2006). Small business employers’ views on hiring individuals with mental illness. Psychiatric Rehabilitation Journal, 29, 166-173.
Kirsch, B. (2000). Work, workers, and work places: A qualitative analysis of narratives of mental health consumers. Journal of Rehabilitation, 66(A), 24-30.
Leong, F. T. L. (1986). Counseling and psychotherapy with Asian Americans: Review of the literature. Journal of Counseling Psychology, 33, 196-206.
Li, H. Z., & Browne, A. J. (2000). Defining mental illness and accessing mental health services: Perspectives of Asian Canadians. Canadian Journal of Community Mental Health, 19, 143-159.
Lin, L., & Cheung, F. (1999). Mental health issues for Asian Americans. Psychiatric Services, 50, 774-780.
Lincoln, Y. S., & Guba, E. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage Publications.
Link, B., Phelan, J. C, Bresnahan, M., Stueve, A., & Pescosolido, B. A. (1999). Public conceptions of mental illness: Labels, causes, dangerousness, and social distance. American Journal of Public Health, 89, 1328-1333.
Loo, C, Tong, B., & True, R. ( 1 989). A bitter bean: Mental health status and attitudes in Chinatown. Journal of Community Psychology, 17, 283-295.
Luk, C, & Bond, M. H. (1992). Chinese lay beliefs about the causes and cures of psychological problems. Journal of Social Clinical Psychology, 11, 140-157.
Matsuoka, J. K., Breaux, C, & Ryujin, D. H. (1997). National utilization of mental health services by Asian Americans/Pacific Islanders. Journal of Community Psychology, 25, 141-145.
Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded source bookjT* Ed.). Thousand Oaks, CA: Sage Publications. Ng, C. H. (1997). The stigma of mental illness in Asian cultures. Australian and New Zealand Journal of Psychiatry, 31, 382-390.
Polit, D. F., & Hungler, B. P. (1999). Nursing research: Methods, appraisal, and utilization (6th Ed.) Philadelphia: J. B. Lippincott.
Saetermoe, C, Scattone, D., & Kim, K. H. (2001). Ethnicity and the stigma of disabilities. Psychology and Health, 16, 699-713.
Shokoohi-Yekta, M., & Retish, P. M. (1991). Attitudes of Chinese and American male students towards mental illness. International Journal of social Psychiatry, 37, 192-200.
Soonthornchaiya, R., & Dancy, B. L. (2006). Perceptions of depression among elderly Thai immigrants. Issues in Mental Health Nursing, 27,681-698.
Tatman, A. W. (2001 ). Hmong perceptions of disability: Implications for vocational rehabilitation counselors. Journal of Applied Rehabilitation Counseling, 32(3), 22-27.
Tsang, H., Lam, P., Ng, B., & Leung, O. (2002). Predictors of employment outcome for people with psychiatric disabilities: A review of the literature since the mid 80s. Journal of Rehabilitation, 66(2), 19-31.
Whaley, A. L. (1997). Ethnic and racial differences in perceptions of dangerousness of persons with mental illness. Psychiatric Services, 48, 1328-1330.
United States Census Bureau (2006). Census Bureau release population estimates by race, Hispanic origin, and age for states and counties. Retrieved from http://www.census. gov on August 6, 2006.
Acknowledgments – This work was supported by a research fellowship awarded to the first author from the Institute for Asian American Studies (IAAS) in Boston. The opinions expressed are those of the authors and may not reflect the position of the IAAS. The authors would like to thank Emmy Tuyet Nguyen and Elaine Chia-huei
Hu-Cook for their assistance in data collection, transcription, and analysis. Also, the audiors appreciate the contribution of all participants to this study.
Nan Zhang Hampton, Ph.D., C.R.C. is an Associate Professor at the Department of Administration, Rehabilitation, and Postsecondary Education in San Diego State University; 3590 Camino del Rio North, San Diego, CA92108. Tel.: (619) 594-6425. Email: nhampton(3).mail.sdsu.edu
Teresa Yeung is a graduate student in the Rehabilitation Counseling Program at University of Massachusetts-Boston; 100 Morrissey Boulevard, Boston, MA 02125-3393. Email: tyeung95(S>alumnet.simmons.edu.
Courtney Hoa Nguyen, M.Ed., C.R.C. is a Senior Qualified Rehabilitation Counselor at the Massachusetts Rehabilitation Commission, 59 Temple PI, Suite 905, Boston, MA02111. Tel: (617) 357- 8137. Email: Courtney, nguy enastate.ma.us.
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