Catherine Kwon

Peggy Wong NUR ’24 watched a mother and father weep at opposite sides of the patient room, separately mourning their child’s rapidly declining condition. 

Their child was the first Asian patient Wong saw during this clinical round. The patient’s blood count and blood pressure were low — it became clear that they were very ill and quickly declining. When the rapid response team crowded the room, Wong saw the mother and father’s distress spike. Yet, they were isolated in their sorrow, crying at opposing ends of the room. 

“As an Asian American, I completely understand,” Wong said. “I thought they should be consoling each other, holding each other and crying together. But at the same time, I think it’s because culturally, they’re just not used to that kind of affection. It made me really sad to see them crying by themselves in separate corners when they’re married. But it’s hard to navigate this because even though I’m Asian and they’re Asian, I felt like I couldn’t communicate with them — I couldn’t just tell them ‘I get it.’”

Wong said that many Asian American and Pacific Islander health care providers grapple with the uncertain role of cultural competency in health care — it is largely unknown how to communicate understanding when it comes to situations specifically influenced by cultural norms. Wong described the cultural training that would guide this approach as being largely absent in nursing education, and only learned either “on the job” or through one’s lived experiences. 

In this case, consoling the parents would deserve more time than a few quick minutes, Wong said. There were emotional barriers she recognized coming from the same culture. The process of figuring out how best to apply a cultural lens to the health care setting will require more cases of “learning on the job.” But when caring for AAPI communities, the first barrier to treatment is actually getting the patient to the doctor’s office. 

“AAPI folks tend to have really low service utilization,” assistant professor of psychiatry and Yale CHATogether founder Eunice Yuen said. “Meaning they don’t get help until they’re severely sick, and then show up in the emergency room and need to be hospitalized. And it is not uncommon to hear an AAPI teen or young adult having depression and suicidal thinking for three to four years, and their parents having no idea until it’s really severe.”

According to Nikita Paudel ’25, in Nepal, medicine is usually seen as something “you succumb to” rather than as a tool to help. Paudel was born and raised in Nepal before immigrating to America with her family. In lieu of “giving up” by choosing medication, her family valued “fighting through” the pain. She noted that this affected women to a greater extent in her culture, with access to health care for women being “a little bit disenfranchised” because of gender bias. Women are commonly expected to fight pain off on their own more often, Paudel said. 

Paudel also noted the cultural fear of hypermedicalization, a perceived trend in American medicine that was “the complete opposite” of medicalization attitudes in Nepal. This, compounded with hesitancy towards substances that they “don’t understand fully coming to a whole different culture,” could influence the low service utilization rates when in America, she said. Paudel additionally questioned where the line was between respecting traditional cultural beliefs and practices — such as home remedies and “spiritual” approaches to healing sickness in her family — and also ensuring that families receive adequate medical care and attention.

“Some people feel like they need a culturally-oriented doctor or therapist or psychiatrist to understand the cultural perspective [of cases],” Yuen said. “If the provider has a similar cultural background, they feel like they will have a similar human connection and will be more easily understood. This is a well known factor for why many people under-utilize [health care] services — they cannot find a provider that shares their cultural background.”

Medical student Nealie Ngo’s ’18 friend only wanted an Asian therapist. In the past, the friend first had to “teach” the therapist their cultural background before they could fully discuss their life. Yet, when addressing concerns such as their obligation to care for their parents financially and holistically — rooted in the key East Asian virtue of filial piety — past therapists would reject this notion, telling them “you’re not responsible for your parents.” 

But core cultural values, like filial piety, realistically cannot be challenged. When caring for patients, there is a need to understand this “complex value system” that a lot of immigrant families have, Ngo said.

“In Nepal, everything stays within the family,” Paudel said. “Even therapy is often completely out of the picture because you can’t speak about your family issues to somebody else. And here, Americans, especially white Americans, will not be able to fully understand the depth or breadth of the issues that we face within our own respective cultures. So people don’t even feel comfortable opening up to these people because they truly have no way of understanding. But [these issues] are also already so stigmatized in our own culture, so you’re just kind of stuck.”

According to Ngo, treatment that is informed by a patient’s cultural values can help put the patient at ease. Ngo’s friend, for example, had faith that an Asian therapist would not teach them a coping mechanism that conflicted with their cultural background. In return, the friend would be more honest and willing to establish boundaries that would “not force them to break ties with their family.” 

“Culture and diversity in medicine are super important, but sometimes are approached as just ticking a box,” Ngo said. “Sometimes categorizing it as cultural understanding can delegitimize [how culture influences a person] — so I would approach it more as values.”

Yuen offered an example of values rooted in Confucianism. In comparison to the emphasis on individualism in Western culture, Confucianism values collectivism. Through this lens, when someone is unwell, this may not be seen as an individual issue, but as a family issue. According to Yuen, some AAPI folks may have trouble reaching out for help because this may be seen as “losing face” or as “bringing shame” to a family.

Wong pointed out the acculturative stress that can arise from identifying with two cultures. Speaking from her lived experience as a Chinese American, while filial piety can cause children to feel indebted to their parents, conflict can arise when children must then identify with a culture that does not emphasize or recognize that philosophy. 

“Filial piety is the need to honor your parents,” Yuen said. “Your body, your life is really given to you by your parents. So in conflict with this concept, when someone is mentally not well, they may self-harm, they may have suicidal thinking — and that is seen as violating the filial piety concept. It is hard for someone to reach out for help, especially to get parents to validate their need to get help. So I think many of these nuances from the cultural perspective are really overlooked.”

Tara Bhat ’25 echoed the principles of filial piety, but through the perspective of South Indian culture. She said that it can be difficult for children to discuss mental health due to fear of further burdening their parents. As a result, mental health becomes a low priority problem when compared to the “many material issues” that children see parents dealing with daily.

“There could be a feeling that telling parents — who have already sacrificed and fought so much to make the conditions for our lives in America manageable — about mental health problems is equal to adding more weight to burdens they’re already holding,” Bhat said.

According to Kasama co-president Resty Fufunan ’24, the utilization of health care has an interesting dynamic among Filipino Americans. Fufunan said that because Filipinos are known for being a significant part of the health care system in America, they are more cognizant of health issues and have a better grasp of the vocabulary, especially as a former U.S. colony. He said this may mean that Filipinos would know how to interact with the American medical system a little better than other Asian ethnic groups.

“I think with Filipinos, it’s less about culture and more about some of the other socioeconomic barriers that they may be facing,” Fufunan said. “A lot of Filipinos are undocumented and we know that undocumented folks may be more hesitant to reach out to health care because of a fear of someone finding out that are undocumented and affecting their ability to stay here in the U.S.”

Furthermore, the culture of work that many Filipinos have causes them to feel obligated to complete their job at the expense of their own personal safety, Fufunan said. Taking off from work may be difficult for immigrants from the Philippines sending money back home to people outside of the nuclear family as the “breadwinner” in America, in addition to supporting the common presence of three generations in Filipino households.

Fufunan said that for Filipinos, the entire network of care of families, both nuclear and extended, has to be considered when working, which can cause some to deprioritize their physical and mental health. Though this culture was “so intimately tied to the health care industry,” mental health was not seen on the same level as physical health, he stated, noting this downplaying of mental health as a common theme in the Asian diaspora.

Wong emphasized the power of sharing stories to empower communities to address stigmatized topics such as mental health. Yuen founded CHATogether — an organization of which Wong and Ngo are members — to open up conversations about mental health, racism and other traditionally taboo topics in AAPI communities, especially in light of pandemic-era anti-Asian hate crimes that could further exacerbate AAPI community members’ struggle with their identity. 

“AAPI Heritage Month is about looking for your identity — who you are,” Yuen said. “And to the Asian American generation who live with more than two cultures, you have the Asian side of you and you have the American side of you. But the Asian side of us is more challenging [to navigate] because you basically learn it from your parents. And if it’s not easy for the parents to talk about their own heritage or their own paths and how they grew up — maybe trauma is in the way — then it is really hard for someone to find their own identity.” 

According to Yuen, many of her patients are not ready to “even think about” the Asian side of their identity, sometimes because it is “too traumatizing” to reflect on family-related issues. However, to reach a stage where topics such as normalizing health care can be discussed, especially in the realm of mental health, it is important to find common ground and close the “acculturative gap” between generations.

“I think we need to change the way people think about medicine in general,” Paudel said. “Medicine is a tool to help you, not something that you are succumbing to. Instead of thinking about it as giving up, we should think about it as just helping yourself.”

Ngo offered one piece of advice from Grace Chiang ’15. Chiang helped her father understand therapy by comparing a therapy session to going to the dentist. By explaining that people may go to a therapist for a regular checkup even if something is not necessarily wrong — like dental checkups — her dad began to understand mental health as concrete enough for there to be professionals to help, not just to “rip you off.”

“Sometimes it’s not easy to understand Asian parents, even for myself [as an Asian parent],” Yuen said. “Although they are loving and caring most of the time, they are perhaps expressing it in a way that is not always being appreciated by the child. But one of my jobs is actually helping the patient to appreciate and keep translating. What is the love language in the action? How do I help my patient to understand translating, closing the acculturative gap with the parents so that they can talk to each other and be on the same page?”

In 2018, Asians were 60 percent less likely to have received mental health treatment services in comparison to white people.