The Other Cultural Competency Presentation
"My name is Marissa L. and I've been an Asian American for 23 years."
I started my cultural competency presentation at the California Mental Health Advocacy Conference last week with that line. Kind of an icebreaker joke. Maybe a little corny. Given the frequency of co-occurring substance abuse with mental illness it had context for my audience. So I rolled with that.
The rest of the presentation did not go over as well. I do not think I gave the cultural competency presentation people wanted me to give and I'm not really sure what to think of it. To check out a great cultural competency meets health care website, visit here: The Provider's Guide to Quality and Culture.
When people attend mental health conferences expecting to learn more about those darnfangled Asians, this is the narrative they usually get:
After you attend a few conferences and workshops about Asian Americans these things get very predictable. Also, one of my co-presenters was Indian American and I figured her presentation would cover the essential Asian American factoids (which she did, admirably.) So I tried for something else.
Cultural competency presentations on Asian Americans and Mental Health often discuss how mental health is an alien concept to Asians. Instead, I wanted to discuss how systems and societies alienate Asian Americans-and how this alienation may make them feel less likely to seek out mental health services.
First, I tried to talk about Asian Americans and Labels - Oriental, Asian, and Asian American.
I started by explaining how the night before, bruinbown had asked me why the word "oriental" is offensive. This is certainly a debate that Asian people living in the United States have gotten into before--it usually ends in some row about political correctness. "Asian is for people. Oriental is for things." (The most epic of debates I ever had with someone about the offensiveness of the term 'oriental' ended with the guy saying "So if I'm nailing an Asian girl am I getting Asian pussy or Oriental pussy?" Ass.)
My point was that in mental health systems, this is not up for debate. If you want to be culturally competent, you do not call Asians Orientals. That's pretty much it. I mean, you can if you want to, but don't expect positive results.
I went on to say that The Psychology of Prejudice and Discrimination dedicates a clean little paragraph about how it is important to make the distinction between Asian and Asian American. (Think: difference between African and African American.) After arguing repeatedly with DMH about their use of Asian instead of Asian American I really wanted to put that out there.
Too often, Asian Americans are treated as foreign born, simply because they have Asian physical characteristics. Calling us Asian Americans instead of simply Asians is one way of acknowledging that we are not foreign, but part of the fabric of American culture. (The perpetual foreigner stereotype). Also, to some Asian Americans, the word "Asian" may refer to overseas Asians so we may not assume that a mental health service or event is designed with us in mind.
I then segued into a spiel about Asian Pacific American Heritage month and how people think it's about studying the history of China. It's not, it's about studying the rich history of Asians in Americana, such as:
The next part of my presentation was a Hand Raising Exercise where I asked people to raise their hand if they agreed with statements I read off.
Hand Raising Hair Raising Mental Health & Privilege Exercise
Marissa Lee, April 2010
This activity was inspired by a famous social class privilege exercise by Will Barratt that is used on University campuses and in some cultural competency curriculum. (Racial diversity iteration.) I was motivated to do this exercise to hone in my point and emphasize that ethnicity can impact how you access or your ability to access mental health services.
There's a 2001 study, Awareness of White Privilege among White Counseling Trainees, where researchers ran McIntosh's famous "Unpacking the Knapsack" essay across 34 white counseling students. Even though these students were engaged in multicultural counseling coursework and training to be mental health professionals at the time, about a third of them reacted with "anger, selective perception, and distortion of the intended meaning of McIntosh’s conditions of privilege." The people denying this systemic racism weren't average joes on the street--these were people being trained to deliver culturally competent mental health care!
In the room I was in and giving the limited time I had people raise their hands instead of stepping around the room. Questions were also adapted to be more related to mental health and Asian American experiences.
Raise your hand if you have encountered these experiences:
I ended the exercise by saying: "The purpose of this survey wasn’t to make you uncomfortable, but to point out that who you are-including what cultural, racial, or ethnic group you belong to-can make a big difference in terms of the kinds of things you experience. And how you experience life as part of a society impacts how you feel about yourself. It impacts how you feel about how you belong."
I talked a bit about the "Where are you from?” question. It's not meant to be offensive, but it can still hurt. Regardless of intention, the impact is that these questions reinforce this idea that Asians aren’t real Americans. No matter how American you think you are, society will always question it. To Asian Americans they can be constant reminders that we’re others, that we’re different. How others perceive us is different from how we perceive ourselves.
Common scenario:
Suddenly they say "oh" and stop asking questions. And I wonder, since you've stopped asking questions, if it's because you've come to a conclusion about me. And I'm curious to know if my friends whose parents immigrated to the United States later than my parents did--but from countries like Poland and Russia--ever have to do this dance. I wonder how often they get told: "This is America. If you don't like it here, then go back where you came from."
In this 2003 NIMH study, 74% of Asian Americans reported experiencing unfair treatment and 63% attributed such instances to racial factors. Participants who had these experiences were more likely to have major depression. Asian Americans who were born in or grew up in the United States were more negatively affected by these situations than recent immigrants.
I think this is because recent immigrants have an easier time dismissing the unfair treatment they encounter in the United States. Maybe they assume it's just how America works, or that they should expect to be treated differently as a foreigner. I really believe that discrimination is a more frustrating experience for Asian Americans who have grown up here being told that they are American, and that people are treated equally here, and that their race doesn’t matter--because it absolutely does matter when it comes to how other people treat you and how other people judge you. How do you reconcile those contradictions?
It’s also interesting to note that the NLAAS study found that Asian Americans who were born in or grew up in the United States have a higher rate of mental illness than Asian Americans who immigrated as adults. A separate study also found that Asian American women born in the US are more likely to commit suicide than any other group, including recent Asian immigrants. In mental health this is often attributed to factors like intergenerational conflict, the culture gap, and parental pressure to succeed.
An audience member asked me why I was not covering this in my presentation. I explained that these factors are important but commonly discussed, which is why she was familiar with them. The impact of discrimination on second generation Asian Americans is not as commonly discussed and discrimination has been found to impact physical and mental health.
Besides, do not underestimate the impact of discrimination on these other factors. I think most Asian Americans can relate to their parents saying things like, "Honey, you are a minority living in the United States. Because of this, you have to make more sacrifices. You are at a disadvantage and you need to work harder to prove yourself. You are a minority and you must work harder to succeed to make up for that."
Furthermore, when Asian Americans are made to feel not a part of "real" America, an in-group stereotype can easily form where Asian Americans feel a world apart from other Americans. Which includes feeling that mental health is for Americans, but not for me (ie: white Americans, not Asian Americans.) This is not helped by day to day experiences that reinforce just how unlike other "Americans" you are. Mental health might already be a foreign concept to this community that has been made to feel foreign. If they don’t feel there is a place for them in mental health treatment, then they won’t use services. They don’t see themselves as clients, they don’t see other people from their communities benefiting. That visibility is important.
If you’re Asian American but you don’t see people like you using services then why would you feel these services have a place for you? If you walk into a clinic or wellness center and assumptions are automatically made about you, or you’re otherized, or the provider can’t even get your ethnicity right? Fear of being misunderstood or being disrespected would drive you away from seeking services.
I touched on the concept of Colorblindness, explaining that colorblindness removes context. I briefly summarized a study by Professor Rebecca Bigler from the University of Texas, who conducted a study with schoolchildren. She asked them about the President of the United States. Even at five years old, the kids knew the President was an important leader. The kids also knew that the President had never been a person of color (in 2006) or a woman. 1 out of 4 kids thought it was currently against the law for women and people of color to be president. When asked why they thought this was, 1 out of 3 children blamed this on the excluded group, saying that it must be because women aren't smart enough, people of color don't have leadership skills, etc.
They were just the best actor person for the job, right?
(wtf? For the record, Analyses of Social Issues and Public Policy.)
The problem with being Colorblind is twofold. A system that does not recognize race will also become unable to recognize when race-based discrimination or disparities do occur. The second problem is related to what I mentioned earlier, which is that your color is part of who you are. It shapes how you experience the world and how others treat you, and providers have to acknowledge that in their clients.
As people in the mental health system, we can’t afford to be colorblind because that is denying the reality of our clients and friends. There is an impact and we have to acknowledge it. It’s not easy-we have to start with an honest assessment of positive and negative assumptions about other people.
At a lot of these conferences, one proposed solution to fight stigma is to train, hire, and retain more Asian American mental health providers and to create more Asian language services. While diversity in the workforce is important, hiring more Asians to create a special "By Asians for Asians" mental health system doesn't solve the overall alienation/integration problem; it can exacerbate it by creating a "ghettoized" system.
It's really easy to attribute Asian American mental health problems to the fact that our community stigmatizes the mentally ill or puts pressure on kids, but I really wanted to drive home that Asian Americans are also impacted by how we currently slot into the fabric of American society, and that as long as we perceive that we are outsiders in society--like we don’t belong--we won’t feel like there is a place for us in the mental health system.
One of our goals with fighting stigma is to make mental health mainstream. To make seeking services accepted by mainstream America. At the same time, we have ancillary projects to make mental health more mainstream for cultural populations. Working to help the rest of America recognize that these cultural populations should be part of the mainstream will make our job a lot easier.
A lot of these concepts I presented seemed really difficult for the attendees to grasp. I don't know why. They were basically:
I started my cultural competency presentation at the California Mental Health Advocacy Conference last week with that line. Kind of an icebreaker joke. Maybe a little corny. Given the frequency of co-occurring substance abuse with mental illness it had context for my audience. So I rolled with that.
The rest of the presentation did not go over as well. I do not think I gave the cultural competency presentation people wanted me to give and I'm not really sure what to think of it. To check out a great cultural competency meets health care website, visit here: The Provider's Guide to Quality and Culture.
When people attend mental health conferences expecting to learn more about those darnfangled Asians, this is the narrative they usually get:
- Asians are a very diverse group.
- Asian culture has no concept of 'mental illness.' They don't know what mental illness is.
- Asians discriminate against people with mental illness so Asians with mental illness don't want to seek services due to stigma...
- ...even though Asians can have frighteningly high rates of mental illness.
- Asians are more likely to somatize mental illness, displaying distress through physical symptoms (ala: "I have a headache alot...I keep pooping my pants, etc.")
- There are very few Asian mental health workers.
- As a cumulative result, Asians don't tend to seek mental health services until their health has deteriorated to a very low point.
- Sometimes, the "model minority" stereotype is mentioned. This can be internalized (where a "successful" Asian will not want to be labeled as "crazy") or external, such as a medical doctor, employer, or school counselor who assumes that everything is hunky-dory because the Asian has good grades, Asians are "really educated and successful people," etc.
- Asians are into all these Eastern spiritual things and to treat their mental illness you should be enthusiastic about incorporating things like acupuncture and herbal medicines and balancing their chi and stuff.
- That university student who shot up Virginia Tech University was Asian.
After you attend a few conferences and workshops about Asian Americans these things get very predictable. Also, one of my co-presenters was Indian American and I figured her presentation would cover the essential Asian American factoids (which she did, admirably.) So I tried for something else.
Cultural competency presentations on Asian Americans and Mental Health often discuss how mental health is an alien concept to Asians. Instead, I wanted to discuss how systems and societies alienate Asian Americans-and how this alienation may make them feel less likely to seek out mental health services.
First, I tried to talk about Asian Americans and Labels - Oriental, Asian, and Asian American.
I started by explaining how the night before, bruinbown had asked me why the word "oriental" is offensive. This is certainly a debate that Asian people living in the United States have gotten into before--it usually ends in some row about political correctness. "Asian is for people. Oriental is for things." (The most epic of debates I ever had with someone about the offensiveness of the term 'oriental' ended with the guy saying "So if I'm nailing an Asian girl am I getting Asian pussy or Oriental pussy?" Ass.)
My point was that in mental health systems, this is not up for debate. If you want to be culturally competent, you do not call Asians Orientals. That's pretty much it. I mean, you can if you want to, but don't expect positive results.
- Me: Although it is sometimes used to describe East Asians in other parts of the world, in the late 80s, the word "oriental" fell out of use in the United States. Avoid using it to describe Asians.
Audience Member: But in the 1910s and 1920s the word Oriental was used to describe Asians positively!
Me: My point is, I could spend hours arguing with you about why words like oriental or negro or psycho are not appropriate words to use in a mental health setting. You could call me a politically correct stickler and say that I am wrong to be offended. That is not the point. It is about who gets the right to label a person or community. It is about respecting another person and their right to self-identify
Another Audience Member: Labels? Why do we need labels? Aren't we all human? Why are you saying people should be labeled?
I went on to say that The Psychology of Prejudice and Discrimination dedicates a clean little paragraph about how it is important to make the distinction between Asian and Asian American. (Think: difference between African and African American.) After arguing repeatedly with DMH about their use of Asian instead of Asian American I really wanted to put that out there.
Too often, Asian Americans are treated as foreign born, simply because they have Asian physical characteristics. Calling us Asian Americans instead of simply Asians is one way of acknowledging that we are not foreign, but part of the fabric of American culture. (The perpetual foreigner stereotype). Also, to some Asian Americans, the word "Asian" may refer to overseas Asians so we may not assume that a mental health service or event is designed with us in mind.
I then segued into a spiel about Asian Pacific American Heritage month and how people think it's about studying the history of China. It's not, it's about studying the rich history of Asians in Americana, such as:
- Asian Americans were not allowed to become US Citizens until 1943. Immigration of Asians was also repeatedly blocked.
- In 1854, the California Supreme Court ruled that Chinese immigrants were "a race of people whom nature has marked as inferior, and who are incapable of progress or intellectual development," that "nature has placed an impassable difference" between Americans and Chinese immigrants, and that Chinese immigrants had no right to "participate with us in administering the affairs of the Government." (Including testifying in court if they were wronged. Making it pretty much impossible for any Asian American victim to get justice in a court.)
- Los Angeles County is historically famous for being responsible for one of the largest Asian American lynchings ever. In 1871, a mob of 500 men looted Chinatown, ransacked every building, massacred 20 Chinese immigrants, and strung their bodies up over Downtown LA.
- Over the next decade more than a hundred other cities in California--including San Francisco, San Diego, and Santa Cruz--all experienced anti-Chinese riots and/or efforts to expel all Chinese from the community.
- Also, that transcontinental railroad thing. And um, internment camps.
The next part of my presentation was a Hand Raising Exercise where I asked people to raise their hand if they agreed with statements I read off.
Hand Raising Hair Raising Mental Health & Privilege Exercise
Marissa Lee, April 2010
This activity was inspired by a famous social class privilege exercise by Will Barratt that is used on University campuses and in some cultural competency curriculum. (Racial diversity iteration.) I was motivated to do this exercise to hone in my point and emphasize that ethnicity can impact how you access or your ability to access mental health services.
There's a 2001 study, Awareness of White Privilege among White Counseling Trainees, where researchers ran McIntosh's famous "Unpacking the Knapsack" essay across 34 white counseling students. Even though these students were engaged in multicultural counseling coursework and training to be mental health professionals at the time, about a third of them reacted with "anger, selective perception, and distortion of the intended meaning of McIntosh’s conditions of privilege." The people denying this systemic racism weren't average joes on the street--these were people being trained to deliver culturally competent mental health care!
In the room I was in and giving the limited time I had people raise their hands instead of stepping around the room. Questions were also adapted to be more related to mental health and Asian American experiences.
Raise your hand if you have encountered these experiences:
- I have often experienced being the only person of my ethnicity in a room full of people.
People have assumed that I do not speak or that my parents do not speak English proficiently. (Asking if you speak English, speaking slowly using simple words, etc.)
When people ask me “Where are you from?” they often don’t mean what city I am from, are asking to try and figure out what my ethnic background is.
(“Where are you really from?” "Do you have the chance to go home often?")
People feel compelled to inform me that they have friends or family members of the same race or ethnicity as me.
People have greeted me with a foreign language that they assumed I knew how to speak.
People have attributed my abilities or lack of ability to my race or ethnicity. (Abilities could be math skills, basketball, organization skills. Lack of abilities could be driving, parenting, controlling my temper, etc.) People have attributed my success or lack of success to my race or ethnicity. In spite of my race or ethnicity.
People sometimes ask me to provide an opinion speaking for all members of my racial or ethnic group.
I have been complimented for being articulate, having great English, etc. (“My you speak English so well.” “Why thank you, so do you.”)
When there is a violent incident/terrorist attack/shooting I wonder if the ethnicity of the perpetrator will affect how other people view me.
This week, I saw a billboard, magazine cover, or TV commercial with a person of my ethnicity on it. More than once. In English? Within the last 24 hours? (And have you visited racebending.com ?)
People have assumed that I am one ethnicity when I am actually another.
I feel comfortable talking about race and ethnicity with people who are not of my race. (I was thrilled to see a ton of people raise their hand for this one!!!)
I or someone in my family was involved in the mental health system.
It would be easy for me to find a therapist who shares my ethnicity if I wanted to.
It would be easy for me to find a therapist for my parents or other family member-a therapist who is from the same culture and speaks the same language.
I ended the exercise by saying: "The purpose of this survey wasn’t to make you uncomfortable, but to point out that who you are-including what cultural, racial, or ethnic group you belong to-can make a big difference in terms of the kinds of things you experience. And how you experience life as part of a society impacts how you feel about yourself. It impacts how you feel about how you belong."
- Audience Member: I think that exercise was unfair.
Me: Well, part of my point was to highlight different experiences people have...
Audience Member: Well, I have been the only white person in the room before when there are minorities and I felt uncomfortable.
Me: Right. Well, I'm not saying the experiences I just listed are exclusive to any one racial group. But your race or ethnicity can and will impact how often you experience these situations on a regular basis. Especially in the mental health system.
I talked a bit about the "Where are you from?” question. It's not meant to be offensive, but it can still hurt. Regardless of intention, the impact is that these questions reinforce this idea that Asians aren’t real Americans. No matter how American you think you are, society will always question it. To Asian Americans they can be constant reminders that we’re others, that we’re different. How others perceive us is different from how we perceive ourselves.
Common scenario:
- Person: So Marissa, where are you from?
Me: Los Angeles.
Person: Oh, and before that?
Me: ...Orange County.
Person: Where did you grow up?
Me: Santa Cruz.
Person: Where are your parents from?
Me: They're also from Orange County.
Person: Where are your grandparents from?
Me: They live in Orange County, too. Few blocks from my parents.
Person: Where did they come from before--what's your ethnic background?
Me: My family is from Taiwan. I'm Taiwanese American.
Person: Oh.
Suddenly they say "oh" and stop asking questions. And I wonder, since you've stopped asking questions, if it's because you've come to a conclusion about me. And I'm curious to know if my friends whose parents immigrated to the United States later than my parents did--but from countries like Poland and Russia--ever have to do this dance. I wonder how often they get told: "This is America. If you don't like it here, then go back where you came from."
In this 2003 NIMH study, 74% of Asian Americans reported experiencing unfair treatment and 63% attributed such instances to racial factors. Participants who had these experiences were more likely to have major depression. Asian Americans who were born in or grew up in the United States were more negatively affected by these situations than recent immigrants.
I think this is because recent immigrants have an easier time dismissing the unfair treatment they encounter in the United States. Maybe they assume it's just how America works, or that they should expect to be treated differently as a foreigner. I really believe that discrimination is a more frustrating experience for Asian Americans who have grown up here being told that they are American, and that people are treated equally here, and that their race doesn’t matter--because it absolutely does matter when it comes to how other people treat you and how other people judge you. How do you reconcile those contradictions?
It’s also interesting to note that the NLAAS study found that Asian Americans who were born in or grew up in the United States have a higher rate of mental illness than Asian Americans who immigrated as adults. A separate study also found that Asian American women born in the US are more likely to commit suicide than any other group, including recent Asian immigrants. In mental health this is often attributed to factors like intergenerational conflict, the culture gap, and parental pressure to succeed.
An audience member asked me why I was not covering this in my presentation. I explained that these factors are important but commonly discussed, which is why she was familiar with them. The impact of discrimination on second generation Asian Americans is not as commonly discussed and discrimination has been found to impact physical and mental health.
Besides, do not underestimate the impact of discrimination on these other factors. I think most Asian Americans can relate to their parents saying things like, "Honey, you are a minority living in the United States. Because of this, you have to make more sacrifices. You are at a disadvantage and you need to work harder to prove yourself. You are a minority and you must work harder to succeed to make up for that."
Furthermore, when Asian Americans are made to feel not a part of "real" America, an in-group stereotype can easily form where Asian Americans feel a world apart from other Americans. Which includes feeling that mental health is for Americans, but not for me (ie: white Americans, not Asian Americans.) This is not helped by day to day experiences that reinforce just how unlike other "Americans" you are. Mental health might already be a foreign concept to this community that has been made to feel foreign. If they don’t feel there is a place for them in mental health treatment, then they won’t use services. They don’t see themselves as clients, they don’t see other people from their communities benefiting. That visibility is important.
If you’re Asian American but you don’t see people like you using services then why would you feel these services have a place for you? If you walk into a clinic or wellness center and assumptions are automatically made about you, or you’re otherized, or the provider can’t even get your ethnicity right? Fear of being misunderstood or being disrespected would drive you away from seeking services.
I touched on the concept of Colorblindness, explaining that colorblindness removes context. I briefly summarized a study by Professor Rebecca Bigler from the University of Texas, who conducted a study with schoolchildren. She asked them about the President of the United States. Even at five years old, the kids knew the President was an important leader. The kids also knew that the President had never been a person of color (in 2006) or a woman. 1 out of 4 kids thought it was currently against the law for women and people of color to be president. When asked why they thought this was, 1 out of 3 children blamed this on the excluded group, saying that it must be because women aren't smart enough, people of color don't have leadership skills, etc.
They were just the best actor person for the job, right?
- Me: Without the context and understanding that adults about how racism and sexism have historically and systemically impacted who can be President, the kids drew some pretty harsh assumptions. We have to be honest about how racism and sexism has affected society, even with children.
Audience Member: What journal was this study published in?
Me: ...um. It was a study performed by Rebecca Bigler from the University of Texas in 2006.
Audience Member: But what journal was this study published in?
Me: I don't know.
Audience Member: Well, then.
(wtf? For the record, Analyses of Social Issues and Public Policy.)
The problem with being Colorblind is twofold. A system that does not recognize race will also become unable to recognize when race-based discrimination or disparities do occur. The second problem is related to what I mentioned earlier, which is that your color is part of who you are. It shapes how you experience the world and how others treat you, and providers have to acknowledge that in their clients.
As people in the mental health system, we can’t afford to be colorblind because that is denying the reality of our clients and friends. There is an impact and we have to acknowledge it. It’s not easy-we have to start with an honest assessment of positive and negative assumptions about other people.
At a lot of these conferences, one proposed solution to fight stigma is to train, hire, and retain more Asian American mental health providers and to create more Asian language services. While diversity in the workforce is important, hiring more Asians to create a special "By Asians for Asians" mental health system doesn't solve the overall alienation/integration problem; it can exacerbate it by creating a "ghettoized" system.
It's really easy to attribute Asian American mental health problems to the fact that our community stigmatizes the mentally ill or puts pressure on kids, but I really wanted to drive home that Asian Americans are also impacted by how we currently slot into the fabric of American society, and that as long as we perceive that we are outsiders in society--like we don’t belong--we won’t feel like there is a place for us in the mental health system.
One of our goals with fighting stigma is to make mental health mainstream. To make seeking services accepted by mainstream America. At the same time, we have ancillary projects to make mental health more mainstream for cultural populations. Working to help the rest of America recognize that these cultural populations should be part of the mainstream will make our job a lot easier.
A lot of these concepts I presented seemed really difficult for the attendees to grasp. I don't know why. They were basically:
- Don't call Asians Orientals.
- Asian American: Asian :: African American : African. Big Difference. Remember that.
- Asians are affected by the "perpetual foreigner" stereotype and if you display that towards them they will be less open to receiving services.
- Your ethnicity impacts how you are treated and how you experience the mental health system and society.
- "Colorblindness" is not an ideal model because it ignores discriminatory realities and does not give mental health providers necessary contexts to understand their clients' experiences.
- It will be easier to encourage Asian Americans to utilize the mainstream American mental health system if they feel mainstream American and that they belong. They will feel that the system is an inclusive one, designed with them in mind.