But we all know there's no shame in shame!

A front page article in today's Philadelphia Inquirer comes within an inch of (gasp!) stereotyping Asians. (But it's OK, because the principal author has an obviously Asian name.) Anyway, I was immediately reminded of Sean Kinsell's earlier post about "whether and how Cho Seung-hui's Korean-ness relates to his having shot at several classrooms full of college students."

Sean has more. But I'll start with today's front page Inquirer story, headlined "Asians often reticent about seeking mental care."

I think it's worth noting that author Lou Yi is a Chinese writer for Caijing Magazine currently on a fellowship at the Inquirer. Caijing Magazine is a Chinese financial magazine which has been described as pushing boundaries of censorship. While I certainly hope this is not why Caijing's home page does not open right now, I'm getting way off topic with Chinese censorship.

The issue here is Asian reticence in seeking mental health care:

"Our culture, you keep your feelings inside," said Helen Luu, who runs the Asian Mental Health Program at the Hall-Mercer Community Center in Society Hill. "When you ask the [mental health] client, 'How do you feel?' they don't know how to answer you."

The reluctance of Asians to acknowledge the possibility of mental illness and seek care takes on new import after the Virginia Tech massacre, in which 23-year-old Seung-Hui Cho killed 32 people and himself.

Cho's mother told relatives in South Korea, where the family lived until Cho was 8, that her silent, affectless boy was autistic. It is not known if he was formally diagnosed or if Cho's parents or staff at the Centreville, Va., schools he attended tried to get him professional help. A statement issued Friday by the family indicates that they were unaware of the depression and alienation so obvious to Cho's professors.

There's no evidence that Cho's ethnicity caused him to avoid the counseling that faculty begged him to get. But it's clear that Asians hesitate to seek care, for reasons researchers suspect are primarily cultural.

Practitioners say patients will talk about their symptoms - loss of appetite, trouble sleeping - but never mention the word depression. That may seem odd in a nation where counseling is commonplace, but more than water separates North America from Asia.

Americans celebrate the individual, Asians the community. Americans want a CAT scan for every headache. Asians prefer to tough it out.

Chinese, for instance, live in a culture that stresses coping and self-reliance. The idea of seeking outside help for an emotional problem creates what experts call "cultural incongruence." It simply doesn't compute.

In many Asian communities, mental illness carries profound shame - not just for the afflicted, but for the entire family.

"Asians come from 'face' cultures," said Stanley Sue, a professor of psychology and Asian American studies at the University of California, Davis. "How you appear to others, your family name, are paramount."

"There is no mental-health [education] in Asian people's culture," said Jingduan Yang, a psychiatrist at the Jefferson Myrna Brind Center of Integrative Medicine in Philadelphia, and an expert on traditional Chinese medicine.

Some doubt the existence of psychiatric illness, seeing laziness, not depression, in a teenager's refusal to get out of bed. For others, it is a punishment inflicted for wrongs committed in a past life - a problem that may require a priest or a shaman, but not a doctor.

I'm fascinated by the shame-based aspect of this (and shame culture generally) and I think it may account for the fact that even in this country, men are far less likely to seek treatment for mental illness than women.

Right now I see a tug of war between two conflicting principles. On the one hand, there's massive public outrage over the fact that too many mentally ill people can buy guns, so there's a push to change the laws. But on the other hand, the therapy community wants to encourage everyone to seek treatment. I realize there are good arguments for both propositions. But two things stand out:

  • 1. there's no way to toughen up the laws without adding to the existing stigma of being labeled mentally ill.
  • 2. People who do not want to be stigmatized will avoid being labeled, and thus avoid treatment.
  • Let's assume that like so many people I were to become so depressed that I no longer wanted to go on living. Each day becomes more and more unbearable, until eventually even getting out of bed becomes a severe test of my ability to go on functioning. That dying is increasingly seen as more desirable than living, etc.

    (Please don't anyone misread me; this is a hypothetical, OK? I'll make it through this post somehow, my dark humor notwithstanding....)

    To continue, there are plenty of suicide prevention lines and psychologists and psychiatrists on call -- all of them available at the push of a few buttons on my phone. But if I know that by dialing one of those numbers and admitting to my problem I will cause my name to be placed on the NICS list of people who have effectively lost their Second Amendment rights, why on earth would I do that? It's tantamount to pleading guilty in court.

    Call me "Asian" in my thinking if you want, but being considered so mentally defective that you are denied an important constitutional right strikes me as a profoundly shameful state to be in, and I can hardly blame Asians (or anyone else) for not wanting to place themselves in an equivalent state.

    So, while I support the idea of getting tough with the clearly hallucinatory classes (like the man who walked around with a stuffed animal until he decided to grab a saw and cut open a subway pasenger's chest), I don't think increasing the stigmatization of all mentally ill people is the way to go.

    I'm a bit concerned about the Monday morning quarterback mentality which seems to take over in cases like that of Seung Cho.

    "We all saw the signs!"

    "Anyone could have seen this coming."

    "The guy was obviously a ticking time bomb."

    "Well, what do you expect from somone with wierd tattoos and bizarre attire?"

    You don't have to look far; here's the front page of the current "Philadelphia Weekly":

    lovetohateme.jpg A guy covered with tattoos (bet they're beauties too) wearing a T-shirt that says "LOVE TO HATE ME" is a perfectly natural thing these days. He happens to be a hard-working DJ, but so what? Yet if the boy next door looked exactly the same way (as many boys next door do), you can be sure that the attire would later be seen as early warning "signs" that were "there."

    For that matter, almost anything can look or seem psychotic in retrospect. If all the kids in school sported tattoos and the normal "LOVE TO HATE ME" T-shirts, the "loner psycho" type might then show his individuality by always wearing a Secret Service-style black suit with a white shirt and tie to school. If he suddenly started shooting, why, wouldn't it have been obvious that all the "signs" were "there"?

    Sean links a very thoughtful discussion by Connie du Toit, and in a comment she discusses the wisdom of hindsight, as well as the Korean factor:

    I think hindsight is a very bad precedent in this case--to apply it as the new paradigm for what kind of society we are.

    Yeah, there were signs and clues, but how many people show those same signs, and never act on them? I'd wager that at least 25% of the young adult population has showed some of those same signs. It is the severity that alters the perspective, and you have to have experience (which young people don't have) to know when to follow up with stronger actions.

    I think there is an aspect to this case that no one has touched on yet, and I'm a little reluctant to bring it up, lest be accused of something... but (like I've ever let that stop me before)...

    He was Korean. His parents were Korean and recent immigrants. Koreans, unless something has radically changed in the last 20 years, do not view psychiatry in the same way we do. They view psychiatry as a really bad thing, and would never seek it out. They view these things (as best as I can describe it) as Gulags, or re-indoctrination centers, and not something the ordinary person (or family) would get involved with.

    Culturally, Asians in general, haven't had the changing experience and attitude about psychiatry (and psychiatric conditions) that we have had.

    She cites examples, and offers what some might consider a disturbing conclusion:
    the real failure point here was not "the government" or any "mental health system." The problem was his family. Families have to deal with their own and they are the only ones who would be able to determine the severity of their child's actions (knowing the difference between a lovesick kid and a truly sick one). Obviously, this kid's problems were not new, as the trail of offenses and "signs" goes way back. But nothing was done by his family--no outreach to mental health has shown up. It doesn't appear to be anything like the Hinkely case (or the Yates case) where "the system" failed the person and their families, despite the families trying desperately to have them locked up.

    I doubt very much, given the Korean family's cultural background, that they would have even supported the idea of psychiatric intervention, had they even been sophisticated enough to know it was needed.

    That's the real story behind all of this, and one I haven't heard discussed AT ALL.

    I'm glad to see the Inquirer make a stab at it, even if (for obvious reasons) the writers are not as free as bloggers to say what they think.

    Like it or not, the Asian reluctance to seek psychiatric intervention does seem to be based on shame. We Americans know better, of course. Being mentally ill is nothing to be ashamed of. Those silly Asians!

    Why, in our enlightened country, mental illness is no disgrace at all!

    (You have nothing to lose but a "right" that none of the rest of us should have anyway.)

    AFTERTHOUGHT: I realize I failed to factor in the growing mental health trend of considering nearly everyone as mentally ill.

    Denial is preferable to acknowledging certain things.

    MORE: What is the difference between Cho and the many others who might exhibit similar characteristics (or take on a "dark side" appearance)? It certainly seems the teachers and psychologists who came in contact with him knew there was a problem or he would never have been ruled mentally ill.

    Is this a case of "I know it when I see it"?

    If so, the problem might be that there is no way to bureaucratize common sense.

    posted by Eric on 04.22.07 at 10:00 AM


    Thanks for the links as always, big guy.

    Just one more thing that I think is important to mention: What people are saying about Confucianism-influenced East Asian is important to recognize, but I doubt there's a bright-line distinction. "Seeing a therapist" for self-discovery or dealing better with blue moods or whatever is something of a status symbol nowadays, since it costs money and requires the spare leisure time to sit around thinking about your shifting moods. (I'm not making light of all psychotherapy, BTW, only describing a specific type.) But I'd be willing to bet that there are plenty of Americans without a drop of Asian blood in them who would still be inclined to live in denial about a real, serious mental disorder on the part of a family member.

    Sean Kinsell   ·  April 23, 2007 1:51 AM

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