The New York Times
"Freud Meets Buddha: Therapy for Immigrants; Disorders from the East Emerge Here"
By Sarah Kershaw l Published: Saturday, January 18, 2003
The patients may suffer from classic mental ailments: depression, anxiety, schizophrenia. But as they make their way to a sprawling mental hospital in northeast Queens, they also complain of problems that the average New York City psychologist has rarely encountered: pa-feng, a phobic fear of wind and cold that occurs in Chinese patients; hwa-byung, a suppressed anger syndrome suffered by Koreans; and Latah, a Malaysian and Indonesian psychosis that leads to uncontrollable mimicking of other people.
They are the kinds of illnesses that psychologists refer to as culture-bound syndromes. Experts say that while they are fairly common among New York’s exploding immigrant population, they are often undiagnosed, or are confused with other conditions. But a growing number of mental health professionals are now focusing on patients’ ethnicity and country of origin to treat their mental illnesses.
Westerners have their own culture-bound syndromes. Anorexia nervosa, for example, most often afflicts young women exposed to movie and television images of an idealized skinny female body. But immigrants tend to have poor access to mental health care and until recently, there were few mental health services like the new program in Queens, the Asian-American Family Clinic at Zucker Hillside Hospital. Dr. Yong Cho and Dr. Quixia Mei Lan opened the clinic four months ago, and they are already treating 40 patients who came from across Asia.
Dr. Cho, 34, an immigrant who was a chaplain in the South Korean Army, blends Zen Buddhism, Confucianism and psychotherapy in treating his patients, he said, tailoring the therapy to each patient’s culture and needs. In his office, there is plenty of Korean green tea, used for meditation. The treatment of culturally specific disorders may wind up being similar to the treatment of classic depression and other more general illnesses, with the use of psychotropic drugs or talk therapy or both. But for Asians it may mix different approaches: meditation and medication, Freud and Buddha. The main difference, cultural psychologists say, lies with the diagnosis: one person’s depression is another’s suppressed anger syndrome.
Dr. Cho’s partner, Dr. Lan, a Chinese immigrant in her 40’s, is a psychiatrist who also specializes in culture-bound syndromes. Dr. Lan said that her patients were accustomed to using herbs or to thinking of their problems as purely physical ones — they often complain only of a backache or a stomachache and not of depression — so it can take several sessions to persuade even severely depressed patients to try drugs. But both doctors said that more immigrants are becoming comfortable with the use of antidepressants like Prozac and other medications.
The stigma and shame attached to mental illness, which can be much fiercer in Eastern cultures than in the West, can keep immigrants from seeking treatment, according to several experts and a 2001 report by the United States surgeon general. Many of the 800,000 Asian immigrants in New York City live in close-knit communities, where word spreads fast.
”Asians are often very reluctant to seek help,” Dr. Cho said. ”They may go to a pastor, a fortuneteller or a friend’s mother, but never talk to a shrink.”
Ol Y., 46, a patient of Dr. Lan’s and Dr. Cho’s from Hong Kong, who spoke on the condition that only her first name and the initial of her last name be used, suffers from bipolar disorder. She waited years to seek treatment, filled with shame and with fear that the members of her church or her neighbors would find out something was wrong with her. She was treated with drugs by a Western doctor, she said, but her ”trembling,” anxiety and depression still would not go away. Her husband, who was laid off from his job as a software consultant for Wall Street companies soon after Sept. 11, 2001 — only adding to Mrs. Y.’s stress — said that he felt desperate to find her some help.
He began surfing the Internet and came upon information about the new program in Queens. Two months ago, Dr. Lan adjusted Mrs. Y’s medications. Then Mrs. Y. began talk therapy with Dr. Cho, who draws on a mixture of approaches, including Mrs. Y.’s deep belief in Christianity, to treat her for the disorder.
Besides her bipolar disorder, Mrs. Y., who immigrated here 20 years ago, suffers from stress related to culture shock and often feels isolated, Dr. Cho said. In treating her, he has focused heavily on the way her mood, her anxiety and her fears have been affected by going to New York and her lack of support in the tiny network of immigrants she knows. While Mrs. Y. was in treatment, she said, her mother, who refused to seek help for her own mental illness while living in Hong Kong, committed suicide.
”I can stand on my own feet,” Mrs. Y said. ”I don’t have to lie down all the time. I’m getting better and better.”
Asian patients have physical differences that also make their treatment different from people of Western backgrounds. According to an article in the September issue of The Western Journal of Medicine, ”Prescribing Medication for Asians With Mental Disorders,” many Asians develop side effects to medications at lower doses compared with other ethnic groups. The precise reasons are unclear, the article said, but it is believed that biology — such as how the liver absorbs and the body processes medication — plays a large role.
Dr. Henry Chung, clinical associate professor of psychiatry at the New York University School of Medicine and a co-author of the study, said that Asians tended to absorb medication more slowly. ”The standard rule of thumb,” he said, ”is to give Asians half the dosage.” Depression has been shown to be a condition that can be aggravated or brought on by adjustment to life in a new country. The stress of learning English or the inability to speak it can also lead to anxiety or can intensify a mental illness, according to Dr. Cho, particularly for immigrants who were highly educated in their native countries but find themselves barely able to communicate here.
Even among immigrants who do seek treatment, many are often afraid or reluctant to spell out what is bothering them. Dr. Cho said that he often had to coax his patients into talking and that traditional approaches to therapy — like asking, ”So what’s going on?” and then just listening — did not work. He might give advice to break the ice, he said, or even teach his patients about terms like depression and anxiety.
In fact, some languages, like Korean, have no specific word for depression, according to Dr. Cho. There is a term for ”a little bit irritable,” and someone feeling depressed may talk about having a ”down heart,” while tapping a fist against the chest. But such culture-bound syndromes, which are listed in the standard reference of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders, are not limited to Asians.
A common disorder among Hispanics, for example, is a condition called ”ataque de nervios,” in which so much pent-up anxiety and anger come out that a sufferer will fall on the floor and may experience uncontrollable shouting, attacks of crying and heat in the chest, said Dr. Julia Ramos-Grenier, a psychologist and professor at the University of Hartford. Dr. Ramos-Grenier said that although some disorders linked to different countries with different names may seem similar, many are distinct. Ultimately, she said, cultural experiences are essential to understanding mental illness.
”Understanding the culture of the individual,” she said, ”has a lot to do with making an accurate diagnosis.”
Making it even harder to diagnose some diseases is that, in some cultures, anger and anxiety can become bottled up because talking about mental distress is not acceptable, Dr. Cho said. The Korean suppressed anger syndrome, hwa-byung, is particularly common among middle-aged Korean women, who may have felt afraid to express their feelings for much of their lives, Dr. Cho said. The symptoms include constriction in the chest, palpitations, anxiety and poor concentration. Dr. Cho said the syndrome is common among Korean immigrants, and knowing about it is crucial.
”Otherwise,” he said, ”you might not be able to understand them. You might be able to understand their symptoms, but you might not understand what’s really happening behind their symptoms.”
Photos: Dr. Quixia Mei Lan, right, and Dr. Yong Cho, second from right, meeting with a patient at the Asian-American Family Clinic at Zucker Hillside Hospital in Queens. A brochure for the clinic, which provides mental health services, is printed in English, Korean and Chinese.