Suicidal Asians Need Help, But Stigma, Language Barrier Impede Access to Care



On June 15th, 43-year-old Youhong Gao called her boyfriend, Wanguo Rao. The two argued over the phone, as they often had recently. Gao told her boyfriend, who was at work, that she was planning to swallow poison to kill herself. Rao didn’t think she was serious. But then he heard her groaning.

When he rushed back home, he found Gao tossing and turning on the floor. Beside her were empty beer and bleach bottles, whose contents she used to make her poison mixture.

Gao was sent to the hospital and survived. But not everyone is as lucky. Between March and August 2010, Chinese and Korean community newspapers in New York reported at least 10 suicide attempts. All but two succeeded, a record spike in New York’s Asian-American community.

The victims included a celebrity -- 35-year-old designer Tobias Wong, who was found dead in his East Village apartment -- and ordinary people like 75-year-old Guanqun Lee, who hanged himself from a tree at a Flushing park. The triggers, according to some victims’ farewell letters, included fatal disease and unemployment. But most didn’t write letters, leaving their family members in deep confusion and self blame

Most of these stories only took a small corner in the newspapers; many more were not reported to the public at all. Misunderstandings about mental illness, and the stigma placed on it by the Asian culture, contribute to the silence about it and lead indirectly to more suicides.

Low Suicide Rate 

Suicide in the Asian community has never gotten much attention. This may be related to its relatively low suicide rate. According to the data collected in 16 states and released by the Centers for Disease Control and Prevention in July 2010, the suicide rate for all Americans in 2007 was 11.6 per 100,000 people. American Indians had the highest suicide rate -- 18.2 -- followed by 14 for whites and 4.7 for Asians, the lowest rate of any ethnicity.

Still, according to the CDC and the American Psychological Association, while suicide is the 11th leading cause of death for Americans in general, it is the eighth leading cause for Asians. For 15 to 24-year-old Asians, it is the second leading cause. And 15- to 24-year-old and 65 and older Asian women have the highest suicide rates among their same age peers of any ethnicity.

Studies have found that 60 percent of people who commit suicide suffer from depression. Depression is a serious issue among Asian seniors. According to a report by the Asian American Federation, two fifths of Asian women 65 or older in New York have depression, twice the rate of all women in this age group living in the city. The New York State Office of Mental Health also found that five to 12-year-old Asian girls have the highest occurrence of depression symptoms among their same-age peers.

Suicide also claims college-age Asians. In 2009, three Asian students at the California Institute of Technology committed suicide within three months. And at Connell University, most of the 21 students who killed themselves from 1996 to 2006 were Asians, even though they make up just 14 percent of students.

“Many times, people only focus on the average suicide rate. But this could be misleading. For example, white men have a high suicide rate, but it is mainly because senior white men’s suicide rate is high. If you look at the Asians this way, the suicide rate is low, but this could disguise a lot of urgent issues in the community,” said Eliza Noh, associate professor in the Asian American Studies Program at California State University, Fullerton.

Why Suicide?

As an undergraduate, Noh decided to devote her academic career to studying the suicide issue among Asian women. At the time, there were few statistics available, a daunting situation for a researcher. But Noh was very determined. To her, this is not only a job, but also a personal mission.

Noh’s younger sister killed herself with a gun in 1990 when she was a junior in college. Noh doesn’t want to talk too much about this heartbreaking incident, but she has been trying to find answers for her sister and other Asian women in the same situation.

Studying suicide is not an easy job because of the sensitivity of the topic and the myth that talking about suicide with a suicidal person might push him or her further to the edge. As a result, research in this field is far from comprehensive.

Nonetheless, Noh has managed to interview 41 Asian women who attempted suicide. She found heredity and the pressure from the culture and the society were major factors.

“For younger Asian women, the stereotype of model minority is overwhelming. They fall in depression or commit suicide when they cannot meet the expectations from the family and the society. For older Asian women, it is more like they don’t want to be a burden for their family when they are sick, or they are drained by the isolation and loneliness set by the language barrier,” said Noh. She acknowledged that her own sister had made it clear before she died that she hated being Asian. She even underwent plastic surgeries to make her face look more Western.     

Irene Chung, a psychotherapy researcher at Hunter College, interviewed 31 suicidal Chinese immigrants, including 19 females, for a report in 2008. She found that the language barrier and lack of job opportunities and a social network all contributed to their suicide attempts. Domestic conflict associated with immigration was a major factor.

“Many women came to the U.S. through marriage. When they couldn’t get along with the husband’s family, they had nobody to talk with. Not even their own parents in China, because they’d be considered as a loser or be told to maintain their marriage. They often felt there is no way out,” said Chung.

Research from Washington University found American-born Asian women are more likely to be suicidal than immigrant Asian women. And the longer Asian immigrants live in the United States, the more likely they’ll think about suicide. Also, more American-born Asians are mentally ill than Asian immigrants, something researchers can’t explain.

One Person’s Battle

June Shieh puts a human face on the research findings.

Settled in the United States with her parents when she was nine months old, the Taiwan-born Shieh lived an outwardly enviable life. The Shiehs lived in a comfortable house in an affluent neighborhood in Rancho Palos Verdes in Southern California. The parents, who had been architects in Taiwan, ran a family-owned real estate firm. The kids went to the best public school in the area.

But within the household, the picture was less rosy. As new immigrants, the parents faced challenges and argued a lot. An older brother suffered from Asperger’s Syndrome. And Shieh herself, bearing the weight of what she calls a “dysfunctional family,”  lost her happy self. She no longer smiled at home. Sometimes she didn’t want to wake up in the morning, and she thought about suicide, even though she was only 11.

What she didn’t know was her own depression paralleled her mother’s. One seemingly normal school day when Shieh was 15, she said good-bye to her mother in the morning, as usual. But in the afternoon, she was surprised that her cousin picked her up instead of her father or brother.

The cousin took Shieh to his own home and told her her mother collapsed in the kitchen and was sent to the hospital. The next day, when Shieh went back to her own home, her father told her her mother had died from a heart attack. “I was totally numb, and I didn’t even cry until several days later,” said Shieh.

Not until her father died from cancer in 1997 did Shieh learn from her brother that the mother had not had a heart attack. She had hanged herself in the yard of the family’s house.

Shieh, now a toy designer living happily in New York, said she had never received therapy for her own depression. Instead, she pulled herself out with the help of a second brother and by writing in a diary. By the time when she went to college, she had more friends and felt better.

In retrospect, Shieh said the isolated life as new immigrants and the lack of understanding of mental health may have been the main reasons that her mother’s depression went untreated and led to her suicide. 

“My mother had few friends in the United States, and she buried her suffering all in her own heart,” said Shieh. “Also, we didn’t have insurance, and we couldn’t afford to see the psychiatrist. But even if we could afford it, we probably still wouldn’t have visited a clinic. Neither I nor my parents believed American psychiatrists could completely understand our Asian problems. At that time, we knew little about mental health.”

Mental Health Neglected

The Shiehs’ neglect and ignorance of mental health is not unique. Rather, it is a nearly universal problem in the Asian community, and it makes suicide prevention a much harder job.

Asian Americans do not often use mental health services. When they fall into depression, they are more likely to focus only on the accompanying physical ailments, such as a stomachache or insomnia, which few suspect are caused by mental illness. Many people miss the best time for treatment as a result.

Xiaochun Jin, a practicing psychologist and assistant professor of psychology at The New School, has a caseload that is about half Asian, mainly Chinese. Most of his Asian patients didn’t come to him until they were very ill.

“To see a shrink is not a big deal for Westerners. They could come to my office only because they feel gloomy. But Chinese take the psychologist’s office as emergency room,” said Jin.

Sometimes, even an appointment early in depression is too late. Jin had a prospective patient who was in deep depression after she broke up with her boyfriend. She talked about suicide. A friend who knew Jin helped her make an appointment. But the night before the appointment, she killed herself by jumping from the balcony of her seventh floor apartment.

Maggie Luo, the coordinator of the Chinese American Mental Health Outreach Program offered by the New Jersey chapter of the National Alliance on Mental Illness (NAMI), knows of similar cases.  When Lou went back to work after a weekend around the Spring Festival in 2007, she found a message in her phone from a Chinese man who said he was suicidal, but would like help. When she called him back, his wife picked up the phone. She told Lou her husband had just killed himself.

Last month, Lou got a phone call from a woman who told her that she got the number from a newspaper clip she had kept since 2004, when she first realized she might need help.

Both Jin and Lou think the Asian culture deserves a lot of blame for these tragedies. “Sharing one’s thoughts is a tradition in the Western culture; for example, the confession of Catholics is a type of sharing. But the Asian culture is introverted. Asians don’t like to share their feelings, especially negative ones,” said Jin. “Also many Asians don’t think mental illness is a disease. They think it was caused by one’s own cowardice. So people who get the disease are reluctant to seek help, fear of being looked down by others.”

Lou pointed out many Chinese immigrants came to the United States seeking success. They see mental illness as the mark of a loser, and, therefore, unacceptable. “When we refer them to mental health clinics, many of our clients prefer clinics far from home because they don’t want friends to know,” she said.

Lou also noted that the lack of insurance could make the situation worse. Many Chinese run small businesses. They don’t bother buying health insurance for themselves and cannot afford mental illness treatments. In New Jersey, only 13 percent of Chinese who are eligible for Medicaid are covered, compared with 24 percent of whites. And even with Medicaid, it is still hard to get help, since many private practitioners don’t accept it.

Cultural Competency in Need

The special cultural background of Asians makes it difficult for professionals unfamiliar with the culture to serve the community. Those with expertise have their own tips for breaking down barriers. Jin, for example, is very flexible about his working hours so the Asian patients can make appointments quickly in urgent situations. And he never says hello to a patient on the street unless the patient talks to him first.

“Many Asians don’t want their friends or family to know they have been visiting a psychologist because of the stigma. I don’t want to expose them in public,” Jin said. Also, Asian patients always want to get practical suggestions in short time. “They won’t give you time to talk about their childhood problems,” Jin said.

Eva Ng, a psychologist with a clinic in Brooklyn, said understanding the etiquette of her Chinese patients is very helpful. For example, when shaking hands with patients, she often uses both hands, because it is considered friendlier than one hand.

Also, when handling psychological problems triggered by domestic conflicts, she always tries to put them in the context of Asian families. For example, tension between the daughter-in-law and the mother-in-law is common in a Chinese household, which can sometimes trigger depression in one of them. “If you don’t understand the Chinese culture, you may not even know why the two have to live together,” said Eng.

Similarly, some counseling methods effective to mainstream patients may not work for Asian patients. Peter Yee, assistant executive director of the Hamilton Madison House, a mental health services organization in New York that mainly serves Asians, found group counseling didn’t work at all with his Asian clients. “Asians don’t like to talk about their problems with strangers. One-on-one counseling works better on them,” said Yee.

Language is another barrier. Maggie Lou of the Chinese American Mental Health Outreach Program has compiled a list of psychologists and psychiatrists in the tri-state area who speak Chinese. There are only 30.

“We consider ourselves as a bridge between people in need and those who can provide professional help. But on one side of the bridge, the need is increasing rapidly, and on the other side, the resources are little,” said Lou.

Community-based organizations are struggling themselves. Lou’s program, for example, lost all its government funding in 2010 due to cuts in New Jersey’s state budget. NAMI is determined to maintain this program by seeking contributions. Still, some activities, such as the Chinese New Year party for clients and their family members, may have to be eliminated.

In New York, things are no better. Asians make up 6 percent of the population, but only get 1 percent of government funding for mental health services. In 2009, with the help of Peter Rivera, chair of the Mental Health Committee of the State Assembly, the state, for the first time, allocated $450,000 for suicide prevention education in the community. Community organizations that got the funding have printed more than 40,000 brochures and plan to provide relevant training to 1,000 people.

But this may be inadequate.. “With the money, we may be able to help raise the awareness, but then there will be a spike of demand, and we won’t have follow-up funding to help them,” said Yee of the Hamilton Madison House.

Asian LifeNet, a suicide prevention hotline sponsored by the New York City government, still has stable funding. “It’s really to maintain the team, because the funding level has not changed for years, and there is no pay raise at all,” said Tracy Luo, the director of the program. In the last year, Asian LifeNet has lost three counselors who speak Asian languages. Now, many callers can only talk to counselors with the help of interpreters, and some have ceased seeking help because of the language barrier. “With the interpreter, the conversation has to be interrupted every now and then. Also, some callers don’t want one more person get to know their secrets. So they stopped calling,” said Luo.

There Is Hope

Although the budget doesn’t seem likely to loosen any time soon, services in the community are inching forward. “At least when we hold suicide prevention workshops now, many people come to attend. In the early years, few people were interested,” said Luo, who’s been working for Asian LifeNet for eight years.

Jin, the psychologist who teaches at The New School, also feels hopeful. The university’s psychology program hadn’t enrolled a Chinese student for many years. But last year, the master’s program enrolled three Chinese students. “Chinese parents didn’t want to pay for their children to study psychology because the market is narrow. They’d like them to get into a medical school. But now things seem to be changing,” Jin said.

To Junjie Chen, a student from Stuyvesant High School, the dream of becoming a psychologist or psychiatrist is motivated by his mother’s mental illness. Chen’s mother was smuggled to the United States 20 years ago from China. She was traumatized by the horrible journey. When Chen was born, his father left his mother. The hardship drove her into serious depression, and she attempted suicide several times.

With the help of a church, Chen’s mother is getting better. But he knows there are many more people like his mother who need help. “I want to study psychotherapy to help them find happiness,” said Chen.   

(This article was conceived and produced as a project for the Dennis A. Hunt Fund for Health Journalism, which is administered by The California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communcation & Journalism.)