Amy welcomes Ti Hsu, a PhD candidate in clinical psychology at the University of Iowa, to discuss stereotypes and stigma surrounding the mental health of Asian Americans and creating culturally responsive therapy services among different populations.

Lauren Lavin:

Hello everybody, and welcome back to From the Front Row. Happy New Year. We hope you enjoyed your holiday season, and we’re excited to bring to you another semester of great podcasts and guests. If you are new here, welcome. We’re a student run podcast that talks about major issues in public health and how they’re relevant to anyone, both in and outside of the field of public health. Now I’m going to turn it over to Amy to introduce our guest.

Amy Wu:

Hi everyone. Today I’m joined by Ti Hsu, a friend and colleague of mine at the University of Iowa, who’s current research focuses on clinical psychology, and she has an interest in Asian American mental health. She’s a fourth year doctoral candidate in the clinical science program here at UIowa. And before this, she got her BA from St. John’s College in Annapolis, completed a post baccalaureate with National Cheng Kung University Hospital and National TiE. University, and she has an additional MS in experimental psychology from William and Mary. Today, Ti and I will be talking about therapy and mental health with our own unique focus on the Asian American experience, and we’ll also talk a little bit about her research comparing loneliness in Asian American students compared to European American students. Well, thank you for joining us today, Ti. Welcome.

Ti Hsu:

Thank you for having me, Amy. This is so exciting.

Amy Wu:

I know. This is so fun. I’ve been looking forward to this episode for a long time. To begin, would you like to talk a little bit about what your clinical work is like? And I know when we’ve talked before, you’ve mentioned that your clinic or where you work offers bilingual Mandarin and English counseling, for example. So, I’d love to hear more about just what clinical work is like and maybe the unique services that you guys offer.

Ti Hsu:

Yeah, thanks. Thanks for letting me put it in a plug for this. So, the clinical psychology PhD program here, we as students are really lucky at UIowa because we have an in-house clinic, and that’s the Carl East Seashore Psychology Clinic. It’s really where we get a lot of our training. We deliver both assessment and therapy services here, and we currently have a new capacity to provide culturally responsive therapy services in Mandarin. So, that will be like a Mandarin-speaking therapist who’s being supervised by a Mandarin-speaking supervisor. So, this is new for us, but in addition to the clinic’s values of providing evidence-based services, we also have the value of providing culturally responsive care. So, I’m happy to talk more about that and why that’s important in therapy with diverse clients. But yeah, I’m just going to stop there and say, yeah, if you’re somebody who would benefit from therapy services and Mandarin, please reach out to us at the clinic. You can find us on our UIowa website with all of our contact information and hours, and yeah, it would be super cool if we could hear from some folks, so…

Amy Wu:

Yeah. Actually, if you could talk a little bit about perhaps the unique set of approaches that you might have to use with students from different backgrounds or different language backgrounds even.

Ti Hsu:

Yeah, so that’s a cool question, and I think in order to address that question, we have to talk about this concept of culture, right? So, what do we mean when we talk about culture and culturally responsive care? So, there’s been a lot of research done by social psychologists about this idea of culture being sort of this sum of lifestyle, behavioral patterns and products of a group of people that involve things like language, music, artifacts, history and social rules. And this amalgamation of things as it’s being sort of passed down through generations is this idea, it becomes this culture, right? And so we know that culture influences the meaning that people attribute to their symptoms of psychological distress as well as their interpretation of the causes and the implication of these symptoms, right? So, we know that, for example, there’s a lot of stigma in the Asian American community about pursuing mental health or even mental health difficulties in and of itself, right?

So, that’s one example. And so it’s really important to take cultural elements into consideration when you are in a therapeutic relationship with somebody, right? We want to understand as well as we can, how people think about the problems that they have and how we can best support them, given that interpretation, right? Rather than putting our idea of what the problem is or how they should interpret the problem on them. So, this culturally responsive therapy idea really was born out of this, the multicultural movement in the 1970s, right? Which involved the acknowledging of these different cultural elements and the emphasis of that in this therapeutic relationship, which can help us use culturally appropriate clinical skills in working with the client, and as well as in formulating a diagnosis, right? So, it really just permeates all aspects of the work.

Amy Wu:

Yeah, that’s awesome. I think I definitely relate to at least having a different paradigm that I’m submersed in and how that might affect how I receive care. And I think that’s especially made distinct in how sometimes when I converse with my parents, I can see, “Oh, they’re very culturally immersed in something different from what I’ve been culturally immersed in here in the States.” So yeah, that’s really cool that you guys do this very tailored approach to counseling with these students.

Ti Hsu:

Yeah, I guess another thing that’s important to emphasize is that this framework can be used with the evidence-based interventions that we have lots of research about, like cognitive behavioral therapy, which is a main focus of our clinic or third wave cognitive behavioral therapies like acceptance and commitment therapy, which I research and other… So, it’s very much congruent with these therapies that we know can really help people, right? So, having those techniques as well as acknowledging the cultural pieces is sort of the emphasis.

Amy Wu:

Right, so I’m hearing a very holistic, progressive type of counseling that involves a lot of different methods used in the past that are still being developed and then also this element of the cultural responsiveness.

Ti Hsu:

Mm-hmm.

Amy Wu:

Yeah. And so on the subject of having different students from different cultures in your counseling, maybe we can talk a little bit about your research or interest into the Asian American population. We talked a bit about how there’s a little bit of stigma still on seeking mental health help in this population, and of course the Asian American population is a diaspora, but what have you learned about this population so far in your research and then anecdotally in your counseling?

Ti Hsu:

Yeah, so that’s an interesting question. So, first what I will say is that there’s a really cool body of research on sort of Asian American mental health, the Asian American experience that is being conducted by really cool Asian American researchers, psychologists. And I think as a subfield we’ve come to recognize that the Asian American experience is not homogenous, right? And yet a lot of the time in research we’re lumping together people with an East Asian background and a Southeast Asian background and the South Asian background, and there should be more research disentangling differences between those groups too, right? Like you said, we’re not a monolith. There’s definitely a lot of variability. And on top of all of that, there is variability in immigration status, right? How long have you been in this country? Are you first generation, second generation, third generation? Right? All of those factors as well as country of ancestral origin can all interact to affect how somebody is in this society, right?

So, those are a lot of the questions that are still being investigated and are salient, I guess in this research. But recently there’s also been a lot of work on the adverse effects of discrimination as a result of the COVID-19 pandemic. There’s lots of important work there that not only gives us the raw data of just the rise of hate crimes, the rise of discrimination during that time, but also its adverse effects on Asian American mental health. And I think part of the power of that research is to show that this is a real thing, right? And this is something that is worth our time to discuss and also worth the time to really think about and dissect. So, I think it’s great that we have all of that work out there. I think another really important aspect of the research on Asian American mental health and psychology is sort of the clarification of the effects of prevalent stereotypes on Asian American mental health. So, when we talk about Asian American stereotypes, the big three are the model minority myth, the perpetual foreigner stereotype, as well as the healthy immigrant stereotype, right?

So, just starting with the model minority myth, it’s probably the most well-known, right? It’s this perception that all Asian Americans across all Asian groups are super high achieving in both terms of academic and economic achievement, right? But we know that that’s not necessarily the case, right? There’s no evidence showing that Asian Americans as this monolith are just better at these things than any other ethnic group. And so it’s important to acknowledge that, “Oh, what this stereotype serves is division among Asian Americans and Black Americans.” Which helps uphold White supremacy and not only has an adverse effect on society as a whole, but also on Asian Americans who are saddled with that expectation to always be perfect, to always be high achieving.

So yeah, and that goes hand in hand with the perpetual foreigner stereotype, which we saw again and again throughout history, right? Asian Americans have been blamed for diseases from starting in the 1800s all the way up to now with COVID, right? It’s like, “Oh, these foreigners, they’re exotic, they’re dirty, they bring these sicknesses.” And so isn’t it ironic that we have both that and the model minority myth, that both serve to sort of hinder this process of assimilation into the society, right? It’s a way to sort of isolate and disenfranchise, right?

Amy Wu:

Right. And it’s also whichever narrative is most convenient at whatever time. And it’s also interesting to see that with the COVID pandemic, that’s not the first time that has happened of people seeing Asian Americans as foreigners who [inaudible 00:13:46] diseases and how that has been [inaudible 00:13:49] throughout history, so…

Ti Hsu:

Right, and I mean, I’m just thinking of the yellow peril, all of those stereotypes that have permeated American history, but that we don’t discuss or point out even when we’re in the same cycle again. But, yeah, and all these stereotypes, including the third one, the healthy immigrant stereotype, right? Which is the assumption that even though folks may not have as much access to healthcare or resources, that it doesn’t matter, because they’re built different and they’re hardy, they can take it, right? So, all of these stereotypes actually contribute to disparities in healthcare just overall and also disparities in mental healthcare. Why would folks who are marginalized in this way trust mental healthcare services to understand these experiences, right? When most of the treatments that we have today are based in western theories of psychology, right? Yeah.

Amy Wu:

It’s also why would… The model minority myth, I think that’s a very tricky narrative, because minorities might want to subscribe to that because it’s almost a compliment. So, that also perpetuates maybe not seeking help because you’re expected to be the model minority or you’ve been told you are, or you expect that even of yourself. So, you have this interplay of the different narratives that are potentially also still affecting or perpetuating just the stigma around seeking mental health.

Ti Hsu:

Yes, yes. Yeah, I really agree with that, yeah and I think a lot of family and individual factors can also reaffirm some of these stereotypes and make it even harder for folks to seek out the care that they might want.

Amy Wu:

So, I got the chance to read one of your research papers, so I thought I would ask a little bit about the background on that. So, for example, in your paper you talked about this thing called acculturation as measured by the Vancouver Index of Acculturation. And so I’m interested to hear you explain what that is in the context of context, for example, loneliness as experienced by Asian American students versus their European American counterparts.

Ti Hsu:

Yeah, thanks for that question. This is a project that I started pursuing when I was still in my master’s program. And this paper has always been a passion project for me, because we have sort of this cool data from this really diverse group of college students, and we have both data collected on the day-to-day level about their mood or their perceived stress, as well as these withdrawal behaviors, as well as more general measures of loneliness, right? Or of acculturation, which I’ll talk about in a little bit, right? And so we’re able to track on these daily behaviors and moods into these more general ideas or trends or concepts actually, yeah. So, one of the special things about this paper is that we did have a measure of acculturation, and it’s something that we took into account when looking at these daily correlates of loneliness. So, acculturation is defined generally as this process through which individuals from one culture when they migrate or when they move to another culture start to pick up on the cultural patterns of that culture, right? So, it’s like learning this other world almost.

And yeah, and this concept really came from research on inter-group relations before, right? So, we’re talking about groups of people, but as psychologists picked it up, it became a more individual level variable of identification with this new culture as well as identification with your what’s sometimes called heritage culture, right? There’s been research on acculturate of stress, right? So, we can both imagine how it would be really stressful to be picked up from one culture and dropped into another, right?

And we know that acculturate of stress is a risk factor for both poor mental and physical health. And so we really wanted to factor that in as we’re looking at this concept of loneliness, right? How much of this loneliness is a result of being in a culture that you just don’t know or aren’t familiar with, right?? Because a large part of our sample constituted students who had lived in the U.S. for less than a couple of years. Yeah, so that was the thought behind that paper, and we wanted to really see whether we would be seeing these different daily patterns, how something like loneliness can really affect someone’s mood or how much they seek out social support.

Amy Wu:

Yeah, and I was actually recently reading a book by Dr. Marisa. G. Franco, called Platonic, and it’s about building healthy friendships. And in it, she talks about how among 106 factors that influence depression, having someone to confide in is the strongest preventer. And she goes on to say that the impact of loneliness on our mortality is akin to smoking 15 cigarettes a day, or that meta-analyses have shown that the decrease risk of death that exercise has on our mortality is about 23 to 30%, diet is up to 24%, but having a large social network decreases our risk of death by 45%. So, it’s actually the greatest decreaser of risk of death. Yeah, I’m wondering also in your experience, even just as a PhD student in your anecdotal work, what are some of the best preventers of loneliness or negative mental health? How do you avoid the isolation aspect or what factors might contribute to being more integrated in a social network?

Ti Hsu:

So, loneliness is really interesting in that it’s not necessarily synonymous with social isolation. So, what I mean by that is that people can live mostly solitary lives and not feel lonely, right? So, we do know that there are folks who are like that. There’s research on folks who are like that, but for other folks, when you are more isolated, you do feel more lonely, right? So, there’s that sort of give and take there. And even the research on social support and loneliness has been really interesting in that it’s not about the size of your social network necessarily, but it’s more about the quality of the relationships that you have, right? That really can sort of ward off the negative health and mental health effects of loneliness. How these findings can be applied to Asian American students, especially international students or students who travel far away from home to go to school, that’s another question, right?

There are so many individual factors, and we’ve talked about cultural factors that can really affect somebody’s experiences of social belonging and of social support, right? And that’s why we have to circle back to that idea of culturally sensitive formulations that take all of those individual as well as systemic, as well as cultural elements into account.

Amy Wu:

Yeah, actually that’s great. I was going to mention that too, how it kind of… Well, first thank you for your clarification on loneliness versus isolation or solitude and how there are different nuances and they can be different. And someone who experiences solitude may not be experiencing loneliness. And I think like you said, that does bring everything back to the culturally attentive care that you and your colleagues provide, because each situation is different, and finding out how to get the best quality relationships over quantity is going to be most likely done on an individual basis. All right, at the end, we always have a fun question for our guests. So, the fun question for today is, what is your favorite piece of Asian American literature at the moment?

Ti Hsu:

Oh, right now, I mean, I can tell you what I’m reading right now. So, I finished this novel called Sea Change by Gina Chung a couple of weeks ago, and that’s a really interesting story actually, about isolation and social connection and abandonment. So, I think for readers who are interested in that theme, as told from the perspective of an Asian American woman, that might be an interesting read. I’ve also been reading work by Ken Liu. I’ve been reading his sort of anthology of short stories called The Paper Menagerie, and that’s also been really interesting to sort of see interpretations of that more sci-fi element by an Asian American author, and I know there are other authors who’ve done that, but, like one of my new exposures.

Amy Wu:

That’s awesome. Well, thank you so much for joining us today. This was Ti Hsu. Thank you again for sharing just your background and a little bit of what you’re researching and interested in the Asian American health space. So, thank you once again.

Ti Hsu:

Thank you, Amy.

Lauren Lavin:

That’s it for our episode this week. This week’s episode was hosted and written by Amy Wu and edited and produced by Lauren Lavin. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team? You can reach us at cph-gradambassador@uiowa.edu. This episode is brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.