Breaking Silence
“For the most part, our patients are wonderful individuals but…,” our Psychiatry clerkship director paused to start passing out personal safety alarms, “you should always have your device nearby while on the unit.”
Her instructions seemed a bit dramatic for my rotation, which was set to take place on the
Child and Adolescent (CAP) unit. When we submitted our site preferences, I envisioned bleached white walls and squashy couches where I would learn how to best support young minds during that tricky transition from adolescence to adulthood.
“Raymond” was the first patient I admitted from the Emergency Department. His parents brought him in after he barricaded himself in the bathroom and texted the family group chat that he was going swallow 10 bottles of Tylenol pills. I asked Raymond if he had any details that he wanted to add from his parent’s account, but he wasn’t interested in answering my questions—or talking to me —in any capacity.
Once he arrived on the unit, Raymond mostly kept to himself. He was highly intelligent but socially isolated. He spent time outside of mandatory group therapy sessions working on puzzles or sometimes, staring out the window overlooking the main boulevard in front of the hospital. I wondered what kind of life existed for him in the outside world, but he refused to engage in any meaningful conversation about his thought process.
Our CAP fellow was not surprised by this behavior. He, like Raymond, was raised by Chinese immigrants and initially decided to pursue Child and Adolescent Psychiatry because he saw the need for more culturally sensitive providers to destigmatize mental health for Asian Americans.
“You have to understand, this is a sixteen-year-old kid who maybe never learned how to have an open conversation about his feelings because some of those words don’t even exist in Mandarin. Give him time.”
In Child and Adolescent Psychiatry, we were instructed to think of our patient’s presenting problem in the context of their environment. Scribbled on the workroom whiteboard were a series of concentric circles labeled “Patient,” “Family,” “School/Peers,” and “Community.” Each circle played a role in their disease pathology and as providers we needed to think about treatment options that offered the most over-lap between all the circles.
Eventually we untangled a complicated dynamic of intense feelings of sadness and loneliness that started when Raymond was in middle school. He knew that his parents loved him but didn’t know how to describe why he felt so alone, especially after knowing how much his parents sacrificed to raise him in America.
Raymond’s experience reflects current demographic data that shows Asian Americans are less likely to receive mental health treatment compared to other racial and ethnic groups. A study from Health Affairs found that 58 percent of Asian Americans reported worsening mental health after the COVID-19 pandemic and accompanying wave of racially motivated hate crimes, exacerbating an already profound need for culturally and linguistically sensitive mental health providers.1 There is no panacea for eliminating health disparities. Some professionals call for greater education about the science behind pharmacologic agents such as SSRIs to dispel thinking that mental health conditions are a result of personal failure. Others emphasize greater acceptance of traditional healing methods through integrative medicine. However, the literature consistently shows the importance of acknowledging cultural background in establishing patient-provider trust and building a strong therapeutic alliance.
One morning during rounds our attending asked Raymond to consider family therapy as a communication tool with his parents so they could learn from each other how to best support Raymond. This would be a change in their family dynamic, but something his parents were open to when the treatment team privately explained to the importance of speaking frankly about his mental health.
At first, Raymond didn’t respond. Just as the silence was becoming awkward, our fellow asked Raymond a question.
“Raymond, are you scared?”
He sunk his teeth into his bottom lip before nodding in agreement.
“I’ve been speaking with them every day and they’re not mad at you. They love you and really want to help you get better. Even if it means trying something new.” Challenging centuries old behavior and creating space for emotional vulnerability is scary. But when there is mutual respect and understanding of someone’s background, physicians can empower patients to build the confidence necessary to take the first step in the right direction.
Kaveri Curlin is a third year PRIME LEAD-ABC medical student at University of California, Irvine School of Medicine. She attended Yale University for her undergraduate studies, and she is interested in using story telling as a form of patient advocacy.
References
- “Addressing The Mental Health Needs Of The AAPI Community,” Health Affairs Blog, September 1, 2021. DOI: 10.1377/hblog20210827.800655