Introduction: The Recovery Concept and Its Origins
The Mental Health Commission defines recovery as “the ability to live well in the presence or absence of one’s mental illness” (O’Hagan, 2001, p. 1). People with mental illnesses have different definitions and views on what it means to live well. The definitions are broad and are mainly based on people’s experiences and cultural backgrounds. Moreover, the recovery process is different for each individual suffering from a mental illness. As a result, the recovery approach necessitates mental health professionals to make use not only of their own resources but also of the resources of the patients and the communities in which they live. Recovery is said to take place when people suffering from mental illnesses are actively engaged in making their lives better, when the communities around them accept and embrace people with mental illnesses, and when mental health professionals make it possible for the patients to interact freely and meaningfully with their families and members of the wider community. The recovery process is therefore a holistic one and involves not only the patients but also other members of the community.
The concept of recovery in mental health originated in the United States and most of the studies on recovery are actually US-based. In the late 20th century, this concept made its way back to the mental health scene thereby facilitating various longitudinal studies in the 1970s and ‘80s, majority of which reported either partial or full clinical recovery of people with mental illnesses such as schizophrenia. In the late 1980s and the 90s, a new meaning to the concept of recovery was given by psychiatric rehabilitation and the user/survivor movement. This movement shifted the focus of recovery away from clinical perspective to a personal perspective. In other words, rather than a mere abatement of symptoms of mental illnesses, recovery was now viewed as a transformed sense of self and return to a life with meaning (Deegan, 1988; Anthony, 1993). Recovery can therefore occur whether or not a sufferer has the symptoms of the mental illness. This new meaning to recovery brought about a distinction between clinical and personal recovery although Slade (2009) argues that this distinction has not always been understood by mental health professionals.
Personal recovery is however viewed differently between psychiatric rehabilitation and the user/survivor movement. In New Zealand, psychiatric rehabilitation as a term is not commonly used although its goal is to address the functional deficits of people suffering from mental illnesses. On the one hand, psychiatric rehabilitation practitioners argue that their practice is more multi-dimensional and optimistic even though their practice is indeed based on the personal deficits of their patients (Ralph & Corrigan, 2006). On the other hand, the user/survivor movement is based on the concept of self-determination. Studies on recovery that are based on the user/survivor movement tend to focus on the deficits that are external to the individual rather than deficits emanating from the individual. As a result, such studies highlight environmental barriers and contributors to recovery (O’Hagan, 2002).
The user/survivor movement was influenced strongly by the social model of disability that emanated from the disability movement. This movement was of the opinion that it is the society that disables individuals and not the individuals themselves. According to proponents of this movement, the society disables individuals by failing to take into consideration the unique needs of people with disabilities and as a result they deny them opportunities that could make their lives better (Oliver, 1990). On the same note, the user/survivor movement argues that people with mental illnesses suffer not because of the illness but because of societal and environmental factors such as discrimination.
The aim of this paper is to critically analyze the concept of recovery from mental illness as is applied to the Asian people living in New Zealand. The paper will compare and contrast Asian perspective and Western perspective of recovery concept and will review various studies on the recovery of New Zealand Asians from mental illnesses.
Asian versus Western Perspective of the Recovery Concept in New Zealand
In New Zealand, changes to the immigration policy in 1987 saw a rapid influx of the Asians into the country. The Asian population makes up the fastest-growing minority group in New Zealand. With the rapid growth of the Asian population, an increase in various health problems specific to this group was experienced (Yee, 2003). Of critical importance has been the mental health of the Asian peoples living in New Zealand. Problems with the New Zealand Asian people have been attributed to various factors which are associated with their migration. These factors include: language difficulties, lack of social support systems, a breakdown of family and social ties, lack of meaningful employment opportunities, negative reception by the hosts, acculturation attitudes and a fall in socio-economic status after migration (Yee, 2003).
Data from official sources show that the Asian population’s mental health problems are similar to those of the general population in both prevalence and severity (Yee, 2003). Nevertheless, the Asians’ mental health problems present additional challenges to the New Zealand due to cultural differences. The cultural beliefs and practices of the Asian population differ significantly from those of the Western people, and these cultural beliefs and practices influence how the Asians view and access mental health services as well as the concept of recovery (Yee, 2003).
The difference between Asian and Western perception of recovery can be viewed from the collectivist vs. individualistic nature of the two societies. The Asian peoples are considered to be collectivist in nature; that is, they uphold family ties, relationships with other people and generally the social support system (Vang, 2007). In Asian, these social ties influence their way of behaviour in all sectors including health sector. Asians also value the hierarchical structure of their traditional households. On the other hand, the Western people are considered to be individualistic in nature (Amering & Schmolke, 2009). Family and other social ties are not as important and are only maintained if there is something to gain from them. Family and friends ties can be broken any time and no one will frown upon such behaviours. These differences have shaped the perception of recovery of the Asian and Western people (Yee, 2003).
The Asian recovery concept entails not only the feelings of the patient but also the patient’s ability to function well in his/her family as well as his/her ability to maintain social relations with others (Vang, 2007). It also entails maintaining the hierarchical structure of the family where the parents are expected to be the caretakers of the children and not the other way round. Any condition that threatens this hierarchical structure is frowned upon. During treatment therefore inclusion of family members in the therapy is considered to be of valuable help. The family is involved because it is considered to be a major source of emotional and moral support to those suffering from mental illnesses (Vang, 2007). Moreover, Asians are value their spirituality and therefore they tend to interpret their experiences in terms of their spiritual being. For instance, some illnesses, such as mental illnesses, have a spiritual meaning to the Asians, and this too may influence their perception towards the recovery process (Yee, 2003).
The Western recovery concept, on the other hand, focuses mainly on the individual patient (Vang, 2007, p. 51). Little or no attention is paid to the family and community. The goal of recovery from a Western person’s perspective is to restore independence and personal responsibility (Tew, 2005). Maintaining mental wellbeing is associated with cultural morals and values. Therefore, because Western people value independence, volition and exclusiveness, then what it implies is a Western person suffering from a mental illness can only recover if these values are restored. On the other hand, Asian people suffering from mental illnesses can only recover in the presence of social harmony, obligation to family and community and family ties (Yee, 2003).
Unfortunately, the recovery approach is Western-based because it promotes values such as “individual self-determination, sense of control, and personal responsibility” (Yee, 2003, p. 7). When dealing with mental problems of the Asian population in New Zealand therefore there is a need to incorporate the cultural beliefs, values and practices of this population so as to ensure effective and quick recovery.
A Critique of Literature
The need to study the mental health needs of the Asian population in New Zealand is highlighted in the article by Kumar, Tse, Fernando and Wong (2006). In the article, the researchers state that New Zealand has experienced a rapid influx of Asians in the last two decades. Between 1991 and 2001, the number of Asian immigrants in the country doubled. The challenges of migrating to a foreign land and leaving their families and friends behind have adverse effects on this population’s mental health (Tse, Tong, Hong & Rasalingan, 2011). The question therefore is: how do the Asian people in New Zealand deal with their mental illnesses and how do they view the recovery concept?
A number of studies have been carried out concerning how the Asian people in New Zealand view recovery from mental illnesses. These studies are recent and evolved following the large influx of Asians in New Zealand. Indeed, researchers began conducting studies on Asians’ health issues in the late 1990’s. Nevertheless, a report by the Ministry of Health in 2003 (dubbed “The Asian Public Health Project’ report) and the first Asian Health Conference held in Auckland in 2004 provided major milestones towards systematic analysis of the health issues faced by the Asian peoples of New Zealand. All in all, the studies focusing on Asian recovery of mental illnesses show that their perception towards recovery is strongly founded on the Asian culture.
Ho, Au, Bedford and Cooper (2003) conducted a literature review on the mental issues faced by the Asian population in New Zealand. This study was commissioned by the Mental Health Commission of New Zealand. The article identifies the major adaptation problems and challenges faced by this population as: language barriers, unemployment, disruption of family and social support systems, acculturation problems, and traumatic experiences before migration. These problems contribute significantly to the mental health problems experienced by this population. One of the protective factors of this population is social support. Given the collectivist nature of the Asian people, it is no surprise that Asian immigrants in New Zealand cope better in the presence of a social support system.
The study also shows that utilization of mental health services by the Asian peoples in New Zealand is affected by their beliefs: the belief that some mental illnesses such as schizophrenia are caused by supernatural forces as a punishment for wrong doing. As a result, sufferers of such illnesses are ashamed and stigmatized and find it difficult to seek treatment. Other barriers include language difficulties and cultural differences. Majority of the Asians in New Zealand are not proficient in English, which in turn makes it difficult for the patients to express themselves and even harder to access information about the existence of such services. The use of interpreters is viewed by most Asians as intrusion into family privacy and where children are used as interpreters it is seen as a reversal of the hierarchical structure of traditional households. Moreover, cultural differences between the Asian and the Western mode of evaluation and treatment make it difficult for both the healthcare professionals and the clients. Misunderstanding between the healthcare professional and the client can lead to misdiagnosis and negative health outcomes. Ho et al. (2003) argue that “professionals may find it difficult to understand the patients’ socio-cultural background, and what is ‘normal’ and ‘abnormal’ behaviour and beliefs in their ethnic communities” (p. 38). All these factors affect the accessibility of mental health services by the Asian population in New Zealand, which in turn affect their recovery process and perception.
Ho et al. (2003) suggest that when addressing the mental health issues of the New Zealand’s Asian peoples, a number of strategies should be taken into consideration such as improving cultural diversity in the public domain, providing extensive information to the immigrants, and improving access to English language. Perhaps the most important recommendation made is developing and supporting community support programmes. These programmes would enable the Asian immigrants to develop contacts with people from the same culture, thereby creating a supportive system for social interaction and mutual support. This can go a long way in helping the newcomers deal with stress of settling in as well as to have support if they develop mental illnesses. The researchers recommend that further studies should be conducted on the mental health of high-risk groups such as women, students and refugees.
The significance of social support in the Asians’ mental health and recovery perception is also highlighted by Scott, Doughty and Kahi (2011). The researchers argue that recovery takes place within a social, political and cultural context and commend New Zealand for being a leader in placing recovery at the centre of mental health services, more so as they apply to the Asian population. The study further states that social support can facilitate recovery in various ways. First, social supporters should focus on the strengths of the patient rather than on the deficits. It involves “not always talking about what was going wrong and what they could not do, but actually forgetting that and moving towards something good” (Scott et al. 2011, p. 24).
Second, the recovery process is about building hope in the patient. It is about cultivating in the patients the belief that although today they are at a disadvantage and are dependent on other people to function, life is long and with flexibility and some resilience, the situation may change for the better in future. Most importantly, social support systems can facilitate recovery by abstaining from judging the patient and allowing the patient to share his/her experiences. This is very important for the Asian peoples especially because of their beliefs that their condition is some sort of punishment for something wrong they did. As one peer supporter put it, “it’s about being part of the journey of recovery no matter where someone is… by sharing our story and demystifying a lot of stuff around having mental illness, it makes a huge difference,” (Scott et al. 2011, p. 24). The study by Scott et al. (2003) aimed at, among other things, looking at the impact of peer support systems on the lives and recovery of patients with mental illnesses. The study has shown that peer support is very crucial in the recovery process of people suffering from mental illnesses.
Following the report by Ho et al. (2003), the Mental Health Commission through Yee (2003) conducted a second study on the mental health needs of the Asian population in New Zealand. The second report is written in response to the reaction of the government and the Asian community to the first publication. In recognition of the health challenges faced by the Asian population in New Zealand, the government has undertaken various strategies aimed at improving this population’s mental health. These strategies include: Asian-focused research studies, provision of information to the population about social and health services, and catering to the direct needs of the Asian peoples. In undertaking these activities, the government uses two approaches, which are sensitive to the culture of the Asian people. The first approach is the verbatim translation approach, whereby crucial documents are interpreted into Asian languages to increase access to vital information by the population. The second approach is the cultural translation approach, which entails understanding the cultural beliefs and practices of the Asian people and acting in a manner that uplifts them.
Yee (2003) argues that of these two approaches, the latter approach – the cultural translation approach – is more vital for Asians’ recovery process. This is because “it requires a shift in mindset; a level of deep immersion in a world of different values, morals and philosophies,” (Yee, 2003, p. 6). This approach takes into account the Asians’ value of family relationships, obligations and filial piety. For instance, through the Guardian Visa programme, young parents are allowed to accompany young Asian students. This helps to reduce the breakdown of family and social support systems and thereby reduces the level of stress of young Asians migrating to New Zealand.
Yee (2003) also mentions the fact that the stigma associated with mental illnesses in the Asian populations is compounded by the small size of these communities in New Zealand. As a result, patients with mental illnesses in these communities engage in somatisation as a way of presenting their illnesses. This strategy is used to hide and avoid stigma from members of the community as well as from external sources. The MHC report therefore emphasizes the need to de-stigmatize mental illnesses in the wider community so as to create a community-based approach to personal recovery from mental illnesses.
The success of the first Asian Health Conference held in Auckland in 2004 led to a succession of other series of conferences in the subsequent years. The most recent of these conferences was held in 2010 and was dubbed “An Holistic Approach to Asian Health” (Centre for Asian Health Research and Evaluation (CAHRE), 2010). CAHRE published a report on the conference’s proceedings. In one of the papers presented at the conference, Wang (2010) examines bipolar disorder (BD) in the Asian population of New Zealand, specifically the Chinese immigrants. The researcher wanted to understand how the New Zealand Chinese cope with the illness. The researcher found that the Chinese immigrants have different definitions for “functioning well.” Majority of the Chinese related the concept to their feelings and experiences. To most, functioning well meant feeling happy, an internal feeling. In addition, the participants associated functioning well with being relaxed and their ability to develop social relationships, having the freedom to make decisions, mental stability and independence. There was a strong belief among the participants that functioning well does not necessarily mean that one is free from symptoms and imperfections.
A sense of hope was also identified as a theme in the study by Wang (2010). Given that BD recurs and is episodic, majority of the participants in the study mentioned that their sense of hope was constantly challenged by relapse, thereby making the process of rebuilding hope difficult. However, the participants argued that their family and having a social support system was very crucial for their recovery process. The family members encourage the patients when they are at their lowest moments and on the verge of giving up. In addition to family and social support systems, the study also found a strong link between mental health and spirituality. Most of the participants mentioned that their religious beliefs and Chinese traditional philosophy (Confucius) play a significant role in their recovery process by restoring their sense of hope. For instance, one of the participants in the study stated that, “… I think God will be with me, he will not give up on me. I was supposed to stay at hospital for three months but I was discharged after one month, I felt that God saved me,” (Wang, 2010, p. 33). This study therefore helps to put into perspective the debate on the religion-mental health link by providing further evidence supporting the relationship.
Like in the previous studies, the study by Wang (2010) also found stigmatization of BD sufferers among the Chinese community. Thus many of them avoid disclosing their condition to others for fear of rejection, or they disclose selectively. An interesting finding was that the stigmatization results from the Chinese people themselves and not from the Western people. Unlike the Asian population, the New Zealanders accept people with mental illnesses. One of the participants said that, “here (New Zealand) … I don’t feel shame anymore… there are lots of information and tools to help people with mental illness to speak up” (Wang, 2010, p. 37). This shows that stigmatization due to mental illnesses is culture-bound.
In another paper presented at the conference, Wong, Au and Long (2010) discussed how talking therapies can be adapted to best suit the mental health needs of Asian people in New Zealand. The study involved an extensive review of literature and consultations with New Zealand practitioners working with Asian communities. Wong et al. (2010) came up with a number of therapeutic recommendations for professionals dealing with Asians suffering from mental health. The first is the importance of understanding the culture of the patient. They argue that values commonly held by the Asians include collectivism, family ties, focus on education and wealth, and perseverance of hardships. Mental health practitioners should therefore strive to understand how these cultural values shape Asians’ perceptions towards mental health and utilization of mental health services. The second recommendation is the need to broaden assessment. The researchers argue that each Asian patient will have a unique combination of migration experiences, language abilities, acculturation attitudes and religious beliefs and practices. Hence there is a need to have individualized rather than generalized approach when dealing with these patients.
Wong et al. (2010) also suggest that the mental health professionals should create goals that are culturally motivated. That is, the goals should move beyond dealing with the symptoms to include collective wellbeing such as better functioning within the family and community, better relationships and satisfactory work duties. These goals may be more valued by the Asian peoples than simply abating the symptoms of mental illnesses. Addressing stigmatization and taking into consideration preferred coping strategies are other suggestions made by the authors. Most importantly, the authors suggest the need to involve and educate the families of Asians with mental illnesses. The family is a key component of recovery from mental illnesses by Asian peoples. Families can directly or indirectly provide support to individually-focused therapy as well as to encourage change. Incorporating improved family functioning and achievement of family obligations as a goal of therapy can go a long way in the recovery process. However, when working with the Asian families, it is crucial to uphold their hierarchical structures and parenting values, which they hold dear.
Recommendation for future research
Despite the crucial information highlighted by the literature review, there are gaps in the literature concerning Asian recovery concept, thereby necessitating further investigations. First, majority of the studies on Asian mental health do not distinguish the different ethnic groups making up the Asian population in New Zealand. Yet the ethnic groups are many and include Chinese, Indians, Koreans, and Japanese to mention but a few. For those studies that focus on a particular ethnic group, the tendency is towards the Chinese ethnic group. Although there are many cultural similarities among these ethnic groups, differences exist too and these differences may influence their perceptions and behaviour towards mental health issues. Future studies should try to study mental health issues in each of the Asian ethnic groups.
A second observation from the literature review is that majority of the studies tend to focus more on the service providers (the mental health practitioners) than on the clients (the Asians affected by mental illnesses). Indeed, only two of the studies reviewed, Wang (2010) and Scott et al. (2011), use a qualitative approach in which the opinions and feelings of the Asians are reported. Future studies should try to focus more on the clients: their perceptions, attitudes, feelings and opinions about mental health and the recovery process. Only qualitative studies can provide such rich and in-depth information because they will require interactions between the researchers and the Asians.
Lastly, the studies reviewed generalize the Asian population. No study has examined how different groups within the Asian population are affected by mental illnesses and their perceptions towards the recovery process. There is a need for future studies to focus on the high-risk groups such as women, international Asian students and refugees. These groups may be affected by mental problems differently from the rest of the population and therefore they need attention of researchers and policy makers.
Conclusion
The literature review brings to light a number of issues surrounding Asian mental health and recovery. First and foremost, the Asian people in New Zealand have many challenges in accessing mental health services. These challenges include language barriers, which not only interfere with family privacy and hierarchy (because of the need for an interpreter) but also make it difficult for them to access information about available mental health services. In addition, cultural differences between the Asians and the health care professionals compound the problem further by hindering quality delivery of mental health services. Second, Asian people in New Zealand value social support systems.
These systems make it easier for them to cope with their illnesses and return to their normal lives. Given that most of the Asian immigrants leave their families behind, the development of social structures of people belonging to similar ethnic groups can go a long way in the recovery process of the Asian people. Perhaps the greatest lesson learned from the review of the literature is the negative perception towards mental illnesses by the Asian communities. It was interesting to note that in this day and age, stigmatization of people suffering from mental illnesses still exists. For the Asian population living in New Zealand, the stigmatization comes from fellow friends and community members. Yet mental illnesses are perceived as just any other health condition in the dominant population of New Zealand. These findings have a number of implications for practice in Social Work.
Social workers dealing with mental problems among the Asian peoples of New Zealand need to first and foremost carry out de-stigmatization work among this population. Because of stigmatization, Asians are ashamed to come out in the open and seek medical attention until the condition becomes unmanageable. De-stigmatization will promote early accessibility of mental health illnesses and this will help prevent the illnesses from deteriorating any further. Second, social workers need to incorporate family and community ties when working with Asians suffering from mental health problems. Most importantly, as the Asians become acculturated into New Zealand’s culture, mental health practitioners should strive to learn about the cultural values, beliefs and practices of the Asian population so as to understand them better and provide them with more effective therapies.
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