AAAS 482D

Stella Huang, "Preventable Tragedies: Analyzing Attitudes on Mental Health within the Chinese American Immigrant Community"

Frank Shyong, a journalist for the Los Angeles Times, tells the story of Lai Yang Hang, a Chinese American widow who, because she feared the worst for her son, 17 year old George Hang, who suffered from schizophrenia, 精神分裂, shot and killed him in a culturally fraught “mercy killing”.

Lai Yang Hang grew up in Laos before moving to Hong Kong in her teens, where she landed a prestigious scholarship to study at a university in Tokyo at a time when "it was rare for women to go to college", her friend Ping Chong recounts. She immigrated to the United States in 1992 to marry her husband, Peter, and the two opened a successful print shop in Alhambra, California. Eventually the couple moved into a gated community in Rosemead and their son George was born soon after in 1998. 

In 2012 during George's freshman year of high school, Frank was diagnosed with cancer and passed away soon after. Lai Yang was diagnosed with cancer soon after her husband's death. George was diagnosed with an illness as well after Frank's death: schizophrenia. In 2015, 49 year old Lai Yang was told she had four months to live. That same year on July 27, 2015, she shot and killed her 17 year old son, George at a local motel near their home. Lai Yang Hang passed away on December 11th, 2016 while awaiting trial for murder.

Lai Yang Hang's case represents a preventable tragedy within the Chinese American immigrant community where mental illness is often stigmatized and mental health literacy is low. Anne Fadiman's The Spirit Catches You and You Fall Down,  famously highlighted the concept of preventable tragedies within the context of cultural misunderstandings in the late 1990s, and advocated for bridging gaps between cultures in medicine.  Similar to cultural misunderstandings, the concept of cultural mismatch explains the inability of certain cultural customs to address and solve problems that do not appear in the native country. In this case, the problem is trauma as a result of immigration and the cultural customs are traditional views of mental illness and mental health illiteracy. The "blindspot" here is lack of emotional support within the community as a result of negative attitudes towards mental illness.

Studies have shown that Asian Americans as a whole do not suffer from significantly higher rates of mental illness compared to other racial groups in the United States. However, data available has been both inconclusive and limited due to the heterogeneity of the Asian American population and other issues regarding the data gathering process such as linguistic and geographic barriers. Experts have acknowledged that different interpretations of mental disorders within the Asian American community as well as the practice of somatization of symptoms may contribute to lower rates of mental illness than accurate. 

 

 

Mental illness has traditionally been treated with Traditional Chinese Medicine (TCM), a field of medicine as well as a life philosophy. The aim of TCM is maintaining an internal balance of energy, known as Qi (气). According to TCM, most illnesses stem from an energy imbalance within the body, either an excess of Yin (阴) or Yang (阳), which manifests in the “form of symptoms or signs of disease”. Mental illness in Chinese culture has traditionally been viewed as such, a view that has fallen out of favor in recent years as national awareness of mental health has increased. However, the longstanding view of mental illness as a result of an energy imbalance within the body, which is still prevalent in older generations and in rural areas, hints at the grave consequences that may result from inadequate treatments for ill understood issues.

Much of the article, which was published after Hang’s death, relied on the testimony of her close friend, Ping Chong. Chong grew up with Hang in Laos where they both attended the same primary school and in Hong Kong where both their families moved to when they were teenagers. She described Hang as “beautiful, smart and ambitious” and spoke wistfully of dinner parties at each other’s homes. After Hang immigrated to the U.S., Chong followed not long after. Even their sons were born in the same year. The two were as close as can be yet the ending was shockingly tragic. Embedded in the article, and glaringly clear in her direct quotes, is a sense of guilt and regret. This case is a tragedy, that much is clear, but with whom does accountability lie? In a moving tribute to her lifelong friend, Chong seems to ask for forgiveness.

Chong’s actions and attitudes towards Hang’s situation appears to reflect the unfortunate practice of providing an inadequate or ill-fitting solution to problems that are largely foreign to the provider. In this case, Chong is the provider of “treatment”, ideally an informal version of emotional talk therapy or simply, emotional support. She chooses instead a treatment of avoidance, according to her personal values that also align with those of the culture. As it turns out, the treatment does not fit the problem and the result if a devastating tragedy.

Mental health has long been overlooked in China since imperial times, and it wasn’t until 1898 that the first recorded psychiatric hospital was opened in the Southeastern province of Guangdong, founded by Dr. John Kerr, an American medical missionary. Although references to mental illness appear in classical Chinese medical literature, mental health is a field that has historically been shrouded in secrecy and surrounded by stigma. During the Mao-era of the 1900’s, “Mao Zedong’s ideology-driven vision of a rational society officially made no concession” for mental health with the government going as far as to close “most of the psychiatric hospitals opened since the 19th century by Western missionaries.” According to a 2010 New York Times article, “Life in Shadows for Mentally Ill in China”, “China has no national mental health law, little insurance coverage for psychiatric care, almost no care in rural communities, too few inpatient beds, too few professionals and a weak government mental health bureaucracy.” Dr. Ma Hong of the Peking University of Mental Health says, “China averages just one psychiatrist for every 83,000 people — one-twelfth the ratio in the United States — and most lack a university degree in any subject, much less mental health.” The lack of qualified professionals may be due to “psychiatry’s bottom-of-the-barrel image in the medical community” which deters medical students from joining the profession, reflecting the magnitude and pervasiveness of stigma surrounding mental health in China.

In recent years, attitudes on mental health in China seem to be improving. According to an article published in 2013 by the American Journal of Psychiatry, a national mental health law was finally passed in 2012 after 27 years of debate. This milestone in Chinese history was a result of a “gradual increase in the perceived importance of psychological well-being and a corresponding heightened awareness of the importance of mental illness to overall public health” which “moved mental health up the political agenda.” However, the authors emphasize that while cultural values have been “changing rapidly”, they are still “quite different from those in high-income countries”, meaning some of the longstanding stigma has yet to completely disappear.

Mass media has played a large part in representing those with mental disorders as violent, and highlighting school shooters as mentally disturbed individuals. It feeds the narrative that portrays mental illness, especially schizophrenia, as untreatable and incurable and portrays those with mental illness as violent or having a propensity towards violence. The reality is much more complicated. In NPR’s “School Shooters: What's Their Path To Violence?”, the question of whether mental illness causes school shootings is answered. “Mental health issues don't cause school shootings,” psychologist John Van Dreal says. Only a very tiny percentage of those with “psychological issues go onto become school shooters”, but he concedes that “mental health problems are a risk factor” that can “decrease one's ability to cope with other stresses” which are common in many perpetrators’ lives. Social exclusion can also be a factor as “studies have shown social rejection in school to be associated with higher levels of anxiety, depression, and aggression in children.” Sue Klebold, the mother of one of the perpetrators of the 1999 Columbine shooting, says, “The piece that I think I failed [in] is, we tend to underestimate the level of pain that someone may be in. We all have a responsibility to stop and think — someone we love may be suffering, may be in a crisis.” 

It’s impossible to say if Hang’s fears would have been realized had George lived, if he would have become another statistic in the pattern of gun violence sweeping across America, would have ended up homeless or in debt from potentially costly treatments for his disorder, or if his condition would have worsened after his mother passed away. However, one thing is certain—Hang herself became the very thing she feared.

Sociologist Akiko Hashimoto says, “Filial piety in East Asia today is at once a family practice, an ideology, and a system of regulating power relations. As practiced in the family, filial piety defines a hierarchical relationship between generations, particularly that of the parent and the child.” Indeed, filial piety has become a basis of Chinese society and the foundation for familial relations, which are rigid and hierarchical. For the mother, filial piety extends to her as well, most specifically in her relationship with her son which is the closest relationship within the family unit. In Confucianism, there is a set of sayings called the Three Obediences and Four Virtues (三从四德) that dictate a standard of behavior for women. The Three Obediences in particular are explicitly clear in their expectations of a woman: obedience to the father before marriage, to the husband after marriage, and to the son after the husband’s death.

A mother’s existence is tied to and defined by her duty to the family, specifically to her son. Stigma against mental illness can be traced to traditional Chinese ideology, which is heavily Confucianist, as well as its history as Communist country. Sociologist Ambrose Y. C. King and psychologist Michael H. Bond state that while “Chinese culture is far from a homogeneous system”, Confucian values “played a prominent role in molding Chinese character and behavior.” Chinese culture is heavily pragmatic and outcome driven. Much of what is considered proper social behavior is dictated by a set of rules or lifestyle habits that serve to keep a country with billions of people on a similar path. 

In Chinese society, the child represents the family and the family is a microcosm of the state. Specifically, the child is not an individual but a relational being whose actions reflect on those around him. In a society where mental illness is viewed as a source of shame, an individual’s diagnosis results in a collective loss of face for the family and for the state. This has adverse effects for all, not just the patient, as it reinforces the idea that what deviates from a rigid path is shameful and creates additional hurdles in the treatment and healing process.

Within a span of two years, Hang experienced a string of devastating news, one after the after. In 2012, she lost her husband to cancer, was diagnosed with cancer, noticed troubling behavior by her son that would qualify him to be diagnosed as schizophrenic, and in 2015, after years of chemotherapy, was told her illness had become terminal. Immigrants in any country, separated from their natal and extended family, facing language and cultural barriers in an unfamiliar landscape, often face feelings of isolation and fear. For Chinese immigrants, to whom family is an integral part of the culture and “a fundamental unit of society”, leaving their families behind can have devastating effects. The loss of a support system as well as a familiar social structure—combined with cultural reticence to speak openly about mental health, find treatment, or access affordable, culturally competent treatment, along with pervasive stigma surrounding mental illness that discourages seeking of help—has tragic results. Rapid deterioration in mental state can occur, and severe depression can develop. By the time those of Asian descent seek help, they are often in dire condition.

As with many who immigrant to the U.S. must leave behind their family, it is not uncommon for immigrants to live in areas that are “culturally concentrated” with people of the same race, which creates a sense of familiarity and ease. To cope with or prevent isolation, they might construct a family by forming “pseudokin ties” with those they have no familial relationship with. In doing so, they are recreating their own support system in a new environment. Yet, support systems and even those who are like family can fail those who need them. 

It is a common assumption that those close to us will provide support in difficult times, yet in Chinese culture, the family, the “natural” support system, is not just a source of comfort and support but also a rigid social structure that is riddled with hierarchical relationships and notions of proper behavior. In Hang’s case, Chong was a close friend she had known since childhood and yet, even in Hang’s darkest moments, Chong felt it was improper to cross lines that separated the pseudofamily from the true family. When Hang asked for Chong’s advice on George’s medication, Chong “quickly changed the subject” and when she asked Chong to accompany her to one of George’s appointments, she agreed to go but maintained a proper distance that would prevent her from hearing what was being said. In this way, Chong was preserving the Hang family’s honor by not violating their private space. As close as the two were, honor came first and the importance of honor and “saving face” transcended a lifelong friendship. These notions of proper behavior are thus shown to be deeply embedded in the culture, and even in times of great tragedy, cannot be broken. Even in the family unit, the vocabulary for emotional support when it comes to coping with taboo and sensitive issues, can be absent due to stigma, generational gaps, language differences, and strict hierarchical relationships. This is especially true for immigrant families.

This case was a tragedy for everyone involved; it was heartbreaking, devastating, and unbelievably tragic. The primary factors that led to this incident, ill-fitting cultural norms and mental health illiteracy, were preventable had the resources been available. In understanding the history of mental health in China, gender roles and Confucianism, as well as Chinese culture, we can work to create culturally competant programs that will increase mental health literacy and create better fitting solutions to problems within the Chinese American immigrant community.

What drew me to this case study were the topics it touched on—immigration, trauma, mental health, gun violence, interpersonal relations, gender roles, Chinese culture, and more—that run the gamut of issues that affect the diverse American population. The way these concepts interact and explode in devastating and complex ways in Shyong’s article makes a strong case for its use as a case study on the topic of preventable tragedies to highlight issues that have gone unaddressed for too long. What is most heartbreaking is George's future was taken away from him by the person who was supposed to support and love him the most in this world. Shyong implies in the article that Hang killed George out of love—that she loved her teenage son too much to leave knowing he had a fascination with violence, that there was a possibility he would act on his fixations, and even if a tragedy did not occur, to leave him to a life of discrimination, financial hardship. Her rationalization was by killing him, she was saving him from an unquestionably tragic fate. Overwhelmed with fear and worry, she let her emotions rule her and made a decision that left her son dead and herself in a jail cell. When asked by authorities why she didn’t kill herself as well, a common occurrence in murder within the family, she said she wanted to punish herself for what she had done. 

I came across a photo of the late Mrs. Hang in court for her trial, dated August 2015, when researching the case—it shocked me. The description of her as a smart and beautiful young woman had not prepared me for what she had become. By August 2015, she was bald and had lost her eyebrows, most likely from chemotherapy. Her facial expression would best be described as haunting. It was clear that whatever burden she had been carrying, in additional to her failing physical health from cancer, was destructive, much like the cancer cells within her body. Her burden had been mutilating endlessly and without control, for all this time. Unlike cancer however, it had gone unaddressed. It is difficult to imagine both the type of strain she must have been under prior to that fateful day in July 2015, and the thought processes in others’ minds as they watched tragedy after tragedy unfold and yet stepside and avoid—with, apparently, good intentions that conformed with traditional Chinese behavioral norms—her desperate attempts for help. Shyong’s article was published in May of 2017, almost two years after the incident and a few months after her death. For two years, all the world knew of Hang was her crime. Hang was nothing more than a mother who had shot and killed her own son. Yet, there was much more to unpack, much of it psychological and cultural. To understand the tragic event, the factors that caused the tragedy, and Hang herself, is not a justification of Hang's crime. It is by understanding the factors that led to George Hang's death, that we can prevent future tragedies from occurring.

                                                                                            Bibliography (Chicago)

Aung, Steven K.H., Heather Fay, and Richard F. Hobbs. “Traditional Chinese Medicine as a Basis for Treating Psychiatric Disorders: A Review of Theory with Illustrative Cases.” Medical Acupuncture 25, no. 6 (2013): 398-406.

Chatterjee, Ruth. “School Shooters: What's Their Path To Violence?” NPR, Feb. 10, 2019. Accessed Dec. 13, 2019. https://www.npr.org/sections/health-shots/2019/02/10/690372199/school-shooters-whats-their-path-to-violence.

Dazio, Stefanie and John Antczak. “California school shooter dies with motive a mystery.” Chicago Tribune, Nov. 19, 2019. Accessed Dec. 10, 2019. https://www.chicagotribune.com/sns-bc-us--california-high-school-shooting-20191115-story.html.

Fadiman, Anne. The Spirit Catches You and You Fall Down. United States of America: Farrar, Straus and Giroux, 1997.

Gaw, Albert. “Working with Asian American Patients.” American Psychiatric Association. Accessed October 31, 2019. https://www.psychiatry.org/psychiatrists/cultural-competency/education/best-practice-highlights/working-with-asian-american-patients. 

“George Hang.” Los Angeles Times, July 30, 2015. Accessed Dec. 13, 2019. https://homicide.latimes.com/post/george-hang/.

Gonzales, Ruby. “Rosemead mother killed son because she was dying and there was no one to take care of him.” Pasadena Star News, Jan. 17, 2017. Accessed Nov. 20, 2019, https://www.pasadenastarnews.com/2017/01/17/rosemead-mother-killed-son-because-she-was-dying-and-there-was-no-one-to-take-care-of-him/. 

Gonzales, Ruby. “Rosemead woman pleads not guilty to killing son in motel room.” Pasadena Star News, Aug. 12, 2015. Accessed Nov. 20, 2019. https://www.pasadenastarnews.com/2015/08/12/rosemead-woman-pleads-not-guilty-to-killing-son-in-motel-room/.

Hashimoto, Akiko. “Culture, Power, and the Discourse of Filial Piety in Japan: The Disempowerment of Youth and Its Social Consequences.” in Filial Piety: Practice and Discourse in Contemporary East Asia, edited by Charlotte Ikels, 182-197. Stanford University Press, 2004.

Hsu, Jing. “The Chinese Family: Relations, Problems, and Therapy.” In Chinese Culture and Mental Health. Academic Press, 1985.

Huang, Yueqin, Zhaorui Liu, Mingyuan Zhang, Yucun Shen, Cheuk Him Adley Tsang, Yangling He, and Sing Lee. “Mental Disorders and Service Use in China.” In The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders, edited by Ronald C. Kessler and T. Bedirhan Ustün, 447-473. Cambridge University Press, 2008.

King, Ambrose Y. C., and Michael H. Bond. “The Confucian Paradigm of Man: A Sociological View.” In Chinese Culture and Mental Health, edited by Wen-Shing Tseng and David Y. H. Wu, 29-45. Academic Press, 1985.

Krishnakumar, Priya. “Since Sandy Hook, a gun has been fired on school grounds nearly once a week.” Los Angeles Times, last updated Feb. 11, 2019. Accessed Dec. 10, 2019. https://www.latimes.com/projects/la-na-school-shootings-since-newtown/. 

LaFraniere, Sharon. “Life in Shadows for Mentally Ill in China.” The New York Times, Nov. 10, 2010. https://www.nytimes.com/2010/11/11/world/asia/11psych.html

Larson, Christina. “China Begins to Bring Mentally Ill ‘Back to Society’.” Foreign Policy, Dec. 21 2015. https://foreignpolicy.com/2015/12/21/bring-patients-back-to-society-china-mental-illness-law-health/. 

Mio, Jeffery Scott, Lori A. Barker, and Melanie M. Domenech Rodríguez. Multicultural Psychology: Understanding Our Diverse Communities. Oxford University Press, 2016.

Niland, Olivia. “Mother Arrested in Connection with Son’s Shooting Death at Hotel.” NBC, July 27, 2015, Retrieved Nov 12, 2019, https://www.nbclosangeles.com/news/local/Woman-Arrested-After-Mans-Shooting-Death-at-Rosemead-Hotel-318722671.html.

Pearson, Veronica. Mental Health Care in China: State Policies, Professional Services and Family Responsibilities. Gaskell of The Royal College of Psychiatrists, 1995. 

Phillips, Michael R. “Characteristics, experience, and treatment of schizophrenia in China.” Dialogues in Clinical Neuroscience 3, no. 2 (2001): 109-119. 

Phillips, Michael R., Hanhui Chen, Kate Diesfeld, Bin Xie, Hui G. Cheng, Graham Mellsop, and Xiehe Liu. “China’s New Mental Health Law: Reframing Involuntary Treatment.” The American Journal of Psychiatry 179, no. 6 (2013): 588-591.

“Schizophrenia.” Harvard Medical School, Feb. 2019. Accessed Dec. 12, 2019. https://www.health.harvard.edu/a_to_z/schizophrenia-a-to-z.

Shyong, Frank. “A dying mother’s plan: Buy a gun. Rent a hotel room. Kill her son.” The Los Angeles Times (California), May 22, 2017. Accessed Dec. 10, 2019. https://www.latimes.com/local/la-me-mother-murder-mental-20170514-htmlstory.html. 

Tribune News Service. “Detectives probe how teen got gun as California community mourns.” Indiana Daily Student, Nov. 17, 2019. Accessed Dec. 10. 2019. https://www.idsnews.com/article/2019/11/detectives-probe-how-teen-got-gun-as-california-community-mourns. 

Wu, David Y. H. and Wen-Shing Tseng. “Introduction: The Characteristics of Chinese Culture.” In Chinese Culture and Mental Health. Academic Press, 1985.