Depression through Chinese eyes: a window into public in multicultural Australia

ƝƝnȴŋūnȴŋūnȴŋū˹˹˹ΥːYΥːYΥːYšɃȾšɃȾ, ˠŽȶɺʥƙdžƧǀɃřɋɉ<

This thesis is submitted in fulfillment of the requirements for admission to the degree of Doctor of Philosophy,

School of Public Health and Community Medicine and School of Psychiatry, University of New South Wales

Bibiana Chan

March, 2007 For all my informants who honestly and courageously shared their thoughts and experiences with me.

To my LORD who gives me HOPE.

Acknowledgment

The quantitative research design adopted some of the earlier research methodologies developed by the Black Dog Institute. The author drafted the survey form of the current study (both the Chinese and English versions). Co-researchers Professor Gordon Parker (GP) and Professor Maurice Eisenbruch (ME) provided input to revise the initial drafts before pilot studies were conducted to test the instruments. The author collected and analysed ALL the data.

The qualitative research design was developed while the author was attending a series of qualitative seminars by A/Professor Jan Ritchie (JR). The conceptual frameworks and ethnographic methods were also crystallised through participation in the , Health and Illness program and by other activities of the Centre for Culture and Health under the direction of ME. The author then developed the two vignettes with input from ME. Subsequently five pilot focus groups was conducted to establish the protocols for facilitating focus groups using different languages. The author collected qualitative data by facilitating a total of 16 focus groups. JR provided some input regarding the framework for conducting theme analysis. The author then perform ALL coding and theme analyses using NVivo 2.

My most sincere thanks to:

All professional and lay helpers who walked along the journey of recovery with me.

The National Health and Medical Research Council for the funding to make this research possible.

My research supervisors Professor Maurice Eisenbruch, Professor Gordon Parker and Associate Professor Jan Ritchie for their intellectual input.

All participating general practitioners, Chinese herbalists, medical centres, and community organizations to facilitate data collection.

My parents and those who instilled the love for Chinese culture into me.

My son, Jonathan who shared his daily encounters as an ABC (Australian-born Chinese) with me.

My friends and colleagues from cultural and linguistically diverse backgrounds who taught me the spirit of multiculturalism.

Professor S Lee, Dr I Blignault, Dr G. Denham, Dr A. Demirkolster, Dr Y. Lucire, Mrs T. Chow and Mr Z. Steel for their invaluable comments on earlier drafts.

Dr. E Dryland and Ms P Gundelach who proof-read and edited my thesis.

i List of publications and conference presentations arising from the work reported in this thesis

Chan B. (2003) Cross-cultural Issues in Depressive Illness: Implications for Mental Health Services among Migrant Communities in Australia. The “Diversity in Health: Innovation, Creativity and Harmony” conference, October, 2003, Sydney. (Part of chapter 2)

Chan, B. (2003) Healthy family, a cross-cultural perspective: An innovative project to promote mental health to the Chinese community. The "Diversity in Health: Innovation, Creativity and Harmony” conference, October, 2003, Sydney.

Chan, B., and Parker, G. (2004) Some recommendations to assess in Chinese people in Australasia. Australian & New Zealand Journal of Psychiatry, 38, 141-147. (Part of chapter 2)

Chan, B., Parker, G., and Eisenbruch, M. (2005a). Depression through Chinese eyes and the implications for Australian multicultural health policy, The First International Congress of Qualitative Inquiry, May 2005. Urbana-Champaign: University of Illinois. Retrieved 30-Jan- 07 from http://www.c4qi.org/qi2005/papers/chan.pdf (Part of chapter 5)

Chan, B., Parker, G., and Eisenbruch, M. (2005b). Help-seeking in Chinese in Sydney - Does make a difference? (Abstract). Australian & New Zealand Journal of Psychiatry, 39 (S2), A51-52. (Part of chapter 6)

Chan, B. (2005c) High Price of Migration - voices from focus group participants. Action Research Conference, October, 2005, University of Technology, Sydney. (Part of chapter 5)

Chan, B. and Parker, G. (2006). Values of cross-cultural research: Insights gained from the validation of the depression screening measure DMI-10 Chinese version. Poster presented at the ASPR 2006 conference, Sydney, December, 2006. (Part of chapter 4)

Chan, B., Parker, G., Tully, L., and Eisenbruch, M. (2007). Cross-cultural validation of DMI-10 measure of state depression: The validation of a Chinese language version. Journal of Nervous & Mental Disease, 195 (1), 20-25. (Part I of chapter 4)

Chan, B. Parker, G. and Proudfoot, J. (in review) Does acculturation make a difference? Help-seeking for emotional distress among Chinese Australians? MJA. (Part of chapter 6)

Eisenbruch, M., Chan, B., and Parker, G. (2005). The meaning of suffering - a Chinese explanatory model tool for depressive episode (Abstract). Australian & New Zealand Journal of Psychiatry, 39 (S2), A51. (Part of chatper 4)

Eisenbruch, M., Chan, B., and Parker, G. (in review). The meaning of emotional distress - a Chinese explanatory model tool. Social Science and Medicine. (Part II of chapter 4)

Parker, G., & Chan, B. (2004). Depression in Australian Chinese. How acculturation informs us about the detection and manifestation of clinical depression. (Abstract). XXIV CINP Congress, Paris, June 20-24. The International Journal of Neuropsychopharmacology, 7:S77. (Part of chapter 5)

Parker, G., Chan, B., Tully, L., and Eisenbruch, M. (2005). Depression in the Chinese: the impact of acculturation. Psychological Medicine, 35(10), 1475-1483. (Part of chatper 6)

Parker, G., Chan, B., Tully, L., and Eisenbruch, M. (2005b). Depression in the Chinese: the impact of acculturation (abstract). Australian & New Zealand Journal of Psychiatry, 39 (S2), A51.

Parker, G., Chan, B., and Tully, L. (2006). Recognition of depressive symptoms by Chinese subjects: the influence of acculturation and depressive experience. Journal of Affective Disorders, 93(1-3), 141- 147. (Part of chapter 7)

Parker, G., Chan, B., and Tully, L. (2006). Depression and help-seeking in a western sample of highly acculturated Chinese and controls. Journal of Affective Disorders, 94 (1-3), 239-242.

In bold - Papers presented at Conferences

ii

Abstract

Under-utilisation of mental health services is widespread globally and within Australia, especially among culturally and linguistically diverse (CALD) communities. Improving service access is a priority, as is the need to deliver culturally competent services to the CALD communities. Having migrated to Australia in waves for approximately 150 years from China and South East for various social, political and economic reasons, the Chinese population in Sydney is now the fastest growing non-English speaking . There is a need to better understand the impact of culture on the emotional experiences of these Chinese in Australia. How do Chinese make sense of their depressive episodes? To address this question, this study explored the ways participants reach out for medical and/or non-medical help. Lay concepts of illness underpin these decisions and were thus unveiled. Mixed-method research design provided the opportunity to bring together multiple vantage points of investigation: population mental health, transcultural psychiatry and medical anthropology. A study combining quantitative survey and qualitative focus groups was undertaken in metropolitan Sydney. Narratives on symptoms, explanatory models and help-seeking strategies were articulated by focus group informants. Surveys covered demographics, symptom-recognition, previous depressive experiences and professional help sought. Depression measurement tools were cross-culturally validated. Self-ratings of ethnic identities and the Suinn-Lew Self-Identity Acculturation Scale were used to quantify Chinese participants’ acculturation level. This allowed comparisons between ‘low-acculturated’ Chinese’, ‘highly-acculturated’ Chinese and Australians. Survey results showed comparable levels of symptom-recognition in all subgroups. Focus group discussions provided rich data on informants’ help-seeking strategies. Highly acculturated Chinese closely resembled the Australians in many study variables, yet qualitative data suggested cultural gaps beyond language barriers in influencing service use. Participants believed that trustful relationships could work as the bridge to link services with those in need. The implications for Australia’s mental health policy include recognising the importance of rapport- building and the existence of cultural gaps. The study indicated professionals can benefit from acquiring information about the mental health beliefs both of individual clients and the wider ethnic communities in which they belong, and respecting the cultural differences between helper and helped as the first step towards cultural competency.

Table of Contents

Chapter 1 Introduction 1

1.1 A glance at mental health issues 1 1.2 My stance as researcher 4 1.3 Chinese migrants in Australia 6 1.4 Meaning of emotional distress 8 1.5 Acculturation 11 1.6 Research propositions 12 1.6.1 Do Chinese and Australians experience similar depressive episodes? 12 1.6.2 Are Chinese less susceptible to depression than the Australians? 12 1.6.3. How do Chinese conceptualise their depressive episodes and mental illness?13 1.6.4. Do Chinese employ similar help-seeking strategies to Australians? 15 1.6.5. Are Chinese less likely to report emotional distress to their general practitioner than Australians? 16 1.7 The lens of inquiry’ 18 1.8 Thesis Structure 20 1.8.1 Literature review 20 1.8.2 Methods 21 1.8.3 Validation of tools 21 1.8.4 Depressive experiences 21 1.8.5 Acculturation and help-seeking 22 1.8.6 Recognition of symptoms and services evaluation 22 1.8.7 Lay illness concepts 22 1.8.8 Discussion: New Synthesis 22 1.9 Summary 23

Chapter 2 Literature Review 25

2.1. Interests in ‘clinical depression’ studies 26 2.2. Prevalence of major depression in different regions of the world 28 2.3. How valid is the diagnostic assessment? 30 2.4. Cross-cultural studies of clinical depression 31 2.5. Cultural construction of illness 33 2.5.1. Idioms of Distress 33 2.5.2. Male-Female Difference vis-à-vis Depression 36 2.5.3 Significance of cross-cultural studies of clinical depression 38 2.6. Traditional Chinese Medicine (TCM) 39 2.6.1. Body-mind link and maintaining overall harmony 39 2.7. Migration and mental health 42 2.7.1. Self-selection 43 2.7.2. The migration experience is itself stress-inducing 43 2.7.3. Misdiagnosis 44 2.7.4. Ethnic density effect 46 2.7.5. ‘Entrapment theory’ 47

iii 2.8. Acculturation and help-seeking 48 2.8.1 Objective measure of acculturation vs subjective measure of ethnic identity 48 2.8.2 The ‘individual’ Self vs the ‘collective’ Self 52 2.8.3. Confucian teaching – backbone of socialisation in the Chinese 53 2.8.4. Studies of acculturation and emotional distress 56 2.9. Utilisation of mental health services 57 2.10. Population mental health 60 2.10.1. Evidence-based research in health promotion and prevention 62 2.10.2. The positive impact of social capital 64 2.10.3. Equity of health and resource distribution 66 2.10.4. The CPR in mental health - Mental Health First Aid 68 2.10.5. The Way Ahead - Mental health promotion and early intervention via the Cyberspace 69 2.11 Summary 69

Chapter 3 Methods 71

3. 1 Study Design 71 3.1.1 Why mixed method? 72 3.1.2 Mixed method research - a rigorous methodology 73 3.2 Quantitative component 75 3.2.1 Approaching doctors in general practices to facilitate recruitment of participants 76 3.2.2 Recruiting participants 77 3.2.3 The questionnaire – general issues 78 3.2.5 State depression 78 3.2.6 Recognition of depression 79 3.2.7 Lifetime depression 79 3.2.8 Help-seeking 80 3.2.9 Acculturation 81 3.2.10 Other variables 82 3.2.11 Analysis 83 3.3 Qualitative component 83 3.3.1 Vignette Development 83 3.3.2. Validating Focus Group Protocols 85 3.3.3 Sampling in qualitative research 86 3.3.4 Focus Group Stratification 87 3.3.5 Flexibility in recruitment strategies 88 3.3.6 Standard Focus Group Procedures 89 3.3.7 Revision evolved as the research progressed 89 3.3.8 Data Management 91 3.3.9 Thematic Analysis and Interpretive Framework 92 3.4 Ethical Issues 94 3.5 Validation of the Chinese version of DMI -10 94 3.5.1 Sub-study 1 95 3.5.2 Sub-study 2 95

iv 3.5.3 Sub-study 3 96 3.6 Translation of the Mental Distress Explanatory Model Schedule (MDEMS) into Chinese 97 3.6.1 Translation 97 3.6.2 Exploratory verification through Focus groups 97 3.6.3 Comparison of an independent back-translation with the original MDEMS 98 3.7 Strengths and Limitations of the study 98 3.7.1. Strengths 99 3.7.2 Insights gained from limitations of the Survey 99 3.7.3 Achieving the best outcome under constraints associated with focus groups 101 3.7.4 Overcoming Limitations 104 3.8. Summary 106

Chapter 4 Cross-cultural validation of Research Tools: Chinese versions of DMI-10 and MDEMS 108

4.1. Cross-cultural Validation of Chinese DMI-10 – a depression screening measure111 4.1.1 Theoretical considerations 111 4.1.2. Findings 114 4.1.3. Discussion 120 4.2. The Meaning of Suffering – a Chinese explaining tool of mental distress 123 4.2.1. Measuring meaning of suffering in Chinese culture 124 4.2.2. Findings 126 4.2.3. The robustness of the psychometrics 131 4.3 Summary 133

Chapter 5 The depressive experiences: Do Chinese experience similar depressive episodes to Australians 135

5.1 Introduction 135 5.2. Survey Results 137 5.2.1. Response rates 137 5.3 Focus Group 145 5.3.1. Demographics 145 5.3.2. Real Scenarios 149 5.3.3. Symptoms and EMs 152 5.4. Summary

Chapter 6 The Impact of Culture on Depression and Help-seeking 155

6.1. Introduction 155 6.2. Survey Results 156 6.2.1. Attributional Style 156 6.2.2. Lifetime depression 158 6.2.3. Cultural Values 160

v 6.2.4. State depression 162 6.2.5. Acculturation domains 162 6.2.6. Comparison with a sub-sample recruited from Chinese Herbalists. 164 6.2.7. Help-seeking 169 6.2.8. Timing of Depressive episode: Are experiences of emotional distress universal across ? 181 6.3. Help-seeking strategies nominated by focus group participants 182 6.3.1. How can focus group informants help? 182 6.3.2. What can health professionals offer? 183 6.3.3. Are there other sources of help? 187 6.3.4. General Approaches 191 6.4 Conclusions 192 6.4.1. Are Chinese as susceptible as Australians to becoming depressed? 192 6.4.2. Do Chinese employ similar help-seeking strategies to those of Australians? 192 6.5 Summary 194

Chapter 7 Mental health literacy: Symptom Recognition and the Perceived Helpfulness of Health and Community Services 196

7.1. Recognition of depressive symptoms by Chinese subjects: the influence of acculturation on the depressive experience 197 7.1.1 Symptom Recognition 197 7.1.2. Factor analysis of the Depression Symptom Questionnaire 198 7.1.3. Interpretation 201 7.1.4. Summary 204 7.2 Perceived Helpfulness of Mental Health Services 205 7.2.1. How can GPs help? 205 7.2.2. Does /counselling help? 207 7.2.3. Are psychiatrists helpful? 208 7.2.4. Are medications effective? 209 7.2.5. Are herbalists helpful? 210 7.2.6. What can community education achieve? 211 7.2.7. What kind of help do friends and families offer? 212 7.2.8. How can support groups be of help? 213 7.2.9. How can mental health services be more helpful? 213 7.3. Summary 214

Chapter 8 Help-seeking and Lay Concepts of Illness 216

8.1. Help-seeking 216 8.1.1. Integrating data from the survey and focus groups 219 8.1.2. Help-seeking puzzle 221 8.1.3. Attitudes and Beliefs 223 8.2. Body-Mind Link 227 8.3. Lay Illness Concepts 228 8.3.1. ‘Sick in the Body’ 228

vi 8.3.2. ‘Sick in the Head’ 228 8.3.3. ‘State of Mind’ 229 8.3.4. ‘Something’ Imbalance 230 8.3.5. Descriptions of the Mentally Ill 231 8.3.6. Descriptions of Depression 232 8.4. Summary

Chapter 9 Discussion 234

9.1. Subjective/Personal View: ‘feeling not well’ 235 9.1.1. Self-nominated most troubling symptoms 236 9.1.2. State Depression as measured by DMI-10 237 9.1.3. How well are symptoms recognised from a given list? 238 9.1.4. Why does this happen to me? (Self-nominated EMs) 241 9.1.5. Implications 242 9.2. The first port of call: “You first talk to your GP…” 246 9.2.1. Are Chinese as susceptible to depression as the Australians? 247 9.2.2. Are Chinese less likely to report emotional distress to GPs? 248 9.3. Cultural Interpretation: “his psychological state is out of balance?” 252 9.4. An Integrating Model: “Go and find some Chinese community organisations’255 9.4.1. Referrals from primary to specialist services 257 9.4.2. Collaboration between GPs and psychologists 260 9.4.3. Linking the Community /Social Worker to Mental Health Professionals 260 9.4.4. Centralised Collaboration Network 263 9.5. Public Health at a Global level: Population mental health 265 9.5.1. Multi-disciplinary approach 265 9.5.2. Building Social Capital to guard against mental ill-health 267 9.5.3. Global Action to reduce stigma associated with mental illness 268 9.5.4. Role of Media in reporting mental illness 269 9.5.5. E-mental health 269 9.5.6 The value of transcultural research 270 9.6 Summary of Implications 273 9.6.1 Depressive Experiences 273 9.6.2. Concepts of Illness 274 9.6.4 Cultural Competence 275 9.7 Future directions of research regarding ethnicity 276 9.7.1 Group heterogeneity 277 9.7.2 Self-identification 277 9.7.3 Generalisability 278 9.8 Future Research in Clinical Depression among non-Western communities 278 9.8.1 Mental Health Literacy 278 9.8.2 Role of religions in Help-seeking 278 9.8.3 Qualitative Enquiry 279 9.8.4 Gender Differences 280 9.8.5 Management of mental health cases by Chinese GPs 280 9.9 Conclusion 281

vii List of Tables Table 1.1: Potential protective/risk factors among Chinese of different acculturation levels 15 Table 3.1: Stratification of focus group by language and age 87 Table 4.1: Bilingual Test-Retest Reliability for each item in the DMI-10 and total scores in Study 1 and Study 3 116 Table 5.1 : Demographics and percentage distribution of informants’ depressive episodes 141 Table 5.2 : Demographics and percentage distribution of informants’ depressive experiences141 Table 5.3: Weighted score of the most troubling symptoms 143 Table 5.4: Percentage distribution of nominated EM of informants reporting previous depressive experiences 144 Table 5.5: Demographics of focus group informants from different language groups 145 Table 5.6 : Real scenarios of emotional distress volunteered by participants: summary of symptoms, EM and help-sought. 151 Table 6.1: Percentage of respondents selecting somatising, normalising and psychologising attributions of three physical symptoms for Low-Acc Chinese, High-Acc Chinese and Control groups. 157 Table 6.2: Percentage of respondents who reported lifetime depression, mean age of onset and longest episode, and associated rates of impairment for the Low-Acc Chinese, the High-Acc Chinese and Control groups. 159 Table 6.3: A Life time depression (self-report) by gender 159 Table 6.4: Relationship between Acculturation and cultural orientation 160 Table 6.5: Correlations of acculturation domains and DMI-10 (state depression screening), figures above the diagonal pertain to Low-Acc Chinese, those below the diagonal pertain belongs to High-Acc Chinese. 163 Table 6.6 : Demographics and acculturation variables 167 Table 6.7: General help non-specific to an depressive episode-seeking strategies of subgroups.168 Table 6.8: Non-specific help-seeking and specific help-seeking in response to experiencing a likely lifetime episode of depression for the Low-Acc Chinese (Herbalist sub-group not included), High-Acc Chinese and Controls. 170 Table 6.9: Participants reporting an episode lasting no more than 4 weeks with no impact on everyday functions; for the Low-Acc Chinese, High-Acc Chinese and Controls. 172 Table 6.10: Participants reporting an episode lasting for more than 4 weeks or with some impact on everyday functions; for the Low-Acc Chinese, High-Acc Chinese and Controls. 175 Table 6.11: Timing of 1st depressive episode 181 Table 7.1: Means, Standard Deviations and F values for depressive symptoms according to cultural group and level of depression. 199 Table 9.1: Research findings supporting ‘protective’ factors against depression and confirming ‘risk’ factors (in bold). Text in italics has been outlined in Table 1.1 as views extracted from earlier literature. 250

List of Figures

Figure 2-1 Summary of Hypothetical Models of Migration and Mental Health 50 Figure 2-2 Spectrum of Mental Health Intervention 61 Figure 2-3 Mental health promotion for mental illness and mental health 62 Figure 3-1 Focus Group in Progress 102 Figure 4-1 Multidimensional Scaling of explanatory models 125 Figure 4-2 Tool Development Pathways 131

viii Figure 5-1: Symbolic representation of relationships between the Chinese and Western Cultures, acculturation, depression, and help-seeking. 137 Figure 5-2 Model for integrating concepts in depression 154 Figure 6-1 Scatterplot of Ethnic identity and Australian Identity of various subgroups demonstrating an increasing trend of ‘acculturation 166 Figure 6-2 Diagrammatic representation of the help-seeking pathway of Low-Acc Chinese. 177 Figure 6-3 Diagrammatic representation of the help-seeking pathway of Australians 180 Figure 6-3 Diagrammatic representation of the help-seeking pathway of Australians 227 Figure 8-1 Mind-map of Lay Illness Concepts Figure 9-1 Recognition of depressive symptoms among Low-Acc and High-Acc Chinese 240 Figure 9-2: Implications for ‘culturally competent psychiatry’ 264

List of Appendices

Appendix 2-1 Additional Notes on Male-Female Difference vis-à-vis Depression 284 Appendix 2-3 Building Social Capital 286 Appendix 3-1a Survey Forms for Chinese participants preferring English language 287 Appendix 3-1b Survey Forms for Chinese participants preferring Chinese language 299 Appendix 3-1c Survey Forms for non-Chinese participants 312 Appendix 3-1d Screening of ‘Depression for the medically-ill’ (English and Chinese version) 320 Appendix 3-2 Focus group scenarios and semi-structured questions 322 Appendix 3-3 Coding Procedures 324 Appendix 4-1 Chinese Characters and corresponding phonetic transcriptions 325 Appendix 4-2 Differential response pattern of some MDEMS items. 326 Appendix 4-3 Third Iteration of MDEMS before test-retest 327 Appendix 5-1 Comparison of demographics and depression variables between retained and excluded participants. 332 Appendix 5-2 Demographics of all Chinese and Australians 333 Appendix 5-3 Demographics of the low acculturated Chinese and Australians 334 Appendix 5-4 Comparison between Highly Acculturated Chinese and Australians 335 Appendix 5-5 Comparison between Low and Highly Acculturated Chinese Subgroups 336 Appendix 5-6 Education levels and Job categories of Chinese and Australians Focus Group Participants 337 Appendix 7-1 Support Groups identified by the focus groups 340 Appendix 7-2 Factor Analysis of common symptoms of depression 338 Appendix 9-1 Issues surrounding the side effects of SSRI antidepressants 341

References: 343

ix Chapter 1 Introduction

̣ȧǙÏƈȺ' ʧƈƅ 'ˮʳƅʧƈyƅų ƲŘƈŭȹŠ yų ƲŘƈɲɰŠ

That, which precedes the expression of joy, anger, sadness and happiness, is called ‘zhōng’; not deviant. That, which is expressed outwardly, but within limits, is called ‘hé’; harmony’. ‘Zhōng’ is the root and origin of the cosmos; ‘hé’ is the common pathway of every human being.” Confucius, Doctrines of Moderate Living

1.1 A glance at mental health issues

Mental health issues have attracted much attention globally. The World Health

Organization claims that by 2020 depressive disorders will rank second in terms of

Disability Adjusted Life Years (WHO 2002) behind Ischemic Heart Disease (IHD).

Mathers and Loncar (2006) projecting ahead a further decade using WHO 2002 data

(2004a) have suggested that by 2030 Unipolar Depression will continue to rank second with HIV/AIDS at the top and IHD dropping to third place. There is thus an urgent need to shift the focus from intervention to prevention. The first step is to set up public education campaigns promoting mental health literacy1. Western developed countries, including the and Britain, have made great efforts to promote awareness of depressive disorders. Hong Kong2, which in the past has reported a low prevalence of

1 Mental health literacy includes the ability to recognise specific disorders, knowing how to seek mental health information, knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking. (Jorm, Korten, Jacomb et al. 1997:182) 2 Hong Kong used to be a predominately Chinese-speaking British colony but returned to the People’s Republic of China’s rule since 1997. It has long been regarded as an international city where East meets West (Hong Kong Observers, 1981). 1 lifetime depression3, has also launched a public campaign (the Joyful Mental Health

Foundation 2004) to promote mental health literacy.

In Australia today mental health issues are acute. It is a problem that the

Australian Government can no longer ignore. The then Prime Minister and the State

Premiers4 met at the Council of Australian Governments (COAG) in February 2006 to discuss the pressing need for more effective programs to combat widespread depression and other mental health disorders (Australian Broadcast Coorperation, ABC 2006). The

New South Wales Premier, acknowledging the shortage of psychiatrists in the public health system (ABC 2006), has expressed the need to ‘think outside the square’. To achieve these goals mental health experts must (a) address the gaps in the existing services and (b) explore ways of utilising the existing mental health workforce more efficiently. Hickie, Groom, McGorry et al. (2005) outline specific service reforms dedicated to increase access to effective care and reduce the social and economic costs of mental ill-health in their paper ‘Australian Mental Health Reform’. They seem to be hopeful about the National Neuroscience Consultative Taskforce (Department of Health and Aging 2004) will develop more research and innovation programs. Regrettably, research funding for mental health is not in proportion to Australia’s total disease burden.

Mental illness accounts for 19% of the disease burden but attracts only 9% of the research funding (ABC 2006). Furthermore, research funds allocated to Australia’s non-

English speaking population groups are a mere 1.5 % of the total for mental health

(Multicultural Mental Health Australia, 2004). In effect there are few existing studies that address the specific issues surrounding mental disorders in people from culturally and

3 1.29%/2.44% (males/females) in Hong Kong (Chen, Wong, Lee et al., 1993) compared with estimates of 6.9% for Chinese Americans (Takeuchi, Chung, Lin et al., 1998) and 16.6% reported in the Duplicate of National Comorbidity Surveys of the United States (Kessler, Berglund, Demler et al., 2005) 4 The Prime Minister: John Howard and premiers of NSW: Morris Iemma; South Australia: Mike Rann; Queensland: Peter Beattie; Tasmania: Paul Lennon; Victoria: Steve Bracks; WA: John Carpenter. 2 linguistically diverse (CALD) backgrounds. Despite the national initiative called

‘beyondblue5’, launched in 2000 to raise public awareness of clinical depression

(beyondblue, 2004), there are lingering doubts as to whether the Australian Government is committed to tackling this serious problem head-on (Commonwealth Department of

Health and Aged Care, Australia, hereafter DHAC 2000, p. x). In a more recent publication titled 'Framework for the Implementation of the National Mental Health Plan

2003-2008 in Multicultural Australia’ (DHAC, 2004), the Chair of the National

Multicultural Mental Health noted in the foreword:

The challenges of a diverse population – of developing culturally inclusive public policy, ensuring equity and access, planning and delivering culturally competent and appropriate services and developing and maintaining a culturally competent workforce – remain.

When interviewing psychiatrists in Hong Kong, Miller (2006) observed an interesting phenomenon in the case of the psychiatrist who said: ‘If I make a diagnosis of postnatal depression, the family will think the mother is mad… [so] I’ll say “Have you heard of postnatal depression? In TCM (Traditional Chinese Medicine) this is how your condition is viewed,” and encourage them to see a herbalist’ (Miller 2006: 463). One of the major reasons Chinese psychiatrists embrace both Western and Chinese medical concepts is that it gives them the chance to focus on the physical root of the illness thus lessening the chance of stigma, e.g. lotus seed cores are used to lower the ‘fire’ and calm the ‘heart’ which will cure and feelings of irritation (Hong, 2002). Green and colleagues note in an earlier report (Green, Brandby, Chan et al., 2002) that even Chinese women who speak English fluently and have integrated well into the mainstream culture prefer to seek help from health professionals with similar cultural backgrounds, hoping that the latter will have a better understanding of the cultural nuances of their emotional

5 ‘beyondblue’ was established by former Victorian Premier Jeff Kennett in 2000, He was appointed by the then Federal Minister for Health to head a $5 million National Centre for ‘Depression’. 3 distress. Culture thus seems to play a vital role in determining where help is sought, especially when the problems are perceived to be more than purely physical. When a person moves from his/her heritage culture to live in another culture, the impact of culture on that person becomes more evident. In anthropological terms this is the process of acculturation: ‘phenomena which result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original cultural patterns of either or both groups’ (Redfield, Linton and Herskovits, 1936:149).

Three important issues emerged from my literature review: (1) there is increasing concern about mental illness among the Chinese in Asia as well as in Western countries; (2) there is evidence to suggest there is some advantages in adopting both Western and Traditional

Chinese medical concepts in the management of emotional distress; and (3) culture and help-seeking for mental ill-health are clearly associated. With these issues in mind, I proceed to explore how Chinese people living in Sydney, who are straddling the

Australian (predominately Anglo-Celtic) and Chinese cultures (a) view their emotional distress /bouts of depression, and (b) employ help-seeking strategies. Even more importantly, I examine the concepts underlying these phenomena in order to elucidate the complex relationship between culture and illness. These findings will hopefully shed light on the kind of mental health services that are culturally competent for the growing

Chinese community in Australia.

1.2 My stance as researcher

In any medical or social science research, investigators bring to the task tacit knowledge acquired through their prior training and insights gained from related personal experience. But a researcher’s stance is formed not only from factors connected to academic background and experience. In a study such as this one where the researcher

4 engages with the informants to explore a sensitive topic and interacts so closely with them as to become part of the research instrument, cultural context is also of critical relevance. Each stage of research, from the conception of research plans, review of literature, collection of data for systematic analysis through to the dissemination of results and findings, is to some degree subject to the influence of the researcher’s stance.

It is therefore appropriate to provide readers with a brief summary of both my academic and cultural background.

I am an Australian citizen of Chinese ancestry. I was born in Hong Kong in the

1960s and received my primary and high school education there. Attracted by Western democracy and a perceived freedom I came to Sydney as an overseas student in 1983 to undertake Speech Pathology studies. My training as a speech pathologist provided me with a good grounding as a rational, objective researcher. Exploration of the complexity of language and other social behaviours that enhance or impede information exchange helped me to appreciate the art of human communication. Reflecting on my past, I have been a ‘mixed’ method researcher right from the beginning of my career. As I travelled life’s journey as a speech pathologist, a clinical supervisor and a university lecturer, I also experienced the rites of passage of marriage and motherhood. It was my own migration from Hong Kong to Sydney and the depression I experienced in the 1990s that led me to study for a Masters Degree in Applied Anthropology at Macquarie University, Sydney, in

2000. By immersing myself in the study of ethnic identity, gender development, the political economy of health and the cultural construction of illness, I gradually emerged as a ‘new’ person, and at the same time reunited with the ‘old’ self who had been lost for so long. I started work as a research assistant at the Black Dog Institute in October 2002 on a project examining the cultural impact of clinical depression on the Chinese in

Sydney. This marked the beginning of my journey into a deeper understanding of the

5 epidemiology and phenomenology of the ‘depressive experiences’ of Chinese-

Australians. While I explored the subject from a few disciplines (cross-cultural psychology, epidemiology and medical anthropology, the analytical framework is predominately from psychology. Nowadays I dedicate my energies to the establishment of more culturally competent mental health services at Multicultural Mental Health

Australia (see www.mmha.org.au for their profile) that will effectively serve multicultural Australia at a national level.

1.3 Chinese migrants in Australia

As highlighted earlier, understanding the influence of culture on help-seeking behaviours for mental ill-health, in this case by following how migrants from a non-

Western culture residing in a predominantly Western setting reach out for help for emotional distress, has the potential to assist mental health professionals to strengthen service delivery. Chinese living in Sydney represent Australia’s fastest-growing non-

English speaking community. There are over half a million Chinese living in Australia representing approximately 3% of the Australian population (Australia Bureau of

Statistics ABS, 2002a), with Chinese ranking fifth after English, Irish, Italians and

Germans among the major ethnic groups. A recent census (ABS 2002a) established that

400,000 people (i.e. 2.1% of the Australian population) are Chinese-speaking.

Researchers in North America (e.g. Kleinman, 1977, 1980; Ying, 1990, 1995) and more recently Australasian (Abbott, Wong, S., Williams et al.,1999; Chiu, 2004; Parker,

Gladstone and Chee, 2001a) are keenly interested in the extent to which Chinese individuals experience and seek help for depression.

Waves of Chinese migration span the period from the Gold Rush in the 1850s

(Culture and Recreation Portal, Australian Government, 2005) to the new millennium.

6 The children of those who came to Australia as indentured labourers would now extend to the third and fourth generations. However, non-white migration was not always welcomed in Australia. It was only in 1966, when the Minister (Hubert

Opperman) undertook to review the immigration policy, that non-Europeans who possessed qualifications useful to Australia were accepted, thus marking the watershed of the White Australia Policy (Department of Immigration and Multicultural and Indigenous

Affairs DIMIA, 2004). Successive governments gradually removed race as a factor in

Australia's immigration policies from 1973. Since then, Australia has seen a sizeable influx of non-white Asian migrants including refugees from Vietnam.

In the mid-1980s the Australian government launched a vigorous education promotion campaign which attracted many students from Asia including China, Malaysia and Hong

Kong (Hon and Coughlan, 1997). After the Tiananmen Square Student Movement in

China in 1989, the Hawke Labour Government granted 25,000 Chinese students

Australian residence (Australian Government, 2005). The political upheaval and anti-

Chinese riots in Indonesia in the 1990s (Ho, 2005) triggered another wave of Chinese migration. In the decade prior to Hong Kong’s return to Chinese rule in 1997, many skilled and more affluent Hong Kong Chinese migrated to Australia, establishing residence in the country’s major cities (Mak, 2001). In 1996, tension between China and

Taiwan (PBS, 2000) also saw many professionals migrate from Taiwan. Since the beginning of the new millennium and the escalation of globalisation, international migration has become increasingly active; it is no longer surprising to find Chinese born in different parts of the world migrating to Sydney, for example. And although they collectively identify themselves as Chinese, they are in fact a heterogeneous ethnic group.

The Chinese community is the fastest growing non-English speaking ethnic group in

Australia and there are well-established Chinese communities enhancing the maintenance

7 of their ‘cultural heritage’. Along with the long history of migration of Chinese at different times, the marked diversity of socio-economic backgrounds allows multiple group comparisons. There are Chinese at various levels of ‘acculturation’ and generation status. This facilitates examination of the impact of culture on the depressive experience.

Chinese culture is considered high on the ‘collective-cultural’ index (Hofstede, 2001), whereas Australian society is rated as more ‘individualist orientated.’ Thus considerable adjustment needs to be made when a person from a Chinese culture migrates to a predominantly Western (Anglo-Celtic) secular country like Australia. Sydney, the base for this research, provides a range of psychological experiences among recently arrived and long settled Chinese migrants. It is imperative to pick up any changes in the expression of distress and help-seeking in order to be able to relieve such distress when people from one culture (e.g. Chinese culture) choose to live among those of a different culture ().

1.4 Meaning of emotional distress

An important pre-requisite to seeking professional help for emotional distress is recognising the need to do so. Do the Chinese explain their emotional distress as normal life responses or as something deviant that warrants medical intervention as in the case of being clinically depressed? Simon and colleagues’ cross-national study (Simon et al.,

2002) indicates that higher thresholds for reaching the state of clinical depression were observed in centres with a low prevalence of clinical depression, in the city of Shanghai,

China, for example. All societies have their own indigenous labels for a condition which in the West is called clinical depression. One classic example is the popularity of the term shen-jing-shuai-ruo or SJSR to the Chinese, borrowed from the concept of neurasthenia and indigenised within Traditional Chinese Medicine (Lee, 1998). SJSR translates as weakness of the body channels carrying qi or vital energy. Historically, neurasthenia 8 allowed a culturally sanctioned and socially acceptable mantle to be developed that was distinct from psychiatric labelling and its consequences. The non-stigmatizing nature of

SJSR is the major reason for its popularity among the Chinese (Lee and Wong, 1995). A further ‘sanitizing’ element lies in the fact that there are specific Chinese herbal remedies that relieve SJSR. In addition, the concept of SJSR blends well with the indigenous belief in Chinese Cosmology, which emphasises the importance of establishing the ‘yin/yang’ balance and restoring the functions of the ‘five organs’ (Cheung, 1989). Thus, in a broad sense, each culture also provides its unique indigenous means of healing which is culturally sanctioned within the local context. It may be that many people are not conscious of this socio-moral aspect of emotions: the suppression and expression of emotions serve the important function of regulating social harmony within the larger community (White, 1990).

From the Western biomedical perspective, the American Psychiatric Association

Diagnostic Statistical Manual Fourth Edition DSM_IV (American Psychiatric

Association, 1994) in Axis 1 sets the diagnostic criteria for ‘Clinical Depression’ as including:

Five (or more) of the following symptoms which have been present during the same

two-week period most of the day, nearly every day, and represent a change from

previous functioning; at least one of the symptoms is either (1) depressed mood, or

(2) loss of interest or pleasure.

(1) depressed mood,

(2) markedly diminished interest or pleasure in all, or almost all, activities,

(3) significant weight loss when not dieting or weight gain,

(4) insomnia or ,

9 (5) psychomotor agitation or retardation,

(6) fatigue or loss of energy,

(7) feelings of worthlessness or excessive/ inappropriate guilt,

(8) diminished ability to think or concentrate, or indecisiveness,

(9) recurrent thoughts of death, recurrent suicidal ideation without a specific plan,

or a attempt or a specific plan for committing suicide.

In addition, the symptoms have to cause clinically significant distress or impairment

in social, occupational, or other important areas of functioning.

This definition was based on clinical observation in the United States. Cultural context is off Axis 1. Yet cross-cultural issues surrounding depression and the cultural shaping of emotion highlights the significant role played by culture. The role of culture will be considered more fully in the chapter that follows.

The meaning of distress can be explored also at an individual level. Kleinman (1980) developed the notion of ‘Explanatory Models’ (EMs), a concept that addresses the micro- perspective of an individual’s own explanation of the experience of suffering. As health practitioners also develop EMs pertinent to their patients’ illnesses and treatment options

(Helman 2001), it is important for mental health professionals to understand how Chinese make sense of their emotional distress before clinical decisions are taken. Enquiry about patients’ own EMs provides an insight into the interplay between culture and human experiences. Kleinman and Cohen (1997) consider the study of the variations (e.g. in symptoms, causes and prevalence) among people from different backgrounds a unique opportunity to examine how human cultures and environments shape the manifestation of mental disorders. The concept of EMs will be explored in detail in Chapter 4 where I attempt to validate the Chinese Mental Distress Explanatory Model Schedule (MDEMS).

10 In the section that follows I address aspects of the acculturation process and explore how

Chinese residents in Sydney experience their new environment.

1.5 Acculturation

In the context of Sydney, a city manifesting a predominately Western culture with multicultural characteristics (National Multicultural Advisory Council, 1999), many

Chinese adapt to their new cultural environment while preserving their social-cultural and religious heritage (Australia Chinese Community Association ACCA, 2004). Though they all face an acculturation process, the experience varies. I have already offered a definition of the acculturation process. Based on that definition Sam and Berry (1997) advance four major ‘acculturation strategies’ commonly employed by diverse ethnic groups. These are: assimilation - rejection of the native group and identification with the target group; integration - identification with both the native group and the target group; separation - rejection of the target group and identification with the native group and marginalisation - rejection of both cultures as ethnic reference groups, albeit to varying degrees. Recently, Ryder and colleagues (Ryder, Alden and Paulhus, 2000) proposed a

“Bi-dimensional Model of Acculturation”, arguing that people exposed to two cultures can incorporate, either through birth or through heritage, two co-existing cultural self- identities; that is, the old cultural identity does not necessarily diminish while the new one grows. One objective of this study is to ascertain whether the level of acculturation has an impact on the interpretation of ‘emotional distress’. It may be that more acculturated Chinese experience emotional distress or a depressive episode similar to that of their Australian counterparts.

In the process of migration and acculturation it is reasonable to expect a heightened level of emotional distress. One possible explanation for this is the social isolation that follows being alienated from the mainstream culture. Bhugra (2003) posits 11 a model spelling out the complex interaction of pre-migration, migration and post- migration phases. Mastery of communication skills is crucial for everyday social interactions. Thus, second language competence is an important factor in facilitating integration into the mainstream culture. Another possible source of ‘stress’ is the lack of culturally familiar pathways to help and support when compared with those in the home town. Does the risk of becoming depressed increase among first generation Chinese? Are second generation Chinese more willing to report their emotional distress as they become more acculturated?

1.6 Research questions

I outline below the five research questions of my study, I also explain how finding an answer to each question can bridge a gap in existing knowledge.

1.6.1 Do Chinese and Australians experience similar depressive episodes?

This is a key issue to be addressed. Many studies in the past have highlighted

‘somatisation’ in Chinese patients suffering from depression and have viewed this as a distinct Chinese trait (Kleinman, 1977). This proposition has been criticized by Cheung

(1982) as a sweeping cultural generalisation, interpreting observations at a surface level.

Kleinman (1986) subsequently expanded the notion of somatisation in Chinese as a legitimate reason to seek medical help. Cheung (1995) cites three possible explanations, drawing upon various aspects of Chinese culture:

(1) Denial, suppression or repression of emotion;

(2) Lack of a vocabulary to express affective states;

(3) Lack of differentiation between mind and body.

(adapted from Cheung, 1995: 158).

12 According to TCM, the body and mind are closely linked by the concept of balancing the cosmos and the body system (Wang, 2004). Ots (1990) emphasises the body-metaphor used to describe different emotions which, when ‘in excess’, will result in illness.

Emphasis on the affected ‘organ’ avoids direct reference to emotion, which is not encouraged in the Chinese culture. With these beliefs in the background, Chinese patients give preference for nominating a symptom involving bodily sensation.

One of the objectives of this study is to ascertain whether less acculturated Chinese are more likely to present with somatic symptoms (as the accustomed way of expressing their experience) than the more acculturated Chinese. Do the latter resemble Australians when reporting psychological symptoms of depression due to acculturation? From a transcultural perspective, the answer to this question is fundamental to the valid translation and application of Western diagnostic tools to non-Western people. The answer to this question could have significant implications for the development of international monitors of mental health in different parts of the world.

1.6.2 Are Chinese less susceptible to depression than their Australian counterparts? Chinese favour ‘culturally sanctioned labels’; for example, they use SJSR when referring to depressive episodes. The term SJSR carries mixed concepts of somatic and emotional distress, which eschew placing heavy moral judgement on personal responsibility for emotional weakness. Direct attention is on the restoration of body-mind balance. Thus, while the Chinese may suffer emotional distress equally as much as

Australians, the former may not refer to the condition as ‘clinical depression’. To avoid confusion over diagnostic terminology, in my study questionnaire, a description of a likely depressive episode is provided to probe participants to answer ‘Yes’ or ‘No’ to questions surrounding similar experiences. Previous research has provided empirical

13 evidence to support the claim that Chinese cultural protective factors inhibit depression.

Chen et al. (1998) concluded that the lower scores on the depression scale recorded by

Chinese-Americans were more likely due to protective factors. Research into a Tongan community in New Zealand revealed that a protective ‘collective’ culture resulted in a lower prevalence of depression (Foliaki, 1997). In a study undertaken in Taiwan, Hwu and colleagues (Hwu et al., 1996) nominate the ‘less broken family’ as a protective factor. A few studies (Lee, 1997; Weng, 1996; Zhang, Yu, Yuan et al., 1997) report family conflict as a source of stress in both traditional and contemporary Chinese society.

Sometimes, due to the different social dynamics faced by different generations, risk factors could also be protective factors for different acculturation groups and vice versa

(Oppedal et al., 2005). A list of possible protective factors, and their likely impact on low and high acculturation groups, is listed in Table 1.1. While a quantitative survey can provide a quick measure of ‘acculturation levels’ and answers to help-seeking behaviour, qualitative method of inquiry can uncover the complicated relationship of informants’

“lived experiences”. Table 1.1 demonstrates how each protective factor needs to be examined in the Chinese individual’s social context and acculturation level to avoid over- generalisation. As detailed in each cell of the table, the same factor could have the opposite impact on a particular Chinese group depending on their acculturation level, e.g. cultural beliefs. By analysing the protective factors critically in a transcultural setting, global public health campaigners can develop more culturally sensitive strategies to manage an increasingly multicultural society.

14 Table 1.1: Potential protective/risk factors among Chinese of different acculturation levels

Low acculturation Chinese High acculturation Chinese 1. Motivation to Low – associate mainly with in-group High – attract racial discrimination acculturate (separation as acculturation strategy) due to frequent inter-group contact reduced chances of inter-group Thus what seems to be a desirable conflict, thus ‘separation’ operates as acculturation strategy – protective factor ‘Assimilation’ can become a risk factor 2. Language skills Poor English language skills lead to High level of English competence acculturation stress – limited ability to facilitate meaningful interactions acquire new language skills (risk with mainstream culture factor) (protective) 3. Social resources Rely on Chinese community Generally are able to gain access organisation and Chinese media can to mainstream services (a be protective at a first glance, but also protective factor) acts to shunt this group from the resources offered by the mainstream society 4. Self identity Strong stable ethnic identity: well- Self-identity can be in dissonance defined self (protective) (if this is the case, the unresolved ‘identity crisis’ will be a risk factor) 5. Family Strong family values and social Torn between interdependence, relationship support (protective). However, role i.e. family expectations and switching and loss of authority due to personal aspirations for reliance on children’s better English independence (the demand on a skills to connect to mainstream society harmonious family relationship can strain family relationships becomes a risk factor) 6. Traditional Provide healing in familiar contexts, Second generation Chinese may Chinese Medicine may delay seeking Western medical approach Chinese medicine as one help (protective) of the ‘alternative therapies’ (protective) 7. Cultural beliefs Major source of moral/spiritual Chinese socialisation competes (Confucius, Taoism) support – serves as a protective factor with Western formal education rendering ‘cultural beliefs’ a risk factor

1.6.3. How do Chinese conceptualise their depressive episodes and mental illness?

In the Chinese culture, the mere expression of negative emotions can attract

adverse socio-moral judgment (Hsu, 1971; Ots, 1990). To this end, it would appear to be

more culturally appropriate to employ a qualitative methodology to explore ‘the meaning

15 of their depressive experience’ rather than ask Chinese participants to admit to a label of

‘clinical depression’ in a survey form of research. An extant literature reports the reluctance of Chinese to seek professional help due to the stigma attached to mental illness (Leong and Lau, 2001; Li et al., 1999; Lim and Bishop, 2000). This thesis seeks to determine whether there is any difference among Chinese at different levels of acculturation vis-à-vis conceptualisation of depression as an illness or depression as an internal emotional state.

The underlying illness concepts held by the Chinese are crucial to their subsequent help-seeking behaviour patterns. Karasz (2005) argues to the effect that there are two different models among South Asian migrant women and White European

Americans: depression-as-feeling and depression-as-disease. Her rich qualitative data demonstrates that the former group subscribes to the concept of ‘depression-as feeling’ whereas American women subscribe to the ‘disease’ model.

In the current study, I will pose the following questions:

1. Do less acculturated Chinese attribute their emotional distress more to physical/non- psychological causes as compared to the more acculturated Chinese?

2. How do Chinese explain their depressive experience and mental illness?

Conducting cross-cultural or transcultural research helps to generate valuable clinical experiences and comparisons between people from different cultures, and stimulate closer examination of many assumptions in scientific research (e.g. uniform interpretations of the ‘stimuli’ under investigation).

1.6.4. Do Chinese employ similar help-seeking strategies to Australians?

Before making a decision in response to some form of physical/mental discomfort or arousal, a person would attempt a personal appraisal of the nature of the ‘bodily

16 sensation’ or ‘psychological state’. Chinese who seek medical help tend to emphasise their ‘somatic’ symptoms: ‘body metaphor’ is a salient feature in the Chinese culture

(Tung, 1994). But what of those who do not consider that ‘arousal’ warrants any active intervention? Phil, Prior and Wood (2001) conducted a qualitative focus group study in

Wales, using a depressed ‘vignette’ to explore lay attitudes to professional consultations for common mental disorders. Their findings indicate that many informants question whether presenting with emotional symptoms constitutes a legitimate 'illness'. A propos of those who identified emotional problems, many had reservations about the GP’s capacity to manage these problems. Most informants considered emotional symptoms to be 'trivial' and an inevitable part of everyday life. It seems that ‘normalising’ emotional distress is in itself a coping strategy. Will the less acculturated Chinese adhere closely to culturally familiar strategies (e.g. TCM)? Will the more acculturated Chinese subscribe to a Western biomedical model more readily? As well, I seek to identify the reasons for the lower rate of accessing mainstream mental health services by the Chinese. Setting out research questions in a ‘neutral’ tone and not to favour mainstream services as superior to other options is important. The WHO initiative to explore the upstream social determinants of health (see Ottawa Charter 1986, Jakarta Declaration 2000 and Bangkok

Charter 2005; full PDF documents available on WHO website: http://www.who.int), especially mental health, and the likely impact on the ‘whole population’, provided public health policy makers with new insights (besides medications) into developing Action

Plans to build a ‘Healthier Nation’.

1.6.5. Are Chinese less likely to report emotional distress to their general practitioner than Australians?

The low incidence of depression among Chinese in the Asian regions (Chen et al.,

1993; Hwu et al., 1996; Shen, Zhang, Huang et al., 2006) and the under-representation of

17 non-English speaking patients with mental health concerns in primary care in Australia today are widely reported in the literature (Stuart et al, 1996; Wynaden et al, 2005). In the interests of this particular research I now pose the following question:

Do Chinese patients report their emotional distress/psychological complaints to their GPs?

How do mental health professionals treat clinically depressed Chinese if the patients hold a totally different illness concept to that of their psychiatrists? Underlying this research question is the assumption that if individuals report their psychological symptoms to their GPs, the latter will ‘detect’ the classic symptoms of depression and refer them accordingly for appropriate specialist management. This notion of ‘early recognition, early detection and early intervention’ has fuelled many nationwide campaigns on ‘mental health literacy’.

1.7 The lens of inquiry

Transcultural researchers have shown that somatisation is an ubiquitous phenomenon in primary care in Western as well as non-Western societies (Kirmayer,

1993; Simon, Von Korff, Piccinelli, et al., 1999). In Draguns and Tanaka-Matsumi’s review of the literature, somatisation seems to be a distinctive presentation of depressed

Chinese patients in Western medical services (Draguns and Tanaka-Matsumi, 2003).

However, indigenous researchers studying the verbal style of expressing depressive emotion among Chinese in China observe reference to both somatic and psychological expression by their subjects (Tung, 1994; Zheng, Xu, and Shen, 1986). These non-

Western voices are often perceived as insignificant or neglected. Foucault (1980) advanced the notion of ‘medical gaze’ and the power at play between health professionals and their patients. More recently, Marsella (2001) alerts researchers to the trap of

‘Western colonization of the mind’ when conducting cross-cultural studies. All of these 18 examples point to an imbalance of power in the different voices, i.e. Western vs non-

Western. In a bid to balance the ‘power equation’ and to give more weight to the ‘other’

(non-Western) voice, the employment of a qualitative methodology would seem more suited to the purpose. An extant literature demonstrates the use of a qualitative methodology to explore the meanings and beliefs that surround mental illnesses (Carr,

1994; Chan, Cheung, Mok, et al, 2006; Ekblad and Baarnhielm, 2002). Because the qualitative method utilises a ‘bottom-up’ approach, it offers the advantage of avoiding the many assumptions, such as cross-cultural equivalence, inherent in quantitative research. I illustrate this point with an example. A recent study involving 15 centres in 11 countries adopted a qualitative approach in reporting ‘morbid unhappiness’ after childbirth (Oates,

Cox, Neema, et al, 2004). All centres observed experiences comparable to ‘postnatal depression’, yet not all perceived them as something warranting health intervention e.g. consulting a doctor. Compared to standard quantitative research, the qualitative approach avoids falling into the trap of reducing illness narratives to a simple symptom checklist

(Kirmayer, 2001).

It is one of the objectives of this thesis to investigate how Chinese view mental health in general so as to better plan culturally competent health services to serve the

Chinese community. Health policies in culturally diverse settings such as Australia need to be based on a clear understanding of ‘idiomatic’ maps of depression and ‘depressive experiences’. I am particularly interested in identifying the differences between Chinese and Australians’ concepts of what ‘depression’ is, how to make sense of it, how to ascertain when medical or professional help is warranted, and how to seek help. Thus, a combined top-down and bottom-up approach is used to unfold the complex relationship between culture and depression. While the ‘what’ of the research questions can be answered by statistical analysis of quantitative survey data, I believe qualitative

19 narratives will better inform researchers on the ‘why’ of the observed pattern.

Methodological details will be outlined in Chapter 3.

1.8 Thesis structure

I believe examining the epistemology and phenomenology in depressive experiences among Chinese living in Sydney may extend the thinking of public health policy makers, in particular mental health campaigners, on issues like access to mental health services and mental health literacy. Beyond the conventional wisdom of early recognition and intervention, utilization of ‘social capital’ and a bilingual multi- disciplinary workforce (GPs, psychologists, nurses, social workers, and clergy) can be a more culturally competent approach in promoting mental health to the Chinese. Cultural competence is defined by Walker, (1991: 6) as ‘the ability to see beyond the boundaries of [one’s] own cultural interpretations to be able to maintain objectivity when faced with individuals from cultures different from [one’s] own and be able to interpret and understand [the] behaviors and intentions of people from other cultures non-judgmentally and without bias’. A genuine interest in understanding the indigenous concepts of emotional distress may demystify the stereotypes surrounding Chinese patients. These themes are taken up in Chapter 2.

1.8.1 Literature review

In the ‘Literature Review’ (Chapter 2) I provide a comprehensive overview of earlier research into cross-cultural issues in clinical depression and previous acculturation studies. Marsella and colleagues (Marsella, Sartorius, Jablensky et al., 1985) highlight the fact that early researchers often ‘focus[ed] on one of these levels to the exclusion of the others’ (p. 314). I outline research perspectives on clinical depression under the rubrics of

20 Transcultural Psychiatry, Medical Anthropology and Public Health. This chapter aims to demonstrate the advantages of employing multiple lenses to explore the interplay between culture and illness.

1.8.2 Methods

In the third chapter I describe the methodologies used in this research. Benedict

(1934) highlights the fact that if scholars are interested in mental processes, they cannot be satisfied with simply relating to the particular symbol(s) without understanding the total configuration of the individual (p. 49). Likewise, mental health researchers cannot focus solely on symptom reporting (somatic vs psychological) without exploring the

'human intention' behind this phenomenon. Employing a mixed methodology can best serve these dual purposes (i.e. the purpose of reporting the symptoms as well as explaining the human intentions).

1.8.3 Validation of tools

Having sketched details of the mixed qualitative and quantitative methodologies employed in this study in Chapter 3, I proceed, in Chapter 4, to demonstrate how integrated bottom-up (qualitative) and top-down (quantitative) approaches are employed to validate the Chinese version of:

(1) A depression screening measure DMI-10 and

(2) A Mental Distress Explanatory Model Schedule (MDEMS).

1.8.4 Depressive experiences

This is followed by Chapter 5 in which I report on the actual depressive experiences; I analyze data collected from the survey and the focus groups covering the symptoms reported and the explanatory models attributed.

21 1.8.5 Acculturation and help-seeking

Chapter 6 explores the relationship between acculturation and help-seeking. The quantitative data shows the different patterns of help sought from the different medical professionals. The narratives extracted from the focus groups provide rich data on help- seeking strategies.

1.8.6 Recognition of symptoms and services evaluation

Chapter 7 reports the results of (a) the recognition of symptoms (one aspect of mental health literacy) as garnered from the quantitative survey, and (b) the evaluation of existing services by the focus group informants. Mental health literacy (Jorm, Korten,

Jacomb, et al 1997) i.e. knowledge about mental illness and the availability of health services will facilitate timely access to existing services.

1.8.7 Lay illness concepts

The underpinning concepts that Chinese hold regarding mental illness and depression often govern their help-seeking behaviours are discussed in Chapter 8. Mental health professionals could certainly benefit from learning how Chinese make sense of their depressive experience.

1.8.8 Discussion: New synthesis

In the last chapter, Chapter 9, I attempt to provide a new synthesis vis-à-vis phenomenology and epistemology and the implications for mental health, public health, and future cultural studies. Research findings from the current study may have widespread implications for mental health programs around the globe in which the

Chinese language is involved. For example, the measurement tools used in this study

22 have the potential to be used as an efficient screening tool for depression for Chinese in

Australia and other countries with large Chinese populations.

Mackerras (1999) describes the essence of Foucault's theory of Power and Knowledge as

'knowledge or 'truth' is in effect a function of power'. Said (1979) argues that Western scholars have misinterpreted or produced distorted accounts of Eastern civilizations based on their ethnocentric attitudes.

If it is true that no production of knowledge in the human sciences can ever ignore or disclaim its author's involvement as a human subject in his own circumstances, then it must also be true that for a European or American studying the Orient there can be no disclaiming the main circumstances of his actuality: that he comes up against the Orient as a European or American first, as an individual second. (1979: 11)

Said is among the first few scholars to advocate listening to the non-Westerner. WHO stresses the basic human right to get the best medical treatment available and UNESCO

(2001) affirms that the cultural rights of people of every background should be respected, a proposition certainly true in the case of mental health diagnoses and interventions. One of the major objectives of this research is to contribute to knowledge which can enhance the cultural competence of mental health services.

1.9 Summary

Three elements drive my research: (1) there is increasing concern regarding mental illness among migrants from non-Western cultures, like the Chinese, living in

Sydney; (2) there is evidence to support the advantage of adopting a pluralistic approach in the management of emotional distress; and (3) culture plays a vital role in the interpretation of emotional distress and subsequent help-seeking behaviours. A mixed- method approach is best suited to unfold the complex relationship between culture and depressive experiences. The value of conducting cross-cultural research lies in a greater understanding of explanatory models and symptom manifestations of people from different cultures, enabling tailor-made interventions to suit individual needs. It also 23 challenges the basic assumptions of Western psychiatry (for example, universal illness experience). Hopefully, this research will make a difference to mental health services for people from diverse cultural backgrounds.

24 Chapter 2 Literature Review

ƕɊťť …

Acquire new knowledge by reviewing old one… Confucius, Analects

In this chapter I present an overview of the literature related to clinical depression around the globe and among the Chinese. Since the focus of the current study is upon how Chinese residents in Sydney make sense of their emotional distress, a review of their cultural construction of illness is provided as a backdrop. Many authors, who conducted research into the depressive experiences of people of different languages and cultural backgrounds, were committed to exploring the subject matter from the perspective they found most ‘comfortable’. Researchers with multi-disciplinary training (e.g. Eisenbruch,

1990; Good, Del Vecchio Good and Moradi, 1985; Kleinman, 1980) have made an effort to cross boundaries to examine the topic through multiple lenses. My own objective is to present the literature from several perspectives: Transcultural Psychiatry, Cross-cultural

Psychology, Medical Anthropology, and Public Health. The literature cited in this chapter serves an illustrative purpose; the references are by no means exhaustive. Due to the complex nature of the phenomenon and the multiple dimensions that can impact a person’s mental health, no single approach can furnish a complete ‘image’. As Benedict wrote seven decades ago:

‘It is not enough to divide perception up into objective fragments. The subjective framework, the forms provided by past experience, are crucial and cannot be omitted.’ (1934: 51)

First and foremost, I discuss the seriousness of ‘the current epidemic of clinical depression’ and the steps that have been taken by Western developed countries to combat

25 the illness. The next section details the prevalence of ‘Major Depressive Disorder’. The third section explores the validity of diagnostic tools, originally developed by Western medically-trained psychiatrists/psychologists for use in non-Western regions. This is followed by a review of cross-cultural studies of emotions. In the section that follows I examine how people from different cultures form their unique ‘cultural constructions of illness’. Section six draws the focus back to the Chinese. I examine some fundamental concepts in Traditional Chinese Medicine (TCM) that are important in explaining a state of ‘un-ease’. In section seven, I shift the discussion from illness models to the link between migration and mental health. Having looked at the backgrounds of migrants who have adapted to a new culture, a review is presented of previous studies that have assessed the role that culture plays in help-seeking. It is followed by an overview of the utilisation of indigenous and mainstream health services by Chinese domiciled in different parts of the globe. I then discuss the latest population approach in global mental health management. The final section presents the research questions of the current study.

2.1. Interests in ‘clinical depression’ studies

Almost a decade ago, Murray and Lopez (1996) caution mental health professionals that depressive disorders have become the fourth leading cause of disease disability in terms of Disability Adjusted Life Years. Recently, Mathers and Loncar

(2006) report new projections of mortality and burden of disease to 2030 starting from

WHO’s estimates for 2002. The three leading causes of burden of disease in 2030 under the baseline and pessimistic scenarios are HIV/AIDS, Unipolar Depressive Disorders, and Ischemic Heart Disease. Global health reports have pressed mental health professionals to (a) evaluate the effectiveness of existing services, and (b) plan public education campaigns to promote mental health literacy. Several Western countries have taken steps to promote an awareness of clinical depression. Many such programs have 26 reported significant results de-stigmatizing ‘depression’ (Goldney, Fisher, Dal Grande et al, 2005; Jorm, Nakane, Christensen et al, 2005; Paykel, Hart and Priest, 1998).

Jorm, Christensen, H. and Griffiths (2005) report that three years following the launching of ‘beyondblue’, Australians’ beliefs about the treatment of depression showed positive effects. However, despite the efforts of various awareness campaigns, endorsement by the public for treatments using antidepressants remains low. In a study undertaken in Japan and Australia, which compared public beliefs on causes of mental illness (Nakane, Jorm,

Yoshioka et al, 2005), social causes were nominated in both countries. Hinshaw and

Cicchetti (2000), review a significant volume of literature on conceptions of mental illness and stigma, to criticise the disproportional emphasise on a Western biomedical approach. This practice runs the risk of over-simplifying complex patterns of human behaviour and interaction with the environment. Halliburton (2004) cites many WHO studies of developing countries, which found that the long term outcomes of patients suffering from schizophrenia are better than in most developed countries. One explanation offered is that the patients are still given an important role in the community despite their illness. It may be that the socio-cultural aspects of our daily lives are so much a part of everything we do that they tend to be taken for granted. It is only through cross-cultural studies, i.e. comparing differences in the prevalence of clinical depression

(Üstün and Sartorius, 1995) and illness experiences (e.g. somatisation vs psychologisation), that researchers realise that many basic assumptions pertaining to psychiatric theory are subject to challenge (Kirmayer and Minas, 2004). Merson (2004) coined the term ‘epistemic captured’ to describe the phenomenon of the concept of causation within bio-medicine being determined by its disciplinary boundary established within itself. For example, the biomedical concept of the abnormally high level of cortisol in the body as the cause of chronic stress, which in turn leads to intervention by

27 means of blocking the release of cortisol into the body. To avoid being captured by one’s own knowledge, Merson urges health professionals in treating patients presenting with mood disorders, not to prescribe medications as a simple knee-jerk action, but rather be open to a thorough investigation of likely contributing factors which could allow other intervening options to be adopted, be it socio-cultural or psychological, social. This is particularly important when treating patients from non-Western backgrounds.

Bhugra and Mastrogianni (2004) describe the impact of globalisation on mental disorders and the need to deliver culturally competent mental health services to people from diverse backgrounds. Researchers can no longer ignore (a) the importance of the

‘contexts’ in which illness behaviour develops (Ballenger, 2001; Beiser, 2003; Kirmayer,

2001; Mezzich, Kirmayer, Kleinman et al, 1999), and (b) the impact of rapid social change on the manifestation of mental illness (Kleinman and Kleinman, 1999; Lee and

Kleinman, 1997). In the paragraphs that follow, I review studies of clinical depression across a wide range of settings. Particular attention will be paid to those relevant to the

Chinese.

2.2. Prevalence of major depression in different regions of the world The prevalence rates of major depression within primary care in the major

Western countries are similar to those reported by the WHO study (Üstün and Sartorius,

1995). Rates range from 6.4% in Seattle, 9.9% in Mainz, 13.5% in Paris, to 17.1 % in

Manchester. However, it was found that two Asian cities had the lowest rates: 1.6% in

Nagasaki and 2.5 % in Shanghai. Two South American centres had the highest rates:

18.3% in Rio de Janeiro and 26.3% in Santiago. Kirmayer and colleagues (Kirmayer,

Robbins, Dworkind et al., 1993) report a prevalence of 10% to 20% for depressive and disorders in primary care settings in Western regions. A recent report on the

28 results of a replication study (Kessler et al, 2005) of the United States National

Comorbidity Survey (NCS) found that the lifetime prevalence of ‘major depression’ has remained stable at a rate of 16.6% (Kessler, Berglund, Demler, et al., 2005) as compared to 17.1% in the last NCS (Kessler et al 1994). In Australia, depression affects one in five people in their adult lifetime (beyondblue 2006). Many of these prevalence studies used either the Composite International Diagnostic Interview (CIDI) or the International

Classification of Disease (ICD) interviews conducted by trained lay interviewers. In contrast, the prevalence of major depression in the Chinese has been reported as low.

Estimates of lifetime prevalence of ‘Major Depression’ vary according to region and study methodology, from 1.14% in Taiwan (Hwu et al, 1996), to 1.29%/2.44%

(males/females) in Hong Kong (Chen, Wong, Lee et al., 1993). The prevalence of depression among Chinese living in the Western regions appears to be higher, with estimates of 6.9% for 1,747 Chinese Americans (Takeuchi, Chung, Lin et al, 1998).

However, in recent reports, the prevalence of depression among the Chinese seems to equal the rate in the West. The prevalence of state depression in 917 Chinese aged 60 years or over in HK (Chi, Yip, Chiu et al, 2005) was found to be 11.0% /14.5%

(males/females) using the Chinese Geriatric Depression Scale with a cutoff of ≥ 8. This finding is comparable to the recent data reported in the NCS-R of 10.6% for a similar age group (Kessler et al., 2005). A study of 503 American-Chinese attending general practice in Boston (Yeung, Howarth, Chan et al, 2002) reported an extrapolated rate of 19.6 % for state depression drawn from the results of a SCID-I/P6 interview.

A study undertaken of 2,462 adolescent students in Shandong, China, reported the state depression rate as 16.9%, using the Zung Self-Rating Depression Scale with a cut- off of ≥ 55 (Liu, Ma, Kurita et al, 1999). Saluja and colleagues (Saluja, Iachan, Scheidt

6 Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Patient Edition. 29 et al. 2004) reported the findings of a school-based survey collected in 1996 through self- administered questionnaires in the United States(N = 9863). Results indicated that 18 % of youths reported symptoms of depression. It is worth noting that the rate for Asian-

Americans (17 %) was lower than that of white-Americans (18%) but higher than that of

African-Americans youths (15%). Although different criteria were used, Chinese adolescents in China (Liu, Ma, Kurita et al. 1999) seemed to show very comparable rate of depression with the Asian-Americans. According to an Australian study (Andrews et al.1999,) the 12 month prevalence of depression in the age group of 18-24 is 3% for male and 11% for female rendering female in this age range as reporting the highest rate.

2.3. How valid is the diagnostic assessment?

It would appear from the review of prevalent studies cited in the last section that the majority of the diagnostic tools have been developed for use among Western populations. Many researchers have expressed concern about the validity of methods and measurement tools used when the target population is Chinese (Chen, Roberts and Aday,

1998; Zheng, Liang, Goa et al, 1988). This issue will be discussed separately in Chapter

4. Others have opted to conduct in-depth research to explore the real or ‘artifactual’ reasons for such a phenomenon. Kleinman (1987), who has conducted extensive research in both Taiwan and Hunan Province in China, proposed the ‘category fallacy’ as one possible reason. He widely documented the ‘somatisation’ of Chinese as a culturally- sanctioned way of illness expression. According to Kleinman, ‘[a] category fallacy is the reification of a nosological category developed for a particular cultural group that is then applied to members of another culture for whom it lacks coherence and whose validity has not been established” (1987: 452) Chinese researchers (Cheung, 1987; Cheung, Lau and Wong, 1984), drawing upon their innate cultural insights, tried to explain how

30 different conceptualizations of illness influence the help-seeking pathway. The majority of patients seen at a Western medical clinic and later referred to specialists already subscribed to a medical model. Simon et al (1999) also found, consistent with 15 different cities in 14 countries, that upon direct questioning the majority of primary care patients were able to attribute psychosocial causes to their physical symptoms (the major concern of the consultation). Thus, for a clinician to make an accurate diagnosis, a patient’s ‘readiness’ to report all relevant symptoms is crucial.

2.4. Cross-cultural studies of clinical depression

Researchers have become increasingly interested in investigating the commonalities and differences between the clinical presentation of depression and the lay beliefs of attribution among people from different cultural backgrounds. However, there is one very fundamental question that needs to be addressed and that is: What is culture?

Marsella (2003, The concept of culture, para. 1) defines culture as follows:

Shared, learned meanings and behaviors that are transmitted within social activity contexts for purposes of promoting individual and societal adjustment, growth, and development. Culture has both external (i.e. artifacts, roles, activity contexts, institutions) and internal (i.e. values, beliefs, attitudes, activity contexts, patterns of consciousness, personality styles, epistemology) representations.

This definition suggests that people from various cultures are likely to experience reality in very different ways, given the analogy that ‘culture’ is the template used in constructing and interpreting the individual’s world view. In contrast, anthropologist

Geertz alerts social scientists to value the fact that culture is beyond the ‘thin surface’ of social actions but contains much ‘thicker’ meanings7(see footnote),

7 Geertz coined the work ‘thick description’ in his book ‘The Interpretation of Culture’ (1973). To illustrate the distinction between ‘thin’ and ‘thick’ description, take the example of ‘the physical act 31 [T]he essential task of theory building here is not to codify abstract regularities but to make thick description possible…” (Geertz, 1973: 25-6)

Kuper (1996) neatly highlights Geertz’s notion of ‘interpreting culture’ as providing ‘the structure of meaning through which men give shape to their experiences’ (Kuper

1999:96). However, for the purpose of this study, an operative definition of ‘culture’ is needed to allow comparisons of ‘cultural differences’ – the differences in the shared history, practices, beliefs and values of a group of people to another group (Chinese and non-Chinese in this context). Helman (2002, a recommended textbook for the course

‘Culture, Health and Illness’ at UNSW) sees culture as ‘a set of guidelines (both explicit and implicit) that individuals inherit as members of a particular society , and that tell them how to view the world, and how to experience it emotionally… and to the natural environment. P. 2-3). With awareness of the dynamic (non-static) nature of culture and its interpretation, the term ‘trans’ as opposed to ‘cross’ was adopted throughout this thesis to emphasise the active and reciprocal process of cultural adaptation, as experienced by the

Chinese-Australians.

Grammar is the set of rules that governs language. The analogy I make here is that culture is the set of rules that governs social behaviour within a particular culture (Chan, unpublished). Rules are not static by nature: changes are made from time to time and the number of rules can be huge. The ‘grammar’ of social behaviours often functions at a subconscious level and there are consequences when rules are violated. Jack (1999) states that depression has a lot to do with the “SELF”; that is, the perceived SELF in the eye of culture. This ‘invisible’ cultural force can drive a person into depression. Lazarus and

of winking’ vs a social gesture? One must shift beyond the action to the particular social understanding of the “winking” as a gesture and the state of mind of the winker, the audience, and how they construe the meaning of the winking action itself. “Thin description” is the winking. “Thick” is the meaning behind it and its symbolic import in society or between communicators (Adapted from Academic Resources - Colorado State University 2007).

32 Lazarus (1994) contend that in order to experience the emotions of guilt or shame that are often associated with clinical depression, one has to have internal standards against which to measures oneself. Emotional experiences are culturally specific in their expression and experience, each society has rules for appropriate emotional expression and behaviour

(Nussbaum, 1999). However, within the same culture, rules can vary for different types of social agents according to social class, gender, and age. It is difficult to devise a comprehensive questionnaire suited to study the link between culture and emotions quantitatively. Kleinman views culture as something not feasible to untangle from political, economic, psychological, and biological conditions (Kleinman, 2004). Thus in

Kleinman’s view, studying culture as a ‘fixed variable’ sharply reduces our capacity to understand mental states such as depression.

Then there is a further question awaiting an answer: ‘Are Chinese as susceptible as their

Western counterparts to become depressed?’ To address this question, it is essential to acquire some understanding of the differences in illness concepts. In the next section, I present a review of the cultural construction of illness and discuss how illnesses of people of different cultures are shaped by their daily encounters.

2.5. Cultural construction of illness

2.5.1. Idioms of Distress

Initial studies of clinical depression among the Chinese were undertaken in the

1980s. Kleinman’s (1982) seminal study conducted in Hunan, China, triggered the controversial debate surrounding whether the Chinese ‘somatise’ their depressive symptoms. Barnes (1998) reported the ‘psychologisation’ of Chinese acupuncture by

Americans: traditional Chinese healing practices imported by the West have undergone major ‘transformation’ and being used in conjunction with psychotherapy to ‘unblock’

33 illnesses attributed to emotional or spiritual unease. This ‘makeover’ camouflages a

‘foreign’ concept to fit in with other Western illness concepts. This example demonstrates that ‘cultural construction of illness’ is not unique to non-Western cultures.

The controversies surrounding ‘Repetitive Strain Injury’ (RSI) illustrate a very unique form of social construction of illness. Lucire (1996) explains that the RSI epidemic would be better explained as somatisation than as injury, because within the somatisation paradigm, ‘undiagnosable symptoms’ are interpreted as functional disorder, i.e. rather than the presence of an organic disease base, the process is driven by its consequences

(see Lucire, 2003 for cited cases in Australia). In the following paragraph I shed light on how ‘emotional distress’ is constructed around specific cultural contexts.

In Northeast Brazil, the term ‘nervos’ (nervousness) is used to describe ‘anxious feelings’. Rebhun (1994) reports the local idiom of ‘swallowing the frogs’, and the belief that emotion, especially anger, is a powerful force that can cause sickness when it is not expressed but ‘swallowed’. The Chinese have a similar idiom, i.e. “swallowing the voice and holding on to the ‘qi’ (tun-sheng-ren-qi)”. Further examples include ‘open chest’,

‘evil eyes’, and ‘blood-boiling bruises’. ‘Susto’ (fright), a recognised ailment in rural

Mexico and other parts of Latin America, manifests as anxiety and over-conformation to social roles (Parsons, 1990). Parsons contends that these culturally specific disorders may allow the temporary expression of distress by subordinate members of society.

According to Good and colleagues, the Iranians consider a sad person as thoughtful

(motafakker), one who is capable of controlling his/her own psychological affects. Those who express happiness too readily are often seen as simple (sadeh) or socially incompetent (Good et al, 1985). Parsons and Wakeley’s (1991) Australian research notes somatic responses to distress in everyday life in both their control and experimental group. Both groups tended to somatise at a rate proportional to the level of distress. This

34 observation serves to support that of the earliest European critic (Von Uexkull, 1963; cited in Ots 1990, pp. 23-24) regarding the concept of somatisation. Von Uexkull, who believes emotional disorders to be ‘integrated organic reactions’ to environmental stimuli, interprets emotional and somatic distress as two aspects of one ‘psycho- biological’ entity. This is palpably contrary to Kleinman’s early contention that somatisation is the presentation of bodily complaints of psychological affects. Such a view implies a ‘superior mind’ and an ‘inferior body’. In a more recent publication

‘Writing at the Margin’ subtitled ‘Discourse between Anthropology and Medicine’,

Kleinman (1995) makes modification to view ‘the outcome of cultural categories and social structures interacting with psycho-physiological processes such that a mediating world is constituted’ (p. 97). Kleinman’s revised explanation is that the experience

‘subjectively’ felt by an individual is made up of the externally observed behaviour as well as the internally perceived socio-moral worldview.

Cross-cultural studies of depression not only illuminate on the cultural shaping of illness behaviour but also reveal the special ‘idioms’ embedded in different cultures/languages to describe the illness, which closely resembles the Diagnostic

Statistical Manual III and IV (DSM-III and DSM-IV) descriptions of Depression or

Major Depressive Illness (Good and Kleinman, 1985; Marsella et al 1985; Schumaker and Ward, 2001). These observations inform cross-cultural researchers on how, at a macroscopic level, ‘depressive experiences’ are expressed in culturally sanctioned ways by means of certain salient features commonly understood by people who share the culture. Without inside knowledge of cultural ‘codes’, clinical judgment may be difficult

(Johnson, Roter, Powe et al, 2004), especially when there is a mismatch of cultural backgrounds between the clinician and the client (Cheng and Chang, 1999). Lock (1987) questions the appropriateness of the use of Western psychiatric tools, such as the edition

35 DSM-III, when dealing with non-Western patients. Stuart, Minas, Klimidis et al. (1996), who conducted a census on mental health services in Victoria, Australia, found over- representation of ‘psychosis’ and ‘dementia’ in in-patient services among Non-English

Speaking Background NESB (now referred to as culturally and linguistically diverse –

CALD – background) patients. The possibility of misdiagnosis due to a mismatch of the worldview between clinician and patient could not be ruled out.

2.5.2. Male-Female Difference vis-à-vis Depression

The data on depression studies suggest that women are approximately two times more likely to become clinically depressed than men (see Kessler, 1993 and Nazroo,

2001). As well as and the responsibility to look after their children, the perceived plays an important part. Jack (1999) employed ethnographic research to ‘listen’ to the ‘silenced’ voices of twelve depressed women and to study the morals an individual has for the ‘self’. Her informants’ act of suppressing parts of the

‘self’ in order to seek approval from their significant others (e.g. the husband and the doctor father), paradoxically became the source of . This ‘invisible’ force (of culture) can drive a person into depression. Lazarus and Lazarus (1994) contend that in order to experience the emotions of guilt or shame, one must have internal standards against which one measures oneself. Jack (1999) cites the pillars of the field

(Freud, Gilligan, Kohlverg and Piaget) findings that female morality is attuned to affection and relationships, whereas a male morality is dependent on abstract principles expressed in rules and laws. Whittaker and Connor (1998) studying a coastal region in country NSW and found that women associated their stress from gender expectations but men rarely talked about their roles as father or husband as sources of stress. The authors view these differences as the differential ‘embodiment’ of social relationships between the genders. This kind of self-imposed ‘morality’ in women makes them feel that they are 36 not meeting the cultural expectations of a good wife or good mother. They have fallen short of being ‘not selfish’. This is again the socio-moral conceptualization of depression.

Depressed men seem to relate their stress mainly to their work, their careers, and a failure to fulfill personal goals (Whittaker and Connor 1998). Similar findings were reported by a British research team: Nazroo, Edwards and Brown (1997, 1998) find that overall, females experienced an 80% higher risk of a depressive episode following a crisis.

Nazroo and colleagues also report the presence of a higher risk of depression in females, following a crisis, but only when clear role differences between the men and women were evident.

Gender-role differences are also prevalent in Chinese cultures. The subordinations of women trace back to the earliest historical record of the practices of rituals in

Confucius’ “The book of Rites” [LiJi fÞ] (Centre for Chinese Cultural Studies, 2002).

Women are expected to perfect themselves through practicing ‘The Three Subordinations and the Four Virtues’(See Appendix 2-1) The gender roles in the Chinese family are unmistakably defined and almost religiously practised by members of the nuclear and extended family (Bao ƶʂΥ, 1991). The female preponderance in clinical depression has attracted considerable interest among researchers from different disciplines.

In addition to the aforementioned social ‘gender’ roles, there are significant number of evidence-based studies that maintain the contribution of biological-hormonal differences between the two ‘sexes’: men and women (Adinoff, Devous, Best et al, 2003;

George, Ketter, Parekh et al, 1996; Parker and Brotchie, 2004; WHO, 2006a; see

Appendix 2-1 for a brief description of these studies). There is an extant literature that reviews the different theories and models and aims to explain this observed gender/sex difference in community studies; for example, Cyranowski, Frank, Young et al (2000);

Hankin and Abramson (1999), and Nazroo (2001). Kovacs and colleagues (Kovacs, 37 Obrosky and Sherrill 2003) believe that the increased prevalence of depression in post- puberty females is most likely the product of ‘a complex interplay of psychosocial factors in concert with overt and covert biological changes,’ (p. 34). Takeuchi et al (1998) demonstrate an absence of gender difference in depression in their low acculturation sub- set of Chinese-Americans residing in Los Angeles. It is apparent that the protective factors for men are diminished suggesting a likely acculturation influence. This serves as important evidence to support the gender roles model as a contributing factor to the observed gender difference in clinical depression.

2.5.3 Significance of cross-cultural studies of clinical depression

American psychiatrist Eisenberg (1995) reviewed the concepts surrounding what parts nature and nurture play in mental function. He concluded that if genetics specify the brain pathways, then connections are activated by daily experiences. From the perspective of transcultural psychiatry, Kirmayer (2001) asserts that biology clearly demonstrates that humans are fundamentally cultural beings. Anthropologist Hsu (1971) proposes a state of socio-psycho homeostasis. These authors all subscribe to a complex interaction between biology and culture. It is beyond the scope of this thesis to discuss the interplay between nature and nurture in terms of human emotions. Recent genetic studies seem to reveal a complex gene-by-environment interaction. One of the most cited studies is by a U.K. team reporting a functional polymorphism in the serotonin transporter (5-HT T) gene which moderated the influence of stressful life events on depression, i.e. individuals’ responses to environmental stresses are moderated by their genetic makeup (Capsi, Sugden, Moffitt et al. 2003). However, results of replication studies are highly inconsistent, Martin (2006) calls for further investigations into the psychiatric constructs of depression measurements and the level of social support

38 individuals received. Alternative to the genetic research, studying the depressive experiences of Chinese at different stages of cultural adaptation may too bring to light the impact of environment on human emotions. Cross-cultural studies of clinical depression may also play a role in revealing the unavoidable bias that may occur when making a psychiatric diagnosis using formal (standardised interview schedule) or informal

(conversations with patients) procedures. With this in mind, it would benefit clinicians to acquire some understanding of the fundamental illness concepts that are specific to people from non-Western cultures. In the next section, I provide a brief overview of

Chinese illness concepts.

2.6. Traditional Chinese Medicine (TCM)

Chinese have a heterogeneous make up and speak many different dialects. Other than those living in majority Chinese regions, e.g. China, Taiwan and Hong Kong, many

Chinese have migrated to different parts of the world for economic or socio-political reasons. A propos of TCM, there is no shortage of reports of its use by Chinese living in

Western regions (Green et al 2006; Ma, 1999) and highly Westernised societies (Chan et al, 2006; Lim and Bishop, 2000). Chinese surveyed in these studies indicated that subscription to a dual system of both Western and Chinese is common. I will now present an overview of illness concepts, especially those pertaining to emotional distress, within the framework of TCM.

2.6.1. Body-mind link and maintaining overall harmony The Western views of mental illness are strongly influenced by the Cartesian dichotomy of mind and body, with psychiatrists as medically trained specialists treating clinically abnormal ‘minds’. Historically, the Chinese embedded the yin/yang cosmology into a complementary balance between the two forces or energies. Such views deem the

39 entire cosmos to be in a state of dynamic equilibrium: the yin/yang forces with ‘qi’ the vital energy are believed to travel within the body. Both Western and Chinese entrenched thousands of years of scholarly observation into developing their viewpoints.

The traditional Chinese belief in using herbal remedies to restore harmony between the individual and his environment could trace its origin to the belief in yin/yang balance (see Figure 2-1, Chinese yin/yang symbol). Chinese medical practitioners stress the ontological cause of disease – with the individuals as part of their environment – to be subject to change in the immediate physical surroundings (Unschuld 1992). By attributing an ‘external cause’ to the ‘distress’, be it somatic discomfort or loss of social- environmental equilibrium, the patient is relieved of the responsibility for the ‘illness’, thereby minimising any prospect of morally-assigned shame and guilt.

Ways in which to restore yin/yang harmony include taking Chinese herbal medicine to balance the vital organs. Chinese, as revealed in the written language, use the words

‘body’ and ‘heart’ to refer to the whole being (Ots, 1990). Medical anthropologist Ots reports the metaphoric use of various body organs to describe different emotions, which can be perceived as a kind of embodiment. Chinese are strong believers in herbal remedies, not only for treating physical illnesses but also emotional disturbances. Young children are likely, through the food prepared by the adults for therapeutic purposes

(Choa, 1967), to develop a strong sense of body-mind link. Various organs are used to symbolise different emotions; e.g.’ angry’ liver, ‘anxious’ heart and the ‘melancholy’ spleen (Ots, 1990). One basic principle of Chinese herbal remedies is “organotherapy’

(yi-xing-bu-xing), which literally means ‘follow the shape’. For example, a remedy for an

‘anxious’ heart can be made from brewing a pig’s heart with a concoction of other

Chinese herbs. Cross-cultural psychologists Russell and Yik (1996) describe how each organ is matched with an emotion and each organ has a well-defined function to nurture a

40 subordinate organ and the emotion associated with it. White (1990), an anthropologist working among Solomon Islanders, also observes how a socially sanctioned emotion

(sadness) ‘counteracts’ a socially undesirable emotion ‘anger’ bearing some resemblance to the traditional Chinese belief in nurturing a ‘subordinate’ emotion ( ‘anger’ in this case) by the superior one (‘sadness’ in this case). This kind of counteractive relationship between the different emotions is particularly important to the Chinese to maintain the harmony and balance which is paramount in the well-being of the ‘mind and body’.

When one considers that Chinese grow up in this kind of ‘reality’, it is less surprising to see the popularity of leuhng-chah, a ‘twenty-four herbs' concoction (literally means

‘cooling tea’) in Hong Kong (Ling, 1997). This is just one example of how Chinese herbal remedies, which are passed down from generation to generation, are used for minor ailments. The recognition of the connection between food and drink and illness can be traced back to Ho, a physician of the Qin State who, around 400 BC, stated that “[A]n excess of yin leads to cold-illness. An excess of yang leads to heat illness. An excess of darkness leads to emotional illness. An excess of light leads to an affliction of the heart.”

(Historical Museum for Medicine of the Shanghai Academy of Chinese Medicine 1985).

His beliefs stemmed from concepts of depletion (hsu) and repletion (shih) in the body’s five depots (heart, liver, spleen, lung and kidney) and obstructions in the transportation channels (ching). Seeking help from a traditional healer rather than from a Western medical practitioner may enable a Chinese patient to re-establish an overall body-mind harmony. Another example is the popularity of ‘neurasthenia’ (shen-jing-shuai-ruo or

SJSR) as a diagnostic concept (a proxy term for depression) among traditional Chinese doctors as well as lay people (Lee and Wong, 1995). In Chinese culture, the term

‘neurasthenia’ literally means ‘weakness of the nerve’; the term ‘weakness’ is also applied to body parts, limbs and the heart. By stressing ‘weakness’, the illness is not

41 distinguished as a disease of the mind but rather one of the body. In this way, any suggestion of stigma is eschewed (Lee, 1998). Lee and Kleinman (1997) note a decline in the use of SJSR by mental health professionals in the 1990s and increased reporting of

‘diagnosed depression cases’ (Lu, Huang, Sun et al, 1998) as a way of utilising a more scientific Western-medical approach after CCMD-II (Chinese Classification of Mental

Diseases, 2nd edition) became widely used in China. Patients who seek help from a traditional Chinese herbalist will receive treatment that enforces emotional change and harmonises emotions by harmonising bodily functions. There is less overt emphasis on distress and more on acquiring harmony and overall balance.

2.7. Migration and mental health

The driving forces behind migration vary considerably, from political asylum seekers and refugees, forced migration resulting from political upheaval, professional commitments to family reunion. Irrespective of the circumstances, mental health may well become an inevitable concern for many migrants (Bhugra, 2004b; Bhugra and

Mastrogianni, 2004), as they confront the geographical and socio-cultural differences that render new migrants vulnerable to environmental and emotional distress. Minas (1990:

255) summarises the migrant experience as ‘… feelings of persistent sorrow for the lost world’. The study of depression in migrant communities provides an insight into the

‘unique experience’ that accompanies migration. Stress could arise at personal level and institutional level, from interpersonal dynamics (social), the change in infrastructure of the receiving country, and from perceived discrimination. A strong sense of dislocation and alienation attributable to language limitations further aggravates the new arrivals’ social isolation. Several authors (Bhugra, 2003; Murphy, 1977; Rack, 1988) acknowledge the circumstances surrounding pre-migration, migration and post-migration as equally

42 important factors that can induce stress (See Figure 2-1, Bhugra’s Model). A substantial volume of literature addressing migrants and mental health highlights the differences in cultural interpretation of illness and culturally approved strategies of coping (Foliaki,

1997; Holtz, 1998; Karasz, 2005; Klimidis and Minas, 1995; Tabora and Flaskerud,

1997). But not all migrants become mentally ill, and for this reason clinicians should explore possible resilience among specific migrants (Bhugra 2003; Rosenthal and

Feldman, 1996). Insights gained from studies of migration and mental illnesses will undoubtedly be of value to future planning of services for migrant populations. In the next section I summarise the theoretical proposition between migration and mental illness.

2.7.1. Self-selection Cochrane and Bal (1987) hypothesise that those who are prone to mental illness

(especially schizophrenia) are more inclined to migrate. While there is some support for this argument (Bhugra, 2004b), there is also counter evidence showing inconsistent rates of mental illness in first generation migrants across different communities (Littlewood and Lipsedge, 1997). Hernandez and Charney (1998) term the health advantage among first generation migrants – as compared to their U.S.-born Anglo-American counterparts

– the ‘Immigrant Health Paradox’. They reported that initial superior mental health and lower risk behaviour appears to fade away over the generations.

2.7.2. The migration experience is itself stress-inducing The ‘Stress Hypothesis’ was first proposed by Ranney (1850 cited in Murphy

1977: 677). For more vulnerable individuals, migration can be a stressful process, which may lead to psychological morbidity. Paykel (2001) describes a link between life events and the initial triggering of Unipolar Depression. The risk of developing this form of morbidity is higher among those who migrate at an advanced age (Minas, 1990). It could

43 be argued that living in an alien culture rather than migration itself is the major source of stress. It seems reasonable to suggest that ‘uprooting’ one from the familiar routine is highly stressful, by extension significantly impacting one’s self-esteem and self-identity.

Minas (1990), who contests the over-simplification of the ‘migration-morbidity’ hypothesis, maintains that many psychological, social and cultural variables, personalities, motivation to migrate and social support, for example, have not been taken into consideration. Moreover, in a dynamic society, individuals may adopt multiple identities and experience a higher fluidity between their different social roles. It well may be that factors like cultural identity, self-esteem, early socialization and attachment patterns all play a part in the genesis of mental disorders (Bhugra, 2004b; Bowlby, 1997;

Brown, Andrews, Harris et al, 1986). There is no shortage of critics to challenge the incidence of higher morbidity in migrants. A study undertaken in Australia by Klimidis and colleagues (Klimidis, Stuart, Minas et al.,1994) examines the emotional distress noted in adolescents in Melbourne from four different cultural backgrounds (Australian- born Anglo-Celtic, Australian-born children of migrants, overseas-born migrants and overseas-born refugees), they found that the migration-morbidity hypothesis lacked support.

2.7.3. Misdiagnosis Accurate medical diagnosis may be impeded (a) by the clinician’s lack of understanding of the client’s cultural background, and (b) by failure to take into account the patient’s own ‘explanatory models’ of the illness experienced (Beardsley, 1994;

Cooper, Roter, Johnson et al, 2003; Hassett, George, Harrigan et al, 1999; Tippett, Elvy,

Hardy et al, 1994). Language barriers - or having to use interpreters - can further complicate the medical consultation. Tabora and Flaskerud (1997) report that Chinese, even those who are fluent speakers of English, reverted to their native language when

44 expressing intense emotions during focus group discussions aiming to explore mental health beliefs. Loring and Powell (1988) reported cases of misdiagnosis and cultural bias, which occurred when psychiatrists were given the same symptoms description but random information on sex and ethnicity. The medical experts’ diagnoses varied according to the variables; severity also varied according to the patient’s ethnic group.

Even black psychiatrists fell into the trap of racial stereotyping, diagnosing black patients as suffering more severe forms of mental illness than white patients. This resonates with

Foucault’s (1980) notion of the ‘medical gaze’: the perception is an active mode of seeing

(i.e. the subjective judgement in the case of the psychiatrist). It is the process through which specific objects, namely disease categories (i.e. the clinical diagnoses in this context) come into existence. A preliminary evaluation of the services provided by the

New South Wales Transcultural Mental Health Centre (NSWTMHC 2001) shows the importance of its service especially in the areas of clarification and confirmation of diagnoses made. Forty-seven per cent of clients from various migrant communities, who had been given a primary diagnosis by a psychiatrist, were provided with an alternative diagnosis after consulting a culturally sensitive diagnostic team at the Transcultural

Mental Health Centre. The level of misdiagnosis and the possible impacts on the clients should not be underestimated. Young (1982) proposed the concept of ‘sickness’ as a process of socialising the bio-medical based ‘disease’ and culturally-shaped ‘illness’. In particular, when a ‘pluralistic’ medical system exists, i.e. one set of signs can designate more than one sickness. The outcome will depend upon the ‘social or cultural’ forces.

The conceptualizations of ‘clinical depression’ among Chinese from different backgrounds may demonstrate this point:

A Chinese person, living in Sydney, with good mastery of the English language and highly Westernised may consult a psychiatrist when experiencing some common

45 depressive symptoms. Yet another Chinese person living in Sydney but doesn’t speak good English nor endorse Western psychiatry models of emotional distress, while experiencing similar symptoms, may reject any suggestion of mental ill-health and turn to a herbalist to restore any hot/cold imbalance. As Young (1982) proposes, conversion of signs into symptoms is a critical stage in the process of providing treatment or help for human emotional distress.

2.7.4. Ethnic density effect

Murphy (1977), assessing adaptation after migration beyond the individual level, debated the significance of ethnic density (the degree to which members of an ethnic group consolidate in a certain area) in the development and continuation of some types of social distress. This is especially true among those who subscribe to collective responsibility when interpersonal conflicts emerge. Bhugra (2004b) suggests that if migrants migrate from collectivist societies into individualist societies, they will run a higher risk of encountering problems in settling down. The distinction between a

‘collectivist or socio-centric’ society and an ‘individualistic or ego-centric’ society has been empirically supported by a series of studies in over 70 different countries around the world (Hofstede, 2001). Mak and Chan (1995), after reviewing the hierarchical structure of power in Chinese families in Australia, drew the conclusion that strong family relationship provided the Chinese not only with a stable environment but also with the core family values that serve to ensure family cohesion. Bhugra (2004b) re-affirms the link between ‘ and migrant mental health. It is likely that migrants with a collectivist orientation, who live with others from similar cultural backgrounds, will be protected from adverse psychiatric impact.

46 2.7.5. ‘Entrapment theory’

Gilbert and Allen (1998) who propose the phenomenon of ‘arrested or blocked flight’ – frequently observed in animals – consider it relevant to the migration experience.

For example, a settled migrant might experience unfulfilled aspirations and feel entrapped by his/her lack of control over the environment. According to Gilbert and

Allen, ‘arrested flight’ in animals usually leads to suppression of exploration behaviour, submissive postures, and severe demobilization. A human analogy vis-à-vis clinical depression could be the suppression of anger, social withdrawal, demotivation and anhedonia. The individual feels trapped in an adverse situation: nothing can be done to alleviate the crisis situation due to the person’s limited capability (Figure 2-1, Gilbert and

Allen’s Model). This is similar to ‘learned helplessness’ (Seligman 1975), which eventually leads to abandoning any attempt to get out of the ‘stressful situation’. It is a model that fits particularly well into the migrant context where personal incompetence including poor language skills and social-cultural obstacles, e.g. perceived discrimination, cannot be overcome by individual effort and is undoubtedly stress- inducing during out-group contact. Eventually, the locus of control of these migrants shifts to become predominately external. Furnham and Bochner (1986) argue that the external locus of control is associated with poor adaptation and sub-standard mental health. The sense of loss and unrealised ambition may be most strongly felt after 5 to10 years of migration (Bhugra 2004a). Negative feelings can be considered as both cause and symptoms of depression. However, as Bhugra (2003) reports, some Indian subcontinent migrants, who settled in the UK, were able to tolerate their stresses more and take on less threatening cognition if they simply accepted their fate (external locus of control). This argument may also apply to Chinese who are influenced by Taoism. Lao-

Tzu’s (600 BC) teaching on “all life is impermanent” is an cultural construct defined as

47 ‘Tao’ (which literally means ‘the Way’), the ultimate reality of the universe and human life, the best way to deal with life is ‘wu-wei’ - letting things take their own course (Wu

1998). Holtz (1998) notes how Buddhist spirituality, which represents an external locus of control practiced by Tibetan nuns and refugees, plays a crucial role in the development of resilience. An external locus of control amalgamated with socio-centric beliefs may protect the migrants against emotional distress. According to Koenig (2001), religious belief provides a positive worldview that gives experiences – whether negative or positive – meaning. This ‘making sense’ of the circumstances, in turn, provides a direction in life, and more optimistic outlook. However, there remain these questions:

“Will environmental change concomitant with moving to a new host country, or a shift from socio-centric to ego-centric orientation, affect people’s belief in health and illness?

Will these changes in belief bring about subsequent change in help-seeking behaviour should the need arise? These issues will be addressed in the next section in which I explore aspects of acculturation.

2.8. Acculturation and help-seeking

2.8.1 Objective measure of acculturation vs subjective measure of ethnic identity

One objective of the current research is to explore the impact of culture on the interpretation of emotional distress offered by Chinese. Salent and Lauderdale (2003) reported a comprehensive review of the literature on the link between acculturation and health, but due to the heterogeneous nature of human experiences covered and the diverse range of methodologies adopted, no clear mode emerged to determine how acculturation would affect health. However, there are studies that demonstrate a positive association between levels of acculturation and positive attitudes towards professional psychological

48 services (Liao, Rounds and Klein, 2005, Sue and Sue 2000; Tata and Leong 1994; Ying and Miller 1992,). Berry and Sam (1997) put forward a four-fold acculturation typology of acculturation attitudes comprising ‘assimilation, integration, separation and marginalization’ depending on the degree of adherence to - or rejection of - the heritage and/or the new culture (See figure 2-1).

49 Figure 2-1 Summary of Hypothetical Models of Migration and Mental Health

Sam and Berry’s 4-fold Acculturation Model Identify with Receiving Country

Assimilation Integration Identity with Country of Origin

Marginalization Separation

Life Events Entrapment Depression’s Arrested Anger downward spiral

Gilbert and Allen’s Model of ‘Arrested Flight’

Bhugra’s Model: contributing factors to mental health

Sup- Pre-migration Resi- port Vulner- lience ability Migration

Post-migration

Acculturation Self However, many of the acculturation measures developed at the time assume a uni- dimensional scale, with the two competing cultures polarized at opposite ends and bi- 50 cultural individuals standing at the mid-point (e.g. Lai and Linden, 1993; Suinn, 1998;

Ward, 2001), however, Ward (2001) is quick to point out the shortcomings of these scales: most failed to distinguish bicultural individuals, who firmly identify with both their heritage and the mainstream (host) culture. Another criticism of Berry and Sam’s model, offered by Rudmin and Ahmadzadeh (2001), is that the measured ‘attitude’ is transferred to mean ‘actual human behaviour’. Elias and Blanton (1987) call for a cautious approach to substituting acculturation ‘attitudes’ for ‘behaviour’, for whereas in the acculturation process attitudes may represent the ideological orientation, the individual’s own capability may limit the actual choice of behaviour, i.e. lifestyle and preferred language. The other side of the argument is also valid: behaviour changes may not necessarily bring about core value changes. Rosenthal and colleagues (Rosenthal,

Bell, Demetriou et al, 1989), comparing Greek-Australians with Anglo-Australians and

Greeks, observed a close match of pragmatic behaviours between the first two groups.

But the Greek-Australians tended to resemble the native Greeks more in their core values.

More recently, Ryder and colleagues (Ryder et al, 2000) have proposed a “Bi- dimensional Model of Acculturation”, arguing that people exposed to two cultures can incorporate, either through birth or through heritage, two co-existing cultural self- identities (i.e. the old cultural identity does not necessarily diminish while the new one grows). This new model sounds convincing. However, Clement, Noels and Deneault

(2001) observe in French-speaking Canadian college students, that while increased contact with the second language community tends to lower first language group identification, it enhances group identification with the second language community. This may indicate a competition between time and resources.

The overwhelming focus of acculturation studies has been placed on either ethnic attitudes or behavioural patterns. Noels, Pon and Clement (1996) propose measuring

51 instead ‘ethnic identity’, the subjective feeling of belonging to a particular ethnic group.

It is ‘that part of an individual's self-concept that concerns how he or she relates to the native ethnic group and to other relevant ethnic groups’ (Phinney and Alipuria, 1990).

Bhugra (2005) observes that interest in finding the link between ‘cultural identities’ and mental health was reignited following a recent review of the literature on migration, ethnic minorities and mental health. Two major themes emerged: (1) cultural identity influences beliefs about mental illness, and (2) ethnic identity and cultural congruity may play a role in the genesis of mental illness (p. 85). However, one may ask: what contributes to ethnic identification or the ethnic ‘self’? Laroche, Kim, Hui et al (1998) demonstrate a non-linear relationship between linguistic acculturation and ethnic identification. The initial sharply rising linear relationship revealed the need to integrate into the mainstream society in order to accomplish everyday encounters such as shopping, daily transportation. It was then followed by a slow non-linear relationship, which plateaued at a certain level. There is a comprehensive literature reporting the link between second language confidence and self-identification (Clement et al, 2001).

2.8.2 The ‘individual’ Self vs the ‘collective’ Self

Study of the difference between self-concept in the East and in the West has been well documented. In the psychology literature, ‘identity’ is linked closely to the concept of ‘self’, which in turn is important in determining ‘self-esteem’ and ‘self-worth’ (De

Vos, Marsella and Hsu, 1985; Hsu, 1985). Higgins (1999) maintains that discrepancies between the actual and ideal self can lead to dysphoria or dejection. Hsu (1985) distinguishes the Chinese ‘Self’ from the Western ‘Self’. According to Confucian teachings, the ‘Asian Self’ is further partitioned into ‘ta-wo’, the greater (or the collective) self, which takes precedence over ‘hsiao-wo’, the smaller (or the individual)

52 self. Thus a Chinese person is defined not just by self but by the complicated social relationships within the family and the society. The Western ‘self’, in contrast, is denoted by the distinctiveness of the person, who is separated from the others surrounding him/her. Within the Chinese culture, modesty and self-effacement are highly praised and thought to reflect Chinese virtues and wisdom, all of which serve to enhance social harmony and the so called ‘common good’ (Russell and Yik, 1996). This resembles

Markus and Kitayama’s (1991) theory of the ‘interdependent self’ observed in non-

Western cultures as opposed to the ‘independent self’, the hallmark of Western cultures.

This dichotomous ‘self’ may become blurred when an individual raised in a collectivist or socio-centric culture migrates to a country with ‘individualistic’ orientation. Beyond the person, there is social interaction working at a group level. During the acculturation process, an individual’s sense of being ‘welcome’ or ‘excluded’ often involves the accumulation of personal experiences carrying subjective meanings for the individual.

Murphy (1977) pointed out three decades ago that the greatest obstacles surrounding migrant integration lie in the reluctance of the receiving society to provide equal treatment for all. Bhugra (2005) argues to the effect that cultural identity is fluid and affected by multiple factors. Werbner (1997) sketches out the dynamics someone with a hybrid identity experiences which is highly relevant to Chinese growing up in Australia.

Acculturation should, however, not be studied simply at an individual level.

2.8.3. Confucian teaching – backbone of socialisation in the Chinese

According to Liang (1987), Chinese are frequently portrayed in Chinese operas and novels as hard-working, forbearing and adaptable. Confucian teaching emphasises self-criticism:

Master Tsang said, “Every day I examine myself over and over again, in acting on behalf of others, have I always been loyal to their interests? In social

53 interaction with my friends, have I always been true to my word? Have I failed to repeat the precepts that have been handed down to me?” Analects 1:48

This is extended to encourage a person to frequently reflect on one’s own daily behaviour and to improve upon one’s weaknesses. Heine and Lehman’s (1999) study found that the

Chinese are positioned between the Japanese and the Americans on the scale of being

‘self-critical’.

The Master said, “Pleasure not carried to the point of over the limit, grief not carried to the point of excessive hurt.” Analects 3: 209

Again, Chinese are discouraged from expressing their emotions. One of the reasons for this is the belief that excess emotion causes illness, e.g. anger will lead to liver depletion or stagnation of ‘qi’. However, Tang (2003) argues that by engaging in artistic activities, a Chinese person could ‘calm’ (ong-tuen) his/her emotions because the unarticulated feelings may be expressed in art (c.f. Art Therapy). The idea of using art to deflect emotions first appeared in Analects 7:610 wherein

The Master said, ‘Set your heart upon the Way, support yourself by its power, lean upon Goodness, seek distraction in the arts. (music, archery, calligraphy, painting , chess and horsemanship)’.

In Western social science terms, this is equivalent to objectifying one’s feelings, i.e. the transformation of abstract feelings into concrete forms, whether the forms be a poem, a painting, or a piece of music. In Tang’s own words,

‘[F]or example, music, painting or drama etc…[art] objectifies the person’s feelings… and then the person’s privately owned feelings turn into publicly displayed emotions…in this process, the original unsettled feelings found an outlet to relieve any distress.’ (p. 412).

Chinese view family life as the most important social interaction (Hsu, 1985; Liang,

1987). Chinese consider the family relationship as fundamental (Tang, 2003). The

8 The original Chinese script is: ‘ : , , , , ’(Cai et al 2002) 9 The original Chinese script is: ‘ : , .’ 10 The original Chinese script is: ‘ .’ 54 practice of filial piety and ancestor worship could be viewed as a person reaching out to connect with the ‘origin of the life force’, i.e. the cosmos or the ‘tien’ (literally meaning

‘the sky’). According to Confucius’s ‘Doctrines of Moderate Living ’(zhōn-yōng)

[J]oy, anger, sadness and happiness etc, when these emotions are not yet expressed explicitly, that is called ‘zhōng’ meaning not deviated from the norms. When they are expressed outwardly, but not over or under the limits, this is called ‘hé’ meaning harmony’. ‘zhōng’ is the root and origin of the cosmos; ‘hé ’ is the common pathway of every human being.” Verse 4 11

Chen’s (1989) interpretation of this verse reads: ‘Chinese believe that if a person acts within the norm ‘zhōng’, s/he will live a long life, if they act in contrary, their lives will be cut short’. Thus, Chinese are brought up to suppress their emotions not only for sound social-moral reasons to achieve ‘harmony’ (hé) within the in-group members but also for one’s own ‘longevity’, both are culturally desirable (Chen 1989). In return, the ‘in-group’ will offer support to any members who may be in crisis.

Often ‘Confucianism’ becomes the proxy term for ‘Chinese cultural values’.

Confucian teachings are indeed influential in many Asian countries including Japan,

Singapore, Taiwan and Vietnam. According to Tu (1993), Confucian Humanism takes an active approach which sees man as ‘co-creator’ of the world in which we live. This belief was inspired by the awareness that ‘Heaven knows me’ (Analects Chapter 14, verse 37) which is based on a deep-rooted faith in the continuation of human culture as a transcendent reality. By placing such emphasis upon cosmological significance within the culture and its subjects, Confucius was able to cultivate a sense of mission. Perhaps it is this ‘sense of mission’ that motivates the Chinese people to work hard, to survive any form of hardship and to achieve the final goal of becoming ‘sage’ (shèng-rén).

11 The original Chinese script is: ‘ , .’ 55 Cultural values set down thousands of years ago may have undergone various forms of

‘metamorphosis’ in their meanings in order to match other ‘progressive’ forms of change: e.g. socio-economic, political, and technological, to name but a few. With the ‘mixed method multiple groups’ design of the current study in mind, I will now address the role that culture plays in the depression episode and the subsequent help-seeking behavior employed both at the individual and acculturation group levels.

2.8.4. Studies of acculturation and emotional distress

Previous studies reported some acculturation effects on clinical depression among

Chinese living in Western regions. Takeuchi et al (1998) undertook a community study of

1,747 Chinese Americans living in Los Angeles. Their study failed to show the significant effect of direct acculturation markers (such as English language skills and length of residence in the States) on depression rates but age of migration showed some correlation. This could be interpreted as suggesting that Westernised Chinese retain some cultural ‘protection’ against major depression. Furnham and Li (1993) studied psychological adjustment and depression symptoms in two generations of Chinese domiciled in Britain, with age being established as a crucial factor. Among the first generation group (aged 19 to 60, who migrated at or after 18 years of age), the younger the individual the more likely he/she was to report both psychological symptoms and a poor sense of belonging to the host community. It appears that being brought up in a

Western culture results in a greater psychologising of symptoms. In terms of somatisation

– where the term is used to describe a culturally accepted way of expressing ‘discomfort’

– a study challenges the view that the Chinese necessarily ‘somatise’. Yen et al. (2000) compared somatisation scores on the CES-D depression scale, for (i) Chinese university students in China, (ii) Chinese-American college students and (iii) their Caucasian-

56 American counterparts, with the Chinese students returning lower ‘somatic’ scores than those in the two other groups. Another study of College students, identified as Chinese-

American, reported that Chinese migrants who left their home country at a very young age more closely follow the pattern of non-migrants brought up in a Western culture

(Ying, Lee, Tsai et al, 2000). Of course, college students are hardly typical of the Chinese in a community. Findings of acculturation studies can inform health policy-makers regarding the role that culture plays in symptom recognition and illness interpretation.

This information is crucial to any planning of culturally competent mental health services for Chinese and other non-English–speaking communities. In the section that follows I provide an overview of mental health services utilisation.

2.9. Utilisation of mental health services

The under-utilisation of mental health services by migrant and non-migrant minority groups has been well documented in different countries of the world that have a substantial migrant intake (Green, Brandby, Chan et al, 2002; Leong and Lau, 2001; Li,

Logan, Yee et al, 1999; Stuart et al., 1996; Wynaden, Chapman, Orb et al, 2005). A brief summary of the most recent ‘Best Practice Psychiatrist Liaison Model’ recommended by the Royal Australian and New Zealand College of Psychiatrists (RANZCP 2006) is presented in Appendix 2-2. Within the Australian National Medicare system, patients are required to obtain referral from their family doctors (GPs) before consulting a specialist psychiatrist, to be eligible for Medicare rebate. Historically, delivery of quality mental health services in primary care faced many barriers (e.g. inadequate undergraduate training). It was until 2001 that the Australian Commonwealth Government acknowledged the fact that people with mental disorders preferred seeking help from their GPs to specialists (CRUfAD 2003). The ‘Better outcomes in mental health care’

57 initiative was launched to fill in the service gap (See Clinical Research Unit for Anxiety and Depression website for an overview: http://www.crufad.com/phc/overview.htm).

Earlier North-American research on mental health services utilization among non-

Western population includes a study of services utilisation by Vietnamese refugees in Los

Angeles (Flaskerud and Nguyen, 1988) showing a higher withdrawal from - and refusal of - treatment among the Vietnamese than among other ethnic groups. This finding is consistent with studies reporting treatment patterns of minority patients in mental health services in the United States. Australian primary sources (see Australian Health Survey

1983, ABS 2006) also suggest that Non-English Speaking Background (NESB, now referred as CALD background) migrants, when ill, appear less likely than the Australian- born or English-speaking background migrants of the same sex and age to take bio- medical health-related action such as hospitalisation or medical consultation. (Tippett et al., 1994) A study undertaken in Victoria, Australia of southern European migrants showed the rate of admission to mental health facilities of a broad range of mental illnesses to be approximately half the rate of other communities (Tippett et al, 1994: 25).

Stuart et al (1996) report a study in Victoria, Australia, where a census was conducted in

1993 to examine the utilisation of mental health services in primary care inpatient and outpatient psychiatric services covering private and public hospitals. Not surprisingly, they found a general under-utilisation of services. Bilingual GPs seemed to be managing the psychological distress of patients with poor English language skills (Stuart et al.,

1996). Consultation with specialist psychiatrists, requiring a higher level of English competence, is rarely utilised by patients from CALD backgrounds. Recently, Chen and

Kazanjian (2005) report an audit of health care use through the immigration database in

British Columbia Province, Canada, which involved more than 150,000 Chinese migrants from Hong Kong, China, Taiwan and Macau. Preliminary findings indicated a lower

58 overall use of health care as compared to Controls matched for age, sex and location.

Echoing the Australian study (Stuart, et al., 1996), the most distinct under-utilisation of mental health services lay in consultations with psychiatrists and psychiatric hospitalisation.

Barriers have been identified as multi-faceted: they include structural, language, illness concepts, lack of knowledge of available services, and (Leong and

Lau, 2001; Li et al., 1999; Thompson , Hunt and Issakidis, 2004; Wynaden et al., 2005).

Many studies report language barrier as a deterrent to mainstream service utilisation in migrant communities (see for example, Green et al., 2002; Li et al., 1999; Stuart et al.,

1996). A study by Comino, Silove, Manicavasagar et al (2001), which compares self- reporting of depressive symptoms between Asian (and other patients from culturally diverse backgrounds) and Australian subjects and found comparable rates of reporting.

Comino et al. found that while reports of depression did not differ, general practitioners were less likely to identify depression in Asian than Australian subjects. However, Steel,

McDonald, Silove et al. (2006) examine the pathways to mental health care by new patients who presented to community and hospital-based services. It was found that the median time taken to access specialist services was 6 months. Unlike earlier studies

(Stuart et al. 1996; Tippett et al, 1994), ethnicity and English fluency were not associated with delays in receiving public mental health care. This could be due to recent improvement in GP referrals.

There are reports in Chinese-speaking regions to suggest that social stigma is highly prevalent among psychiatric out-patients currently under treatment (Lee, Chiu,

Tsang et al., 2006). Thus it appears likely that the barriers to psychiatric services extend beyond language difficulties. However, to date no systematic cross-cultural comparison of the various types of barriers to mental health services utilisation has been undertaken.

59 Noting the worldwide effort by World Psychiatric Association to reduce the stigma associated with mental illness (Kadri and Sartorius, 2005), it is important to document how ‘social stigma’ affects the utilisation of mental health services in migrant as well as non-migrant communities.

2.10. Population mental health

The high prevalence of clinical depression is a concern for many Western developed countries. WHO has long been advocating for a multi-sectoral approach to promote health (see Declaration of Alma-Ata, WHO 1978) and this is especially true in mental health promotion. Involvement of government sectors ‘such as health, employment/industry, education, transport and community services as well as non- governmental or community-based organisations such as churches, clubs and other bodies’ are essential (WHO 2001a). A whole population systematic approach has been on agenda of WHO International Conferences on Health Promotion. It is also the main focus of two recent WHO publications on international policy over mental health promotion and the prevention of mental disorders (WHO, 2004b and 2004c). Comprehensive

National Mental Health Promotion Policies have been developed in Scotland, England and other European countries (Friedli, 2005; Hannah, 2002).

Raphael (2000) proposes, in her publication titled ‘Unmet needs in prevention’, the adoption of preventive approaches in disease conditions featuring depression, anxiety, internalizing and social withdrawal. She advocates strongly implementing precautionary measures in school-based interventions, early intervention programs, and programs for children and young adults facing stressful life events (Raphael 2000). The Australia

Government consequently commissioned a discussion paper “A Population Health Model for Mental Health Care’ (Raphael, 2000) to address such a paradigm shift – to encourage

60 individuals to focus on improving mental health well-being across the life-course, especially the high-risk group. Raphael adapted the model by Mrazek and Haggerty

(1994, see Figure 2-2 below) to view ‘Prevention, Early Intervention and Maintenance’ as a spectrum of Health Promotion. At the beginning of my literature search, when population mental health was still in its infancy, it has now evolved to become a global strategy. Targeting the upstream of social determinants of health in promotion program and advocating for health on the basis of human rights are two of the dominant themes in the 2005 Bangkok Charter discussed at the 6th International Conference of Health

Promotion (Rissel 2005).

Figure 2-2 Spectrum of Mental Health Intervention

Rowling (2001) cited the two-continua conceptualisation of interventions (See Figure 2-

3) originally proposed by the Canadian Mental Health Association in a publication titled

‘Bridging the Gap’ (CMHA 1992). Rowling maintains that the advantage of such a

61 conceptualization is being able to accommodate the population health approach to health promotion with its emphasis on the social determinants of health (and mental health). The

2004 annual report ‘Making Connections’ (CMHA 2004) explicitly advocates for their concerns about mental health issues with agencies outside the mental health sector which could broaden their platform to urge public policy makers to address the unmet needs of the mentally ill. This is in resonance with Rowling’s (2002) call for advancing mental health promotion that entails strengthening individuals as well as communities’ capacities which then serves as a buffer against stressful life events. Outlined below are some important aspects of this approach.

Figure 2-3 Mental health promotion for mental illness and mental health (Rowling, 2001 adapted from Canadian Mental Health Association 1992)

Absence of mental disorder Maximum mental disorder

Optimal mental health Minimum mental health

Mental Health Promotion

2.10.1. Evidence-based research in health promotion and prevention

The conventional wisdom of ‘Prevention is Better than Cure’ has been supported by studies in physical health (e.g. immunisation in infants), but funding for mental health

62 promotion and prevention of mental illness needs to be justified by robust evidence-based research. Take the US example, Dorfman (2000) cited a total of 54 randomised control trials, the gold-standard of medical research, published between 1981 and 1999 covering the full life-span from infants to people age 65 and over. The document details the cost impact of some preventive programs in terms of monetary savings: for example, Vickery et al’s (1983) study assessing the ‘Effect of a self-care education program’ undertaken among 1,623 households enrolled in the Rhode Island Group Health Association of

Providence, including those enrolled for the 6 months pre and post intervention12. It was estimated that the decreases in utilisation could result in a savings of approximately $2.50 to $3.50 for each dollar spent on educational interventions. Randomised control trials, best fitted for the study of downstream interventions of health, may not be suitable to monitor mental health gain resulting from positive changes in upstream social determinants of health, such as employment, transportation, social cohesiveness and racial discrimination. Other methods of research, such as ‘narrative evaluation’ (see

Victorian Government Health Information VGHI, 2006 and Wadsworth 1997) by interviews or focus groups can prove a valuable adjunct to the quantitative methods. The monitoring of mental health indicators in ‘natural experiments’ (or social-laboratories) will be needed. In recent years, the focus has shifted to explore the ‘spill-over’ positive outcomes on mental health in programs targeting improving the upstream social determinants of health (WHO 2004a). Irrespective of whether the program targets individuals or populations, mental well-being is influenced by the macro socio-cultural, economic and political environment.

12 The intervention consisted of two books ‘Take Care of Yourself’ and ‘Taking Care of Your ’ and a newsletter ‘Life Plan for Your Health’, delivered monthly and brochures on lifestyles and a self-report health risk appraisal. 63 As Rowling and colleagues (Rowling, 2003; Wyn, Cahill, Holdsworth et al. 2000) argues for the need to promote ‘School Mental Health’ in the education sector, her team

(Rowling and Rissel, 2000) use a metaphor to illustrate the importance of intersectoral collaboration between the health and education sectors: the former has long been the driving force behind numerous promotion initiatives, if the latter is taken as the ‘vehicle’, then both the driver and the car need to arrive at the final destination. What is the relevance of these new directions in mental health promotion to people from non- mainstream (ethnic) communities? Kleinman (1998) theorises that health promotion or intervention which give significant weight to the meaning a culture or an individual give to illness can enhance outcomes considerably. This is a strong argument against

‘medicalising emotions’. Thus conducting qualitative studies to unveil these meanings (to address the ‘why’ of the behaviours) becomes an inevitable step preceding any health promotion programs for communities from culturally and linguistically diverse backgrounds.

2.10.2. The positive impact of social capital

In terms of population health, social capital provides a ‘sense of community’ which gives individuals ‘immunization’ against ‘social isolation, feelings of helplessness and low self-esteem’ (comparable to worldwide infant immunisation against infectious diseases).

Confucian cultures ultilise social capital to the fullest extent. According to Cullen and Whiteford (2001), the phenomenon of social capital as a whole is greater than the sum of the individual contributions to it. As a consequence of its collective nature, social capital is a public good, one that enables the supply of other critical public goods. The interest in studying the ‘social capital’ among countries greatly influenced by Confucian

64 culture originated in the near ‘miraculous’ economic success of the East Asian ‘Dragon’ countries: Japan, Hong Kong, Singapore, South Korea, Taiwan and the economically- reformed China (Yao, 2002). In Cullen and Whiteford’s (2001) terms, ‘social capital’ means the networks of people deriving benefit from common interaction with each other.

It emerges from interactions and shared norms that are social, external to the individual, not lodged within individuals (as is human capital, compared with Weber’s Protestant

Ethics, 1905, on-line edition 2001). It is the glue that holds together all the norms, civil participations, trust and other social networks that enhance mutual benefit.

It is generally agreed that networks, trust, reciprocity are important to social capital.

Communication between people with shared social norms is usually easier because of the greater tolerance, respect and reciprocity which characterise among them. In particular, reciprocity encourages individuals to strike a balance between personal interest and the public good. Although it sounds like a circular proposition, that tolerance of different cultural values and beliefs builds upon shared norms that imply tolerance, there is considerable wisdom in just such a claim (ABS 2002). The premise of social capital as being multi-dimensional is ascertained by many scholars, e.g. Bush and Baum (2001),

Coleman (1988), Putnam (1993, 2000). These dimensions include relationships, trust, reciprocity and action for a common purpose. Winter (2000) places special emphasis on the contribution of the ‘family’ as a source of social capital. Kirmayer is among the few

North-American transcultural researchers who has a deep understanding of Chinese

Confucian values. In an interview with an American on-line magazine ‘Stay Free’

(McLaren, 2003) Kirmayer talked about the fact that Americans’ desire for happiness was not universal,

“In many other cultural contexts, however, people don't view the point of life as being happy; they may view it as being productive, as being honorable, as being a contributing member to society or to a family… It's certainly possible that the strategies someone uses to pursue well-being (such as through economic 65 productivity) have built into them inevitable unhappiness, but we're not really encouraged to question our value system.”

No doubt, there is an increased awareness of the influence of social determinants on mental health outcomes. A recent (Sept, 2006) RANZCP Social and Cultural Psychiatry

Conference encourage theoretical debates and provide evidence-based research findings on positive influences of the social determinants of mental health. This, in turn, plays an important role in empowering families and promoting innovative models of care

(RANZCP, 2006). In many early intervention programs targeting adolescents and young adults e.g. ‘Resilience in Teenagers against Adversity’ (see Black Dog Institute 2006), the Melbourne ‘Together We Do Better’ VicHealth (2002) and Scotland’s ‘Towards a

Healthier Scotland’ (1999), see Appendix 2-3 for more details. ‘Social cohesion and resilience (self-strength)’ are perceived as protective factors against clinical depression.

These kinds of health promotion programs unmistakably endorse the collective value in which ‘common good takes precedence over individual benefit’, a concept generally observed in Chinese and Asian cultures.

2.10.3. Equity of health and resource distribution

Health research and promotional programs to CALD community hardly can match up with the unmet needs. Jorm and colleagues report that in Australia, the research funding for transcultural comparisons in mental health is close to negligible (0.04% of total medical funding). According to Jorm, Griffiths, Christensen et al’s (2002) categorisation, ‘Transcultural comparisons’ received $7,000 compared to research in

‘Genetic causes’ 3.5 million, ‘Risk factors’ 2.1 million, and ‘Physiological and anatomical differences’ 1.9 million. Jorm and his team observe marked differences in research priority ratings for different categories of mental disorder between ‘stakeholder groups for research’ (p. 63) and draw inferences that the observed disagreement appears 66 to reflect these stakeholders’ familiarity with a particular mental disorder. The same explanation may apply to the low priority given to the research among the Non-English

Speaking (NES) population: this category attracted the bottom 3 setting from half of the stakeholder groups and did not make any appearance in the top 3 setting13. It is apparent from Jorm et al’s (2002) report that ‘social disadvantage’ (e.g. poverty) is seen as at risk for poor mental health which requires more research funding. So, is linguistic and cultural disadvantage also a risk factor for mental health? Research priority ratings seem to judge ‘geographical’ remoteness from service (e.g. people in rural Australia) as worse than ‘cultural’ alienation because mental health services could be right next door. This leaves me in doubing the representation of ‘Non-English speaking’ people among the survey participants.

The above is an Australian example of funding allocation to medical research.

However, different countries or different states within the same country may have their own standards when it comes to distributing health promotion funds to top priority areas.

Equity in health, different from equality in health, has the additional moral and ethical dimension of ensuring high quality of health care is accessible to all (Whitehead, 1990;

Whitehead and Evans, 2001).

In a publication by the Department of Health and Aging of Australian Government

(2004) titled ‘Framework for the Implementation of the National Mental Health Plan

2003-2008 in Multicultural Australia’, the mental health care of the CALD communities is reviewed both in quantity and quality. It acknowledges the Government’s failure to deliver quality service to CALD communities since the Second National Mental Health

13 Research priorities ratings given to ‘rural and remote’ populations by all ten stakeholder groups were higher than those given to the Non-English Speaking. Research priority for the ‘Socially Disadvantaged’ was rated highly by six of the ten stakeholder groups. Jorm et al. did not provide a definition for the socially disadvantaged. The other sub-groups include ‘unemployed’; ‘Aboriginal people’; ‘Carers’; Children and adolescents’; ‘Gay and lesbian’; ‘Health workers’; ‘Offenders’; ‘Older people’; ‘Physically ill’ and ‘Women after childbirth’. 67 Plan in 1998. Prompt measures to address the mental health needs of people with ‘Low

English Proficiency’ in Australia are impeded by either intended or unintended exclusion from research to establish the prevalence of major mental illness due to methodological difficulties. Echoed by other Western countries with huge Chinese migrant populations, emerged patterns of mental health services utilisation among the Chinese are typically

‘late presentation’ and ‘more unwell’ than the mainstream population (Chen and

Kanzanjian, 2005; Yee and Au, 1997; Ponzio, 2006). In order to promote and support the development of sound policies and best practices for CALD communities, new funding and resource distribution formulae taking social and cultural needs into account is critical.

2.10.4. The CPR in mental health - Mental Health First Aid

Riding on the waves of ‘public good’, ‘Mental Health First Aid’ (MHFA), developed in Australia (Kitchener and Jorm, 2002) has been implemented in different parts of the world ( the U.S., Finland, Ireland, Scotland, Sri Lanka, India, Hong Kong and

China, see www.mhfa.com.au 2005). Research into assessing the benefits of the MHFA not only found and confirmed the expected outcomes of raising mental health awareness, but also an unintended bonus – i.e. enhancing the mental health of the participants (Jorm and Kitchener 2005). Community leaders around the globe are now receiving training to teach lay people knowledge and skills required to handle mental health crises in everyday contexts. In Australia, there is a current proposal to make MHFA training compulsory for secondary school teachers (Kitchener and Jorm, 2005). Government funding to cover the training costs is currently pending.

68 2.10.5. The Way Ahead - Mental health promotion and early intervention via the Cyberspace

Research undertaken in America has provided evidence of a preference for individuals’ self-help rather than for other forms of professional programs (Davison,

Pennabaker and Dickerson, 2000, p.205). Christensen et al (2002) forecast that ‘e-mental health’14 programs will suit Australians as well because disseminating accurate mental health information to consumers and carers can result in increased mental health literacy and by extension a more empowered society. In a recently released report on efficacy of mental health delivery models within Australian primary health care, Christensen,

Griffiths, Wells et al. (2006) observed programs which focus on consumers or patients playing an active role in early intervention or treatment were most successful. They call for service providers to implement more evidence-based effective computerized and

Internet programs as well as self-help and guided self-help therapy plans.

2.11 Summary

The prevalence of clinical depression in Western primary care settings is around

10-20% (Kirmayer, 1993). While the rate is considerably lower in Chinese regions as I have reported earlier, a recent account shows a rate comparable to the Western regions among Chinese-Americans (Yeung et al. 2002) and adolescents in China (Liu, 1999).

Many explanations have been offered for the low prevalence rate in the Chinese in earlier research. This include validity of diagnostic tools; somatised presentation by Chinese patients; collective-orientated culture as protective factor, and a reluctance to admit emotional distress in the face of social stigma. However, more fundamentally the body-

14 ‘E-mental health’ refers to mental health services and information delivered or enhanced through the Internet and related technologies. It could take the form of any exchange of information available through use of the World Wide Web technologies, e.g. e-mail, chat groups and data transfer. 69 mind link embedded in the Chinese illness conception, which is quite distinct from the

Western body-mind dichotomy that strongly influenced Western bio-medicine, directs

Chinese to implement culturally appropriate help-seeking strategies (e.g. herbal/food therapy or self-help). In the case of Chinese migrating to Western countries, encounters with Western may induce stress. Different models have been proposed for the relationship between migration, mental illness and acculturation.

However, more recently the focus has shifted to the ‘cultural identity’ of migrants in line with the notion that cultural identity influences people’s beliefs about mental illness

(Bhugra 2005). More researchers today acknowledge the fluid and context-dependent nature of these ‘self-identities’ and call for acculturation studies at individual as well as group level. Well-designed acculturation studies of help-seeking among Chinese at different stages of ‘cultural adaptation’ could shed light on the part that culture plays in illness conception. The underlying reasons for the under-utilisation of mental health services by culturally and linguistically diverse migrants in predominantly Western societies need further investigation.

There is a recent worldwide paradigm shift in public health to a ‘Population

Mental Health’ approach which focuses on improving the upstream social determinations of health and the ‘spill-over’ positive outcomes for mental health. Intersectoral collaborations between different government and non-government sectors are pressed to promote optimal mental health of the whole population and maintain mental health problems of those at risk. More insightful planning is needed to deliver culturally competent mental health services to all. In the next chapter I will outline a cross-cultural study, adopting both qualitative and quantitative methods to explore the meanings of depressive experiences in Chinese-Australians residents in Sydney.

70 Chapter 3 Methods

Œ˰ť

Extension of knowledge lies in the investigation of things

Confucius, Analects

Overview

In this chapter I provide an overview of the methodology employed in this study.

I spell out in detail the rationales underpinning the choice of a mixed-method design.

Comprehensive outlines of (a) the different components of the research; (b) the instruments used for collecting different types of data; (c) the descriptions of the variables measured; (d) the statistical analyses used and (e) the framework for qualitative data management are presented in the text. This chapter also covers the procedures undertaken to validate the instruments used in this research. These are crucial steps to ensure cross-cultural comparisons are valid and meaningful. The strengths and limitations of the current study are discussed at the end.

3. 1 Study Design

In order to address the research questions, previously detailed, in as systematic and thorough a manner as possible, this study adopted a sequential mixed method design.

Initially, a quantitative survey was carried out in primary care settings with self-identified

Chinese speaking Cantonese, Mandarin or English. A subgroup of English-speaking

Australians (non-Chinese), with matching age and gender, were later recruited as controls. Some existing survey instruments were first adapted to the local context and then translated into Chinese. Translated versions were validated prior to incorporation

71 into the survey to explore relevant issues with this study group. Following the survey, a series of focus group discussions (conducted in either Cantonese, Mandarin or English) were undertaken with participants responding to an advertisement posted at community facilities in the same areas as the primary care settings. This was the qualitative component of the mixed-method study. Both survey and focus group participants were recruited in Sydney metropolitan areas with high Chinese populations.

3.1.1 Why mixed method?

Large-scale epidemiology studies, which are frequently used to ascertain the general pattern of prevalence of clinical depression, enable generalization to a broader population. In contrast, qualitative data collected by means of in-depth interviews or focus group discussions are often drawn upon to explain the observed phenomena. In the current study I explore depressive experiences at the objective level of symptom manifestation and seek to establish how culture shapes the underlying conceptualization of subjective illness experiences. As suggested in Chapter 2, help-seeking behaviours are directly governed by the individual’s illness concepts. So I attempt to determine what meanings Chinese attribute to individual emotional distress. A mixed-method approach was selected as best fitted to address the range of questions in this inquiry which are fully set out in Chapter 1. In the context of cross-cultural research, carefully planned and robustly conducted epidemiological studies add new information about the prevalence rates of clinical depression among different cultural groups. To understand why these rates differ requires investigation of a set of hypotheses that researchers have yet to formulate. Phenomenological inquiry into the meaning of emotional distress in the lived experiences of Chinese and Australians should help to ascertain why different rates exist.

72 Understanding how Chinese interpret their depressive episodes should help mental health professionals develop more culturally competent intervention programs for them.

3.1.2 Mixed method research - a rigorous methodology Mixed-method inquiry in social sciences research has been used primarily to gain better understanding of the social phenomena of human behaviours under investigation

(Cook, 1985; Greene, Caracelli and Graham, 1989). The purpose of research for any discipline is to discover the various constitutions of reality and neither a quantitative nor qualitative approach is to be regarded as superior to the other (Carr, 1994). While affirming the invaluable contribution of qualitative research to the exploration of subjective experiences of patients in health research, Carr maintains that quantitative research best facilitates the extraction of quantifiable information. Both approaches have attracted criticisms. The assumptions posted before asking the research questions in many quantitative studies are difficult to prove or disprove and qualitative researchers are often thought to be subjective in their data analyses. Carr (1994) points out that:

[A]lthough qualitative methodologies may have greater problems with reliability than quantitative methodologies, the position is reversed when the issue is validity. The weakness in quantitative research is that the more tightly controlled the study, the more difficult it becomes to confirm that the research situation is like real life. (p. 719)

Sale and colleagues suggest that mixed-methods design could be an option which allows data obtained from different methods to complement each other (Sale, Lohfeld and Brazil

2002), e.g. interviews can offer internal validity of the statistical results revealed by questionnaires.

Tashakkori and Teddlie (1998) consider the triangulation of methods as the intellectual wedge that finally breaks the dichotomy of quantitative and qualitative approaches. They traced the origins of triangulation to Denzin (1978) who first used this system to refer to the combining of data sources to study the same social phenomenon.

73 Denzin listed four types of triangulation: data triangulation (e.g. data sources drawn from patients visiting GPs and Chinese herbalists); investigator triangulation (e.g. teaming together researchers from different cultural backgrounds); theory triangulation (e.g. adopting multiple perspectives such as ‘insider’ and ‘outsider’ to interpret data) and methodological triangulation (e.g. both quantitative and qualitative methods are integrated into inquiring the same research question). Mixed-method design has since extended beyond establishing convergence of results and now frequently aims at gaining deeper understanding of the human experience. Greene (2005) recently summarised the advantages of mixed-method inquiry as making understanding more comprehensive, defensive and insightful as well as promoting understanding with greater diversity and value-consciousness. Bloor and colleagues (Bloor, Frankland, Thomas et al., 2001) describe how focus groups may be used to interpret survey results, and to provide meaning to reports of attitudes or behaviours. By employing a mixed-method design, quantitative survey findings (the ‘what’ answers) can be complemented with the participants’ own meanings (the ‘why’ answers). Qualitative methods are particularly important in the study of cultural issues as Geertz (1973) emphasized that

Culture is not a power, something to which social events, behaviours, institutions, or processes can be causally attributed; it is a context, something within which they can be intelligibly - that is, thickly – described. (p. 14) Through focus group research, questions regarding help-seeking strategies to cope with stressful events can be addressed. The use of scenarios/vignettes in focus groups allows the participants to voice their opinions without feeling intimidated or pressured to please the researchers (Helman, 2000). The researchers, on the other hand, can explore the views or attitudes towards emotional distress within a bi-cultural (in this case

Chinese-Australian) context (in this case Sydney). Focus group discussion appears to be

74 the best method for the sampling of ideas and conceptual differences across different target groups (Ekblad and Baarnhielm, 2002).

3.2 Quantitative component

Quantitative data can be objectively and efficiently collected by means of a survey requesting the target information. The questionnaire used in this study (see

Appendix 3-1) was part of a larger research project conducted by the Black Dog Institute,

School of Psychiatry, University of New South Wales. The Black Dog Institute (formerly the Mood Disorder Unit, Prince of Wales Hospital) which was first established in 1980 specialises in research into different forms of mood disorders. The majority of the quantitative instruments and strategies described below were developed by Parker (Parker

Cheah and Roy, 2001; Parker, Hilton, Bains et al., 2002). The psychometric properties of

DMI-10 (used to assess state depression in the survey) have been established and widely reported (Hilton, Parker, McDonald et al., 2006; Parker & Gladstone, 2004; Parker,

Hilton, Hadzi-Palovic et al., 2003; Wilhelm, Kotze, Waterhouse et al., 2004).

3.2.1 Approaching doctors in general practices to facilitate recruitment of participants Ten suburbs (Auburn, Burwood, Central, Chatswood, Eastwood, Hills District,

Hornsby, Hurstville, Parramatta and Strathfield) with Chinese among the top three most nominated ‘ancestry’ references in the Australian National Census 2001 (ABS, 2003) were identified. The first step was to contact primary care doctors in these suburbs.

Letters were dispatched inviting general practitioners with Chinese surnames (as listed on the website www.yellowpages.com.au) to facilitate this study by allowing myself to hand out questionnaires to patients at their surgeries. There were only two responses.

Therefore in the capacity of a researcher I door-knocked clinics in the identified suburbs

75 that were located near train stations and I invited supporting doctors to recommend their friends to contact me, similar to a ‘snow-ball’ effect.

In all 11 practices supported the study. They extended into North, West, North

West, and Central Sydney covering a wide range of socio-economic backgrounds. In the initial stage (May 2003 to January 2004), most of the research was carried out between

9:00 am and 6:00 pm on weekdays. In order to recruit more male informants and more acculturated Chinese, recruitment was then conducted in the evenings and on Saturdays

(January 2004 to April 2004). I also approached Chinese herbalists in the same areas as the GP practices; five herbalists supported the study.

3.2.2 Recruiting participants For the quantitative survey individuals attending the surgeries of supporting general practitioners were to be recruited. All 11 practices had bilingual Chinese doctors on duty. I approached Chinese patients attending these clinics using their preferred language (Mandarin, Cantonese or English) asking if they would complete a questionnaire (either English or Chinese version) anonymously, while waiting to see the doctor. Completed forms were returned to a collection box in the reception area. For those who preferred to take the questionnaires home to complete at their leisure replied paid postal envelopes were supplied. An Australian group (control subjects) was subsequently recruited representing approximately one-third of the Chinese sample number, with selection weighted to promote age and sex matching from 5 of the 11 practices (covering West, North and Central Sydney) where both Chinese and Australian doctors were present. The time space between the recruitment of the two samples was only four months. The inclusion criterion was ‘anyone who is non-Chinese either born in

Australia or has lived in Australia for more than 20 years’. (The same inclusion criterion was used for the ‘Australian’ participants for the focus groups). Within this Control

76 group, 78.6% were Australian born, 21.4% were born outside of Australia (all were from non-Asian countries except 2.9 % were from Vietnam and India). This composition of local and overseas born non-Chinese reflected well the multicultural mix of the

Australian population. The creation of the category ‘Australian Control’ was for the purpose of cross-cultural comparison, the author was aware of the heterogenous nature of this group. Participation of the research was voluntary. A sub-sample of Chinese attending the five Chinese herbalists’ rooms was recruited in similar ways.

3.2.3 The questionnaire – general issues The questionnaire sought socio-demographic, occupational, educational, migration and study-specific information. A Chinese version of ‘State Depression’ measurements (the Depression in the Medically Ill DMI-10 and the Suinn-Lew Self-

Identity Acculturation Scale (Suinn, 1998) was translated from English by a team of translators, including a professional bilingual translator to ensure that Western constructs were translated with cultural sensitivity. Though a literal translation may lead to a straight forward back-translation, semantic translations were frequently adapted to elicit the concepts conveyed in the Chinese language. The translated versions were independently back-translated into English. I developed items specific to cultural knowledge and heritage in the general questionnaire (e.g. the question regarding ancestor worship) , in consultation with the team of translators. Chinese idioms were used where appropriate. In the questionnaire compiled for the control subjects, the word ‘Chinese’ was replaced by

‘culturally diverse background’.

Pilot work on both the Chinese and the English versions was carried out using a convenient sample (Chinese as well as Australian colleagues and friends). An attempt had been made to include a table similar to the list of 35 ‘symptoms likely to be experienced by a depressed individual’ but instead called it ‘symptoms likely to be

77 experienced by people with SJSR’. After the initial pilot study, participants commented that they were confused by the tasks of ‘checking-out’ two very similar tables (even though the orders of the 35 symptoms were different) on two seemingly ‘unfamiliar’ terms (namely ‘depression ‘ and ‘SJSR’). Thus the final version was slightly shorter than the first draft.

3.2.4 Attribution

A strategy used previously with primary practice attendees (Parker & Parker,

2003) and adapted from a British primary practice study (Kessler, Lloyd, Lewis et al.,

1999) was used to examine how participants considered three different symptoms, namely fatigue, insomnia and loss of appetite, and to nominate for each the most likely of three explanations, one somatic, one normalising and one psychologising. Respective options for insomnia were: ‘There is likely to be a physical reason’, ‘I’m just not tired’ and ‘I’ve been worrying too much or must be stressed’. In addition the questionnaire included a ‘social desirability’ measure, with items asking respondents whether they liked everyone they knew’ (Question No. 7), were always nice to others (Question no. 10) and had never broken any parental rules (Question no. 15), with the yes/no answer format producing a score of 0-3.

3.2.5 State depression

State depression was assessed by DMI-10 (Parker et al., 2002), a self-report measure designed for assessing depression in the medically ill (excluding somatic items and weighting of cognitive features of depression). In both primary practice (Parker et al.,

2003) and out-patient (Parker and Gladstone, 2004) psychiatric settings it has been shown to be a useful clinical tool.

78 3.2.6 Recognition of depression

Depression recognition was probed by providing a list of 35 symptoms people may have when they are emotionally distressed and asking subjects to rate whether someone experiencing depression would be likely to experience each symptom. Parker,

Hilton, Bains et al. (2001) employed this strategy in an earlier study of Chinese and

Caucasian depressed out-patients in Malaysia and in Australia. Items in the current study included ‘purely’ cognitive features of depression (e.g. thoughts of death, feeling depressed, feeling life is not worth living, feeling suicidal), common somatic concomitants of depression (e.g. fatigue, loss of appetite, headaches, body aches and pains) and features more suggestive of anxiety (e.g. feeling anxious and tense). For each of the 35 items, subjects selected one of following three responses: ‘Definitely’,

‘Sometimes/to some degree’ and ‘Not at all’.

3.2.7 Lifetime depression

Previous studies (Cheung, 1987; Lee, 1998) reveal that Chinese tend to confuse the concept of clinical depression with Traditional Chinese Medicine terms and cultural idioms such as shen-jen-shuai-ruo (SJSR). To avoid cuing the probe question did not use the term ‘depression’. A description of a possible ‘lifetime depression’ episode was presented; then subjects were asked whether they had experienced a (minimum) two- week period of ‘a loss of energy and motivation to do things, a decreased ability to cope, feelings of helplessness and hopelessness’. Thakker and Ward (1998) make it clear that

‘whether or not “depression” is the same across different cultures will depend on whether they share certain cultural institutions or processes; it is something to be discovered not assumed’ (p. 523). By not asking questions about ‘previous diagnoses’ but rather

‘symptoms experienced’, I provided intellectual space for ‘theoretical development’. In the current study, if the informant affirmed a previous episode of ‘depressive 79 experiences’, s/he was then asked a series of questions related to the most severe episode ever experienced.

The schedule of questions used in the study is very similar to that proposed by Pleto and Pleto (1997) and ran as follows: 1. To nominate the four most worrying symptoms about the most severe episode.

These symptoms were then coded according to the 35 symptom checklist presented

to participants in the previous section of the questionnaire.

2. To state the perceived causes of that episode and provide their age at the time of

the episode, these causes were then coded for qualitative analysis.

3. To indicate whether they judged such episodes as ‘only normal blues to be

expected over one’s lifetime’, ‘at times, a distinct disorder – above and beyond what

could be viewed as reasonable distress given circumstances or ‘always a distinct

disorder’.

4. To report impairment resulting from the depressive experiences: whether they

were unable to go to work, to school, perform home duties or any other negative

consequences.

5. To report the kind of help sought, i.e. professional and non professional. Multiple responses were allowed in pre-set type of responses.

3.2.8 Help-seeking

Help-seeking was assessed firstly as a general response to psychological symptoms, and secondly and more specifically in relation to any lifetime depressive episode experienced, as described in the last paragraph. When asked to specify their professional helper participants were offered four types to choose from plus one further option: ‘others’. Choices obviously cannot be endless. Depending on the frequency of

80 responses, usually quite small, researchers may at their own discretion expand on their

‘others’ category by setting up new categories in the coding process.

3.2.9 Acculturation

All subjects were given the Suinn-Lew Asian Self-Identity Acculturation Scale

(SL-ASIA), modified slightly to respect Australian contextual issues. An overall acculturation score (SL-ASIA score) was obtained for each subject. For subjects who preferred an English questionnaire, preliminary analysis of data showed that those born in

Australia and those who migrated at or before the age of 10 years did not have any significant difference in the majority of acculturation items. The cut-off age to distinguish the first generation from the second generation of Chinese was ten years as used by

Furnham and Li (1993).

The SL-ASIA, which has been used in many acculturation studies of Asians in

North America (Salant and Lauderdale, 2003), provides scores from 1 to 5 with 1 representing the lowest level of acculturation. In a recent report Chung and colleagues

(Chung, Kim and Abreu, 2004) adapted the SL-ASIA to a multidimensional acculturation scale in acknowledgement of the limitations of the original uni-dimensional approach in measuring acculturation. They applied factor analysis to the data obtained from 138 (41 men and 97 women) Asian American undergraduates attending a West Coast university.

Four factors were identified: cultural identity, language, cultural knowledge and food consumption. In the current research, questions regarding cultural knowledge and food consumption have been covered by the SL-ASIA; questions exploring perceived self- identity, English language competence, and social support were asked more specifically, to allow for an in-depth analysis of possible acculturation variations in the different domains.

The three acculturation domains of interest were probed as follows: 81 1. In the Language domain subjects were given three functional tasks (e.g. making a

telephone enquiry) to rate their difficulty in conversing in English from 1 to 5 (1

being most difficult).

2. In the Self-Identity domain subjects were given three 100 mm lines upon which to

indicate how much they rate themselves as Chinese or Australian with the left end

indicating ‘not at all’ and the right end indicating ‘completely’. The length from the

left to the mark was measured as the respective self-identity.

3. In the Social Support domain questions regarding general help-seeking (asking

for physical help or a small favour) and sharing emotional distress with either

Chinese-speaking/English-speaking friends or family members were designed to

ascertain the pattern of social support.

3.2.10 Other variables:

(a) Unemployment Unemployment has been reported in depression studies undertaken in Western countries to be highly correlated with depression (Dew, Bromet and Penkower,1992; Vinokur,

Schul, Vuori et al., 2000) ‘Under-employment’ is a widely reported phenomenon among immigrants (Flatau, Petridis and Wood, 1995; Hawthrone, 1994). Informants were asked about their current job situation and their job situation before migration.

(b) Chinese or Western cultural values Participants were invited to write down in a few sentences their thoughts and ideas on either Chinese or Western cultural values that they found helpful during adverse situations in life.

82 3.2.11 Analysis

The Statistical Package for Social Sciences (SPSS 13.0 for Windows, 2004) was used for all statistical analyses. Specific tests for various dependent variables are described in detail in Chapters 4, 5, 6 and 7.

3.3 Qualitative component:

Qualitative research using focus groups has been widely reported in the literature of social sciences research and marketing studies. Fundamentally, focus groups or group interviews are a way of listening to people and learning from them. The multiple lines of communication set up within the group allow participants to share ideas and beliefs with minimal pressure (Madriz, 2000). The use of focus groups is well suited to discussions of sensitive topics like sexual health (Robinson, 1999) or when informants perceive a gap in the level of power between the ‘researched’ and the researchers (Ritchie and Herscovitch,

1995). Qualitative methods have also been employed to study community beliefs about cancer in Chinese-Australians (Eisenbruch, Yeo, Meiser et al., 2004; Yeo, Meiser,

Goldstein et al., 2005). In the next section I outline the procedures undertaken in the qualitative component of the study.

3.3.1 Vignette Development

Focus groups are typically facilitated by a researcher who has preset objectives and arrives with an outline of semi-structured questions to encourage open-ended dialogue. Kitzinger (1999) asserts that the vignettes set-up in focus groups is extremely useful because ‘it offers a common external reference point’ (p.143) which permits cross- comparisons between groups even though each group differs in its direction and dynamic.

Ying (1990), who studied the help-seeking behaviours of Chinese-Americans in San 83 Francisco, used a major depression vignette to elicit responses regarding cause, impact, chief problems and help-seeking behaviours. The vignette was also created to meet DSM-

IV diagnostic criteria for major depression. Ying maintains that the respondents readily related to the vignette because they could find relevance to their own experiences. Some mental health literacy research also uses vignettes to assess how well the subjects can identify the intended ‘diagnosis’ of the vignettes (Goldney et al., 2001; Jorm et al., 1997;

Jorm et al., 2005). The advantage of the use of vignettes is to elicit open-ended responses from informants without affording them clinical diagnostic labels.

Two scenarios were set up (the Chinese version was first prepared by myself and then translated into English following consultation with colleagues who were native speakers of English). Blind back translation was carried out after the pilot focus groups. The two vignettes were: a young mother with insomnia and other mild depressive symptoms and an unemployed male with more severe symptoms. They followed the criteria described in

DSM-IV and gave a brief outline of social context. The Chinese version of the scenarios was given to a Chinese psychiatrist (a visiting Fellow from Shanghai, China) who, following review, judged the vignettes to be typical major depression cases. A semi- structured question schedule was prepared bilingually; blind back translation from

English to Chinese was carried out after the pilot focus groups to ensure that linguistic equivalence was observed. A set of semi-structured questions along with the vignettes is shown in Appendix 3-2.

Groups of three to ten informants were invited to attend a meeting at their local community facility to discuss issues surrounding ‘Mental Health and Depression’.

At each focus group meeting, the facilitator (myself) described the first vignette to the group and then asked the schedule of questions and invited participants (a) to share their ideas on the major problems of the person in the vignette, (b) suggest how they would

84 respond and help, and (c) to express their own feelings upon hearing such stories. The second vignette was delivered following the same steps after a 10-minute tea break.

I then informed the group that the person in each of the vignettes was later referred to a psychiatrist for investigation with query of ‘depression’. Views on depression and public attitudes towards depression were discussed. After the discussion, a questionnaire on explanatory models – the Mental Distress Explanatory Model Schedule (MDEMS), either the English or Chinese version, (Eisenbruch, 1990; Eisenbruch et al., 2005) was distributed. This was a scientific tool used to provide data on informants’ cognitive mapping of beliefs both Western and non-Western cultures, pertinent to the causes of mental distress in general.

3.3.2. Validating Focus Group Protocols

Researchers often recommend that participants not know each other (Ekblad and

Baarnhielm, 2002) so that they will be more open and freely discuss issues. In contrast,

Kitzinger (1999) recommends that researchers recruit informants from pre-existing groups, i.e. a collection of people who are already connected with each other through, for example, working or socializing together. One rationale for working with pre-existing groups is to allow researchers to capture group members’ interactions which are likely to approximate to naturally occurring data which might have been collected through participant observation. Khan and Manderson (1992) agree this is a benefit and support the notion that common social contexts facilitate the generation of opinions. Natural clustering, e.g. which might occur with a migrant group in a well-established Chinese community organisation, offers some of the ingredients found in scripting research questions. Participants in the pilot groups seemed comfortable expressing their ideas.

85 Their feedback was sought and subsequently some minor changes were made to the descriptions in the vignettes.

Most focus group participants for the study were recruited from regular community groups within established Chinese community organisations. Informants from different cultural backgrounds and age groups responded to the scenarios by projection and reviewed their own experiences in relation to help-seeking. All focus groups were run according to the same standard procedures; informants were not pressured to disclose any personal experiences. Chinese informants seemed to be able to volunteer examples of personal depressive experience throughout the discussion and reflected upon how

Chinese cultural heritage contributed to their emotional distress and, in particular upon how they responded to both the causes of distress and subsequent help-seeking.

3.3.3 Sampling in qualitative research

Coyne (1997) has outlined the different sampling methods and discussed the qualitative principle which requires purposeful sampling for 'good' informants, that is, individuals who are articulate and willing to share their experiences. Morse (1991) states that 'when obtaining a purposeful (or theoretical) sample, the researcher selects a participant according to the needs of the study’ (p. 129). For example, by putting up posters on community notice boards and advertising in local newspapers, the researcher is likely to attract informants who are interested in the topic of mental health and depression. Many participants revealed their own stories of emotional distress during group discussion. In this study, much attention has been paid to informants’ language preferences (Mandarin, Cantonese or English), age and acculturation levels. The findings from the larger scale quantitative arm of the research serve as a backdrop of rich normative data and the demographics of the Chinese in Sydney. The demographic details

86 of informants from qualitative focus groups could be compared to the norms obtained in the survey to ensure sample representation.

3.3.4 Focus Group Stratification

Early grounded theorists recommend the use of themes saturation as the index for ceasing further data collection (Glaser and Strauss, 1967; Glaser, 1978). De Jong and Van

Ommeren (2002) advise researchers to run at least two groups in every stratification to ensure observation made of one group is replicated in the other group. They warn that otherwise researchers run the risk of recording ‘unique dynamics of selected participants’

(p. 425). I thus stratified the focus groups by language and age (shown in Table 3.1) to enhance better communication during discussion (A Chinese speaker of one dialect may not understand the speakers of another dialect).

Table 3.1: Stratification of focus group by language and age

Lang Cantonese- Mandarin- English-speaking Australian Age speaking Chinese speaking Chinese Chinese Controls 18-40 2 group 2 group 2 groups 2 groups

40 or over 2 group 2 group 2 groups 2 groups

The selection criterion for Cantonese or Mandarin speaking Chinese was: (1) identifies oneself as ethnic Chinese.

The selection criteria for the English speaking Chinese were: (1) identifies oneself as ethnic Chinese and (2) self-rates his/her verbal English as fluent.

87 The selection criteria for the Australian Controls were: (1) identifies oneself as Australian (2) born in Australia or has resided in Australia for at least 20 years.

The ratio of Chinese groups to Australian groups was 3:1, similar to the quantitative

survey. Each group ran for approximately 90 minutes; four groups of each language

category generated a total of 6 hours (360 minutes) of narratives. ‘Theme saturation’

was reached after data from all 16 focus groups was coded.

3.3.5 Flexibility in recruitment strategies

McLean and Campbell (2003) recommend that researchers adopt a range of recruitment methodologies such as recruiting participants from a diverse range of methods and sites. I had developed a good social network with the Chinese community long before commencement of research. There are linguistic and cultural advantages of ethnic matching of researcher and informants (McLean & Campbell 2003). Studies in mental health using community focus groups seem to attract more females than males

(McNair, Highet, Hickie et al., 2002; Schulze and Angermeyer, 2003). This could be a reflection of the social construction of gender via group activities. Focus groups targeting the highly acculturated Chinese were scheduled in the evening or weekends to accommodate their work routines. Details of focus group meetings were advertised through a network of local newspapers. Australian groups were recruited via the press and through some depression websites. Recruiting Australians was made easier by the public interest in and expressed concern about clinical depression in a Western society like Australia.

88 3.3.6 Standard Focus Group Procedures

A subject information sheet outlining the objectives and nature of the research was given to each participant in their preferred language. Written consent was obtained from all participants before the commencement of the focus group discussion (which was recorded onto audio-tapes that were de-identified to respect informant confidentiality).

The Suinn-Lew Acculturation Scale and demographic questionnaire were given out to

Chinese informants at the meeting. Participation was totally voluntary and confidentiality strictly observed. All 16 groups were facilitated by myself. Most of the groups were conducted at community centres in the suburbs in which the quantitative survey was conducted. All of the work was carried out between April and November 2004.

3.3.7 Revision evolved as the research progressed

The importance of qualitative research design remaining flexible has been mooted by many authors (Barnes, 1992; Coyne, 1997; Glaser, 1992; Glaser, 1978) In the current study, different aspects of the original plan were modified to (a) achieve maximum variation in sampling and (b) to stimulate deeper discussion.

(a) Semi-structured Questions

Review of the narratives of the first few Chinese focus groups indicated that participants did not use many emotional words when the facilitator asked specific questions such as ‘how do you feel after hearing this vignette?’ In many instances, however, they were eager to offer help-seeking strategies. As a result, the order of the semi-structured questions was altered to first ask participants about their perceptions of the major problems and subsequent help-seeking strategies. The question about informants’ feelings towards the person in the vignette was put last. Additional questions relating to cultural differences were specifically set to allow the English-speaking 89 Chinese groups to tap into their interactions with people from both Chinese and Western cultures.

(b) Contexts of emotional words

After analysing the data of the screening measure for ‘DMI-10’ used in the quantitative survey, a subset of bilingual focus groups was utilised to discuss the contexts and usage of the Chinese emotional word phrases in the screening tool. This step formed part of the important procedure of validating the constructs in the Chinese translation.

Findings are presented in the next chapter.

(c) Purposeful sampling

Following the principles of purposeful sampling, I recruited two English-speaking second generation Chinese groups who would match closely to the sub-sample of the high acculturation group in the quantitative survey. The aim was that the input of these groups would augment the qualitative data of individuals caught between two cultures.

(d) Multiple venues and different meeting times to suit target groups

Most groups seemed to attract participants in the same age brackets due to the times and venues of the focus groups (e.g. the day group convened at the community centre attracted senior participants; evening groups at local clubs attracted younger working professionals).

(e) Gender issue A preponderance of females was observed in the focus groups. A review of the transcriptions of earlier focus groups suggested that the over-representation of female voices was counter-balanced by their discussion of the carefully ‘planted’ vignette of the unemployed man. In the female majority groups women were able to talk about their

90 male partners or other male relatives and friends. Specific questions were asked as to whether participants had encountered anyone in a similar situation to those in the vignettes.

3.3.8 Data Management

Audio-tapes were first transcribed into the corresponding languages. All

Mandarin-speaking focus group accounts were given to native Mandarin speakers who checked the accuracy of the transcriptions. Some minor corrections were subsequently made. The English translation of one Mandarin transcription was given to a bilingual participant of that language group to verify the accuracy of the translation. The English translation of one set of Cantonese transcriptions was inspected by an Australia-born informant fluent in both Cantonese and English. Both sets of translations were deemed accurate. The Chinese transcriptions were then translated into English. One set of transcriptions from the English-speaking Chinese group and one from the Control group was given to a participant of the corresponding group to inspect. Both participants were satisfied with the transcriptions. One inspector commented that the transcription was accurate and respected greatly the views of all of the informants. A total of 7 out of 16 sets of transcriptions were inspected by native speakers and rated as accurate.

Translations of the remaining Chinese transcriptions were then carried out.

Thematic analysis was conducted using NVivo 2 software (2004). In this qualitative data management software, a small file can be freely read and carefully analysed. I then coded the data by following detailed inclusion/exclusion criteria and other procedures which could be written explicitly in the form of memos during the entire research process. Due to the capacity of the program to process massive data, I could retrieve data coded previously to serve as quick reference while carrying out more coding. The use of NVivo

2 to assist data management enables continuous interaction between the collecting and 91 coding of data and writing the memos which form an essential part of the audit trail

(Richards, 1999). This strengthens the ‘replicability’ of the whole qualitative study design. Cross-references and other search procedures can be conducted using relatively simple operations.

3.3.9 Thematic Analysis and Interpretive Framework

Garza (2005) reminds researchers of the fundamental differences between quantitative and qualitative studies, i.e. the external validity of the latter should be judged through criteria related to ‘meaningfulness.’ He cautions all qualitative researchers to make an extra effort to spell out explicitly to their readers all aspects of the interpretive framework. The schedule of questions to facilitate group discussion was kept brief with phrases such as ‘major problems’ and ‘ways to offer help’. I then followed Ryan and

Bernard’s (2000, p. 781) recommendation of setting up some general themes as guided by earlier literature and adding more themes during the coding process. I also searched the data for interesting comments and then coded the key themes that arose. Themes were coded using the following procedures.

A. Free nodes: an initial analytic process was used to identify concepts by examining the properties and dimensions of the events revealed in the narratives.

B. Tree nodes: after inspecting the free nodes, some were converted to ‘tree nodes’ with secondary nodes. For example, under the parent tree node of ‘symptoms of distress’ were all the symptoms mentioned during focus group discussions. Each individual symptom was considered as the ‘child’ node (a branch of the tree) of that particular tree node. The following examples demonstrate how ‘parent and children’ tree nodes could be identified using such a coding paradigm:

‘Parent’ Tree Nodes ‘Child’ Tree Nodes

92 1. The phenomenon under study – Depressive symptoms nominated by Symptoms of distress informants 2. Its causal conditions (Explanatory Causes of distress attributed by informants Models) 3. Its context Informants talked about the vignettes or their real life experiences 4. Intervening conditions (the Informants conceptualised the experience appraisal or conceptualisation of the as ‘medical illness’, ‘psychological experiences) imbalance’ or ‘personal weakness’ 5. The action and interaction strategies Help-seeking behaviour when people of the actors involved became emotionally distressed

Throughout the qualitative research process I assiduously documented my own reflections for each focus group as recommended by Ritchie (2001) to ‘enhance understanding by someone external to the study’ (p. 156). I discussed thoughts and subjective perceptions with my research supervisors. Some of the flexible adaptations and changes to the running of the focus groups outlined earlier were made possible through this reflection process. The reflection documents also became useful references for thematic analysis which added rigour to this process.

Initial free nodes or tree nodes were set up using transcripts of one Chinese and one

Control group following coding in vivo, the procedure supported by the NVivo 2. The advantage of having one researcher to perform all coding is ensuring ‘thematic coherence’, consistency in the coding procedures. My supervisors also acted as a sounding board on the objectivity of the procedures, e.g. rationales for the codes and the inclusion-exclusion criteria. Peer involvement is considered helpful in establishing rigour in qualitative studies (Ritchie 2001) and I was able to regularly engage with a fellow doctoral student to discuss coding of themes.

C. Establishing inclusion/exclusion criteria 93 In order to make certain the coding of themes was performed objectively, I

established clear ‘inclusion/exclusion criteria’ for the themes (see Appendix 3.3

for the procedures). This measure is crucial to ensure consistency in content

among the ‘narratives’ coded in each theme (c.f. face validity in quantitative

measure).

After setting up the basic framework of codes I followed a stringent procedure to establish inclusion/exclusion criteria for all codes using another two sets of transcripts.

By adopting the vigilantly planned coding procedures described in Appendix 3.3 the coding process was transparent and the thematic analysis process rigorous.

3.4 Ethical Issues

The Human Research Ethics Committee of the University of New South Wales granted approval for this research. For the survey, a subject information sheet was given to each participant to explain in detail the nature of the study and contacts for further enquiry. Completed questionnaires were returned to a collection box located near the

GP’s or herbalist’s receptionist or via pre-paid envelope to the researchers. The return of questionnaire by the subjects implied informed consent as no additional written consent was required to respect confidentiality. For focus group participants, information regarding the nature and duration of the discussion was provided. Written consent was obtained prior to the focus group discussions.

3.5 Validation of the Chinese version of DMI -10

Three sub-studies were conducted to validate the translated Chinese version of the

DMI-10. The following section outlines the methods of these three sub-studies.

94 3.5.1 Sub-study 1

Bilingual test-retest determines whether the original version (here the English version) of the instrument and the translated version are measuring the same constructs

(Westermeyer & Janca, 1997). The same bilingual subjects complete both language versions on separate but not widely spaced occasions and the resulting correlation coefficients are used to assess the significance of the test-retest data. Typically, test-retest studies are used to assess the reliability of a measure. In the case of cross-cultural studies this methodology is deemed appropriate for assessing the validity of a translated measure.

For this test-retest reliability study, a sub-sample of 28 bilingual participants in the quantitative survey completed one language version of the DMI-10 before consulting their general practitioner. They then completed the alternative language version after their consultation, approximately 15-20 minutes later. They selected their preferred language version for completion first. The DMI-10 required the subject to specify a rate of agreement for each item in relation to how s/he had been feeling over the last 2-3 days.

The four possible options were ‘Not True’ (‘0’); ‘Slightly True’ (‘1’); ‘Moderately True’

(‘2’) and ‘Very True’ (‘3’). Thus, the total DMI-10 score (10 items) ranged from a minimum of ‘0’ to a maximum of ‘30’. The order of items in the DMI-10 for the Chinese version was different to that of the English versions to reduce ‘learning’ effects.

3.5.2 Sub-study 2

After a preliminary analysis of data from Sub-study 1, it was deemed important to examine the cultural nuances implicit in the Chinese emotional words and phrases in the translated version of the DMI-10 addition to the original research objectives. Participants from five focus groups were asked to complete the DMI-10 in their preferred language before discussion commenced. After a schedule of semi-structured questions for the

95 focus group study had been delivered, the participants were each given new forms of the

Chinese and English DMI-10. I then invited participants to provide feedback on the specific meanings of the key-words used to describe emotions embedded in all items of the Chinese DMI-10, as well as the contexts in which these words were used. This process usually lasted 10 to 30 minutes and all discussions were audio-taped and transcribed. Based on these qualitative data, a revised version of the Chinese DMI-10 was prepared.

3.5.3 Sub-study 3

This study consisted of a second bilingual test-retest process with participants drawn from another five focus groups (N= 26) using a revised Chinese version. Each participant was given the DMI-10 in their preferred language version. After the scheduled questions for the main qualitative study had been delivered, the participants were given the alternative language version of the DMI-10 approximately 90 minutes later. Instead of adopting the scoring scheme in the original English version, a visual analogue strategy was used (a blank line of 70 mm in length with end points labelled ‘Not true’ on the left and ‘Very true’ on the right) to overcome issues of scalar equivalence (Van de Vijver &

Leung, 1997), a strategy used by Eisenbruch (1990). For each item, the length from the left end-point to the informant’s marking was measured and converted to a ‘raw score’ with a minimum of ‘0’ and a maximum of ‘1’. Thus the total DMI-10 score (10 items) ranged from a minimum of ‘0’ to a maximum of ‘10’. As with Sub-study 1, the order of items for the Chinese version was different to that of the English version. This was designed to reduce ‘learning’ effect. The results of these 3 sub-studies will be reported in the next chapter.

96 3.6 Translation of the Mental Distress Explanatory Model

Schedule (MDEMS) into Chinese

3.6.1 Translation

In developing the Chinese version of the MDEMS, I followed Van Ommeren’s team’s recommendations (Van Ommeren, Sharma, Thapa et al., 1999) - (a) translation by bilingual, indigenous translators (b) review of translation by a bilingual professional; (c) testing of translation through focus groups; (d) comparison of a blind back-translation with the original instrument and (e) pilot testing.

Having had formal training in linguistics and anthropology, I prepared the first draft of the translation. An experienced clinical psychologist who had used a different translated version of the MDEMS in her study of Chinese hereditary cancer (Yeo, Meiser,

Goldstein et al., 2005) then reviewed the draft. Feedback was also sought from a third bilingual health professional who had worked as a medical interpreter in a hospital setting. The necessary modifications were then made by integrating the ideas gathered to form the second draft, in consultation with the original author (Eisenbruch, 1990).

3.6.2 Exploratory verification through Focus groups

The first stage of pilot testing was conducted using four pilot focus groups

(Mandarin, Cantonese and English speaking). Informants’ ages ranged from 20 to 78

(Mean age being 48.8). Each participant was given the Chinese MDEMS to fill in at the end of the focus group.

97 3.6.3 Comparison of an independent back-translation with the original

MDEMS

Sperber, Devellis and Boehlecke ( 1994) first proposed the procedure of discussing with the translator the back-translated English version with the original version to assess psycho-linguistic equivalence. The original author, the translator and the back-translator negotiated triangularly and then documented in detail the decision- making process involved in the choice of Chinese words/phrases in the third draft.

3.6.4 Bilingual test-retest

By the third iteration (Appendix 3-4) the MDEMS Chinese version was ready for a sub-study, the aim of which was to establish the bi-lingual test-retest reliability. A group of thirty-one bi-lingual Chinese people was selected from a convenient sample

(university students, colleagues, multicultural mental health workers and acquaintances of mine). Each person was given the information sheet and a set of Chinese and English questionnaires with instructions to fill in one language version first and wait at least 24 hours before filling in the second language version. Pearson correlation coefficients were established for each pair of Chinese-English items. Depending on the magnitude of discrepancies that emerged, the relevant items were modified to increase or re-establish psycholinguistic equivalence. The findings and significance of the validation process will be discussed in the next chapter.

In this next and final section I present a critical review of the strengths and limitations of the current study. I acknowledge the advantages of having a multidisciplinary team and a mixed-method research design. I also admit to constraints relating to time, experience and resources.

98 3.7 Strengths and Limitations of the study

3.7.1. Strengths

(a) Vignettes

The use of the vignettes has proven powerful in eliciting discussion of everyday examples. Informants, Chinese and Australians alike, could relate to the two vignettes suggesting that similar depressive experiences are encountered among both. Informants from different cultural backgrounds, however, may not uniformly describe the condition as ‘clinical depression’

(b) Cultural diversity of participants

Recruiting participants from diverse cultural, linguistic and socio-economic backgrounds has made possible the cross-cultural comparison of many variables. Even stringent criteria employed to narrow down participant inclusion and exclusion may not guarantee homogeneity. Rather, they run the risk of ‘distorting reality’. The multi- disciplinary training of the researcher fuelled an interest in a wide range of variables, that include prevalence, acculturation levels, linguistic competence, modes of help-seeking, cultural values and illness concepts drawn from available rich ‘emic’ – experience near and ‘etic’ experience far data .

3.7.2 Insights gained from limitations of the Survey

(a) Researcher’s intended meaning vs participant’s own interpretation

In the survey a basic assumption is made that respondents will interpret the question in the same way the researcher has intended, e.g. the section on ‘talking to your

GP about emotional distress’. Respondents were expected to answer ‘yes’ if they had raised any concerns with their GPs about their psychological symptoms. A Chinese may have told the doctor that s/he was worried about her/his insomnia but still answered ‘no’ .

99 On the other hand, the same Chinese may have told the doctor that her/his insomnia was caused by family conflicts, but never mentioned that s/he felt upset or angry about the situation. In future studies, to eliminate any discrepancy between the researchers’ intended meaning and the respondent’s interpretation, additional prompts such as ‘I told my GP I was feeling …….’ could be included.

Another such example can be found in the question regarding the request of help from participant’s social network. The intended meaning of theterm ‘friends’ was ‘All friends excluding those from another language/cultural background.’ Participants could take an all inclusive view rendering the two response options (namely ‘friends from another language/cultural background’ and ‘friends’ ) to overlap.

(b) Participants’ literacy level

The length of the survey meant it required basic literacy and good concentration to complete. Bond (1996) argues that most self-reporting quantitative surveys tend to restrict participant involvement to literate and educated subjects. In the current study design, participants were recruited from primary care settings, thus it may have limited generalisability. This shortcoming is counterbalanced by the qualitative strategy of focus groups which might have included the more articulate but less literate. Future researchers may consider the option of providing assistance to participants by delivering the questions verbally.

(c) Projected response vs intelligent guess

In the survey questions were asked about the likelihood of a particular symptom being experienced by a depressed person. In the analysis this is treated as the recognition of depressive symptoms by the participants. From my observation of the time taken for survey informants to think about each symptom on the list and the response pattern of

100 some of the returned questionnaires, there is some doubt about the reliability of some responses. Subsequently 60 participants were excluded from the sample due to their non- discriminatory response pattern, i.e. ticking the same column for all 35 symptoms. Even with this measure in place the researcher cannot be certain whether the participants were making (a) a ‘projected response’ based on personal experience; (b) an ‘intelligent guess’; (c) had observed friends or family members experiencing such symptoms or (d) obtained the information from sources such as the media. However, this constraint was equally applicable to all participants. In hindsight, it would have been preferable to ask participants to state explicitly on what basis they responded to the questions.

(d) Self-selection

Random sampling is often reported to be the strength of the quantitative survey. A subject response rate of 64 % falls in the expected range of a survey. However, there remains that 36% who either declined to take a questionnaire or failed to return the completed questionnaire. It may be that they were not interested in the topic or did not want to give out personal information. Thus the participants in the current study might make up a self-selected sample. An alternative would be to ask the general practitioners to assist in recruiting a fixed number of patients attending their clinics on a given day

(e.g. the first 20 patients). However, this strategy may not be approved by most human research ethics committee out of concerns over coercing participation (HREC-UNSW

2006 pers. comm. May, 22).

3.7.3 Achieving the best outcome under constraints associated with focus groups

(a) Insider research As an insider researcher, I have the advantage of being more alert to my subjectivity: ‘Am I seeing things through my own cultural lens?’

101 Figure 3-1 Focus Group in Progress

I I I S Coffee I R Table F I R’ I I I

One way mirror Keys: S-self F-facilitator I-informants R-researcher

Figure 3-1 demonstrates the ‘One-way Mirror’ approach used to minimize the subjective views of an insider researcher. The small circles represent the Chinese informants. The facilitator (myself) is an ethnic Chinese competent in both Chinese and English languages. The dark circle behind the mirror represents the researcher after the focus group. The rectangle represents my research supervisor(s). I facilitated the discussion following the protocol which was a well-defined role requiring my Chinese language skills and cultural knowledge. However, at times I switched to the role of ‘self’: a

Chinese female fellow migrant. This switching is an intrinsic part of humanistic research when tapping into the emotional aspect of human behaviours. Throughout the process I subconsciously changed from being a facilitator to being a fellow Chinese migrant. I was aware of this because I could see my own ‘reflected’ image in the one-way mirror and realised that I had started ‘playing’ myself. This ‘conscious’ realisation alerted me to switch back to my facilitator role. This kind of switching, as indicated by the two-way arrow in the above diagram, was not restricted to the facilitator: most participants coming to the group, who wanted to find out more about mental health and depression, ended up sharing their deep emotions.

102 After the discussion, I worked behind the one-way mirror at a conceptual level and was ‘objective’ during replay of the audio-tape and the recall of visual images.

During this ‘decoding’ process, my professional knowledge acted as a one-way mirror that allowed me to keep a safe distance from my ‘emotional self’.

(b) Female Preponderance The focus groups attracted more female participants than male. One male informant explained this phenomenon as ‘talking’ not being the preferred social activity of men. The second vignette, however, provided the opportunity for female informants to reflect on what had happened to the men in their social networks. In future studies, researchers may wish to explore other formats to ensure male input.

(c) Retrospective account and retold stories Informants either gave accounts of their own experiences retrospectively or retold stories pertaining to friends or family. As with all studies relying on informants’ memories to give retrospective accounts, accuracy and reliability could be affected by the passage of time. However, details surrounding negative emotions are usually remembered better than positive events.

(d) Non-random sample Focus group informants were recruited through purposeful sampling, i.e. those interested in expressing their views were invited to take part in the focus group. This makes sense in the context of the intention of research methodology, to collect

‘informative’ data.

(e) Ambiguity in the vignettes

The daily life events embedded in the two vignettes were common ones but did not specify age, length of residency and other details. Some Chinese informants could not cope with this ‘ambiguity’ and commented that it was hard to give an opinion regarding

103 help-seeking. I then explained the reasons for not providing more detail, namely so that informants could identify with the vignettes and themselves fill the gaps in the information. This strategy has proven powerful in eliciting stories from informants of different demographic groups.

3.7.4 Overcoming Limitations

(a) Insider Research with a multi-disciplinary team

As a Chinese with previous depressive experience I have insights into what questions to pose, but I need to establish measures to ensure objectivity. The use of vignettes and open-ended questions help set the focus for discussion. During the process of data collection and analysis, I frequently discussed with the non-Chinese supervisors my reflections on and plans for revising the focus group procedures. Any subjective views I had were challenged by them during these exchanges.

(b) Accommodating the differences in different cultural subgroups

Designing a questionnaire that asked culturally specific questions and had to be adapted to ask relevant questions of members of different cultural groups was a huge challenge. There were three sets of questionnaires. The two vignettes were first set up from the Chinese migrants’ perspectives; these vignettes worked equally well with the

Australian groups as the life events cited in the vignettes seemed to be common across different cultural groups.

(c) Dual users of TCM and Western Medicine

Recruiting participants from both general practitioners and Chinese herbalists enabled a more representative sample of low acculturated Chinese since dual users of

TCM and Western Medicine are common in the Chinese community. This phenomenon was observed in both GPs’ and herbalists’ rooms: a Chinese mother gave a toddler 104 Western medication in a herbalist’s waiting room; a Chinese lady told a friend about taking Chinese medicine prior to her GP visit. In future research, questions regarding participants’ prior GP and herbalist visits may shed light on the consumption of dual health services.

(d) Communication between translators and researchers

It is important for translators and researchers to establish good communication.

This is the case for the current study where the researcher and the translator engaged in frequent communications. As Larkin, de Casterle and Schotsman (2002) assert such

‘Mutual reciprocity between researchers and translator offers greater possibility for construction of nuance and meaning’(p. 468). In the ‘translation of the Chinese expression of negative emotional words, sensitivity to cultural parameters is paramount .

Temple and Edwards (2002) pointed out the fact that the translator has to choose between

‘a dazzling array of possible word combinations’ to convey as close a meaning to the original word or word phrase. A close dialogue between the translator and the researcher is very much needed to find the ‘best-fit’.

3.7.5 Apparent Limitation

While a multidisciplinary approach has been employed to explore what the researcher sees as complex issues, readers specialized in their respective disciplines

(psychology, psychiatry or anthropology) may find such an approach over-ambitious and one would run the risk of not achieving anything. There is no simple clear-cut answer to the question ‘what is the best approach in researching mental health issues in multicultural society?’

I declared my stance as a researcher in Chapter 1 and I have also made an effort to provide a systematic presentation of the limitations of this mixed-method research in this

105 chapter. I encourage readers to be mindful of these limitations when they interpret the remaining chapters of this thesis. The final chapter will provide some directions for future research into clinical depression in non-Western communities.

3.8. Summary

Chapter three has outlined the rationale for using mixed methods and described the step-by-step procedures of data collection and analysis. In medical and social sciences research, surveys, questionnaires and other diagnostic measures are frequently used to collect quantifiable data from a large sample; for example, demographics and rates of lifetime depression. Qualitative methods like interviews or focus groups are often used to obtain more in-depth information about a topic; for example, the context in which the depressive experiences occurred. The two methods represent different ways of knowing, and neither should be regarded as superior to the other. Rather, the two serve to complement each other, for, as I have suggested, both methods have their strengths and limitations.

Chinese and Australians were recruited for both the survey and focus groups in this study. This chapter has explored the questions addressed in the quantitative survey in detail: somatisation and psychologisation attribution, state and lifetime depression, recognition of depressive symptoms, acculturation and help-seeking. The rationale, sampling methods and protocols for conducting focus groups are spelled out. The development of the two vignettes and the observations made from pilot focus groups are described. Continuous review and revision of qualitative research methodology and recruitment strategies is considered one of its important elements. Recruitment challenges existed in both the quantitative and qualitative phases of this study, i.e. in generating 106 support from general practitioners for the survey and engaging Chinese informants to voice their opinions in focus group discussions.

In relation to data analysis the Statistical Package for Social Sciences (SPSS 13.0) and NVivo 2 were used. The computer-assisted qualitative data analysis software NVivo

2 made analysis more manageable and objective. This chapter has outlined coding procedures and provided a detailed account of the development, translation and validation of the Chinese research instruments through two series of sub-studies. The findings of these sub-studies facilitate some important epistemological insights for cross-cultural research.

In the next chapter, I present an in-depth discussion of the validation of the

Chinese depression screening measure DMI-10 and the Chinese survey on explanatory models, Mental Distress Explanatory Models Schedule (MDEMS).

107 Chapter 4 Cross-cultural validation of Research Tools: Chinese versions of DMI-10 and MDEMS

Ʋź̮ŭɲýΖŋŠ Ȱ˷Qǀ΋̖QBĖਭQɿĽŬǦQ.

When Heaven intends to bestow a great mission on a person, it makes him suffer in mind and body… Mencius

This chapter is divided into two parts. Part I, ‘Cross-cultural validation of state depression measure DMI-10 Chinese version’, demonstrates how to quantify the level of suffering associated with depression among the Chinese in a series of three studies. Part

II is a report of the cross-cultural validation of a Chinese version of Mental Distress

Explanatory Model Schedule (MDEMS). Besides the technical necessity of ‘moulding’ a tool, these two validation studies add new insights to the ‘Erkläre vs Verstehen’ debate.

Historically, German scholars have had a continuous debate between ‘Erklären’

(objective explanation) and ‘Verstehen’ (subjective understanding/meaning) regarding the methodological paradigms within the discipline of social sciences, in particular sociology. German economist/ sociologist Max Weber refers to the German word

‘Verstehen’ (translated to mean ‘interpretative sociology’, see Weber, 1968) as an attempt to interpret both the intention and the context of human action which involves some form of empathy or understanding from the participant’s perspective:

We can accomplish something which is never attainable in the natural sciences, namely the subjective understanding of the action of the component individuals.

(Weber, 1968:15)

Baldwin and Baldwin (1978) use the parallel distinction between explicit (objective, public) knowledge and tacit (subjective, private) knowledge to illustrate the “Erklären

/Verstehen” dichotomy. They also cited Skinner’s (1969) criticism on the positivistic 108 methodology of excluding subjective experiences from the range of scientific studies.

Rather than advocating for replacing one with the other, Baldwin and Baldwin argue that

‘both are needed and are natural components of human behavior.’ (1978: 335).

In the current study, an integrated ‘top-down’ (quantitative) and ‘bottom-up’

(qualitative) approach has been utilised to validate different concepts of emotional distress in Chinese and Western cultures. While the pre-designed survey promoted a scientific analysis of frequently observed human emotions and behaviours, the focus group discussions allowed personal and subjective meanings of emotions to be documented. Integration of data obtained from the two lenses of instruments is also vital in confirming that the meaning of ‘emotional expression’ in both the Chinese and English languages shared some common ground.

Part I reports the cross-cultural validation of a 10-iem depression screening measure, Chinese DMI-10. Three sub-studies were undertaken: an initial bilingual test- retest (N = 28); a second study involving a series of focus groups exploring the meaning of translated items with Chinese-speakers; a third study (N = 26) repeated the bilingual test-retest.

Part II reports the cross-cultural validation of a Mental Distress Explanatory

Model Schedule (MDEMS) into the Chinese language using a similar approach: an initial qualitative (focus groups) followed by a quantitative (test-retest) method. Throughout the process, the meanings of suffering from the Chinese perspective are unveiled. The

Chinese informants attributed mixed Western and non-Western concepts, that is naturalistic and supernatural causes, to two scenarios of typical depressive episodes. This was followed by a robust procedure of translation and back-translation with triangulated communication between the original author (Eisenbruch, 1990), the translator (myself)

109 and the back-translator. The final instrument was one that struck both an

‘etic’(experience-far) and ‘emic’ (experience-near) balance in construct presentations.

Both measurement tools have important clinical implications. The Chinese DMI-10 is useful in that it facilitates an understanding of the Chinese experience of depression in cross-cultural research. Chinese MDEMS enables culturally competent diagnoses to be made by providing key information about patients’ explanatory models (EMs). There are also implications for international health, as widespread globalisation and international migration demand culturally competent clinical management, which are covered in the discussion in Chapter 9. The instruments and approach offered here demonstrate the importance of sharpening the tools which could enhance the quality of mental health service.

Before I spell out the details of the validation studies, I outline below the issues in translating and validating psychometric tools developed for the Anglo-Celtic dominant culture. This will be addressed further in later sections.

1. Validity of instruments - focusing on achieving psycholinguistic equivalence between original and translated measurement tools (Berry, Poortinga, Segall et al., 2002; Cheng,

Tien, Chang, Brugha, Cooper, Lee, Yip, Chiu, et al., 1998; Poortinga, 1989; Van

Ommeren, 2003).

2. Idioms of distress – as expressed by people from Western and non-Western cultures and which are readily understood by those with shared similar cultural background and knowledge (Chan and Parker, 2004; Ots, 1990; Phan, Steel, and Silove, 2004; Rebhun,

1993, 1994).

3. Translation and back-translation procedures – the gold standard to ensure the new translated version can be ‘decoded’ back to the original language without derailing from

110 the initial intended meaning (Sperber, Devellis, and Boehlecke, 1994; Van Ommeren,

Sharma, Thapa et al., 1999).

4. Verbal repertoire – as occurred spontaneously in daily encounters of those in the target culture is captured in the translated version (Lutz, 1983; Ng-Tse, 2001; Tung, 1994;

Zheng, Xu, and Shen, 1986).

5. The balance between ‘emic’, experience-near, relativistic, ideographic and ‘etic’, experience-far, universalistic and nomothetic approaches is mindfully accomplished

(Casino, Lewis-Fernandez and Bravo, 1997; Cheung, 1996; de Jong and Van Ommeren,

2002).

4.1. Cross-cultural Validation of Chinese DMI-10 – a depression screening measure

4.1.1 Theoretical considerations

The following report on the process and findings of a series of three studies undertaken to validate the Chinese DMI-10 may help to elucidate the following fundamental question: ‘Are human emotions universal across cultures?’ Anthropologists have long been interested in the study of specific emotions and expressions of distress in different cultures (Levy, 1984; Lutz and White, 1986; Rosaldo, 1983). Cross-cultural studies of mental disorders, such as depression, are important in order to (a) challenge the basic assumptions of existing psychiatric theory and practices, and (b) to examine the relevance of transposing Western concepts of mental illness into non-Western cultures

(Kirmayer and Minas, 2004). Chinese make up the planet’s largest ethnic group and though they are scattered over different regions they are heterogeneous in terms of culture and language spoken (Parker, Gladstone and Chee, 2001). Cross-cultural studies of depression in the Chinese are particularly important, given reports on the low prevalence of depression among Chinese in different parts of the world (Hwu et al., 1996;

111 Kleinman, 1986; Lin, 1985; Zhang et al., 1998). Parker et al (2001) reviewed rates of depression in community studies undertaken in China and Taiwan and proposed a number of explanations for the lower prevalence rates. These included: (1) symptom reporting restricted by stigma, and the Chinese view that emotional illness is ‘just part of life’; (2) socio-cultural values and family cohesiveness serving as protective factors against depression in Chinese communities; and (3) the tendency for Chinese to somatise, representing an idiomatic style for reporting emotional distress. In relation to the latter explanation, the high prevalence of somatization among depressed Chinese patients has been discussed by many authors (e.g. Cheung, 1995; Kleinman, 1986; Lee, 1998).

A final explanation for the low prevalence of depression detected in Chinese communities relates to the lack of culturally sensitive case-finding tools which may make detection difficult (Chen et al. 1998). Although quantitative self-report measures for assessing depression in the Chinese have been developed (e.g., Beck Depression

Inventory) and demonstrate satisfactory internal reliability and concurrent validity

(Cheung and Bagley 1998, Yeung et al., 2002), cultural biases still exist. As Zheng et al

(1988) report in the validation of the Chinese Beck Depression Inventory, three out of six factors extracted by principal component analysis did not satisfactorily explain clinical features of depression. Chen et al (1998) report a study using the DSM Scale for

Depression (DSD-26), which is derived from the Diagnostic Interview Schedule and the

DSM-IV (American Psychiatric Association, 1994) criteria for ‘caseness’. Results indicate that Chinese and Anglo-Americans with similar levels of depression responded differently to five items assessing somatic complaints and guilt, suggesting that these items were likely to have different cultural meanings.

Parker and colleagues developed the 10-item ‘Depression in Medically Ill’ (DMI-10) measure as a clinical depression screening tool (Parker et al., 2001b, 2002). During the

112 development of DMI-10, 81 provisional items were refined to 16 items by obtaining concurrent validity against the Hospital Anxiety and Depression Scale and the Beck

Depression Inventory for Primary Care (BDI-PC); (Parker et al., 2001b). Parker et al

(2002) subsequently developed the brief 10-item measure DMI-10, which uses a cognitive focused item set to assess depression, thereby avoiding any confounding influence of physical symptoms. DMI-10’s psychometric properties have been assessed using different samples including hospital in-patients and out-patients, attendants of general practice, and psychiatric out-patients (Parker and Gladstone, 2004; Parker,

Hilton, Bains et al., 2001, 2002, 2003). As this measure focuses on cognitive rather than physical symptoms to assess depression, it may be used in Chinese samples to explore cultural nuances. Thus, validating the Chinese version of the DMI-10 may assist cross- cultural research in depression as well as enabling future application in clinical settings.

In relation to establishing the cross-cultural validity of measures, issues regarding psycholinguistic equivalence (Poortinga, 1989) seem to pose the greatest challenge for researchers. As mentioned in Chapter 3, Westermeyer and Janca (1997) describe the use of a bilingual test-retest methodology to establish the psycholinguistic validity of different language versions of a measurement tool. Another issue relevant to cross- cultural validation of measures relates to the use of a ‘top-down’ approach (involving a priori hypotheses) versus a ‘bottom-up’ approach (hypotheses not well-defined but guided by data collected). Many research projects translating Western psychiatric instruments or depressive measurement tools have followed a top-down approach to establish content validity and/or concurrent validity (Cheung and Bagley, 1998; Lee, Yip,

Chiu et al., 1998). The procedures usually involve (1) translation of the original instrument by bilingual translators, (2) blinded back-translation by another translator, (3) examination of Cronbach’s alpha as an indicator of internal consistency, and/or factor

113 analysis to verify construct validity. However, Bhui, Mohamud, Warfa et al. (2003) emphasise the benefits of using a bottom-up approach such as focus groups, pilot studies and consultation with community agencies to strengthen the face and content validity of the adapted instrument. A number of researchers have used qualitative data to explore the cultural meaning of terms (e.g. Cheng, Tien, Chang, et al., 2001; Ng-Tse, 2001). To this end it appears advantageous to integrate both top-down and bottom-up approaches within the cross-cultural validation of measures (de Jong and Van Ommeren, 2002).

This series of three studies aims to establish the cross-cultural validity of the

Chinese version of the DMI-10, a self-report measure which has previously been validated for use in western samples of medically ill and psychiatric patients. This measure may be particularly well-suited to research into depression in Chinese due to its focus on cognitive rather than somatic symptoms. Cross-cultural validation will enable it to be used in future studies seeking to gain further understanding of the Chinese experience of depression. For the purposes of this thesis I combine both top-down and bottom-up approaches to explore the meanings of emotional expression in the Chinese context and to establish cross-cultural validity of the new Chinese version as compared with the original English version. Detailed methodology of the three sub-studies was outlined in the Methodology Chapter.

4.1.2. Findings

(a) Sub-study 1

Two strategies were used to examine bilingual test-retest validity. Firstly,

Pearson’s correlation coefficients were used to compare item scores and the total score of the Chinese and English versions. Secondly, mean total scores for the Chinese and

English versions were compared using paired sample t-tests. The mean age of informants

(n = 28) was 31.5 years (SD = 9.0), the mean age of migration was 17.7 (9.24), and the 114 mean years of residence was 13.8 years (SD = 7.8) with a female preponderance of

57.1%. Table 4.1 presents the correlation coefficients between the English and Chinese versions for each item and for total DMI-10 scores. For the total DMI-10 score, while the

Pearson correlation coefficient was large and significant (r = 0.73, p < 0.001), coefficients for individual items ranged from 0.28 to 0.74. Three of the items failed to reach significance for the individual correlations (see Table 4.1). The mean total score of the Chinese version (M = 9.7, SD = 7.2) was significantly higher (t = 2.81, p = 0.009) than that for the English version (M = 7.1, SD = 6.1).

115 Table 4.1: Bilingual Test-Retest Reliability for each item in the DMI-10 and total scores in Study 1 and Study 3

Study 1 Study 3 Original item Descriptive rating Visual analogue option (N=28) rating option (N=26) 1. Are you stewing over things? 0.45* 0.47*

2. Do you feel more vulnerable than usual? 1 0.33 0.55**

3. Are you being self-critical and hard on 0.61** 0.63** yourself? 4. Are you feeling guilty about things in your 0.54** 0.79*** life?

5. Do you feel as if you have lost your core and 0.45* 0.62** essence? 6. Are you feeling depressed? 0.74*** 0.59**

7. Do you feel less worthwhile? 1 0.50** 0.70***

8. Do you feel hopeless or helpless? 0.41* 0.77***

9. Do you feel more distant from other people? 1 0.28 0.49*

10. Do you find that nothing seems to be able to 0 .29 0.67*** cheer you up? 1

Overall correlation (sum of 10 items) 0.73*** 0.87***

* p < 0.05; ** p < 0.01; *** p < 0.001 1These 4 items were revised prior to Study 3.

(b) Sub-study 2 Study 2 explored the cultural nuances of the items in the DMI-10, revising them for a second test-retest study. There were five items in the initial Chinese translation of the DMI-10 that did not raise any concerns for the focus group participants. Among these five items, three used a Chinese idiomatic expression in the translation of the original:

‘Are you stewing over things?’; ‘Do you feel as if you have lost your core and essence?’ and ‘Are you feeling depressed?’ The other two items: ‘Are you being self-critical and hard on yourself?’ and ‘Do you feel hopeless or helpless?’ contained easily identifiable 116 equivalent constructs in the Chinese language. Thus, no changes were made to these five items for the second iteration of the DMI-10.

The item ‘Do you find that nothing seems to be able to cheer you up?’ did not raise concern among the participants. However, in the original translation, the phrase gāo-xíng (happy) is very formal, often used in writing and less frequently in daily conversation (especially in Cantonese). Given the low initial correlation, the less formal phrase kāi-xín was used in the revised version in an effort to improve psycholinguistic equivalence (all the Chinese characters for the corresponding phonetic transcriptions can be found in Appendix 4-1).

The remaining four items were discussed more extensively by the focus group participants. In relation to the item ‘Do you feel more vulnerable than usual? ’, participants with different language backgrounds (Mandarin and Cantonese) agreed that the translation cuì ruò (vulnerable) was an appropriate choice. One Mandarin-speaking female said:

[C]uì ruò (vulnerable) means ‘break’, easily breakable, cuì ruò (vulnerable) is to say when you face a ‘pull back’ or a blow, you fall ill, your mental state ‘collapses’ or falls apart, this is cuì ruò (vulnerable).

A Cantonese-speaking female related the word cuì ruò (vulnerable) to one’s mental state in contrast to a similar word, which describes one’s temperament:

I think your feeling is cuì ruò (vulnerable) that is no doubt. cuì ruò (vulnerable) is an adjective; cuò zhé (frustration) is a noun, is different. cuì ruò (vulnerable), I think that is more related to your mental state, ruăn ruò (weak), is something to describe a person’s personality or temperament etc.

However, traditionally the word cuì ruò (vulnerable) carries strong feminine connotations. In order to eliminate this gender bias, and confusion with the physical sense of easily breakable as raised by one informant, a decision was made to replace the word cuì ruò (vulnerable) with a phrase that spelt out the meaning explicitly into the two

117 components: găn-qíng (literally meaning emotion) and shòu-shāng-hài (literally meaning get hurt).

The item ‘Do you feel less worthwhile?’ was viewed as too severe: the alternative phrase bù zhōng yòng (‘no + use’) was described as more familiar by focus group participants. In the first translation, the Chinese term ‘no’ was combined with the term

‘worth’ to convey the meaning ‘less worthwhile’. To illustrate, a young Cantonese- speaking female compared the phrases méi-yǒu jià-zh (literally meaning ‘no + worth’) and bù zhōng yòng (‘no + use’; mentioned as a better alternative) in terms of the tone or degree of intensity that these two expressions carry:

[M]éi-yǒu jià-zhí (literally meaning ‘no + worth’) is too strong, bù zhōng yòng (literally meaning ‘no + use’) is like ‘just venting out’; i.e. it is lighter in tone.

The phrases bù zhōng yòng in Mandarin or mo mat yòng in Cantonese are often observed in the spontaneous repertoire of Mandarin or Cantonese speakers. Given their familiarity they come over as less severe and have less psychological impact.

In relation to the item ‘Do you feel more distant from other people?’, the original phrase

(shū-yuăn) contains the concept of ‘distant’. But it is usually used as a verb to denote the

‘act of distancing a relationship’ for some valid reason. A female Mandarin-speaker demonstrated how the experience of ‘not wanting to socialise’ fitted well into Chinese interpretations of the kind of behaviour one would expect when one’s mood was not good:

I prefer ‘not willing to socialise’. ‘Socialise’ means when I am very happy , then I will tend to like to meet many people from different places and go out and have fun, meaning I like to socialise! When I am not happy, and my mood is down, then I will turn down all the invitations, and that means I don’t want to socialise’. shū-yuăn (keeping a distance) means regardless of whether I am happy or not, if I don’t like that person I will try to keep a distance from him, not wanting to befriend him…

Though Chinese might find the meaning of the phrase ‘not willing to socialise’ very different from the literal meaning of the original English expression ‘feeling distant’, for

118 them it matched the intended meaning of the construct in the original DMI-10 more closely. [

In relation to the item ‘Are you feeling guilty about things in your life?, bilingual

Chinese responded differently to the word ‘guilty’ in Chinese and English. For a bilingual participant, the word ‘guilty’ (as used in English) stimulated feelings of emotional distance from people. But the same word in Chinese (nèi-jiù) triggered guilty feelings of not fulfilling family obligations:

The word ‘guilty’, you use it quite frequently to describe, right, how you feel about your work and stuff like that…But in Chinese, when you read this nèi-jiù, you actually use it to describe more serious offences like you know my child… (feel guilty towards your child)… the Chinese one is more intense, but then the English one…

This participant maintained that the Chinese phrase ‘guilty’ was able to trigger more intense emotion than its English equivalent. Thus, while the translation of this item was not modified, caution was observed vis-à-vis the inherent emotional difference in the construct of the Chinese and English words.

(c) Sub-study 3 Following the modification of the four items described in Study 2, the second test- retest study was conducted. The mean age of informants (n = 26) in the second test-retest reliability measure was 33.7 years (SD = 10.0), the mean age of migration was 22.0 years

(SD = 9.3), the mean years of residence was 11.0 year (SD = 7.0) with a female preponderance of 61.5%. Compared with the informants in Study 1, the differences between the mean age, mean age at migration, and mean length of residence between the two groups were insignificant.

Paired t-tests were used to determine cross cultural validity of items and mean total scores for the Chinese and English versions. Table 4.1 presents the results of Study

3 (in comparison with Study 1 results). The test-retest coefficients for the total DMI-10 were r = 0.87 (p = 0.001) with all individual item correlations reaching significance and 119 ranging from 0.47 to 0.77. Study 3 findings showed an improvement when compared to the results of Study 1. Three items that failed to achieve significance in Study I reached significance in Study 3. The mean total scores of the Chinese and English DMI-10 were

2.4 (SD = 1.8) and 2.0 (SD =1.8) respectively. However, they were still significantly different (t =2.44; p <0.01) with Chinese language scores again exceeding English language scores.

4.1.3. Discussion The aim of the three studies was to establish the cross-cultural validity of the

Chinese version of the DMI-10, a self-report measure of cognitive-based depression symptoms. This study included both top-down and bottom-up methods, with a series of focus groups following the initial bilingual test-retest study to explore the psycholinguistic equivalence of constructs and a second test-retest study of the iterated version.

While the first test-retest study achieved a satisfactory overall level of cross- cultural validity (0.73), three items in the scale failed to reach significance. Several other items produced only moderate-sized coefficients. Two strategies were used to improve the test-retest coefficients. Firstly, focus groups were used to explore the meaning of the items, with revision of four items so that they better reflected cultural nuances. It was of interest to find that three items in the first translation that incorporated a Chinese idiomatic expression, matched closely the emotional construct in the original version.

Idioms convey well-defined meanings based on experiences to which most people of the language concern can relate. Other researchers have emphasised the importance of including idioms into self-report measures (e.g., Phan et al., 2004). As a consequence of focus group discussions, revisions were made to four items as more culturally appropriate words and phases were identified.

120 The second strategy designed to improve the test-retest coefficients was the use of a visual analogue scale to overcome cultural differences in measuring the abstract concepts in different cultures. Importantly, significant improvements in test-retest coefficients were observed from Study 1 to Study 3 in three of the six items with no revision. Improvement in the correlation coefficients between the two test-retest studies may also reflect the use of the visual analogue strategy. As a result, the revised Chinese

DMI-10 has strong correlation with the English version, thus arguing for its validity.

The findings of this study have implications for cross-cultural research into depression in

Chinese communities. Concomitant with the dramatic increase in international migration over recent decades is a pressing need to find a valid depression screening tool for

Chinese living in the West. With the robust methodology used in the present study to validate the DMI-10 Chinese version using bilingual subjects, the measure has the potential to be used as an efficient screening tool for depression among Chinese.

However, it would be important for future validation studies to examine its use in other

Chinese communities and with clinical samples of depressed patients. The fact that the

DMI-10 focuses on cognitive symptoms rather than on physical symptoms allows interpretation of the results without the complication of issues surrounding somatization.

Exploring meanings through qualitative research is a crucial step in testing for the existence of overlapping concepts in emotional constructs within different cultures. There are obvious advantages in integrating top-down and bottom-up approaches. For example, the first set of quantitative test-retest reliability results was able to identify any mis-match in the English and Chinese expressions. During the first translation the phrase shū-yuăn, literally meaning ‘keeping a distance’ was used, but this was revised following focus group discussion. Overall, the narratives gathered in the qualitative study provide an opportunity to understand the emotions associated with the Chinese terms/phrases and by

121 extension to improve the translation of the items. The qualitative component in the study enabled exploration of meanings in cultural contexts which Good (1992) has described as

‘the importance of addressing the “lived experience” to reconstruct the concept of the phenomenology of clinical depression’.

Bilingual speakers express emotions differently depending on the language used and the context of its use. This was demonstrated by the narratives of a bilingual informant, who explained how ‘guilty’ in English elicited feelings pertinent to her work environment and more related to the breaking of rules. The same word in Chinese tapped into feelings connected with family obligations. Koven (2004) describes a single case study of a French-Portuguese bilingual speaker who expressed emotions differently in narratives of personal experience in her two languages. Koven argues that it is not the mere difference of the structures of the two languages but the repertoire of the role to which this speaker has access in each language. The bilingual informants who participated in the present study obtained a significantly higher score in the Chinese over the English versions, even in the second iteration of the measure. This may be due to the cultural differences in language usage, an inherent difficulty in cross-cultural research.

Chan (1991) administered the original and Chinese version of the Beck Depression

Inventory to a large sample of bilingual subjects. While he reported overall similar mean scores for both the Chinese and English versions, at the same time he observed some differences in item scores which were judged to be due to intrinsic language differences.

Aside from the inherent language differences, the difference in scores could also be due to the small sample size (in both Study 1 and Study 3). Therefore replication of this study using a larger sample size is required.

122 4.2. The Meaning of Suffering – a Chinese explaining tool of mental distress

In the last section I outlined the cross-cultural validation of the DMI-10 with the emphasis on the idioms of distress and the emotional expressions in the Chinese language. I now switch focus to validating the meaning of suffering using a similar integrated top-down and bottom-up approach: validation of the Chinese Mental Distress

Explanatory Model Schedule (MDEMS). This approach reflects the importance of understanding mental distress from the Chinese viewpoint. While there are a range of possible epistemologies to explain mental distress, I choose an emic (experience-near) approach; I am not privileging anthropology, social science over biomedicine, the objective is to demonstrate how these ‘meanings of suffering’ can be managed in a scientific and systematic way. The qualitative data presented in this section were drawn from four pilot focus groups while consolidating the methodology for the qualitative component of the overall study. As suggested in Chapter 3, the method used to draft items and the iterative validation through focus groups, back-translation and test-retest, describes and analyses the profile of popular causes of mental distress through the eyes of

Chinese informants.

The social and cultural construction of mental suffering and illness has been taken seriously by authors interested in ‘human beings’ subjective meanings’; such as Weiss

(1997), Eisenbruch (1990) and Lifton (2005). However, how do clinicians and health workers calibrate and measure these explanatory models (EMs), for Chinese groups?

Perhaps, more importantly, it is the understanding of how Chinese interpret their bodily symptoms and emotional distress. To the Chinese, it is apparent that they need first to attach a meaning to their concrete bodily experience before they can spell out their

‘abstract’ feelings. As mentioned in Chapter 2, Chinese culture has long disapproved of

123 any public display of emotion (Ots, 1990; Stevenson, Chen and Lee, 1994). Such observations could well be summarised in Spiro’s (1961) proposition of how the invisible regulatory function of culture can be maintained. It would be intrinsically rewarding to follow the goals set by the cultural meaning system. As Spiro stated,

if the social function of a role is internalized as a personal drive, its performance, which is intended to serve a social function, serves a personal function – albeit unintentionally (p.106).

It is worth exploring how people find meanings for their emotional distress. In the context of a multicultural society, Chinese-Australians, positioned at the crossroads of

Chinese and Western cultures, are the ideal informants to reveal the ‘cultural meaning’ of distress.

4.2.1. Measuring meaning of suffering in Chinese culture

Culture shapes patients’ attributions of suffering and sadness (Cheung, 1985;

Eisenbruch, 1991; Greenfield, Borkan, and Yodfat, 1987; Helman, 1986; Weiss, Sharma and Gavr, 1986; Ying, 1990). Health workers intuitively ask their patients about their beliefs. When the health worker and the patient share similar ‘assumptive worlds’ and are of similar cultural background, there is a shared unspoken meaning.

Eisenbruch (1990) developed a simple ‘universal’ instrument which led to a Mental

Distress Explanatory Model Schedule (MDEMS) that in theory could be used by people of any cultural background to profile their view of the causes of mental distress. The

MDEMS comprises a 45-item self-report questionnaire. Items are derived from

‘culturally ubiquitous’ natural and supernatural (mystical, animistic and magical) categories devised by Murdock and colleagues (Murdock, Wilson and Frederick, 1978), with the addition of items more explicitly covering Western notions of physiological causation and stress. Initial findings from 261 people (mostly college students of diverse

124 cultural backgrounds) demonstrated how various taxonomies proposed by different authors (Landy, 1983; Murdock, Wilson and Frederick, 1978; Young, 1976) can meld together as a standardised structured instrument (See figure 4-1).

Figure 4-1 Multidimensional Scaling of explanatory models (Eisenbruch, 1990)

125 The present study responds to the imperative to understand how Chinese living in Sydney might mix Chinese and Anglo-Australian concepts while also mixing ‘naturalistic’ and

‘supernatural’ understandings of the causes of their mental distress. Do the Chinese readily understand culturally familiar notions such as ‘being hot’ (zào- re’) as a cipher for

‘easily irritated’, ‘out of harmony’, a condition that is part of the state of dysphoria, perhaps physical unease – which the Western observer would call depression? (Parker,

Cheah and Roy, 2001)

An ethnographically piloted version of translated Western instruments, such as the

MDEMS, has played a crucial part in unfolding subtle nuances, e.g. the MDEMS translated into Khmer (Eisenbruch and Handelman, 1989; Casino, Lewis-Fernandez, and

Bravo, 1997; de Jong and Van Ommeren, 2002) and Chinese people affected by cancer

(Eisenbruch, et al., 2004; Yeo et al., 2005).The clinical application of ‘explanatory models’ has been cited by many medical anthropologists (Heilscher and Somerfield,

1985; Katon and Kleinman, 1981), who understand ‘illness’ as referring to the culturally constructed ideas held by the patients about the cause and nature of the disease.

As outlined in the Methodology chapter, a spontaneous repertoire of likely attributions of mental distress was established during the focus group discussions. A bilingual test-retest process was administered to Chinese participants to establish linguistic equivalence.

4.2.2. Findings

(a) Blatant causes of mental distress The informants of their own accord named 28 of the 45 items in the MDEMS as possible causes of mental illness. Thus most items in the MDEMS matched the verbal expression of the natural Chinese repertoire, e.g. Migration to a new country, unemployment, bad experiences during childhood, chemical imbalance in the brain, general life stresses, too much work or study, conflict with family or friends, and breakup of family or a failed 126 relationship were frequently nominated as the causes of mental distress. Non-Western constructs such as the movements of winds or draughts, the body being out of balance or harmony (yin/yang, hot/cold), bad luck or chance, seeing, hearing or feeling something ominous were also mentioned in the narratives.

The response patterns of the remaining 17 items fell into two groups:

(i) evenly distributed responses;

(ii) responses clustered between mid-point and the ‘not at all likely’ end (See

Appendix 4-2).

The first group consisted of a mixture of Western and non-Western concepts as well as naturalistic and supernatural causes. This reflects the multiple beliefs held by most people in multicultural societies as discussed in Eisenbruch’s original paper (Eisenbruch, 1990).

The second group consisted of mainly non-Western/supernatural items. Such a low rating of this ‘explanation model’ item could be a reflection of the participants’ education level.

However, in a follow-up interview with one of the participants (a female medical doctor from mainland China), when prompted by the question ‘Do people in mainland China believe that mental illness is caused by coming in contact with something taboo?’, she commented that this is a superstitious belief that most people no longer hold except where every means of treatment has been exhausted then the family might resort to such an explanation.

Comparing the two items related to spells:

Item 40: Someone wanting to hurt the person and wittingly casting a spell, and

Item 39: Someone unwittingly casting a spell.

127 The former, which relates to intentionality only, was readily nominated as a possible cause of mental distress, whereas the latter, which compels the presence of some sort of magic, was not.

(b) Iterating the meaning of culture-bound terms

Mental health professionals who do not speak the language of the patient would assume that the interpreter has provided a precise linguistic equivalent, but what about instances where key Chinese concepts have no matching English terms. Rarely will the interpreter clarify with the original speaker the intended meaning. In the translation process in this study there were such opportunities. A key example follows:

The back-translator wrote:

English version Being hot (but not from fever or weather)

Chinese version ͗ï / ǖ# zào -re’/ ’huo-qi

Back-translation Suffering from excessive internal heat/getting angry easily (but not caused by fever or hot weather)

Most of the original meaning is retained by the back-translation, except for the second

phrase, ’huoqi’ (‘getting angry easily’), which is not present in the original English

version. During the initial translation, ’huoqi’ (ǖ# a phrase used in Chinese

medicine to mean ‘internal heat’) was added to illustrate the fact that this ‘heat’ is not

related to the weather. In the back-translation, the second part seems to carry extra

meaning (i.e. anger), which is not intended in the English version. Eisenbruch (2004

pers. comm.) , the original author, made a decision to leave out the anger component

but to retain the phrase ͗ï ‘zào re,’ which is a Chinese idiom for body heat (not

related to weather). 128 (c) Bilingual Test-Retest

The correlation coefficient (Paired Pearson r) between each pair of items of the English and Chinese MDEMS was obtained. 40 of 45 items achieved statistical significance

(range from r = 0.43 to r = 0.88). Correlation coefficients of the five poor-fit pairs were examined and their significance reached by removing a small number of random response pairs of three items. As regards the remaining two items, item 7 appeared to convey different meanings in the two versions. To rectify this, an idiomatic Chinese expression was adopted for the Chinese version, which was then translated into English to create an item with an original Chinese construct: “Movements of external ‘yin-yang’ forces and

‘the five elements’ (metal, wood, water, fire, and earth).”

A second item requiring attention was:

Item 22 ‘Doing the wrong thing during pregnancy’.

The mismatch between the Chinese and the English version stems from the lack of specificity in the English version. Informants rated the English version as ‘much more likely’ to cause mental distress, whereas the Chinese version conveyed deeper shades of meaning such as ‘violating a cultural taboo during pregnancy, when giving birth, and also while doing the month’ (Pillsbury, 1978). The new Chinese entry expanded the original

Chinese concept to specify the period in which a person is most susceptible to breaking taboos and this item became the second Chinese construct for the schedule:

Doing the wrong thing during pregnancy, when giving birth or in the first month following baby’s birth.

The Chinese translated version was then finalised after replacing the two items with the

‘emic’ Chinese constructs. This step was a response to the call for a combined etic-emic approach. As Cheung (1996) points out,

129 [A] fundamental deficiency in these adaptation methods is the omission of important emic constructs, which are important to the Chinese culture. (p.411)

Such thorough examination of item-pairs’ statistical correlation is, I believe, a more robust approach to establishing psycho-linguistic equivalence. Figure 4-2 below is a diagrammatic mapping of the validation processes.

130 Figure 4-2 Tool Development Pathways

Translation by bilingual speakers

Triangular Negotiations Review by experts (author & translators)

Qualitative Community Focus groups Quantitative test-retest validity

4.2.3. The robustness of the psychometrics

In order to achieve satisfactory translation for cross-cultural research, I closely followed the Translation Monitoring Procedure recommended by Van Ommeren, Sharma, Thapa et al.(1999). The Chinese version of the MDEMS has achieved high inter-version consistency. As well as ensuring a good representation of beliefs, the focus groups proved a powerful way of understanding how Chinese make sense of their emotional experiences. Culture can be viewed as a set of rules governing individual behaviours according to shared values and morals (knowledge common to the members within the particular culture). The culturally-sanctioned way in which the Chinese deal with

131 negative emotions is to embed the emotion into a body metaphor or fit it into the indigenous mode of explaining everyday events or entities (e.g. the yin/yang and Five

Elements cosmology). This type of process helps to externalise the emotionally distressing event so it can then be manipulated by external sources, thus taking the pressure or responsibility off the individual. For example, an angry liver can be fixed by taking some herbal medicine that improves the ‘qi’ circulation to the liver. Once the anger energy is transported out of the body system the original symptoms of distress will start to improve (Ots, 1990). Several cases of such remedies, for example liver- circulation-improving soup, were recommended by focus group participants as ways to help relieve the intense mood swings of the ‘young mother’ vignette.

There are rituals of grief in the Chinese culture which explicitly lay down how each member of the extended family should act according to the family hierarchy (Chan unpublished). Western-trained mental health professionals tend to label such culturally- prescribed behaviours as ‘unscientific’. However, each society has its own cultural codes through which distress can legitimately be expressed. By having focus groups discuss explanatory models of mental distress among the Chinese at different levels of acculturation and language backgrounds, an excellent sample of spontaneous narratives was collected. This ensured that explanatory models offered by the MDEMS actually exist in the natural Chinese language repertoire (as compared to highly structured clinical settings).

A subsequent back-translation by an independent professional translator was carried out to achieve the highest possible standard. There was triangulation between the original author, Eisenbruch, the translator and the back-translator vis-à-vis phrases and matched coherence in meaning across both the Chinese and English languages. A pilot-test, using thirty-one bi-lingual Chinese to establish statistically significant correlation between each

132 pair of Chinese and English items, was conducted. The final modification was made by replacing items falling outside the significant level with two indigenous Chinese constructs (and the corresponding translated English phrases). This last step was necessary in order to preserve the Chinese cultural concept rooted in these two items. The results of this study not only offer a culturally appropriate, sensitive instrument to explore meanings, they enable clinicians using the MDEMS to extract important information about what the patient believes which facilitates a more culturally competent diagnosis.

4.3 Summary

In this chapter, I have adopted a social sciences perspective to explore how informants from non-Western backgrounds make sense of their mental distress, both in terms of explanatory models and the actual negative emotions generated. In Part I, I establish the validity of the DMI-10 Chinese version, with excellent test-retest reliability being found in the second iteration of the questionnaire. This is also a measure to ascertain the psycholinguistic equivalence of the Chinese version and should be followed by further validation studies using clinical samples in different regions. In Part II the Chinese participants using a Chinese version of MDEMS mix Western and non-Western concepts, in other words they mix naturalistic and supernatural causes, to make sense of mental distress. The integrated qualitative and quantitative approach to the validation of the

DMI-10 was also employed to establish psycholinguistic equivalence between the original MDEMS and the Chinese version. This has proved valuable in revealing etic

(experience-near) vs emic (experience-far) differences between the two languages in important concepts related to Explanatory Models. Key information that will assist clinicians to make culturally competent diagnoses is thus provided. Given that Chinese

133 comprise the planet’s largest ethnic group and that they have migrated to so many different regions, this study, which integrates both top-down and bottom-up approaches to validate the Chinese versions of MDEMS and the DMI-10, has the potential for application to mental health programs around the globe, particularly where the Chinese language is involved. Two efficient tools for depression have been made available for use with Chinese-speaking communities in Australia and beyond. At a global level, WHO

(2002) endorses the contribution of ‘meaning of events’ in their model of clinical depression; these tool validation reports presented here demonstrate not only the model’s importance but also identify subtle cultural nuances in emotional expression across cultures.

134 Chapter 5 The depressive experiences: Do Chinese experience similar depressive episodes to Australians

ÏˮƄȦ'(ǙˮƄþ(.

Pleasure not carried to the point of over the limit, grief not carried to the point of excessive hurt. Confucius, Analects

5.I Introduction

The aim of this chapter is to discover how Chinese in Sydney experience their

‘emotional distress’. As mentioned in Chapter 1 Introduction, the informants of the study were Chinese living in Sydney, Australia’s largest-growing non-English speaking ethnic group. With all the Chinese dialects included - Mandarin, Cantonese, Hokkien, Chaozhou and Hakka - Chinese is the most widely spoken language after English in Australia (ABS

2002). Smith and Bond (Smith and Bond 1999) criticise early research into cross-cultural psychology stating that scholars frequently simplified or polarized culture into Western and Chinese. For the purpose of providing ‘a point of reference’, one may consider the cultural division at a ‘symbolic’ level. In recent years, the exchange of knowledge and information has also been accelerated, due largely to the process of migration and acculturation (Bhugra and Mastrogianni 2004). The complexity of such exchange or acculturation cannot be adequately addressed simply by ticking the boxes on a questionnaire. Focus group discussions fill the gap as a means of discerning the effect of migration and acculturation among Chinese-Australians. It is important to note the two- way exchange, as the Chinese become more and more ‘Westernised’, the Australians also pick up some aspects of the Chinese way of living. In a survey conducted of households in Adelaide, South Australia (Fonesca, 2002), 20 per cent of men and 26 per cent of women visit alternative therapists, e.g. chiropractors, acupuncturists, naturopaths.

135 Eastwood (2000) points out that GPs can’t afford to ignore the rising demand for

Complementary/Alternative Medicine from patients. Figure 5.1 is a symbolic representation of the influence of Chinese and Western cultures on the Chinese people living in Sydney: the current study is to explore the experiences of depression from the

Chinese perspective and the subsequent help-seeking behaviours. In order to find out the cultural dimension of the depressive experiences, I will focus on the reporting of such experiences among the Chinese and Australians. The findings from the quantitative and qualitative data will address the first research question:

Do Chinese have similar depressive experiences to Australians?

Historically, and as reviewed by the traditional Chinese Illness Terms, there is a clear link between the ‘body and mind’. The word [ʽ+ Ƀ] ‘juān’; ‘yōuyù’ [ʯၐɭ] is the closest equivalent of a Chinese word to denote 'depression' which means ‘xīn-tòng-tǐ- fán’ [Ż˩ညX]. A literal translation could be ‘heart + ache + body + irritated’(China

Press, 1968). This chapter will provide an insight into the similarities and differences of the ‘depressive experiences’ encountered by both Chinese and Australians.

136 Figure 5-1: Symbolic representation of relationships between the Chinese and Western Cultures, acculturation, depression, and help-seeking.

Chinese in Sydney

Depression

Migration Chinese Western Culture Culture Acculturation

Help-seeking

5.2. Survey Results:

5.2.1. Response rates Out of those accepting a questionnaire, the response rate was 64.8% (64.1% for

Chinese subjects and 66.2% for Australians). Six subjects returned substantively incomplete questionnaires and these were excluded. Recruitment was ceased when a sample of 431 Chinese subjects and 157 Australians was obtained. Subsequently

137 inspection of data sets for non-discriminatory responses (e.g. checking the same response option for all questionnaire items), and subsequently 46 Chinese and 14 Australians were excluded (See Appendix 5.1 for the comparison of demographics and depression variables between the excluded and retained participants). The final sample made up of

385 Chinese subjects (256 completing the Chinese version and 129 the English version) and 143 Australian Controls.

Table 5.1 shows the demographics of Chinese and non-Chinese (Controls) survey informants. The mean ages for the Chinese (38.5, SD 15.7) and Controls (41.4, SD 17.9) were comparable as were the female preponderances (56% vs 53%). In the total Chinese group, the 256 Chinese subjects who answered the Chinese questionnaire were significantly older than the 129 Chinese who answered the English questionnaire (42.4 vs

30.6; t = 7.5, p < 0.001). However they did not differ greatly by gender (57% vs 54% female). They also differed in terms of direct and indirect measures of acculturation (see

Table 5.2). For the purpose of categorising the two Chinese subgroups, the term ‘Low- acculturated’ Chinese and ‘Highly- acculturation’ Chinese were used. A more detailed account of the relationship between language skills and acculturation will be presented in the next chapter. Table 5.2 provides a comparison of demographics between the ‘Low- acculturated’ (Low-Acc) and ‘Highly-acculturated’ (High-Acc) Chinese subgroups according to the level of acculturation as measured by Suinn-Lew Self-Identification

Acculturation Scale (SL-ASIA) (Suinn, 1998; Suinn, Ahuna and Khoo, 1992)

The age differences in the two Chinese subgroups reflected the participants’ characteristics and the nature of their migration. The High-Acc acculturated Chinese recruited were significantly younger than the other Chinese subgroup and had migrated at

138 a younger age (see Table 5.2). They preferred an English questionnaire to a Chinese one.

Preferred questionnaire language can be taken as a proxy ‘linguistic acculturation’ measure (Clement et al. 2001). Those Chinese born outside Australia would most likely be professional migrants (Mak 2001). Those born in Australia were children of migrants from an Asian region, e.g. Hong Kong, China, Taiwan and Vietnam. A small percentage of Chinese in this group migrated from other South-East Asian countries such as

Singapore, Malaysia and Indonesia. Participants in this subgroup were more educated (a detailed statistical analysis of education levels and occupations will be presented in

Appendix 5.2). This can be explained by the Chinese traditional emphasis on children’s education, and the wider education opportunities available in Australia as compared to those of their parents (Stevenson et al. 1994). For the low acculturation subgroup, nearly

40% were not in the workforce (See Appendix 5.3). As I suggest in the Introduction

Chapter, many migrated as part of the ‘family reunion’ program to join their adult children in Australia. In the Low-Acc Chinese subgroup the current age as well as the age at migration was older. Though this group reported a lower percentage of ‘depressive episodes’ (in broadly defined terms) than the High-Acc Chinese group, the rate did not have statistical significance.

In terms of current occupation categories: (1) managerial; (2) professional and para-professional; (3)sales and services (4) labour/blue collar and (5) not in the work force, the Chinese as a group returned a lower level than the Controls (χ2 = 23.8, df 4, p <

0.001) but their education level: (1) Bachelor Degree or above, (2) High School or

Diploma, (3) Junior High School or below, was higher than the Controls (χ2 = 13.7, df 2, p = 0.001). Using current occupation as an index of socio-economic status may not be appropriate in the case of Chinese migrants. A high percentage of migrants regardless of place of origin suffered a loss in seniority in their first job (Flatau et al 1995). Therefore,

139 when the Low-Acc Chinese subgroup was compared with the Australians (See Appendix

5.3), while they did not differ in education level (χ2 = 3.9, df 2) they were lower in the current job level (χ2 = 41.8, df 4, p < 0.001). However, the opposite was true for the comparison between the High-Acc Chinese and Australians: the High-Acc Chinese subgroup did not differ with the Australians in the area of current occupational levels (χ2

= 9.5, df 4). But they returned a higher level of education than the Australians (χ2 = 32.9, df 2, p < 0.001; see Appendix 5.4). When the Low-Acc and High-Acc Chinese subgroups were compared, the current occupation level of the former was significantly lower than the latter (χ2 = 50.8, df 4, p < 0.001), but when examining the occupational level prior to migration, the two subgroups did not differ (χ2 = 6.5, df 4, n.s.). Therefore occupational level differences between the two Chinese groups were likely to reflect post-migration factors (See Appendix 5-5). As outlined in the Method Chapter, participants were recruited from a total of 11 medical centres in areas which span a wide spectrum of socio-economic levels. Thus the Chinese and Australian samples were assumed to be as close a match as recruitment strategies would allow (See Table 5.1 and

5.2).

140 Table 5.1 : Demographics and percentage distribution of informants’ depressive episodes

Chinese Australians t/ χ 2

n = 345 n = 143

Age 38.5 (15.7) 41.5 (17.9) t = 1.86 N.S.

Female 56% 53% χ 2 = 0.37 N.S.

Depressive Episode 31.9 49.2% χ 2=11.6 ; p=0.001

Table 5.2 : Demographics and percentage distribution of informants’ depressive experiences Chinese Comparison of Low-A Vs High-A Chinese subgroup Degree of Low-Acc High-Acc t χ 2 acculturation (Chinese Survey) (English Survey) n= 256 n = 129 Age 42.4 30.6 7.5***

Age at Migration 31.4 13.4 12.3**

SL-ASIA 2.05 2.72 15.2***

Female 57.0% 54.3% 0.27(N.S.)

Depressive 29.0% 37.6% 2.83 (N.S.)

Episode*

** p < 0.01 *** p < 0.00

141 (a) Most troubling Symptoms (self-nominated)

Participants who answered ‘yes’ to the question regarding whether they have experienced an episode of depression, were asked to report the four most troubling symptoms within the episode (Please refer to Appendix 3-1 for the question in the survey form). Table 5.3 shows the percentage distribution of weighted score of the most troubling symptoms. Comparisons were made between the two Chinese subgroups and

Controls. The top six most troubling symptoms were very similar across these groups.

‘Insomnia’ came first for the low acculturation Chinese subgroup and second for the other Chinese subgroup. This result is similar to that of a study comparing Chinese-

Malaysians and Australian depressed patients. (Parker et al., 2001) However, while the symptom ‘fatigue’ was ranked third and sixth by the Controls and the highly acculturated

Chinese respectively, it was ranked 14th by the Low Acculturated Chinese. In recent years, there has been considerable interest shown in chronic fatigue syndrome (Ward

1998). The response patterns listed in Table 5.3 may shed some light on the cultural saliency of some bodily sensations and emotional states. It was interesting to note how the highly acculturated Chinese showed a close resemblance to the other two groups demonstrating the moderating effect of culture. It is noteworthy that the criterion for inclusion in the symptom ‘feeling depressed’ was extended to idiomatic references such as ‘xin-qing-bu-hau’ (literally meaning mood is not good), ‘fell into a dark hole’ and

‘feeling grey’.

142 Table 5.3: Weighted score of the most troubling symptoms

Chinese Australians

Questionnaire Low-Acc Chinese High-Acc Chinese Australians language n=71 n=47 n=65 Weighted score* Weighted score Weighted score Insomnia 67 (1)# 20 (5b) 18(6)

depressed 42 (2) 39(1) 24 (5)

Anxious and tense 31 (3) 25(4) 46 (1)

No motivation 20 (4) 27(3) 29(2)

withdrawn 18 (5a) 14(7) 25 (3a)

Hopeless 18 (5b) 11(10) 10 (11)

Sadness 9 (12) 29 (2) 16 (7)

Fatigue 7 (14) 20(5a) 25 (3b)

* The 1st nominated symptom was given 4 points; 2nd nominated symptom 3 points; 3rd 2 points and 4th 1 point. # The number in parentheses is the ranking for that symptom; the intensity of the shades reflected the ranking visually.

(b) Most nominated Explanatory Models (EMs)

Informants who reported having experienced a depressive episode were asked to nominate what they thought to be the likely causes of their depression. Table 5.4 shows the percentage distribution of most nominated EMs. The most marked difference between the Chinese across the two acculturation groups and the Controls was that both Chinese subgroups frequently specified ‘family challenges’ as contributing to their distress. One possible explanation could be the emphasis placed on ‘interdependence’ in a collective culture like the Chinese (Markus and Kitayama 1991). Harmonised family relationships are highly valued; thus any deviation from an optimal state could cause emotional distress. Unlike the Chinese, Controls are more likely to relate their depression to

143 physical illness or other health issues. However, common themes of ‘Life Stress’, ‘Work

Stress’ and ‘ Issues in Romantic Relationships’ were nominated by all groups with no significant differences in terms of the relative percentage. Another expected result was that the Low Acculturation group experienced more migration-related stress, such as language difficulty and adjusting to a new environment. Bhugra (2004b) describes the processes of pre-migration, migration and post-migration stating that they are likely to impact migrants’ mental health. The findings of this current study are particularly important, for they will enable mental health professionals to appreciate the cultural differences of patients from non-Western backgrounds. Asking patients how they make sense of the depressive episode (patient’s own EM) could be the first step towards culturally competent management. Paykel (2003) emphasizes the association of major life events with the first onset of depression; gaining an understanding of how the patient interprets his/her depression would facilitate long-term planning of therapeutic intervention.

Table 5.4: Percentage distribution of nominated EM of informants reporting previous depressive experiences*

Chinese Australian Statistical Analysis Questionnaire(Qn) Low-A Chinese High-A Chinese Controls language n=59 n=44 n=60 χ 2 % % % df = 2 Life Stress 11.9 15.9 23.3 2.82

Work Stress 16.9 15.9 8.3 2.19

Relationship 15.3 22.7 20.0 0.97

Study-related 11.9 13.6 3.3 4.01

Health-related 10.2 4.5 20.0 6.01*

Family Challenges 20.3 22.7 6.7 6.21*

Finance 6.8 9.1 1.7 2.96

Migration 11.9 4.5 N/A 1.69 df=1

*more than one EM was allowed. 144 5.3. Focus Group Findings:

5.3.1. Demographics Table 5.5 showed the demographics of focus group informants of the 16 focus groups which were comparable to those of survey participants except the mean age of the

Mandarin-speaking informants was relatively higher. The English-speaking Chinese informants resemble closely in mean age and mean SL-ASIA with Chinese preferring

English questionnaires. Statistical analysis was not conducted since qualitative data collected were not meant to generalise to other populations. The education levels and job categories of focus group informants were presented in Appendix 5.6 for reference purposes only.

Table 5.5: Demographics of focus group informants from different language groups Acculturation Low-Acc Chinese High-Acc Chinese Australians

Language Mandarin Cantonese English English n = 26 n = 33 n= 17 n = 25 Mean Age (range) 59.4 41.1 29.4 47.0 (33-79) (20-78) (18-42) (24-78) Mean Age at 48.7 25.75 17.88 N/A Migration (range) (18-71) (0-52) (0-39) Mean SL-ASIA# 1.90 2.72 2.84 N/A (range) (1.24-2.43) (1.33-2.95) (2.00 – 4.00) Mean Language 1.74 2.40 3.51 3.76 competency (0-4) (0-5) (1-5) (0.33-5)

# SL-ASIA : Suinn-Lew Self-Identified Acculturation Scale

5.3.2. Real scenarios The pilot focus group demonstrated that the vignettes could be used as a projection test.

In the 16 focus groups, participants readily talked about how they would help the

‘person’ in the vignettes. Once participants become engaged in the discussion on the facilitator’s probe questions, rapport was gradually established. Most likely this was through having friends or relatives who had encountered something similar to the two 145 vignettes. Participants from all language groups willingly talked about their ‘real scenarios’. The theme ‘real scenario’ was coded as ‘an episode of depressive experience in real life’ retold by a participant. Some quotes from this theme are presented here:

(a) Real scenario similar to the first vignette

(1) One Mandarin-speaking female informant talked about her friend who was experiencing emotional distress. She was reminded frequently by her friend ‘not to tell anyone!’ (similar to the first vignette) indicating that ‘shame’ attaching to negative emotions is prevalent among the Chinese.

After she migrated to Australia, she stayed with her son. There are issues between the in- laws, (daughter-in-law), house chores etc., this is the second level. The third level is: she remarried. Of course, this is the attitude towards the different life experiences and towards money, and how to use money. At the beginning, the couple often fight (argue) over tiny little things …Her situation was just like what has been described here. She can not tell anyone about what’s deep inside her heart…she had the courage to confide in me. Firstly, she thought I would understand; secondly, I won’t spread the news outside… every time I meet her, she would remind me ‘You don’t tell anyone! (MA: 8-12)

(2) Another female informant in the same Mandarin-speaking group recalled the

experience of a friend in China almost 20 years ago. At the time her friend had

consulted a herbalist and her condition was described as ‘shen-jen-shui-ruoi’ which was

a popular proxy of clinical depression among Chinese medical doctors in Asian areas in

the 1980s.

At that time, my neighbour, because her husband was transferred out of the home town, she could not stop thinking about it, she then had “shen-jing-shuai-ruo’ SJSR (or Neurasthenia in Western medical terms). Therefore she got very irritated (the original Chinese phrase literally means explode fire), her mood is not good, she neglected the five children. In winter,(they) didn’t wear shoes. The family was very well off…but the house was all a mess! Eventually, (she) had Chinese herbal medicine, she slowly restored the balance, and restored the balance, very slowly, the condition was all stabilized. She originally was quite chirpy, but she got this illness, she lost a lot of weight, like “skin wrapped over bones. (MA: 237-240)

(3) A Cantonese speaking informant told the group how she tried to help a friend who was experiencing similar symptoms to those of the first vignette. She felt helpless as she didn’t know how to offer assistance. 146 I have a friend who is in exactly the same situation… (CB: 63) …[S]he is only in her 40s, her husband died about 2 years ago... I don’t know how to help. I try to convince her, “You’ve got money, financially you don’t have to worry, why are you still so unhappy?” She said, “Every night, I have insomnia, no way I can fall asleep!” (CB: 74-76) I asked her to attend today’s discussion, but she wouldn’t come, because, whenever we talked about this topic, she wouldn’t want to talk any more. I am her friend and I reacted like this, not to mention her then (in tears). (CB: 98)

(4) In an English-speaking group, a recent female migrant talked about her grandmother’s experience in China. It seems that in a descriptive sense, China is catching up with the Western medical model.

I agree that depression is a mental illness because my grandmother, she was diagnosed with depression. We were so surprised, in Shanghai, before that we didn’t have any idea about depression. Or just think she is older and older, there is something wrong with her, she cannot sleep and also she feels it is not very well here or not very well there. And she went to different hospitals, saw so many doctors and had so many different medicines. And yeah she just finally went to the ‘psychological’ specialist, and she is diagnosed with ‘depression’ and given the medicine, But she took the medicine, yes, she is better. I mean, she can control herself because she has good sleep and she feels better and she feels she is fine. Nothing wrong, not painful. (EB: 244)

(5) In a highly acculturated English-speaking group, a high school graduate talked about how she searched for information about depression to help a male friend. She readily subscribed to a medical model of depression: brain chemistry imbalance.

I have a friend who has felt depressed and everything, he is in a similar situation [showing similar symptoms described in the first scenario] like yes, he found that..… going to website, writing to them and getting answer back, it’s anonymous (on-line professional help). (EH: 242)

They [the adult]) think that they [depressed teenagers] are just making excuses. If that is not an actual problem, it’s’ just that they don’t quickly jump to the conclusion that something has become chemically wrong with their brain. (Where did you find out about this?) [N]ot sure, through the internet and from school, I’m not sure! In P.E.[talked about depression] and you just randomly surf the net on things like this. Is it on Beyond Blue or something?( EH: 43) (laugh) I’ve read thro’ cos for PE. Mental Health is one of their priority areas, yeah, as in Australia the priority area is cancer, mental health is actually one of them. I looked through the Kid’s Helpline. They actually have a website and they talked about this. (EH: 56)

147 (6) Another informant from the same group talked about her younger sister and how she dealt with the pressure to succeed academically. Her sister seemed to use cigarettes as a form of self-medication. This put her at risk of developing depression:

In most families, they have their degree, they have their career established, but there is one sheep straying off there. She is kind of the funny one doing her own thing in the corner and I think about 11 or 12 people in my generation, and only one of us doesn’t have a degree, And my sister, she really got pointed out. She really got treated like a novelty by those of my generation. She is not going into anything like that. I think that she admitted quite openly that she find it depressing to hang out with the family and be treated like that… you can see her just tense up over the course of the day if it is family gathering. You can see her sneak out the back and have as many cigarettes as she can have. She just winds up tighter and tighter and then she has to go”. (EH: 114-119)

(7) In the same group an informant talked about the importance of family support when dealing with her mother’s low mood because of the latter’s reluctance to seek medical help, even though her own daughter is a GP.

…my mum is really very low, she won’t seek any help at all, we’ve given her heaps of …my sister is a GP, my sister thought, I do agree with her, that she can just go on anti- depressants, but anyway, my mum won’t see anybody. You know what, there is not much you can do except for like just try to support her, because she won’t take any other help. She needs the family, in the Chinese culture, the family is very important, you know you need the support of the family, it is very important for her. (EH: 214-217)

(8) A male informant from an Australian group said the first vignette reminded him of his daughter:

For in some ways, she reminds me very much of my daughter, particularly when she said she can’t even manage everyday household chores. I think it is a great shame that it would appear to me that her husband is not aware that she’s got these problems. I think that is really bad news, she obviously has depression; she needs to see a doctor to make sure and may be a referral to a specialist. It is a very sad case but then it is extremely common. It is becoming increasingly so. So overall I think it is a community problem that needs to be dealt with. And at the moment it is sort of hidden in the cupboard. (AK: 19)

(b) Real scenario similar to the second vignette (1) A Mandarin-speaking informant talked about a relative experiencing something similar to the second vignette, having hardship finding jobs and showing some obvious symptoms:

148 I have a relative, he migrated here, and his English communication is not good…he worked for ‘Chinese’, the pay was very low. He quit the job and found work with the ‘foreigners’ (Westerners). He could not speak English well, the pay was high but he couldn’t manage. Therefore, it was extremely difficult for him to find work… He then developed …he became ‘mentally ill’, He attempted suicide for 2-3 times. This is a real example, he is my relative... he is already in his 40s. Now the welfare department won’t chase him up to look for jobs because he is mentally ill. There is a doctor’s certificate. (MA: 180-181)

She talked about the symptoms:

He is like that [described in second scenario], dull gaze, somewhat depressed, can’t think straight about any things. Has depression. That is his problem.(MA: 187)

(2) An Australian informant talked about the depressive experiences of her parents and how she could relate to the two vignettes:

If he [Dad] was still working now, he wouldn’t be an alcoholic, because he would have something to look forward to everyday! So, it was like, he couldn’t get a job, he just tried, and when he got knocked back a few times, he thought: ‘That’s it then! I am retiring!” And he retired too young! And everything went down hill, She (Mum) has a mental illness. My mother, she was a very depressed person. As a child, I always saw her lying on the lounge every day. My friends came over from school. One said, “What’s wrong with your mum?” “Oh, I don’t know. She is asleep again, she is tired. Don’t worry about her!” You know I got so used to not having a mother! She was always asleep! This is just horrible. I can relate a lot to the two stories. ! (CS: 189)

It seems that the Australian groups could identify the vignettes’ major problem as

‘depression’. Many saw professional help as being most appropriate.

5.3.3. Symptoms and EMs

The ten scenarios presented here are real events (true stories) voiced by the focus group participants. Some have been clinically diagnosed; all reported their stories as being very similar to what has been described in the two vignettes. Table 5.6 provides an overview of some common themes on most troubling ‘symptoms’ and the ‘EMs’ participants attributed to explain depressive experiences that occur in the ‘real scenarios’ they cited. In the next chapter, I will explore the help-seeking strategies in more detail.

There was one report of SJSR in China (the Chinese idiomatic expression for neurasthenia) which was a popular ‘proxy’ term for depression in the 1980s (Lee and

149 Wong 1995). Another informant described a more recent example in China where a

Western medical diagnosis of ‘depression’ was given to an elderly female. This indicated that the term ‘SJSR’ had lost its popularity to Western psychiatric ‘labels’, concomitant with China opening its door to economic reform and by extension to Western influences

(Evans 1997). This phenomenon has been reported by some Chinese authors (Lee 1997).

The Low acculturated Chinese talked about ‘insomnia’ as a prevalent depressive symptom. They also cited other somatic symptoms such as body ache and weight loss. In one example, ‘feeling not well’ was mentioned, this could be physical AND psychological. In all examples, the theme of ‘psychological symptoms’ was also dominant (e.g. irritated, sad and depressed). The highly acculturated Chinese seemed to suggest a ‘bio-medical’ EM. Perhaps the Australians have a higher medical literacy, they seem to readily attribute a bio-medical EM. In Chapter 7 I will compare different groups’ mental health literacy in a more systematic manner and examine the focus group informants’ evaluation of health services as one aspect of mental health literacy.

150 Table 5.6 : Real scenarios of emotional distress volunteered by participants: summary of symptoms, EM and help-sought. Themes

Symptoms EMs Group Context Somatic Psychological Bio-medical EM Non Bio-medical

L-Acc Sydney 02-04 F Insomnia Tearful, sad, Prolonged grief friend. L-Acc Sydney 04 Insomnia, Emotional pain Family relationship. Finance F friend 60+ breathlessness L-Acc Sydney89-04 M Dull gaze, Can’t think straight, Language difficulty relative 40+ suicide attempts depressed, Work Stress L-Acc China 80s F 50+ Loss of weight Irritated, mood not SJSR Balance upset Neighbour good H-Acc China 90s insomnia Unwell, mentally ill Grandma Body ache and pain, H-Acc Sydney 04 M Depressed Brain chemistry friend H-Acc Sydney 04 Sister Tense Low self esteem Academic pressure, Family Expectation H-Acc Sydney 00s Mother Mood very low Medical

Aust. Sydney Parents Depressed (Mum) Mentally ill Things went down hill Work related stress (Dad) Aust Sydney Can’t cope with house Medical daughter chores

151 5.4. Summary

This Chapter examines the depressive experiences of Chinese and non-Chinese drawn from both qualitative and quantitative data. As shown in the focus group narratives, the less acculturated Chinese are less certain about the Western psychiatric diagnosis of ‘depression’ whereas the highly acculturated Chinese were more familiar with Western medical terminology. The use of the vignettes has proven powerful in eliciting discussion of everyday examples. Informants, Chinese and non-Chinese alike, could relate to the two vignettes suggesting that ‘depressive experiences’ are similar across the Chinese and Controls. However, informants from different cultural backgrounds may not uniformly describe their condition as ‘depression’ described in

Western diagnostic manuals. In the survey, participants who had previously experienced a depressive episode were asked to nominate their most troubling symptoms. Results indicated that the top six symptoms were very similar across all three subgroups (Low-

Acc Chinese, High-Acc Chinese and Australians), though the order of ranking for individual groups was different. The survey findings established the proposition that some depressive symptoms are culturally more salient to the Chinese than to the

Australian Controls and vice versa. The most complained of symptom among the Chinese was ‘insomnia’ which is consistent with previous research findings. Non-Chinese participants nominated the cognitive symptom ‘anxious and tense’ as the top troubling symptom. Somatic symptoms were frequently reported by the low acculturated Chinese in the focus group narratives.

The survey established that those who had experienced a depressive episode to nominate their explanatory models (EMs). Regardless of ethnicity, some common themes were

152 cited such as ‘life stress’, ‘work-related stress’ and ‘relationship issues’. Both the low and highly acculturated Chinese nominated ‘family challenges’ as a leading cause of their emotional distress. The Australians were more likely than the two Chinese subgroups to relate their depressive experience to other health concerns. During focus group discussion, the theme of ‘family challenges’ was also mentioned repeatedly by the

Chinese groups as the source of stress. This could reflect the ‘interdependent’ nature of the social roles at play in a Chinese family.

Kleinman (1980) first coined the term ‘Explanatory Model’ in 1980 and now, after more than two decades, mental health professionals have come to (a) recognise the importance of patients’ own explanatory model to subsequent help-seeking behaviour

(WHO 2002), and (b) develop an integrated model of concepts of depression, taking into consideration patients’ own explanation of events (see Figure 5.2 for this model). In the next chapter, an in-depth report of the help-seeking strategies of the participants in both the survey and focus groups will be presented.

153 Figure 5-2 Model for integrating concepts in depression

154 Chapter 6 The Impact of Culture on Depression and Help-seeking

Liveth he who follows the Heavens; dyeth he who be against.

Mencius

6.1. Introduction

As discussed in the literature review, it has long been held that the Chinese have low rates of depression, a phenomenon that might be valid or reflect cultural and

‘artefactual’ influences. Yet the impact of culture is difficult to measure directly, and can often be better clarified by studying the influence of cultural change and acculturation.

The first part of this chapter reports the findings of the survey which compares several depression variables and help-seeking behaviours in Chinese and Australian subjects in metropolitan Sydney. In the second half of the chapter, quotes from narratives of focus group informants will be presented to illustrate the contexts in which help was sought when dealing with emotional distress. Finally, I will address the following two research questions:

Are Chinese as susceptible as Australians to becoming depressed?

Do Chinese employ similar help-seeking strategies to Australians?

155 6.2. Part I: Survey Results

6.2.1. Attributional Style

Table 6.1 reports percentages of respondents selecting a somatising, normalizing or psychologising attributional response to the three physical symptom questions, with somatising responses being less common across all three groups. Chi-square analyses indicated that responses did not differ between the High-Acc Chinese subjects and the

Australian Controls. However, the Low-Acc Chinese were more likely than the High-

Acc Chinese to offer a somatising interpretation and less likely to offer a psychologising interpretation in response to the ‘fatigue’ and ‘insomnia’ symptom cues. When the psychologising of ‘fatigue’ was examined more closely, Controls were more likely than

Low-Acc Chinese to offer such an interpretation. High-Acc Chinese were more likely to give a psychologising interpretation than the other Chinese subgroup but showed no significant difference from the Australians. These findings suggest that the lower the level of acculturation, the lower the tendency to psychologise a physical symptom.

Mean Social Desirability scores differed in the three sub-sets (F = 15.3, p < 0.001), being highest in the High-Acc Chinese (2.5), intermediate in the Controls (2.2) and lowest in the Low-Acc Chinese (2.0). Other analyses restricted to the Chinese sample established that Social Desirability scores were not significantly associated with age (r =

-0.01) or age at migration (r = -0.10), but positively associated with SL-ASIA scores (r =

0.22, p < 0.001), indicating a slight increase in such a response bias with acculturation as suggested by the sub-set scores. One of the components of social desirability is ‘need or social approval’ (Phillips and Clancy, 1972). Since the researcher who collected the data

156 has a similar cultural background to the Chinese-speaking participants (Low-Acc

Chinese), one would have expected a higher mean social desirability score for this subgroup. Contrary to the prediction, the Low-Acc Chinese returned the lowest social desirability scores, thus participants in this subgroup were less inclined to seek social approval from the researcher of similar cultural background.

Table 6.1: Percentage of respondents selecting somatising, normalising and psychologising attributions of three physical symptoms for Low-Acc Chinese, High-Acc Chinese and Control groups. Low- High- Controls Chi-square analyses Acc Acc Chinese Chinese C A B (n = 115) A vs C B vs C A vs B (n =214) (n = 115) Fatigue χ2 χ2 Χ2

Somatising 18.5 6.3 8.1 6.19* 0.29 8.98*

Normalising 58.5 50.9 50.5 1.91 0.01 1.72

Psychologising 22.9 42.9 41.4 11.89** 0.05 13.71***

Insomnia

Somatising 21.0 11.3 17.4 0.62 1.73 4.87*

Normalising 25.7 23.5 20.0 1.34 0.41 0.20

Psychologising 53.3 65.2 62.6 2.65 0.17 4.37*

Appetite loss

Somatising 21.7 23.6 14.6 2.22 2.82 0.16

Normalising 39.4 33.6 44.7 0.79 2.72 1.02

Psychologising 38.9 42.7 40.8 1.00 0.08 0.43

*p < .05, ** p <.01, ***p <.001

157 6.2.2. Lifetime depression

Table 6.2 provides data on reported lifetime depression rates, variably defined depressive patterns, age of onset, episode length, and associated rates of impairment.

Group comparisons indicate that the Low-Acc Chinese were less likely to report experiencing lifetime depression than Controls. There were no significant group differences in rates of reporting episodes as being only “normal blues”. However, both

Chinese subgroups were less likely than the Controls to report an episode as being a

“distinct disorder at times”, while the Low-Acc Chinese were less likely than the High-

Acc Chinese to report such a pattern. The low prevalence makes group comparison of those judging episodes as “always a distinct disorder” problematic.

For all those affirming the probe for broadly defined lifetime depression, age at first episode did not distinguish either Chinese group from the Controls, but the High-Acc

Chinese returned a younger mean age at first episode than did the Low-Acc Chinese subjects. In terms of episode duration, the mean length of the longest episode was significantly shorter for the Low-Acc Chinese than for the Controls, while duration data did not distinguish the High-Acc Chinese from the Controls. Impairment data indicated that the Low-Acc Chinese reported less impairment in comparison to both the High-Acc

Chinese and the Controls. The self-report lifetime depression rate by gender among the three subgroups is shown in Table 6.3 for readers’ reference1.

1 Since this study explores the differences in illness concepts of clinical depression in Chinese and Western cultures, a broadly defined definition of ‘depressive episode’ was used in the questionnaire to probe for

158 Table 6.2: Percentage of respondents who reported lifetime depression, mean age of onset and longest episode, and associated rates of impairment for the Low-Acc Chinese, the High- Acc Chinese and Control groups. Low-Acc High-Acc Controls Chi-square analyses Chinese Chinese A B C (n = 245) (n = 125) (n = 132) A vs C B vs C A vs B Depressive episode χ2 χ2 χ2 29.0% 37.6% 49.2% 14.1** 3.70 2.83

Episode judged as ‘normal blue’ 16.0% 18.9% 15.6% 0.01 0.46 0.45 Episode judged as a ‘distinct disorder at 6.3% 15.6% 25.8% 27.5** 3.95* 8.03** times’ Episode judged as ‘always a distinct 5.1% 1.6% 7.0% 0.59 4.32* 2.52 disorder’

For those who have experienced depression (n = 68) (n = 43) (n = 62) Wilcoxon W Test Mean age at first Z Z Z episode (yrs) 30.4 22.3 27.1 1.81 1.19 3.37**

Mean of longest Z Z Z episode (months) 7.3 7.7 22.1 2.15* 1.93 0.20

χ2 χ2 χ2 Impairment 29.9% 51.2% 66.1% 17.00*** 2.37 5.04*

*p < .05, ** p <.01, ***p <.001

Table 6.3: A Life time depression (self-report) by gender Low-Acc High-Acc Controls Analysis of χ2 Chinese Chinese n = 385 n = 129 n = 143 Episode > A B C A vs C B vs C A vs B 2 weeks All 29.0 37.6 49.2 15.3*** 3.5 2.8 Subjects Males 21.2 31.0 46.7 11.7** 3.0 2.0

self-reported episodes without any clinical diagnosis. In-depth analysis of gender differences across subgroups was deemed not justifiable.

159 Females 34.8 43.3 51.4 5.5* 0.9 1.4

*** p < 0.001; ** p < 0.01 ; * p < 0.05

6.2.3. Cultural Values All participants were asked how their cultural values (Chinese or Western) help

them when facing adversity. The raw data on cultural values within the survey were

recorded in SPSS. Although similar questions were not directly addressed in the focus

groups, most participants made reference to their cultural values when offering ways to

help the person in the vignettes. The data on how Chinese draw on their cultural values to

manage their emotional distress were coded into themes and then analyzed. The table in

Table 6.4 shows a systematic comparison of these data at different levels.

Table 6.4: Relationship between Acculturation and cultural orientation

Coping with Low-Acc Chinese High-Acc Chinese Chi-square analyses adversity Depressed vs never-depressed Depressed Yes No Yes No A1 vs A0 B1 Vs B0

A1 A0 B1 B0 Low-acc High Acc

Rate of endorsing 1.93 Chinese Confucian 28.9 35.2 23.1 39.1 0.54 values Rate of endorsing 4.11* family values (family 9.9 4.4 3.8 21.7 1.20 bonding, filial piety). p = 0.043 Rate of endorsing fate or Taoism, 13.3 15.7 3.8 4.3 0.14 0.01 Buddhism. Rate of relying on 15.6 12.1 11.5 13.0 0.32 0.03 self Social support from 2.69 6.7 11.0 11.5 28.3 0.65 friends p = 0.10 Rate of subscribing 4.55* to religious belief 26.7 12.1 11.5 10.9 0.01 (e.g. Christianity) p = 0.033 Rate of endorsing Western cultural 6.21* values (e.g. freedom 20.0 15.4 38.5 13.0 0.46 of speech, open p = 0.013 communication)

160 * p < 0.05

Among the depressed Chinese, the high acculturation subgroup showed a higher rate (not statistically significant) of subscribing to Western cultures when managing hardship. According to the depressed informants many of the causes of emotional distress arose from family conflicts, relationships and work stress. It would be reasonable to argue that adhering to Chinese cultural values when facing adversity (or at least in managing social relationships, family or romantic ones) is more likely to lead to a harmonised outcome. It seemed that this was the observation made by the never- depressed High-Acc Chinese; their level of subscribing to Western culture was low and similar to their counterparts in the Low-Acc Chinese. Although their ‘objective’ acculturation score (SL-ASIA) on overt behaviour was higher, their ‘subjective’ overt value system in endorsing Western culture was similar to the Low-Acc group.

It is worth noting that among those reported to have had prior depressive experiences , over a quarter (26.7%) subscribed to a non-Chinese religion (e.g. Christianity, Catholic) which was significantly higher than the never depressed group (12.1%). This raises an interesting question as to whether subscription to non-Chinese religion reflects a higher level of acculturation which in turn implies a more open attitude towards expression of emotions (especially negative ones). Qualitative data may be able to explain this observation.

‘Open communication’ was cited as one of the Western cultural values that

Chinese found helpful in managing difficulties they confront. The seemingly helpful

Chinese value was the ‘family values’ as indicated by the high level of subscription by

161 the non-depressed High-Acc group. This implies that these participants hold on tightly to their family values in order to deal with their problems; their counterparts in the Low-Acc group might have more options such as their belief in fate. The high rate of endorsing

Chinese values among the never-depressed High-Acc Chinese suggests a protective mechanism. The percentages of participants who relied on ‘self’ to cope were fairly consistent across the subgroups, implying that ‘self-reliance’ might not be affected by acculturation.

6.2.4. State depression

The mean total DMI-10 (state depression) scores were 7.0 (SD = 7.2) for

Controls, 12.3 (SD = 6.3) for the Low-Acc Chinese and 7.1 (SD = 6.4) for the High-Acc

Chinese-Eng, with the Low-Acc Chinese group scoring higher than both the High-Acc

Chinese (t = 7.4, p < 0.001) and the Controls (t = 7.3, p < 0.001), but without the latter two differing.

6.2.5. Acculturation domains:

A. In the ‘English Language’ domain, participants were given three functional tasks

(e.g. making a telephone enquiry) to rate the difficulty in conversing in English from 1 to

5 (1 being most difficult). Cronbach’s Alpha for the three items was 0.83.

B. In the Social Support domain: questions regarding general help-seeking (asking for physical help or small favours) and sharing emotional distress with either Chinese- speaking, English-speaking friends or family members were asked, to explore the pattern of social association.

162 Cronbach’s Alpha for ‘social support from Chinese-speaking friends, English-speaking friends and family members’ stood at 0.83, 0.84 and 0.79 respectively showing good internal consistency for all acculturation domains.

C. In the ‘Self-Identity’ domain, participants were given two 100 mm lines to mark on each line how they rate themselves as ‘Chinese’ and as ‘Australian’ with the left end indicating ‘not at all’ and the right end ‘completely’. The length from the left to the mark is measured as the respective ‘self-identity’. Table 6.5 shows the correlations of acculturation domains and DMI-10, state depression measure. In the High-Acc Chinese subgroup, family support was negatively correlated with DMI-10 (r = 0.26; p < 0.01).

This result is consistent with other studies on the relationship of social support and depression. However, within the Low-Acc Chinese group, DMI-10 (Chinese version) was not correlated with any of the acculturation measures. The psycholinguistic properties of this Chinese version of DMI-10 require further validation.

Table 6.5: Correlations of acculturation domains and DMI-10 (state depression screening), figures above the diagonal pertain to Low-Acc Chinese, those below the diagonal pertain belongs to High-Acc Chinese.

Variables 1 2 3 4 5 6 7 8

1.SLAS –.11 .63*** –.01 .50*** –.04 –.39*** .37*** 2. DMI-10 .11 –.05 .11 –.00 –.05 .06 –.09 3. English Skills .03 –.12 .11 .58*** –.04 – .36*** .32***

4.Support : Chinese –.42*** –.04 –.19 .25*** .29*** .06 –.15*

5. Support : English .44*** –.01 .15 .03 –.04 –.20** .35***

6. Support : .07 –.26** –.23 .04 .13 .08 –.15* Family

163 7. Chinese Identity –.49*** –.05 –.05 .42*** –.22* –.08 –.53***

8. Aust. Identity .37*** .02 .11 –.24* .28** –. 06 –.43***

*** p < 0.001; ** p < 0.01 ; * p < 0.05

There was an inverse relationship of Chinese and Australian ‘Self’ for both

Chinese subgroups (See Table 6.5). This may suggest competition in self-identity within the Chinese individual. It is interesting to note that English competence positively correlated with the SL-ASIA, ‘support from English-speaking friends’ and Australian identity for the Low-Acc Chinese subgroup ONLY. It is apparent that in the case of the

High-Acc Chinese, their English-skills were well mastered and language competence was no longer a valid acculturation indicator.

6.2.6. Comparison with a sub-sample recruited from Chinese Herbalists.

In an attempt to examine the acculturation effect more closely, I included a sub- sample (n = 54) recruited from five Chinese Herbalists’ rooms. This sub-sample was then compared with participants, answering Chinese questionnaires, recruited from GP practices. Preliminary analysis of their direct and indirect acculturation indices were conducted, results showed the following pattern: in increasing order of acculturation level ‘Herbalist group’, ‘born in China - GP group’ ; ‘born in Hong Kong – GP group ’ and ‘born in Taiwan - GP group’.

Within participants who preferred an English questionnaire, the age of 10 years was used as the cut off to distinguish first generation from second generation Chinese. This cut-off

164 age was used by two independent teams of researchers in the UK (Furnham and Li, 1993;

Narzoo, 1997). From preliminary analysis of data (Table 6.6), those born in Australia and those who migrated at or before the age 10 years did not evince any significant difference in most acculturation items in SL-ASIA. The categorization of the Chinese groups was deemed appropriate after a pattern of increasing acculturation effect on ‘self-identity’ namely the ‘Chinese Self’ and the ‘Australian Self’ was confirmed (see Figure 6.1).

When subgroups were arranged in the order shown in Figure 6.1, there was a clearly increasing trend towards ‘Australian Self’ Identity but a decreasing trend towards

‘Chinese Self’ Identity. In terms of Help-seeking (Table 6.7), 41% of the Herbalist sub- group had talked to herbalists about their emotional distress but only 11.8% mentioned this to their GPs.

This contrasts with the Australian group where the reverse trend was observed.

36.4% talked to their GPs about their psychological complaints and 17.0% raised the issue with a herbalist. The rate of ever having taken any anti-depressants among the

Low-Acculturation subgroups was consistently low, in the range of 4.4% - 5.9%. Among the High-Acc Chinese subgroups there was an increasing trend of having taken antidepressants. Overall, Chinese subgroups differed significantly with Controls in their lifetime rates of consulting GPs for emotional distress and having previously taken anti- depressants. Within the ‘Herbalist sample’, the differential rate of reporting emotional distress to their herbalists and their GPs suggests the different perceptions of the roles of a Chinese herbalist and a Chinese GP.

165 Figure 6-1 Scatterplot of Ethnic identity and Australian Identity of various subgroups demonstrating an increasing trend of ‘acculturation

Herbalist sample Born in China Born in HK   100.0 

     

f   l 75.0    e         S       n         a         i        

l 50.0        

        a    

r        t          

s             

   u              Mean  = 35.0 25.0  Mean = 32.4  

A        Mean = 29.4                                        0.0     

Born in Taiwan 1st G Chinese-Eng 2nd Chinese-Eng        100.0                   

f     l 75.0            e          

S        

n            a            Mean = 61.8 i      

l 50.0    

      a   Mean = 49.8 

r    t       s  Mean = 40.1  

u    

25.0  A                     0.0    0.00 25.00 50.00 75.00 100.00 0.00 25.00 50.00 75.00 100.00 0.00 25.00 50.00 75.00 100.00 Chinese Self Chinese Self Chinese Self

166 Table 6.6 : Demographics and acculturation variables

st nd Herbalist group Born in China Born in HK Born in Taiwan 1 Gn Chinese 2 Gn Chinese Aust ANOVA (1) GP group GP group GP group GP group GP group F df=6 control 2 N = 54 (2) (3) (4) (5) (6) χ n=91 n=41 n=143 n=93 n=66 n=62 mean mean mean mean mean mean

Chinese version English version Subset C Subset A Subset B Age (year) 46.87 (14.17) 45.61 (18.37) 41.73 (13.61) 32.93 (12.83) 35.17 (11.25) 25.92 (10.02) 41.45 (17.92) 15.83***

SL-ASIA 1.98 (0.29) 2.00 (0.26) 2.15 (0.29) 2.16 (0.32) 2.48 (0.41) 2.95 (0.42) N/A 70.88***

Age@migratio n 35.31 (13.23) 35.11 (15.77) 30.40 (12.45) 24.88 (12.33) 22.50 (8.67) N/A N/A 12.99*** (year)

POLA (Part of life 0.25 (0.13) 0.23 (0.13) 0.28 (0.16) 0.26 (0.17) 0.35 (0.18) 0.84 (0.17) N/A spent in Australia)

Gender (female) 72.2% 50.5% 58.2% 65.9% 47.0% 61.3% 53.1% 12.02 N.S.

Eng. Confidence Cronbach’s 2.16 2.29 3.00 3.02 3.67 3.56 3.40 17.47*** α = 0.91

Ethnicity 73.7 68.5 69.6 59.5 64.7 54.2 N/A Chinese

As Australian 28.8 33.8 35.0 39.8 49.8** 61.8 N/A

* p < .05; ** p< .01; *** p< .001

167 Table 6.7: General help non-specific to an depressive episode-seeking strategies of subgroups.

st nd Subgroups Herbalist Born in China Born in HK Born in Taiwan 1 Gn Chinese – 2 Gn Chinese Aust χ 2 group (GP group) GP group GP group GP group GP group Control (1) (2) (3) (4) (5) (6) GP group N = 54 n=93 n=91 n=41 n=66 n=62 n=143

Answer Chinese version Answer English version

1.98 2.00 2.15 2.16 2.48*** 2.95*** (0.29) (0.26) (0.29) (0.32) (0.41) (0.42) SL-ASIA N/A F = 83.77*** (5) Vs (4) (6) Vs (5) Consult herbalist about 41.2% 20.0% 14.3% 7.5% 13.6% 14.5% 17.0% 24.2*** emotions Consult GP about 11.8% 14.3% 12.1% 17.5% 17.2% 24.2% 36.4% 30.6*** emotions Taken anti-depressant 5.9% 5.7% 4.4% 5.0% 6.2% 16.1% 27.1% 44.5***

*** p < 0.001; p value is indicated if the cell to the left of a particular cell shown significant difference

168 This contrasts with the Australian group where the reverse trend was observed.

36.4% talked to their GPs about their psychological complaints and 17.0% raised the issue with a herbalist. The rate of ever having taken any anti-depressants among the

Low-Acculturation subgroups was consistently low, in the range of 4.4% - 5.9%. Among the High-Acc Chinese subgroups there was an increasing trend of having taken antidepressants. Overall, Chinese subgroups differed significantly with Controls in their lifetime rates of consulting GPs for emotional distress and having previously taken anti- depressants. Within the ‘Herbalist subgroup’, the differential rate of reporting emotional distress to their herbalists and their GPs suggests the different perceptions of the roles of a Chinese herbalist and a Chinese GP. A comparison of help-seeking between participants recruited from GP practices only is presented next.

6.2.7. Help-seeking

In terms of help-seeking which may or may not be related to a depressive episode,

Table 6.8 demonstrates the patterns: both ‘High’ and ‘Low’ acculturation Chinese subgroups were less likely than Controls to have consulted a primary physician or to have received an antidepressant drug. There was no difference between Chinese subgroups and Controls taking Chinese herbal remedies. In relation to any lifetime depressive episode, both Chinese sub-sets were less likely than Controls to seek professional help

(significant in relation to consulting a primary physician and a psychiatrist). The Low-

Acc Chinese were more likely than the High-Acc Chinese subgroup to report consulting others (generally family or friends). Participants who had never consulted a primary physician, psychologist, psychiatrist, Chinese herbalist or lay helpers for a depressive episode of at least two weeks were identified as ‘no help sought’. The comparative rates were 38.8% for the Low-Acc Chinese, 47.5% for the High-Acc Chinese, and 24.6% for

169 the Controls, with only the comparison between the High-Acc Chinese and Controls proving significant (χ 2 = 5.7, p < 0.05).

Table 6.8: Non-specific help-seeking and specific help-seeking in response to experiencing a likely lifetime episode of depression for the Low-Acc Chinese (Herbalist sub-group not included), High-Acc Chinese and Controls.

Low-Acc High-Acc Controls Chi-square analyses Chinese Chinese A B C (n =252) (n =128 ) (n = 140) A vs C B vs C A vs B % % % Help-seeking non-specific to any episode of emotional distress

Lifetime rate of consulting a primary physician for 15.5 20.5 36.4 22.3** 8.3** 1.5 psychological problems Lifetime rate for ever receiving antidepressant 5.6 10.9 27.1 35.8** 11.2** 3.5 medication Lifetime rate for receiving any Chinese herbal remedy 17.5 14.0 17.0 0.02 0.5 0.8 for psychological problems In relation to those experiencing a likely lifetime episode of depression (2 weeks or more)

Rate of consulting a 28.4 35.0 57.4 11.0** 4.8** 0.5 primary physician Rate of consulting a 17.9 22.5 29.5 2.4 0.6 0.3 psychologist Rate of consulting a 10.4 12.5 29.5 7.4* 4.0* 0.1 psychiatrist Rate of consulting a 3.0 2.5 4.9 0.3 0.4 0.02 Chinese herbalist Rate of consulting friends 22.4 5.0 13.1 0.9 1.8 4.3* or family Rate of no-help sought 38.8 47.5 24.6 0.8 5.7* 3.0

*p < .05, ** p <.01, ***p <.001

In order to maximise the number of depressed subjects to allow statistical analysis across mild and persistent episodes, ‘Herbalist subgroup’ was merged with the Low- Acc Chinese subgroup (both answering Chinese questionnaires).

(a) Mild Episode (emotional distress lasting 2- 4 weeks):

In a mild episode with no impact on daily functions, the Low-Acc Chinese were less likely to seek help from GPs than the Australian Controls (6.9% vs 37.5%; χ 2 =7.48, p< 170 0.05). The rate for High-Acc Chinese fell between the other two groups (25%) but the differences were not significant. The life-time rates of consulting GPs for psychological problems were low for the Low-Acc Chinese and High-Acc Chinese (their rates were

12.5% and 10.3% respectively) and significantly different from the Controls (42.3%), see

Table 6.9.

171 Table 6.9: Participants reporting an episode lasting no more than 4 weeks with no impact on everyday functions; for the Low-Acc Chinese #, High-Acc Chinese and Controls.

Low-Acc High-Acc Controls Chi-square analyses Chinese Chinese A B C (n =32) (n =29 ) (n = 26) A vs C B vs C A vs B % % % Help-seeking not necessarily related to an episode of emotional distress

Lifetime rate of consulting a 4/32 3/29 11/26 6.65* 7.38** 0.07 primary physician for (12.5%) (10.3%) (42.3%) p = 0.01 p = 0.007 psychological problems Lifetime rate for ever receiving 1/32 1/29 4/25 2.91 2.52 0.01 antidepressant medication (3.2%) (3.4%) (16%) p = 0.088 Lifetime rate for receiving any 1/32 2/29 4/24 3.09 1.25 0.46 Chinese herbal remedy for (3.2%) (6.9%) (16.7%) p = 0.079 psychological problems Help-seeking specific to an episode of emotional distress

Rate of consulting a primary 2/29 6/24 9/24 7.48* 0.87 3.36 physician (6.9%) (25%) (37.5%) p = 0.016 p = 0.067 Rate of consulting a 1/29 0/24 3/24 1.54 3.20 0.84 psychologist (3.4%) (0%) (12.5%) p = 0.074 Rate of consulting a 2/29 0/24 4/24 1.25 4.36* 1.72 psychiatrist (6.9%) (0%) (16.7%) p = 0.037 Rate of consulting a Chinese 0/29 0/24 1/24 1.23 1.02 N/A herbalist (0%) (0%) (4.2%) Rate of consulting friends or 8/29 0/24 3/24 1.82 3.20 3.36** family (27.6%) (0%) (12.5%) p = 0.074 p = 0.005 Rate of no-help sought 16/29 18/24 12/24 0.14 3.20 2.25 (55.2%) (75%) (50%) p = 0.074 # Herbalist-subgroup included *p < .05, ** p <.01, ***p <.001; approaching significance 0.05 < p < 0.10

Such findings suggest that the High-Acc Chinese were more likely to visit a GP when experiencing a mild episode compared to the Low-Acc counterparts (25% vs

6.9%). However, they may not necessarily review their emotional concern to the GPs.

This speculation was confirmed by the narratives collected during focus groups of

English-speaking Chinese. Many Chinese went to see their GPs to get sleeping pills for

172 insomnia (reported in more detail in Chapter 7). It is worth mentioning that in the case of a mild episode, more Low-Acc Chinese preferred to seek help from friends (27.6%) when compared to the High-Acc Chinese. Due to the small number of subjects who reported having had a mild episode, the statistical analysis should be interpreted with caution.

(b) Persistent episode (emotional distress lasting over 4 weeks):

The help-seeking behaviour patterns of those who had experienced a persistent episode of more than 4 weeks or had noted some impacts on everyday functions were compared across the different groups. Low-Acc Chinese had the lowest lifetime rate

(40.8%) of consulting a GP for psychological problems. This result was significantly different from both the High-Acc Chinese and the Controls (70.6% and 76.3% respectively, see Table 6.10).The lifetime rate for ever receiving antidepressant medication showed an increasing trend with increasing Westernisation. The Low-Acc

Chinese result was significantly different from that of the Australian Controls (18.8% vs

63.8%; χ 2 = 19.63, p < 0.001). The High-Acc Chinese had rates higher than the Low-Acc

Chinese but lower than that of their Australian counterparts. The χ 2 statistics were approaching significance in both comparisons. Chinese and Australians showed non- significant difference in receiving any herbal remedy (Chinese or Alternative), self- prescribed as well as herbal therapist prescribed. In the Literature Review chapter, I mentioned the dual use of Western and Chinese medicine among Chinese and the practice of taking herbal remedies/drinks from home recipes. Natural therapies

(homeopathic) have gained considerable popularity in recent years as many products have become commercially available. Mass media, including newspapers, magazines, radio (Fonseca, 2002) and TV (ABC, 2005) have also played an important part in educating the public about new developments in alternative medicine.

173 For specific help-seeking, the Low-Acc Chinese were less likely to consult GPs and psychiatrists than the Australians. They were less likely to seek any form of help. All these differences were significant as indicated by the χ 2 statistics. In terms of seeking help from psychologists, herbalists, friends and families, the differences between these two groups were not significant. When the High-Acc Chinese were compared with the

Controls, none of these specific help-seeking variables showed significant difference. A possible explanation for this is that as the Chinese become more acculturated they are more likely to raise emotional concern with their doctors and are aware of the services available. When the two Chinese subgroups were compared, the High-Acc Chinese were more likely to seek help from psychologists and psychiatrists and more likely to seek help. Though the differences were only approaching significance (Table 6.10), considering the small number of subjects a trend towards increasing help-seeking from mental health professionals concomitant with an increased level of acculturation was ascertained.

174 Table 6.10: Participants reporting an episode lasting for more than 4 weeks or with some impact on everyday functions; for the Low-Acc Chinese # , High-Acc Chinese and Controls.

Low-Acc High-Acc Controls Chi-square analyses Chinese Chinese A B C (n =49) (n =18 ) (n = 38) A vs C B vs C A vs B % % % Help-seeking not necessarily related to an episode of emotional distress

20/49 12/17 29/38 10.97** 0.20 4.48* Lifetime rate of consulting a (40.8%) (70.6%) (76.3%) p = p = 0.034 primary physician for 0.001 psychological problems 9/48 7/18 25/38 19.63*** 3.61 2.89 Lifetime rate for ever receiving (18.8%) (38.8%) (63.8%) p < p = 0.057 p = 0.089 antidepressant medication 0.001 18/49 7/18 12/36 0.105 0.16 0.03 Lifetime rate for receiving any (36.7%) (38.8%) (33.3%) Chinese herbal remedy for psychological problems Help-seeking specific to an episode of emotional distress

21/47 8/16 26/36 6.30* 2.41 0.14 Rate of consulting a primary (44.7%) (50%) (72.2%) p = physician 0.012 12/47 8/16 14/22 1.69 0.56 3.30 Rate of consulting a psychologist (25.5%) (50%) (38.8%) p = 0.069 7/47 6/16 15/36 7.50** 0.08 3.73 Rate of consulting a psychiatrist (14.9%) (37.5%) (41.7%) p = p = 0.054 0.006 3/47 1/16 2/36 0.025 0.01 0.000 Rate of consulting a Chinese (6.4%) (6.3%) (5.6%) herbalist 5/47 2/16 6/36 0.064 0.15 0.042 Rate of consulting friends or (10.6%) (12.5%) (16.7%) family Rate of no help sought 13/47 1/16 2/36 6.73** 0.01 3.17 (27.7%) (6.3%) (5.6%) p = p = 0.075 0.009 # (Herbalist subgroup included), *p < .05, ** p <.01, ***p <.001 ; approaching significance 0.05 < p < 0.10

175 Figure 6-2 Diagrammatic representation of the help-seeking pathway of Low-Acc Chinese.

Low-Acc Chinese (n = 47) (13)No help (34) Help Sought

(5) Informal Help (1) (30) Prof Help (4) no Other (1) (3)Herbalist (24) GPs help (1) (12) Psychologist

(2)(2) AntiAnti- - (1) (7) Specialist (17)No-specialist Depressant Herbalist Only (2) No Anti- Depressant (3) No Anti- (15) No Anti- Depressant (5) Anti- (2) Anti- Depressant Depressant (1) Depressant Rx (2) (2) (13) (1) Rx Rx (1) No Rx (3) No Rx (1) Rx No Rx No Rx

Note: A. Among the 34 (72%) individuals who reported to have sought some forms of help (the 1st grey rectangle at the top), 5 of them sought informal help (the white rectangle labeled ‘informal help’). and 4 did not continue to seek further help, which might suggest that they did not conceptualise their experiences as warranting medical intervention. The remaining person joined the others to seek help from either a herbalist, a GP or a psychologist (the grey rectangles at the next level down).

B. There were a few basic assumptions made in constructing Figures 6.2, 6.3 and 6. 4: 1. Participants were asked a series of three questions on general help-seeking, one of which was whether they had received any antidepressant medication before, without specifying the source. In the Chinese language, ‘antidepressant’ literally translates as ‘kang’ (meaning fight) + ‘yau-yi’ (meaning depression) + ‘yue’ (meaning medication). Thus the first assumption would be: participants who responded positively to this question understood what ‘antidepressant’ meant. 2. In the section of the questionnaire which asks about previous depressive episodes, participants were asked to base their responses on the longest/most severe episode. Thus the second assumption would be: if a participant had taken anti-depressants in a prior occasion, they most likely would be prescribed for this particular episode.

176 3. All participants who reported having consulted psychiatrists were assumed to have first visited a GP for a referral. In Australia, medical referrals are a pre-requisite for secondary care. It is worth mentioning that some respondents only marked the response of ‘psychiatrist’ without marking the response of ‘GP’ when answering the question on help-seeking.

C. There are always doubts about the accuracy of retrospective self-reporting. Two out of 47 (4.3%) Low-Acc Chinese and 2/36 (5.5%) Australian Controls reported having received antidepressant medication in their lifetime but they only consulted a psychologist (and not a GP or a psychiatrist)

Figure 6-3 Diagrammatic representation of the help-seeking pathway of Australians

Australians (n = 38)

(2) No help (36) Help Sought

(35) Prof Help (5) (6) Informal Help (1) (27) GPs (1) no (2)Herbalist (14) Psychologist h (1) (15) Specialist (12) No-specialist ((2)) Anti- Depressant

(1) No Anti- (2) No Anti- Depressant Depressant (14) Anti- (6) No Anti- Depressant (6) Anti- Depressant (1) Depressant (5) Rx (2) Rx (4) (2) (4) Rx (9) No Rx No No

Note: Only two (5%) Australians did not seek any form of help. Five out of six of those who sought informal support also sought professional help; this suggested a bio-medical illness concept.

In Figures 6.2, 6.3, and 6.4, I present an overview of the help-seeking pathways of the different groups of survey participants. Referring to Figure 6.2, thirteen (27.8%) 177 participants reported having a persistent episode of more than 4 weeks that had affected their daily functioning. However, they did not seek help. The rate was much higher among the Low-Acc Chinese compared to the High-Acc Chinese and the

Controls (6.3% and 5.6% respectively), due perhaps to poor mental health literacy. But it could also be the difference in illness concept in which case these Chinese did not view their emotional distress as warranting professional help. This interpretation is supported by the fact that four out of five Chinese in this subgroup sought help informally through family and friends and did not pursue further professional help. This help-seeking pattern was distinctly different from that of the Australian Controls: only one out of six

Australians sought help informally without pursuing further medical or psychological services (Figure 6.3). Those Australians who had suffered from a depressive episode that affected their daily functioning, considered it as a distress requiring some form of professional attention.

Referring to Figure 6.2 again, among the 24 Chinese participants who sought help from GPs, 13 did not consult either specialists or psychologists and had never received any anti-depressants. This observation may be explained from two different perspectives:

I. In terms of patient’s reporting, 1. The Low-Acc Chinese may not have reported their psychological symptoms; only

40.8% who had experienced such an episode had consulted GPs previously for psychological problems.

2. Chinese patients refused to take any medication associated with mental illness, e.g. antidepressants. Even though GPs may have prescribed antidepressants, the lifetime rate of taking antidepressant medication among these Low-Acc Chinese remains low.

II. In terms of GPs making diagnoses,

178 1. Chinese GPs are less likely to make diagnoses associated with mood disorders

(cultural taboo or lack of professional knowledge)

2. Chinese GPs are less likely to prescribe antidepressants

3. Chinese GPs are less likely to refer patients to specialists or psychologists

However 5/7 (70%) of those who had seen specialists had taken antidepressants indicating the need for medication. Among the 15 participants who had neither been referred to specialists nor received any anti-depressants previously, only two had seen a psychologist. Did the remaining 13 patients simply present somatic symptoms to their

GPs? Alternatively, did GPs ask questions regarding emotional distress? Focus group informants’ narratives seem to suggest that GPs were usually too busy to listen to non- somatic concerns or in some situations, the patient’s (especially females) psychological concerns were dismissed as hypochondria (see Part II, Chapter 7). Thus it becomes apparent that the 13 patients (27.7%) who did seek help from primary care were ‘filtered’ out of the mental health services at the primary care level (see Goldberg and Huxley

1980, 1992 for discussion of ‘filters’). Figures 6.3 and 6.4 were the help-seeking pathways of the Australian Controls and the High-Acc Chinese , 11.1% and 10.5% participants respectively had never received antidepressant or consulted psychologists.

Figure 6-4 Diagrammatic representation of the detail help-seeking pathway of High-Acc Chinese

179 High-Acc Chinese N = 18

(1) No help (17) Help Sought

(1) Informal Help (16) Prof Help

(1) no (1)Herbalist (11) GPs other (8) Psychologist

(6) Specialist (5) No-specialist (1) Herbalis t (2) No Anti- O Depressant (2) Rx (4) No Anti- (4) Anti- (1) Anti- Depressant Depressant (1) Depressant Rx (2) (2) (1) Rx (2) Rx (2) No (1) No No Rx R

In Chapter 8, I present an overview of the help-seeking patterns when I discuss the underlying lay illness concepts of different acculturation subgroups.

6.2.8. Timing of Depressive episode: Are experiences of emotional distress universal across cultures?

Participants were not obliged to commit to a psychiatric label of clinical depression; however, those who admitted to having experienced a depressive episode reported the age of onset retrospectively. A comparison of percentage of first episodes that occurred before, within,

180 or after 12 months of migration across the different acculturation groups (only applicable to 1st generation subgroups) is shown in Table 6.11 No significant difference is found among the groups. Their respective rates were very similar with no significant difference. It was apparent that within the first generation Chinese the level of acculturation had no mediating effect on the timing of the first episode. This echoes with Bhugra’s (2004b) suggestion vis-à-vis specific pre- migration, migration and post-migration events and stress when examining the relationship between migration and depression.

Table 6.11: Timing of 1st depressive episode

Timing of Recruited Born in Born in HK Born in Chin-Eng χ 2 1st from China Taiwan 1st Gn depressive Herbalist (3) (4) (4) df = 3 episode (H) (1) n= 29 n = 16 n=18 N = 10 n= 10 Chinese version English version before 40.0% 40.0% 34.5% 37.5% 22.2% migration 4.60 within first N.S. 12 months 0.0% 20.0% 6.9% 12.5% 16.7% of migration more than 12 months 60.0% 40.0% 58.6% 50.0% 61.1% of migration

In Part II of this chapter, I report the themes extracted from focus group narratives that provide a more in-depth understanding of Chinese participants’ help-seeking behaviours.

6.3. Part II: Help-seeking strategies nominated by focus group participants

After each vignette was presented to the focus group participants, the initial question posed to the group was: ‘If you were a good friend of the person in the vignette, how would you feel?’ Many Chinese informants, instead of answering this question, were

181 very eager to offer their ‘advice’ as close friends. (As outlined in Chapter 3, Methods, the question of ‘How would you help?’ was the third on the list, printed on a sheet along with the summary of the two vignettes (See Appendix 3-2 for the list of questions).

6.3.1. How could focus group informants help?

In the first stage of thematic analysis, the following themes were coded:

• Practical help (taking the children to school, helping with household chores) • Listening (making time available to listen to the person’s emotional concern) • Encouraging expressing emotion (encouraging the person in the vignette to talk about issues surrounding the circumstances and express his/her emotions) • Talking to the partner of the “person in the vignette” (offering to talk to the partner if person knew the family well enough) • Indirect approach (inviting the person in the vignette to some social gatherings and only offering help when s/he was ready) • Problem solving (analysis of situation, assisting the person in the vignette to analyze the current situation in order to find some likely solutions) The following are extracts from the narratives:

An Australian informant, who is the carer for her depressed relative, said:

Maybe she just wanted to talk about it and sometime later she feels better, by talking she could work out something for herself. (AC: 165)

A Cantonese female, who had migrated to Australia in her late teens and received tertiary education locally, suggested:

…you offer help in a sense to care and support him, connect with him closely, to understand him more, with deeper understanding, then you can help him. (CB: 488)

A male participant from a High-Acculturation Group, working in the education sector, said:

182 I am concerned. She doesn’t sound very severe. I’ll arrange time to talk with her. (EB: 43)

Some informants were very keen to analyze the situation so that they could help in solving the problems. The following are some examples:

An Australian female said,

…maybe it is good to try to make it clearer what is going on, to rule out bits and pieces… (AC: 61)

In an English-speaking Chinese group, a university postgraduate student spoke of the following,

…discuss it, analyze it, think about it, consider it and find a solution…’ (ER: 232)

This theme was also echoed by a Cantonese-speaking lady who had experienced emotional distress herself.

If you really want to help her, you have to take it slowly and just listen to her, and then you help her to analyze. (CS: 107)

6.3.2. What can health professionals offer?

Themes were coded under medical or professional help: consulting GPs, psychiatrists, taking medication, receiving psychotherapy or counselling and seeing a

Chinese herbalist or naturopath.

(a) Consulting GPs

A Cantonese-speaking female, a volunteer for a Chinese community organization, stated:

I think seeing a doctor is necessary, if she has difficulty sleeping for example. To a certain extent, doctors can help her. (CV: 133)

Another informant from a different group, who traveled between Hong Kong and Sydney quite frequently, also suggested getting help from a family doctor:

…if her situation is “not able to sleep and insomnia”, then for this problem you have to see a doctor. You may see a family doctor. You first talk to your family doctor. He is a doctor; of course he will give you his expert opinion. (CS: 136)

183 Australian participants were collectively in agreement vis-à-vis seeking medical advice from their GPs:

When I got her trust, I would recommend her to go to a GP.’ (AC: 49)

‘He certainly got some major problems. If someone could talk to him and seek medical attention. That would be the obvious thing to do. (AK: 117)

However, in the case of a more ‘serious’ condition (i.e. showing psychological distress),

Chinese informants were more cautious, stressing the importance of employing ‘indirect’ ways to build up a trusting relationship before recommending medical help. A member of a Chinese consumers and carers support group said:

I won’t say to him immediately, “You are sick!” Therefore I have to make some connection, that is ‘tackle from the side’. If he is willing to communicate, then I will introduce him to see a doctor. (CM: 114)

Based upon the above narratives it would seem that Chinese are likely to seek help from their GPs. These GPs usually speak the same language and come from the same cultural background.

(b) Consulting Psychiatrists

Among the less acculturated Chinese, language barrier seems to be of major concern when consulting a mental health specialist.

One female participant in a Mandarin-speaking group and from a low-middle socio- economic background raised this issue:

What kind of doctor do you want to see? But there are no Chinese doctors practising in the specialty you want to see. We need to hear Cantonese, Mandarin, yes! If you find a ‘foreigner’, then how can I say anything? [If I] can’t say clearly, then I won’t go… Perhaps that’s why it get worse and worse… perhaps go to jump off from the roof! I don’t know! (MG: 394)

Another Mandarin-speaking female with limited proficiency in English, who accessed the mainstream mental health service through interpreters, spoke of the benefits of consulting a psychiatrist:

184 One option is to see a psychiatrist; a psychiatrist can help you to manage the problems in your thinking process. (MG: 12)

One informant from a high acculturation group who worked in the banking sector, although recognizing the need for medical help, was hesitant to take premature action.

I think she may not feel comfy to approach a professional for help yet, but she definitely needs some medical help. (EB: 55)

The same theme was echoed by an English-speaking Chinese postgraduate student from a different group:

I mean at this stage probably not for professional help, but if the situation persists, like for several weeks of sleeplessness and fatigue, I will encourage her to see a GP. (EP: 172)

Informants from Australian groups apparently recommended medical help more readily.

One female commented:

I would definitely recommend seeing a doctor… but it depends on how depressed the person is. If they are very depressed, they need to see a psychiatrist. (AS: 63)

However, not everyone agreed, as evident in one Australian male’s account:

It depends on what she thinks her problems are. Somebody will take the advice, somebody else will just move away. To me, that (seeing a psychiatrist) will be a last resort. (AC: 103)

(c) Consulting Psychologists and Counsellors

Professional help, counselling, yes! But GPs only give you sleeping pills and stress pills. It didn’t solve the problems. For professional help such as counselling, the husband needs to be involved. It looks like there is a communication breakdown between the lady and her husband. (EB: 58)

She hasn’t discussed her problems with a psychotherapist or a counsellor or even her doctor or someone like that. Yeah, that might be something to do first. (ER: 67)

Australian informants also indicated the need to discuss the problems with a counsellor.

I think he has to go to someone to talk about his problems, ring a counsellor’s number or figure out what he has to do next, (AC: 353)

Less acculturated Chinese seemed to be aware of available counselling services provided by the Chinese community organisations. In a Cantonese-speaking group one informant suggested the person in the vignette seek out such service:

185 Go and find some Chinese community organisations, read the newspaper to find out something like the Gambling Hotline. Then you can ring and talk to someone. (CS: 138)

Over the past few years several Chinese community organisations have been provided with funding to run counselling and parenting services other than the traditional ‘Migrant

Settlement Services’ and ‘English Courses’ (Chinese Australia Services Society, 2006,

Australian Chinese Community Association 2006).

(d) Consulting Herbalists

The detailed accounts of different Chinese herbal remedies given by Cantonese and

Mandarin-speaking informants are summarised in the following quote:

…the herbalist mentioned a few remedies. Food therapy and also emotion therapy that help your thinking process. She mentioned a few remedies. According to Chinese medicine research, this is quite effective. (CM: 80)

Australian informants also suggested natural remedies, a volunteer for her local neighbourhood centre suggested:

Perhaps some of the natural remedies like Vitamin B or whatever, also proper nutrition. (AK: 47)

In the Australian groups, the concept of ‘seeking professional help’ was discussed mainly in the context of informants’ own personal experiences. This was not surprising as the survey results clearly point to a higher rate of lifetime anti-depressant use and consulting of psychiatrists (see Part I). Among the twelve Chinese focus groups, one

Cantonese consumer support group and one Mandarin mother’s group reported first hand experiences of utilising main stream mental health services. In Chapter 5, Depressive

Experiences, examples of real scenarios similar to the two vignettes are cited. According to the informants all of these scenarios were real life experiences of friends or relatives.

186 6.3.3. Are there other sources of help?

(a) Self Apart from getting external and professional help, self-help was another frequently cited strategy by all groups. This approach includes the following: employing self-initiative, positive self-talk, going on holidays, consuming drugs and alcohol, engaging in physical exercise, pursuing knowledge and practising relaxation. The following are some examples:

One Cantonese speaker, herself a young mother who had experienced an depressive episode, stated:

I think no one can “rescue” her except for herself. (CS: 115)

This was echoed by an elderly Mandarin speaker in a migrant settlement group:

That would require himself to find the solution. This will be much better than you telling him the outcome, like this or that. (MM: 242)

An Australian informant, who worked in the welfare sector, also shared this view:

Many services, the client, the person has to take the initiative to go there. (AS: 173)

(b) Community resources

Utilisation of community resources was a common theme in all the focus groups.

Informants suggesting these help-seeking strategies seemed to be very knowledgeable about existing community resources especially those offered by Chinese community organisations. This could be explained by the fact that many of the groups were recruited through these organisations; some informants were either volunteers or active members of community centres. Both Chinese and Australian informants saw community support such as mothers groups or migrants’ groups as helpful.

Sub-themes under community resources included: attending group activities and participating in voluntary work.

187 Informants’ narratives are cited below. One Cantonese-speaking female comments:

I should come out more to this mother group. Then we get to talk to each other! (CS:53)

A woman in her fifties who had migrated to Australia from New Zealand many years ago, talked about her daughter’s experience:

She was coming to Backstop [referring to Backstop Service’ mother group]. That really helped her. (AS: 36)

Doing voluntary work in the local community as a means to obtain community support was another recurrent theme. One Australian female, who was a voluntary telephone counsellor, said,

‘She probably will go down to the local community centre to do some voluntary work or somehow get back into the social circle.’ (AC: 306)

A male Mandarin-speaker expressed a similar view:

I think one needs to be a volunteer. If he worked as a volunteer, his situation will get much better! (MM: 383)

Maintaining social contact was considered a strategy to manage a depressed mood. A bilingual Chinese from a highly acculturated group recommended that the person in the vignette participate in group activities to gain social support.

She could go to classes and make more friends. If you stay at home all the time, of course you would be depressed… (EB: 67)

(c) Spirituality

Tapping into the strength of prayers and other types of spiritual support offered by churches and temples was a theme nominated by the more religious among the informants. Religions seem to provide a source of emotional support to believers which can bring about positive health outcomes (Kalab, 1990; Koening, 2001; Krause, 2002).

The religions mentioned by focus group informants included Christian, Catholic,

Buddhist and Hindu. Some common themes from different groups included:

An Australian informant in her sixties who recently lost her husband said,

188 As a Christian, I would pray for her, offer to pray with her, (AK: 13)

Her thought was echoed by an active Chinese community leader:

When a person encounters adversity, how to face it? Perhaps religion could be a very good way to offer insight to living one’s life! (CB: 438)

Buddhism was mentioned by a male participant in a highly acculturated group who was born in Taiwan and could speak and read Chinese:

If you look at authentic Buddhist teachings, they actually talk about how human suffering is a natural state, because we suffer from want, we suffer from desires and you can rid yourself of these desires then you rid yourself of suffering.(ER: 345)

It is noteworthy that palm-reading was raised by a Mandarin-speaker as a help-seeking tactic:

Since I often read books on fortune-telling and Chinese astrology, therefore many people ask me to look at their palms. (MM: 74)

(d) Cultural Values

Many Chinese idioms and adages were quoted by older participants from the Mandarin speaking and Cantonese speaking groups, who advocated drawing on Chinese values for inner-strength. The long-standing influences of Confucianism and Taoism on Chinese people were evident. The younger informants, although not quoting the Chinese sayings directly, talked about the importance of family support and parental expectations which reflected the cultural values that were imprinted on them. To some English-speaking

Chinese, the helpers’ (especially the medical professionals) understanding of Chinese cultural nuances was a crucial factor for effective therapy. The highly-acculturated

Chinese frequently contrasted Chinese and Western cultural values (though the latter were not mentioned as a help-seeking strategy) when they talked about problems associated with cultural hybridity (see Chapter 2, Literature Review, and Werbner 1997 for more detail on self-identity).

189 The following are some examples of this theme:

Therefore in his circumstances, (he) shouldn’t be disappointed by the trials he was facing. This is because there is a Chinese saying “Unpleasant events happen 80-90% of the time!” Therefore what is pleasant only occurs 10-20%. (MM: 187)

An English-speaking informant suggested that the person in the vignette return to his country of origin, a place of familiar culture.

He doesn’t have to be in Sydney. He can go back to China where he probably goes back to the same sort of job or something different. (ER: 300)

6.3.4. General Approaches

(a) Normalisation of depression

This could be viewed as a means of encouraging people to seek help and by extension could contribute to de-stigmatization. An Australian informant, an active volunteer in the local neighbourhood centre, said:

…There are hundreds and thousands of other people out there in the community who are suffering the same, and to admit that she is feeling ‘down’ is the first step towards helping her. (AK: 17)

(b) Multi-sectoral Collaboration

This was seen as an effort to integrate community resources, as illustrated by the voice of an advocate for consumer rights who recently returned to Australia after residing overseas:

…how do we integrate and encourage more connection in our community say schools and business…Instead of resources being separated and duplicated, how can we integrate these things across the board and take collective responsibility… (AK: 160)

(c) Empowerment of consumers

The voice of a young female university student advocated this as a way to boost self- esteem and self-confidence:

I did the advocacy training, run by the Institute of Psychiatry, which is for mental health advocates and other mental health consumers. And it was for 3 days. It is really helpful. (AR: 387)

190 (d) Recognition of professional help

This suggests informants’ recognition of the need to seek professional help:

Perhaps there are some professionals who can help. I will try as far as possible to make contact and communicate with her. (CM: 13)

6.4 Conclusions

6.4.1. Are Chinese as susceptible as Australians to becoming depressed?

One key finding was that when compared to the Controls, the Low-Acc Chinese were less likely to report an episode of putative lifetime depression lasting at least two weeks. Group differences were most distinct in regard to rates of reporting episodes as being a ‘distinct disorder’, with both Chinese subgroups being less likely to so report than the Controls, and with the Low-Acc Chinese being less likely to so report than the High-

Acc Chinese. I suggest that acculturation in Westernised Chinese appears to be associated with being more likely to report an episode of lifetime depression and with episodes being more likely to reach clinical depression status.

6.4.2. Do Chinese employ similar help-seeking strategies to those of Australians?

From the results of the survey, it seems clear that regardless of the acculturation level, Chinese were less likely than Controls to seek help from GPs and psychiatrists, even if they were experiencing something similar to the Western medical condition of clinical depression as defined in broad terms. It is worth noting the insignificant rate differences of consulting other helpers - psychologists, herbalists, friends and families.

Except for those recruited from Chinese herbalists’ rooms, subjects were recruited from

191 the surgeries of GPs who practise Western medicine. For this reason, these findings may not be representative of the general public in the community.

From the focus groups finding, there were common themes regarding help- seeking in all groups. One of the reasons for not taking up medical intervention is revealed by Chinese informants from low acculturation groups. They acknowledged the depressed state of the person in the vignettes but failed to label such a ‘mood not good’ condition as warranting medical attention. Even in the more severe case in the vignette of the unemployed man where psychomotor retardation was obvious, elderly Chinese informants who had recently migrated from China still insisted that the issue was to do with personal determination and setting realistic goals rather than a condition or illness requiring professional help.

The Chinese informants frequently spoke of drawing upon Chinese values for inner strength. The theme of cultural understanding on the part of the therapist was prevalent among the highly acculturated groups. Informants raised the need for having psychologists who understand the subtle nuances of the Chinese culture as an important aspect of psychotherapy. Some Chinese informants were very keen to seek help from their GPs to alleviate their somatic symptoms. Chinese GPs who speak the same language and come from the same cultural backgrounds can be an important source of information.

Informants from Australian groups related their positive experiences with psychiatrists and medications. They also raised issues of advocacy vis-à-vis their journey to healing which suggested their strong belief in human rights in a democratic Western society. This was not mentioned by members of the Chinese focus groups. Different groups advocated common pathways to care. There were also ‘indigenous’ help-seeking strategies (drawn from Chinese cultural values of personal virtue vs those drawn from Western values pertaining to human rights). 192 193 6.5 Summary

The survey findings showed significant differences in the self-reported rate of

‘depressive episodes’ between the different cultural subgroups with the highest rate within the Australian Controls followed by the High-Acc Chinese subgroup, and the lowest rate among the Low-Acc Chinese subgroup. The results of statistical analysis of the likelihood of participants seeking professional help for persistent episodes suggest an increasing trend of consulting psychologists/counsellors with increased acculturation.

Perhaps the more acculturated Chinese are in touch with their depressive experiences and have a more positive attitude towards seeking help from the mental health system.

However, the rate of having taken antidepressants to relieve depressive symptoms remained low among both Chinese subgroups. The meanings of such a correlation remain unaddressed by the quantitative findings.

Reviewing the narratives of the Chinese and Australians who have personal depressive experiences or have known someone with such experiences, I was able to explore in depth the observed phenomenon. What kind of help were Chinese seeking when they consulted mental health professionals as well as lay helpers? Quotes from the focus group discussions shed light on this question. Low acculturated Chinese not only draw upon both Western medical and Traditional Chinese herbal remedies, but also culturally familiar services in the community or religious organizations to manage their emotional distress. Chinese family values and Confucian teachings are also important sources of support during stressful life events. In the next chapter, I present my findings on the mental health literacy of both survey and focus groups. Mental health literacy is

194 closely linked with help-seeking. Knowledge of existing mental health services, attitudes and beliefs about mental illness are some of the crucial determinants of active help- seeking behaviours.

195 Chapter 7 Mental health literacy: Symptom Recognition and the Perceived Helpfulness of Health and Community Services

ŗŋ́ȰˎΒγȳ̔QSųˮʑƈQƄSųˮΧƈ

Whilst walking in the company of others, there must be someone I can learn from. I shall follow others’ strengths and identify others’ shortcomings to guide my own improvement. Confucius, Analects

In Chapter 6, I considered the different rates of reporting emotional distress to

GPs by participants from the various subgroups. This invites the further question as to whether the low level of reporting of psychological problems among Chinese is culturally shaped. I noted in Chapter 2, the Literature Review, that many mental health campaigns are built on the posit that raising the awareness/knowledge of depressive symptoms is the prelude to symptom-reporting which then opens the way to prompt diagnosis and early intervention. However, I also pointed out that such a stance over-simplifies the complex patterns of human behaviour.

In the first part of this chapter I demonstrate how acculturation influences the recognition of somatic and cognitive symptoms among the Chinese. Are the Low-Acc

Chinese more likely to recognise somatic symptoms and less likely to recognise cognitive symptoms than the High-Acc Chinese and Australian Controls? This could be viewed as an appraisal of the mental health literacy of the survey participants. In the second part I explore the focus group narratives for the crucial factor that governs active engagement in help-seeking behaviours: the perceived helpfulness of mental health services or consumer satisfaction. At the end I discuss how the findings reported in this chapter

196 illuminate the pressing need to provide culturally competent mental health services to the

Chinese community in Sydney.

7.1. Recognition of depressive symptoms by Chinese subjects: the influence of acculturation on the depressive experience

7.1.1 Symptom Recognition

The Literature Review reveals that Chinese present predominately somatic symptoms to medical professionals. Such factors may be influenced by mental health literacy, a construct which in turn may be influenced by culture, as well as by education and the actual experience of depression. In this section, I examine the impact of acculturation on the recognition of a number of depressive symptoms in the same sample of subjects. Recognition of depressive symptoms can be seen as one aspect of mental health literacy which is likely to influence reporting of depression and help-seeking.

As outlined in Chapter 3, Methods, a 35-item Depression Symptom Questionnaire2 comprising (i) commonly experienced cognitive depressive symptoms (e.g. ‘depressed mood’) and (ii) common somatic symptoms nominated by depressed Chinese individuals

(e.g. ‘headaches’, ‘chest pain’) was given to each participant in their preferred language

(See Appendix 3-1 for the survey questions). In this report, focus is upon acculturation and depression. I examine the impact of acculturation and personal experience of depression on the reporting of depressive symptomatology.

2 Subjects were invited to rate whether “someone experiencing ‘depression’ would be likely to experience each of the 35 symptoms people may exhibit when they are emotionally distressed”, with scoring options being ‘definitely’(‘2’), ‘sometimes/to some degree’ (‘1’) or ‘not at all’ (‘0’). 197 7.1.2. Factor analysis of the Depression Symptom Questionnaire Using the data collected from the survey, an exploratory factor analysis of the 35 common depressive symptoms suggested, there were 5 components with Eigen values over 1 and the Scree Plot ‘elbowed’ after component 3’, that a three-factor solution was superior to a two-factor (somatic vs cognitive) solution. Subsequently I imposed a 3- factor solution with Unweighted Least Squares extraction and Oblimin Rotation on questionnaire items (See Appendix 7-1 Table A and B). The three factors explained

43.8%, 6.9% and 3.7% of the total variance respectively, with the first factor interpreted

(all items loaded > 0.40) as a general factor quantifying depression ‘core’ symptoms

(with the highest loading items being loss of essence and energy, being less able to laugh, feeling withdrawn, helplessness, feeling guilty, thinking too much, and feeling everything was not under control). The second (‘cognitive’) factor had the following highest loading items: feeling suicidal; feeling like giving up and hopeless; thoughts of death; judging live as not worth living; being unable to look forward to things; feeling bad about oneself and feeling depressed. The third ‘somatic’ factor had the following highest loading items: body aches and pains, headaches, breathlessness, talking very softly, disturbing dreams, feeling agitated and loss of weight.

The seven highest loading items from each factor were selected to form separate scales, with each allowing scale scores between 0 and 14 to be generated. To examine the effect of cultural group and experience of depression on scale scores, 3 (cultural group: Low-

Acc Chinese, High-Acc Chinese and Controls) x 2 (depressed, non-depressed)

ANCOVAs were performed with age as a covariate. Table 7-1 reports the means, standard deviations and F values for comparison of subscales across cultural groups for the total sample as well as for those who had and had not experienced depression.

198 Table 7.1: Means, Standard Deviations and F values for depressive symptoms according to cultural group and level of depression.

Low-Acc High-Acc Controls Main effect for Main effect for

Chinese Chinese N = 126 group depression

N = 200 N = 119 Mean (SD)

Mean (SD) Mean (SD)

Core symptoms F p F p

Total sample 9.3 (3.6) 9.0 (3.4) 8.4 (3.6) 4.3 0.014 16.1 <0.001

Depressed 10.5 (3.0) 9.7 (3.3) 9.0 (3.3)

Not-depressed 8.8 (3.8) 8.6 (3.5) 7.7 (3.8)

Cognitive symptoms

Total sample 7.9 (4.4) 8.8 (4.3) 8.0 (4.3) 0.4 0.667 6.3 0.013

Depressed 9.1 (3.0) 9.3 (3.9) 8.2 (4.0)

Not depressed 7.4 (4.7) 8.5 (4.5) 7.7 (4.8)

Somatic symptoms

Total sample 7.0 (3.4) 5.7 (3.1) 6.2 (3.1) 8.7 <0.001 15.4 <0.001

Depressed 8.2 (2.8) 5.8 (2.9) 6.9 (3.2)

Not depressed 6.4 (3.4) 5.6 (3.2) 5.5 (2.8)

Significant main effects for cultural group were found for the core symptom scale and the somatic symptom scale but not for the cognitive scale. Tukey’s Post Hoc tests were used to examine significant main effects. For the somatic Scale, the Low-Acc Chinese scored significantly higher than the High-Acc Chinese (p = 0.002) but neither group differed from the Control group. For the core symptoms scale, while differences between the

Low-Acc Chinese and Controls approached significance (p = 0 .059), the High-Acc

Chinese did not differ significantly from the other groups.

Significant main effects for depressive experience were found for all three scales, with subjects reporting a previous depressive episode scoring higher than those not so

199 reporting. For the core symptom scale, the mean scores for depressed and non-depressed subjects were 9.7 (SD = 3.2) and 8.5 (SD = 3.7) respectively, for the cognitive scale mean scores were 8.8 (SD = 3.6) and 7.7, (SD = 4.8) respectively, and for the somatic scale, mean scores were 7.1 (SD = 3.1) and 6.0 (SD = 3.2) respectively. No significant interactions between the cultural groups and reports of previous depressive episode were found for any of the three scale scores.

To determine associations between level of acculturation (as measured by SL-

ASIA) and the three scale scores in the Chinese subjects only, Pearson’s partial correlations were conducted partialling out the effects of age and state depression levels

(as measured by the DMI-10). The correlation between SL-ASIA and the core symptom scale scores was small and not significant (r = 0.07, p = 0.26). There was a significant positive, albeit small, correlation between SL-ASIA and the cognitive scale scores (r =

0.13, p = 0.045), while the correlation between the SL-ASIA and somatic scale scores was negative and not significant (r =-0.11, p = 0.083).

Finally, I examined the impact of SL-ASIA score on recognition of depression, after controlling for the effect of depressive experience. I could only examine SL-ASIA scores within the Chinese subjects as the SL-ASIA measure was not extended to the

Controls. I divided the Chinese subjects into two groups (‘high’ and ‘low’ acculturation on the basis of their SL-ASIA scores using the group median SL-ASIA = 2.2 as cut-off), and examined the effect of SL-ASIA scores (i.e. degree of acculturation) on Depression

Symptom Questionnaire scale scores when ‘depressive experience’ was included as a covariate. Those Chinese scoring high on acculturation scored higher on the cognitive scale (9.2 vs. 7.5 , F= 11.8, p < 0.01), but no significant main effects were identified for core symptom or somatic scale scores.

200 7.1.3. Interpretation

This report extends previous research on acculturation and depression by examining the impact of acculturation and personal experience of depression on recognition of depressive symptoms as a component of mental health literacy. Factor analyses identified three dimensions of depressive symptoms: somatic, cognitive, and core depressive symptoms. Marsella et al (1985) suggest the use of multivariate techniques to assist clinical judgment vis-à-vis identifying symptoms cluster regardless of diagnostic labels. In this study where there was no absolute certainty as to whether the term ‘depression’ and the Chinese translation you-yi-jing meant the same thing to those answering the English and Chinese questionnaires, factor analysis did serve the purpose of identifying symptom clusters.

Overall, I found that both acculturation and personal experience of depression influenced reporting of depressive symptoms. Partial support was found for the hypothesis that those lower in acculturation would be more likely to recognise somatic symptoms of depression. The Low-Acc Chinese recognised significantly more symptoms than the High-Acc Chinese, but neither group scored significantly differently to the

Controls. The difference between the two Chinese groups may reflect the Low-Acc

Chinese group being older and having lower educational and occupational levels, factors that might influence mental health literacy and exert a range of response biases. The tendency for Chinese to somatize their depressive experiences has been well documented

(Kleinman, 1980, 1986; Parker Gladstone and Chee, 2001). This is hardly surprising when one considers that the Chinese have long linked body and mind in their traditional medical beliefs. The Chinese acceptance of the concept of neurasthenia (see Kleinman,

1982, Lee, 1998) or, as translated, shen-jing-shuai-ruo (SJSR) is illustrative of that

201 linkage. As I suggest in the Literature Review Chapter, SJSR translates as weakness of the body channels carrying qi or vital energy, and is therefore capable of subsuming a range of physical and psychological conditions. More recent studies indicating that psychological complaints are usually reported after direct questioning (Simon et al. 1999) suggest that such somatising reflects more an initial defensiveness against psychological questioning. It might be surmised that such a mode would attenuate with acculturation.

In fact, while those lower in acculturation were more likely to recognise somatic symptoms, there were no significant differences between the two Chinese groups and the

Controls. It could be that a tendency to somatize has been disproportionately ascribed to the Chinese and neglected among Westerners. This notion is supported by a study by

Cape (2001), who after examining a sample of western patients in London, found that those who were mildly emotionally distressed presented only somatic symptoms to their general practitioners. So somatisation may be a function of severity of depression and/or a general social negotiation strategy than usually recognised.

Contrary to expectation, differences between the three comparison groups for recognition of cognitive symptoms did not reach significance. However, significant differences did emerge when using SL-ASIA scores and controlling for previous depressive episodes. Chinese who were higher in acculturation scored higher in cognitive symptom recognition than those lower in acculturation. As these contradictory findings make it difficult to determine the effects of acculturation on recognition of cognitive symptoms, further research is required to clarify the relationship between these variables.

It was found, however, that Low-Acc Chinese scored higher than the Controls in the core depressive symptoms, although this difference did not reach statistical significance.

Hence, acculturation does not appear to impact significantly on recognition of core depressive symptoms. 202 Previous experience of depression was relevant to recognition, with those who had experienced depression rating recognition of all three dimensions of depressive symptoms significantly higher than those who had not experienced depression. From theses findings, it would appear that for the Chinese, previous experience of depression is more relevant than acculturation to recognition of a range of depressive symptoms. Given the comparable levels of recognition between the Chinese and the Controls, it would be of interest to ascertain if they report actual depressive symptoms similarly. This suggests that mental health practitioners may need further education in the area of identification of depression in Chinese patients. A series of recommendations for clinicians (Chan and

Parker, 2004) has been tabled, in an effort to improve early detection of depression in

Chinese patients.

As reported in Chapter 6, a greater tendency for reporting persistent and impairing depression was detected in those who were highly acculturated. As compared to those low in acculturation and the Controls, it was surprising to find that recognition of depressive symptoms was similar between Chinese and Controls. This would suggest that there are factors other than mental health literacy that mediate the relationship between acculturation and reporting of depression, such as conceptualisation of illness and stigma, which I discuss in the next chapter.

However, it should be emphasised here that the usual vignette methodology does not enable recognition of a broad range of symptoms to be addressed. Additionally, this particular methodology may not be appropriate for those unfamiliar with diagnostic labels (as is usually the case with people from non-English speaking backgrounds). Thus, the method used in the present study may help advance methodological considerations for studies of mental health literacy

203 7.1.4. Summary

In summary this research demonstrates that Chinese subjects recognised a range of depressive symptoms equally as well as the Control subjects. While Chinese who were lower in acculturation were more likely to nominate somatic symptoms and less likely to nominate cognitive symptoms than those with higher acculturation, personal depressive experience was found to be more important for recognition of depressive symptoms than acculturation. It is clear that the impact of acculturation on mental health literacy, as measured by symptom recognition in this study, is not straightforward. Mental health literacy also includes beliefs about treatment availability and effectiveness and knowledge of risk factors. In the next section I will quote from the focus group narratives and report on a different aspect of mental health literacy: the perceived helpfulness of mental health services. This is not easily assessed by quantitative methods.

It could be viewed as an index of consumer satisfaction which in turn determines the likelihood of these consumers using the services in the future.

204 7.2 Perceived Helpfulness of Mental Health Services

In the first part of this chapter mental health literacy is measured by the participants’ recognition of common depressive symptoms. I discuss how this construct may be influenced by culture as well as by education and actual experience of depression.

Symptom recognition, if augmented by knowledge of mental health services, could lead to prompt help-seeking and contact with health professionals. As reviewed in Chapter 6,

Chinese of various acculturation levels and Australians employed different strategies to manage their emotional distress. Some participants spoke of their first hand experiences; others shared the examples of friends and loved ones. The degree of perception of the helpfulness of existing services is also a component of mental health literacy.

Throughout the focus group discussions many ideas and opinions were raised regarding perceived helpfulness, information vital for policymakers seeking to learn about consumers’ issues and unmet needs. If these contributions are taken seriously, culturally competent services will come one step closer to reality. The following sections describe the key examples of the common themes from the qualitative data.

7.2.1. How can GPs help? Focus group participants talked about the circumstances in which they would consult their family doctors. In most cases the discussion indicated that there may have been organic causes.

I went to see the doctor because I had not been sleeping well for so long. (CB 50)

Some Chinese informants considered their GPs helpful in terms of prescribing medication and providing information, as well as in their role of a counsellor.

…she can get some information… (EP: 368)

At least the doctor can help her sleep better, sleep is very important. (ME: 20)

205 Doctor can counsel him: help him to think from other perspectives (MM: 365)

Within the Chinese community, medicine is a well-respected profession. However, informants from different language groups mentioned their concerns regarding GPs only prescribing medication.

I will be worried if he went to a GP, he may just get a script for antidepressant. (AC: 395)

GPs only give you sleeping pills and stress pills. (EB: 58)

One informant complained about the doctors being too busy:

… they want to get you out the door and see the next one … (AR: 381)

From the perspective of someone who had seen a medical professional before, the following Cantonese-speaking informant stressed the importance of approaching the topic delicately with the person in the vignette, and then encouraging him/her to see a doctor!

If he is willing to talk about it, then I will introduce him to see a doctor. (CB: 114)

It is apparent that GPs, especially those who speak the Chinese language, play a significant role in managing patients’ somatic symptoms. Some participants believed that

GPs could provide further help such as counselling. Others mentioned the constraints of time. A female informant cited an example in which her family doctor invalidated her claim of depressed mood as overanxious or perhaps what is commonly referred to as hypochondria by many doctors.

Yes! I also asked my family doctor before, I said ‘Sometimes, my ‘essence and spirit’ was no good, that time perhaps was my period being irregular… Sometimes when your ‘body’ was not well, you felt you might have some problems. But the doctor said ‘You are too anxious!’ (MG: 394)

In the next section I examine how participants evaluate professional counselling services.

7.2.2. Does psychotherapy/counselling help?

206 Many informants in the Australian groups talked about the positive outcome of counselling or talk therapy whereas Chinese informants cast doubt upon its effectiveness when their helper’s cultural expectations and upbringing differed from theirs. Some indigenous means of help were mentioned such as palm reading, which may provide a form of psychotherapy at the same time.

One Australian female with young children viewed counselling as an opportunity to talk about her emotions which in turn lifted her moods.

We talked about everything that happened over the last month and to me that made me happy. (AS: 63)

When I came out of that office, I feel so positive and so like I can take any problem on when I walk out of there. (AS 69)

One young Chinese postgraduate student, speaking of cultural issues, emphasised that her

Chinese upbringing discouraged the seeking of professional help:

You are too shameful and you don’t go and you don’t do it because it is not in your DNA to do this kind of stuff. (EH 209)

Another English-speaking Chinese informant expressed concern regarding the counsellor’s limited knowledge of her cultural background:

... the worse thing that could happen is that …somebody [counsellor] has no idea about what your background culture is, like without knowing it, they will make mistakes in their treatment. (EH: 180, 186)

Many Chinese have little awareness of the availability of resources; thus promotion is very much needed:

…the services are too limited, because we don’t know through what means to find out about this. Yes, you have to do more promotion. (CV: 117)

In order for counselling to work, it needs to be adapted to Chinese cultural expectations, such as using a more directive approach:

…they have expert opinions, which would be much better than for us (lay person) to say anything. They will tell you what you should do and how to handle the situation.(CS 150)

207 7.2.3. Are psychiatrists helpful?

Those participants who had had previous contact with psychiatrists expressed the following views that there are some advantages in getting a psychiatrist’s expert opinion.

An Australian female observed:

I can trust the psychiatrist not to gossip, (AR: 46).

One Chinese male who had already seen a psychiatrist previously recommended a health maintenance approach:

…seeing a psychiatrist is part of ‘mental hygiene3’. That is not to wait till there are big problems. …Therefore there is the need to raise this ‘mental hygiene’. (CB: 206)

The same informant considered that early consultation with psychiatrists would lead to accessing the appropriate therapy promptly:

I think the best is to find a psychiatrist for therapy. It is because one won’t know to what extent the illness has developed? (CB: 237) However one informant, a psychologist working in research, mentioned the high specialist consultation fees:

[S]he may decide to see someone professionally that she can afford, Psychiatrists can be expensive (AC: 124).

Another participant doubted the willingness of people to consult a psychiatrist.

…[I]f you asked her to see a psychiatrist, she would very much reject (the idea) “(CB: 271).

In the English-speaking Chinese group, this theme was also apparent:

If you suggest her to go to see a specialist, it could be too frightening for her (EB: 70).

Another reason for this reluctance might relate to how psychiatrists could be of help: …[E]ven you go to see a psychiatrist, in the end, they can’t solve your family problems. (CS: 122)

3 Mental hygiene is the English translation of the Chinese phrase ‘xinli-weisheng’ literally meaning ‘psychological + hygiene’. This phrase has been widely used in Taiwan’s medical field to emphasize the positive or preventive aspect of psychological issues, the closest proxy medical jargon in Western medicine would be ‘mental health’ (Pers. Comm. Hsing 2003) 208 Some participants voiced concerns about becoming dependent on medication. One female talked about her grandmother’s experience (after treatment by a psychiatrist for depression):

…she now thinks the only problem is that she now needs to take medicine. She is still strong and she could do so many things. (EB: 260)

From the above narratives, it seems that participants who have benefited from the service of their psychiatrists spoke positively about their experience. Others did not know exactly how psychiatrists could help and had concerns regarding drug dependency. The quotes in the next paragraph give details about participants’ views of medication.

7.2.4. Are medications effective?

During the focus group discussion many informants spoke of the advantages and disadvantages of taking medication based on either their own or their loved ones’ experiences. Some opinions were drawn from general observation. One informant, addressing the benefits of medication when the symptoms become more serious, stated:

If it gets more serious, one needs to get help from a doctor¸ take medication. (CB:516)

One Cantonese informant was concerned about side effects

…[I]n general, all medicine has some side effects. (CB: 488)

A female participant shared with the group her doctor’s claim that:

It was quite safe, there weren’t many side effects, therefore I took it (Librium). (CB: 53).

In some cases, doctors failed to explain to their patients the mechanism of the medications. Another informant recalled her friend’s doctor as saying,

Medication makes you laugh! ... but [s/he] did not explain the nature of the medication (CB: 481).

This may result in poor concordance with medication as mentioned by some informants.

Say the doctor prescribed him with medication, he either secretly threw it away, or he cheated to say (to the doctor) he had taken it. (CB: 537)

209 A Mandarin-speaking informant had reservations about how medications can treat illnesses of a cognitive/psychological nature:

He [the person in the 2nd vignette] has a kind of ‘psychological [heart] illness’…it cannot be treated by medication nor a doctor can cure him. (MM: 261)

The above quotes reveal some of the participants’ attitudes towards medications. Did those with reservations about Western medicine prefer an indigenous alternative? This is now discussed.

7.2.5. Are herbalists helpful?

Some Chinese participants spoke of a herbal drink that could help relieve tension and make one sleep better.

Talking about Chinese medicine and Chinese herbs, there are some herbal teas …it is the one to relieve the tension, it will make you sleep better. (CS: 219)

However, some informants expressed concern over non-standardisation of herbalists’ qualifications:

Many herbalists got a certificate in China and called themselves doctors; you don’t know whether they are reliable. (EB: 83)

If people harbour doubts about the quality of care they receive, there is a dire need to make sure information about legal registration of these herbalists is available to the public and education on consumers’ rights regarding health services are provided to the community.

210 7.2.6. What can community education achieve?

Informants from Australian groups were strong advocates of community education as a means of normalising depression. They especially welcomed public campaigns featuring famous people talking about their mental illness:

Keep it out there on the television, in the newspapers, in the magazines everything...it is all the famous Rugby players. Did you know this? Yeah, someone there who was famous… (AC: 209).

However, one Australian informant, herself the carer of a depressed relative, pointed out that it may not be relevant to the average person. But still the glorified success stories of the rich and famous may be better than nothing:

… [C]elebrities who talked about their challenges with mental illness and I think that is a good thing but I still feel that is quite a separation between … kind of an average person…(AK: 215).

There was support for the media as an effective means to combat stigma:

…[I]f the media can actually educate us and let us know what mental illness is that is to get away from this stigma…. (AC: 602)

However, one male informant who insisted he would rather carry out his own research, stated: “One may not take the media reports too seriously [could be far from honest and sensationalized]. (AC:590)

Chinese informants, while agreeing strongly that community education is much needed, suggested integrating western and indigenous concepts when delivering health talks:

…[W]e should add something like ‘Nurturing Life’ or ‘Mental Hygiene’ that kind of stuff because people are very sensitive…I think that kind of slogan should be appreciated by everyone... (CB: 496)

Many Chinese informants considered public seminars effective as a means of raising people’s awareness and knowledge of mental health:

I hope in the future [you will] run more seminars to let more people raise their knowledge in this area. (CB: 11)

211 However one Chinese female who knew a severely depressed friend was concerned that those who need this information most don’t attend the seminars:

I asked her [a ‘depressed ‘friend] to attend today’s talk, but she wouldn’t come because whenever we talked about this topic, she wouldn’t talk any more. (CB: 98).

Public seminars and/or education campaigns may not reach everyone who is in need; perhaps some informal means of information delivery would work better for those who are reluctant to attend public meetings.

7.2.7. What kind of help do friends and families offer?

As reported in Chapter 6, many informants turned to their friends for help. They talked about the pros and cons of doing so: issues of trust within the were echoed in all group responses. Many found the sharing of real experiences with each other rather than the advice aspect the most helpful feature of the exchange. Many raised concern about when ‘outside help’ is warranted?

Depends on the friend, if she doesn’t seem to think that it was an emotional depression that she is having… I don’t want to be the first one to say it. (AR: 126).

One perceived drawback associated with getting help from friends or families was that they tend to give advice without appreciating the level of difficulty the person is facing.

Don’t tell me to do anything because none of this will ever work, I’ve done it already!’ You know, there is no solution, it’s just very hard. (AR: 323)

This theme was echoed by a Cantonese-speaking informant:

…I can’t really do this, you said so many things, I really can’t do them! (CB: 34)

While families and friends are keen to offer help, it may in fact be difficult for them to appreciate the level of distress/disability that a depressed person experiences. Support groups can serve this purpose.

212 7.2.8. How can support groups be of help?

Those who belonged to a support group (see Appendix 7-2 for groups mentioned in the discussion) found it helpful:

I started opening up, I started talking to people… they had been through what you are going through, so they understand. (AS: 27)

People who share similar experiences and understand the scope of challenges provide mutual support for each other:

If one has gone through the same problems, they would certainly understand. (AC: 33)

Being able to share with one another in a group gives group members different perspectives:

...we press on to offer our care… we can develop each person’s talent…(CB: 193).

You are put into more perspectives. (AS 42)

7.2.9. How can mental health services be more helpful? The following quotes outline some general comments made by participants from different focus groups regarding current mental health services.

1. Depression possibly involves complex social life events. Are GPs prepared to deal with these issues or give patients a quick fix of medication? (AC:609)

2. Service providers need to be more flexible, to take a pluralistic approach (CM: 80).

3. Motivation of the self is very important (EB: 166).

4. Families need to become involved therefore public education targeting family members would be useful (EH: 146, 149).

5. Ethnic matching of clinician and clients is needed (EH:162).

213 7.3. Summary

From the survey results, I established that both Chinese participants and the

Controls were likely to recognise depressive symptoms. However the more acculturated

Chinese tended to recognise the cognitive symptoms more. There was no link between level of acculturation and previous depressive experiences. Consistently across all subgroups participants with experience of depression were more likely to recognise depressive symptoms than those who had never experienced depression. However the

Chinese were less likely to talk to their GPs about their psychological problems. Focus group informants explained the phenomenon as follows: most people who consult their

GPs have the impression (a) that GPs will only prescribe medication, and (b) that they are usually very busy. However informants also stressed the importance of establishing a close bond before they would feel comfortable encouraging their friends to consult a GP.

The level of trust required for someone to disclose their emotional distress was revealed as quite high. This is not surprising for Chinese culture has long discouraged the expression of negative emotions. Others were concerned about the mismatch between the cultural backgrounds of patient and helper which could lead to misdiagnosis. Those who had taken part in a support group found it helpful. It could prove an important source of knowledge about the availability of services and means of emotional support. All of this information is valuable to assist policymakers to understand why some Chinese favour consulting health professionals such as psychiatrists, GPs and psychologists while others don’t. Health promotion could usefully aim at correcting negative perceptions, for example explaining the mechanism of medications and clarifying the roles of the various mental health professions. Some Chinese informants said they preferred to talk to their

214 friends; but friends or family members may lack the mental health literacy required to provide the often urgent help. Health talks are greatly welcomed by the Chinese at the lower acculturation level so health promotion campaigns delivered in Chinese could be well worthwhile.

215 Chapter 8 Help-seeking and Lay Concepts of Illness

ɰɋŃŃɋŊŊɋŗŗɋǤŒǤŒ̔˵ˮôÚω#Ǩʑy

Tao is the unique life energy; this energy gives birth to yin/yang forces. Yin and yang coexist in harmony and give birth to all living creatures. These creatures embrace the yin/yang forces; yin/yang mix together to maintain an equilibrium. Lao-Tzu

This chapter focuses on the following research question: Do Chinese conceptualise clinical depression differently from Australians? Firstly I discuss help- seeking data obtained from the two different methods of enquiry, survey and focus groups, and identify common themes. To help readers to understand Chinese illness conceptualisation I reiterate the important underlying notion of body-mind link. I present concrete examples spontaneously articulated by Chinese informants during the focus group discussions. I then make an attempt to decode the underlying lay illness concepts of the Chinese utilising the observed help-seeking behaviours and informants’ narratives to support my claims.

8.1. Help-seeking

8.1.1. Integrating data from the survey and focus groups When interpreting the themes of help-seeking strategies suggested by the focus group informants, I made an attempt to detect any similarities and differences in the patterns as compared to the responses obtained from the survey questionnaire. These strategies were built upon who the helpers were. The narratives followed a natural sequence according to the informant’s own EMs, extending from what the ‘self’ could do to help to what the ‘professionals’ could do. GPs were frequently mentioned as the first

216 point of professional contact if the condition was perceived as a medical concern. Despite the diverse views surrounding the use of psychiatric services, seeking help from a family doctor to relieve the more obvious somatic symptoms appeared to be a recurrent theme in all focus groups.

The following was a typical response:

‘I think seeing a doctor is necessary, for example difficulty sleeping. To a certain extent, doctors can help her.’ (CV: 133)

Those informants, with first hand experience, had known friends or relatives in similar circumstances, or had learnt about it through the media, Internet or other sources, recommended specialist care such as psychiatrists or psychologists. One Mandarin- speaking female, who had consulted a psychiatrist through interpreters, shared her experiences towards the end of the focus group meeting.

Many Chinese informants raised the issue of shame in relation to the young mother’s over-concern with gossip in the first vignette and the unemployed male not being able to support the family in the second vignette. Non-medical strategies were often suggested such as engaging in leisure activities with friends or socialising with people in the community. The term ‘helper’ in these cases was extended to non-medical helping professionals such as social workers, migrant settlement workers, and multicultural health workers. The importance of ‘self-help’ was another common theme (see Part II, Chapter

6). In several instances, a certain degree of moral judgement was leveled at the person in the vignette for having put him/herself in such difficult circumstances. For example:

‘Wasn’t it a mother’s responsibility to care for her kids?’ (MA: 37)

‘He must be very picky when he looked for jobs! Why wouldn’t he just take any job?’ (MM:180)

It may be that the above value judgements reflect the cultural values of the informants.

217 I considered these observations and then looked at the responses to the two survey questions reproduced immediately below:

Section I

17. Please write down some Chinese/Western values that have the most impact on your life especially when facing an unhappy event. In not more than 3 sentences, give an example to illustrate this.

Section III

E. For any such episode, have you ever consulted a: ______

1 – general practitioner 2 – psychologist 3 – psychiatrist 4 – traditional Chinese herbal doctor 5 – others; please specify ______

I next constructed a ‘Help-seeking Puzzle’ to figuratively present how I interpret the help-seeking phenomenon reported by informants who took part in the various focus groups. Each piece of the puzzle signifies a distinct helper strategy suggested for the individuals in the vignettes to solve their problems. Themes extracted from informants’ narratives vis-à-vis help-seeking strategies are grouped into nine specific categories which directly involve the person in need of help. The four themes surrounding the puzzle pieces represent approaches to depression; they name therapeutic changes in belief or practice that also involve the society that surrounds the person in need of help (a fuller exposition on these is in 8.1.3 below). Thus the ‘Help-seeking Puzzle’ serves as a conceptual mind-map to describe the different strategies employed by the focus group informants to provide direct help to the individuals in the vignettes and by extension to someone really suffering from a depressive episode.

8.1.2. Help-seeking puzzle

218 Figure 8-1 Help-seeking puzzle

At individuals’ At societal level level Normalisation of Depression

Self- Family & Recognition of professional hel help friends

GPs Social & community Chinese Psychiatrists workers Herbalist

Psychologists

Empowerment of consumers & p Cultural Spirituality Counsellors Values

Multi-sectoral collaboration

219 In Figure 8.1, the central piece of the puzzle represents psychiatrists for whom patients require referrals from GPs in Australia’s medical system. Placing them in the centre does not mean they are the most important but the least accessible. Psychiatrists are usually not the first port of call of professional helper. As voiced by the some Chinese focus group participants, they didn’t know what kind of specialist doctors to see and whether these doctors could speak a Chinese language.

The four puzzle pieces attached to this centrepiece represent the professional helpers mentioned in the focus groups, namely GPs, psychologists/counsellors, Chinese herbalists and social/community workers. These professional services usually attract a fee, although membership/activity fees for some community groups are only a token few dollars. These services were mentioned by members of different focus groups, due to the levels of acculturation of individual participants, the activities suggested could be different (see Chapter 6, Section 6.2).

GPs, Chinese herbalist, psychiatrists and psychologists were response options in the questionnaire regarding professional help seeking (see Tables 6.8, 6.9, and 6..10 for survey findings). There was a response item ‘other’ to allow participants to write down

‘helpers other than those listed’. Among examples of others nominated as sources of help were: ‘close friends’, ‘my mum’, ‘my friends and my sister’, ‘talk to my wife’, ‘ talk to the church minister’, ‘Buddhist chant’, ‘read self-help book’, ‘get through it myself’,

‘homeopath’, ‘talk to early childhood nurse’. So the survey results strongly suggest the availability of helpers outside the orthodox mental health field. Lee stated that self-help has become increasingly important to depressed individuals in Hong Kong as compared to help from extended family and close friends (Lee, pers. comm. 2004). Some low- acculturated Chinese focal group participants mentioned their visits to Hong Kong or

China, the theme of self-help was prevalent in their discussion. 220 For the focus group study, theme saturation (see Chapter 3, Methods) was the criterion for ceasing recruitment. I was reasonably confident that the narratives sampled covered a considerable number of themes. Some themes were common in groups from very different age, language and cultural backgrounds.

The four corners of the Help-seeking Puzzle are ‘family and friends’, ‘self’,

‘spirituality’ and ‘cultural values’. They represent help at the non-professional or non fee- incurring level, i.e. help relatively easy to access if the individual chooses to do so. This kind of help is the ‘social capital’ within the Chinese community which is freely available to their members. They are also the preferred strategies when the episodes are mild or transient. I quote examples of narratives for each category in Part II of Chapter 6, and the participants’ evaluation of the helpfulness of professional and lay helpers in Part II of

Chapter 7. In the survey, some participants reported that they found their beliefs, including their religious and cultural values, helpful in times of hardship.

8.1.3. Attitudes and Beliefs

Around the puzzle pieces in Fig 8.1, encompassed by the oval, are the four overall approaches to depression (See Section 6.3.2 for participants’ narratives.). These strategies require a change of attitude not only in those needing help but also in the helpers and the surrounding community i.e. those that the person in need rubs shoulders with in the public domain.

1. ‘Normalisation (or De-stigmatization) of Depression’ signals recognition of how common this condition is and encourages a more empathetic approach to its sufferers.

2. ‘Recognising Professional Help’ signals awareness of the different avenues of professional help and the fact that clinical depression is treatable if the right help is sought promptly. This is especially true for the prevention of suicide.

221 3. ‘Multi-sectoral Collaboration’ signals the combined effort of both medical and non- medical professionals working together to promote mental health and mental health literacy for everyone, including the self, family and friends of the depressed and spiritual leaders. At the professional level, encouraging referrals within the health professions are equally important. In Chapter 9, I discuss the significance of professional collaboration in more depth.

4. ‘Empowerment of consumers’ signals the major step forward in the healing process.

Consumers need to be encouraged to exert more influence on the very system that provides services for them. Both Chinese and Australian informants saw it, by reaching out to help a person in a similar situation, this results in the depressed person progressing towards managing their own episodes. As mentioned at the end of Chapter 6, only informants from the Australian groups spoke of advocacy as part of their empowerment and journey to healing, which is linked to the strong value accorded human rights in a democratic Western society.

In summary, to describe the ‘oval’ encircling the ‘Help-seeking puzzle’ more precisely, it symbolizes a higher level of help, i.e. the attitudes and values pivotal to managing mental well-being.

I pointed out at the beginning of this chapter that the choice of ‘helpers’ was closely related to the EMs of the informants. For example, one of the reasons why

Chinese informants opted against medical intervention is that while they may have acknowledged the depressed state of the person in the vignette, they failed to label such a

‘mood not good’ condition as requiring medical intervention. Thus they may turn to lay helpers for emotional support or practical assistance. In Chapter 7, I describe in detail the

‘Perceived Helpfulness’ of the different helpers, using quotes from the focus group

222 narratives. The linking together of all of this information may shed light on the underlying illness concepts which are the driving force behind help-seeking behaviours.

Before discussing the illness concepts themselves, I briefly reiterate the notion of ‘body- mind link’ (outlined in Chapter 2) so fundamental to the Chinese conceptualization of mental illness. I utilise informants’ narratives as well as citations from the teachings of the Chinese philosopher Confucius to explain and explore the full significance of this holistic view to Chinese attitudes.

8.2. Body-Mind Link

During the focus group discussions Low-Acc Chinese from different groups talked about how negative emotions could affect physical health. They maintained that tiring the body by engaging in such activities as physical exercise facilitated better sleep.

Having a good sleep was considered important for both physical and mental health.

…got stuck at home and that is meaningless, if (you) can’t sleep well, then you sit at home doing nothing. In the past, I have a friend, her ‘body’ is not well, and she is like this. (ME-195) Perhaps do some activities that will make you very tired physically, such as running, swimming, switch your ‘mental/psyche’ off the worry. All these can help. (MG-14) [not being able to sleep] affected her ‘shēn-xīn’ health (literally meaning ‘body’ and ‘heart’ health) (CB-8) Informants from Mandarin and Cantonese-speaking backgrounds seemed to agree on the concept of qì, which is fundamental in Traditional Chinese Medicine and represents the life source of energy that circulates throughout the body. It is seen as important to physical and mental well-being.

If you are not happy, or emotionally suppressed, it will affect your physical health. And Chinese herbalists often claim to be able to relieve these conditions, e.g. [herbs] to calm the ‘psychi’ ‘jīng-shén ’ and make you slightly happier, and boost your ‘qì’ and improve your mental well being’ (CM-176)

Also you can sing songs to get rid of the ‘dull qì’ (literally meaning bored qì), and do some exercises. All this can let out the ‘dull qì’. And also do some 223 exercises, then (you) can get sweaty! (You) get rid of the toxins in the body. This is of great help, and more exercises will do you good. (MA-47)

Chinese often talk about whether or not someone is jīng-shén. As a form of greeting they might say “You look very ‘jīng-shén ’”, meaning you look ‘sparkling’ or very well. The opposite would be ‘You appear to be méi-yǒu ‘jīng-shén or méi-shén-méi-qì’ when someone is obviously looking unwell or is sick. Though the literal meaning of the term jīng-shén is ‘mental well-being’, the term applies equally to someone who is physically sick. Many Chinese do not distinguish between mental and physical health but see the two as closely connected. This holism is also found in people from other cultural backgrounds. The following quotes from a Mandarin-speaking focus group illustrate the link between the negative emotions of anger and anxiety and sleep.

But sometimes I got emotionally stirred up, I was angry, I quarrelled with my partner over some trivial things. But I was very angry, and then I couldn’t sleep well, and then I forgot about it, and then I could sleep.(ME-91)

This was the situation… when the stress is too great… if the next day, there is an important event, I’m afraid that I’d be late. (I) look at my watch after a while…I kept looking at my watch … I couldn’t sleep well. (ME-91)

Body-mind holism is not only present in daily conversation it is also found in Confucian teaching. In the Analects (lùn-yǔ) and the Book of Great Learning (dà-xúe), the interchangeable use of the words ‘shén’ (literally meaning ‘body’) and the word ‘xīn’

(literally meaning ‘heart/mind’) is apparent. The following two quotes illustrate the holistic body-mind concept taught by Confucius, one of the most influential of the

Chinese philosophers.

Master Tsang said: Every day I examine myself (shēn) over and over again. In acting on behalf of others, have I always been loyal to their interests? In [social interaction] with my friends, have I always been true to my word? Have I failed to repeat the precepts that have been handed down to me? Analects Book 1, verse 44

4 The English version is taken from (Confucius, 1996) The original Chinese reads “

224 To train and cleanse the ‘heart/mind’, one starts by training the body ‘zhèng-xīn-xiū-shēn’

[Ƚǀ͕]. Here the author talks about the emotions and moods (anger, fear, joy, anxiety/worry) that can affect one’s reasoning and peace of mind. Being either excessively joyful or sad can affect one’s rational powers to the point that one is out of one’s mind or unable to concentrate. ‘Eyes are wide open but cannot see clearly, ears are there but cannot hear clearly. Food is chewed but cannot be tasted’. This is equivalent to

‘a state of madness’. The way to avoid getting into such a state is ‘to train the body’ and to resist the influence of emotions’. (Confucius, The Book of Great Learning, Lesson 75)

The interchangeable use of the Chinese terms for ‘body’ and ‘heart’ are clearly revealed in this excerpt. A Chinese person expressing concern about not being able to sleep may simply be reporting his/her illness in the most culturally appropriate way, but

Western psychiatrists are inclined to view the symptom thus expressed as somatic.

Whether or not the Chinese person suffering distress will go beyond describing his/her symptoms as insomnia to a GP, i.e. proceed to describe so-called psychological symptoms, is determined by the level of trust developed with the GP not by reference to somatic/ psychological (body/mind) distinctions. As discussed in Chapter 6, focus group narratives suggested that a high level of trust is required between the ‘helper’ and the

‘helped’ when dealing with sensitive topics like ‘negative emotions’, ‘mental illness’ and

‘seeking professional help for depression’.

In Chapter 7, I discuss mental health literacy as measured by the recognition of common depressive symptoms. It is particularly valuable to hear the Chinese voicing their evaluations of the helpfulness of ‘helpers’ based on their own or their families’ or

5 This is my own translation. The original Chinese reads Here the words ‘heart/mind’ and ‘body’ are interchangeable.

225 acquaintances’ experiences. However, earlier mental health literacy studies of perceived helpfulness of a professional or lay helper do not necessarily predict the use of that helper’s services when intervention is required (Jorm 2000; Jorm et. al 1997, 2000).

Taking this a step further it would seem that what people think about help-seeking prior to taking action does not always predict their subsequent behaviour. Thompson and colleagues, in their Australian sample (Thompson et al 2004), note that the reasons people give for delaying getting help for mental health problems were quite different from what finally prompts them to seek help. As suggested by the Chinese during focus group discussions (outlined in Chapter 7), prior knowledge of mental illness and available services may not translate into active help-seeking. Lack of trust between helper and helped, feelings of guilt heaped upon those who sought help and extended family factors all played a role in help-seeking behaviour. In the section that follows, I outline my proposed model of ‘Lay Concepts of Illness, supported by citations from qualitative data.

8.3. Lay Illness Concepts

A summary of lay illness concepts is set out in Figure 8.2. In 8.3.1, I provide quotes from relevant focus group discussions that revealed the underlying concepts of illness held by Chinese informants.

Figure 8-1 Mind-map of Lay Illness Concepts

Lay Illness Concepts

226 Sick in the head Sick in the body

Could Short snap out course State of Mind Attacked by pathogens Emotional Could get Ups and Downs worse Could it be SJSR?

SJSR Something Serious Imbalance Disability Mentally Ill Start to attract stigma Self-talk, suicidal Mad, Depressives Crazy Manic

Violent, out of Schizophrenia control Highly Stigmatized

227 8.3.1. ‘Sick in the Body’

‘Sick in the body’ or physical illness is recognisable from the obvious causes which prompt someone to seek medical help early.

[W]hen you have cold or flu, you will go to see a doctor…the process is relatively shorter. (CV: 127)

A minute bacterium will make one sick. (CB: 450)

This kind of illness does not usually attract stigma unless it appears to be congenital or chronic or serious.

…[A]nyone with any abnormalities and deformities or whatever, the family is much more likely to keep that person out, … because it is culturally considered as not successful. It’s more like you mess up with the bad things, you have a hard time. (EH: 79)

Even for my mum’s generation, when you see someone with cerebral palsy…or perhaps it is polio, someone who can’t walk properly; you will think that these people are mad and not normal! (CS: 331)

8.3.2. ‘Sick in the Head’

An Australian informant talked about the notion of ‘sick in the head’:

‘Mental illness is like any other illness except it is mental and not physical and just because I am sick in the head instead of sick in my body...’ (AC: 178)

8.3.3. ‘State of Mind’

One English-speaking Chinese female described the experiences of the person in the vignette as being in ‘state of mind’ rather being physically sick:

In Chinese culture, they might think that it is not a physical illness in a sense that you are not like attacked by pathogens or stuff...it is kind of in your mind, you will get over it… it is a kind of state of mind vs something really wrong. (EH: 431).

A less acculturated informant viewed the situation as a ‘mind’ matter, yet it was not perceived as mental illness:

This is not mental illness, it was completely a psychological [mind] matter (MM: 307)

228 This ‘state of mind’ was interpreted as ‘emotional ups and downs’ by informants from

both Chinese and non-Chinese groups:

It is only the emotions, but everyone has their ups and downs. Many people will not think depression is a psychological problem. (CV: 148)

[A]lmost 100% in these cases think that their problems are quite normal. (ER: 210)

Given that these Chinese informants viewed ‘‘emotional ups and downs’ as something

common to everyone, seeking medical help for something considered a normal life

encounter becomes an ‘extraordinary act’. This may explain why over 80% of the

Chinese survey participants with previous depressive episodes, who had sought help from

family and friends, did not pursue professional help (See Chapter 6, Figure 6.2 for the

pathway).

Some non-Chinese informants also held this ‘depression-as-emotion’ view:

‘Depression is a natural human reaction and we all express depression… we can’t have highs all the time, I think we got to accept this – that there are downs.’ (AK: 166).

8.3.4. ‘Something’ Imbalance Given that the concept of ‘imbalance’ is frequently used in Traditional Chinese

Medicine it is not surprising that the concept of imbalance was often raised. Chinese informants frequently referred to ‘psychological imbalance’.

She encountered some pressure on her emotions, perhaps this is to say ‘psychological imbalance’. (MG: 12)

Is he just a little bit weak physically? Or is his psychological state of being out of balance? (CB: 458)

Some informants indicated that the first vignette looked like shen-jing-shaui-ruo (SJSR)

or possibly a case of hormonal imbalance:

Then I thought this happened (like the first scenario) in every era, at that time (citing her friend’s experience) the doctor said it was imbalance of the hormones, others said this was ‘shen-jing-shuai-ruo’ (CB:55)

229 According to Cheung (1989) commonly reported SJSR (or neurasthenia) symptoms are mainly somatic in nature or manifested in somatic terms. If such imbalance does not improve, it is believed that the condition can get to a stage where it is considered a

‘mental problem’.

I couldn’t sleep, very anxious, when my face became red, [I] felt some form of mental and emotional disorder… (CB: 53)

If it is very serious, somebody doesn’t want to speak to anyone, and then it is a mental problem. (EB: 195)

Some Chinese informants who knew someone who had been depressed before nominated

‘chemical imbalance’ as a possible cause.

Something becomes chemically wrong with their brain. (EH: 38)

By using scientific analysis, that is his brain is lacking some chemicals, (one) needs to take medication with those chemicals. One will gradually get balanced.(MG:356)

Some low acculturated Chinese informants retained a very traditional view:

In the mainland, many people talked about ‘feng shui’. The last generation often believed in ‘feng shui’, called it something like ‘hit by evil’. There are many such things in China. (MG: 305)

8.3.5. Descriptions of the Mentally Ill

Chinese informants described their encounters with people with depression or mental illness as follows:

All day long self-talk. (MA: 291)

He can’t control anymore. (MA: 293)

[I]if really there is violence associated, losing total self-control, by that stage, you define that as mentally ill. (CM: 173)

There are those with manic depression, any time will wave a knife or a fist. I am not joking. (CB: 579)

Dull gaze, walked slowly, weight loss. (ME: 345)

The mental illness you talked about is ‘schizophrenia! (MM: 319)

230 8.3.6. Descriptions of Depression

One English-speaking male Chinese used the analogy of a ‘nose-dive’ to describe depression.

[Y]ou get very de-motivated, you don’t feel like talking to people, you don’t feel like doing anything at all, not even something you used to like. You just don’t want to do it , you are just going through a ‘nose-dive’ if I can put it that way. (EB: 207)

However, he didn’t support getting help from a doctor but had in a previous section recommended counselling as the preferred option.

A member of the Mandarin-speaking group, who often reads palms for his friends, recommended that the person in the second vignette see a doctor for counselling but not for a prescription:

For his illness, it is not necessarily to get a prescription. His ‘depression’ has already turned into ‘mental illness’. Seeing a doctor, the doctor can counsel him, help him to think from other perspectives (MM: 365)

As the illness (regardless of whether it is the body or the mind) becomes serious and chronic, it will start to attract stigma as illustrated in Fig 8-1. The degree of stigma seems to be proportional to the severity of the illness.

231 8.4. Summary

It is apparent that many low acculturated Chinese perceive depression as an emotional state; thus it is not unexpected that they do not seek medical advice. When their so-called somatic symptoms, which in their eyes are simply the culturally salient modes of expressing their distress, develop to a point where they start to cause ‘unease’ or ‘discomfort’, consulting a family doctor does become a priority, a means of ‘restoring comfort’. The concept of imbalance is highly prevalent in the Chinese informants’ narratives; someone might be ‘out of balance’ with the cosmic force yin/yang or be experiencing ‘psychological imbalance’ or ‘hot/cold imbalance’. Given that the balance concept is deeply rooted among the Chinese, an explanation of ‘imbalance of brain chemistry’ should not prove too foreign a concept if offered by a Western trained professional. However, there is a longstanding cultural belief that excessive expression

(indulgence) of negative emotions can cause illness (To et al., 2004). Depressive experiences, when articulated openly, tend to attract little sympathy, let alone empathy.

As one informant put it,

“…the reason I don’t feel sorry for this guy [the unemployed person in the second vignette] in the same situation…. And [when] I migrated to Australia… my Dad just go and do it [take up a job that requires less qualification than you have] and they [my Dad and his friends] don’t give a crap what other people think…. And I think if they can do it at such a kind of close to their fifties and why can’t all these people [those in similar situations to the vignette]?” (ER: 306)

The strong stigma attached to mental illness serves as yet another deterrent from seeking help early. Stigma represents the social response to depression and is shaped by cultural interpretation (Good and Kleinman, 1985). However, among the highly acculturated groups, many informants who were educated in Australia had more knowledge of this

232 condition. Having enjoyed contact with both Chinese and mainstream cultures, many of them are more resourceful and have more choices in seeking professional advice.

In the next and final chapter I integrate all the findings reported in Chapters 4, 5,

6, 7 and 8. I present an overall picture of the complicated relationships of cultural beliefs, acculturation, and illness concepts and discuss how these have impacted on the help-seeking behaviours of the Chinese domiciled in Sydney. I utilise knowledge gained from earlier research and draw comparisons with this study. The main thrusts of my discussion are to provide an insight into how depression is seen through Chinese eyes and to facilitate an understanding of how my Chinese informants approach the broader aspects of mental health.

233 Chapter 9 Discussion

Ƚǀ͕ĿŗPΞȫƲŘ

One must cleanse one’s heart, build one’s character, manage one’s family affairs, govern one’s country, so that one rules the world.

Confucius, Greater Learning

In this chapter, I adopt a macroscopic approach to discuss the research findings. To dissect the complex phenomenon of clinical depression in the Chinese community, one cannot focus on a single perspective, be it medical anthropology or transcultural psychiatry. Using the analogy of completing a jigsaw puzzle, most of the pieces making up the parts of the puzzle have been put into place (e.g. depressive experiences, help- seeking, and illness conceptualization). Now I need to take a few steps back to examine how to link these parts to form the whole. In the following paragraphs I present my thesis using a multi-disciplinary approach to relate to audiences from different backgrounds.

Part I aims to enhance understanding of how Chinese construe different aspects of emotional distress. Part II addresses the medical professionals, specifically, early detection by bilingual Chinese GPs of patients at risk from clinical depression. For social scientists and medical anthropologists too it is important to discern why Chinese seek one form of help and not others. In Part III, I discuss the findings from a socio-cultural perspective. Many subtle cultural nuances need to be considered when managing mental health in a non-Western community. Findings of this study undoubtedly identify interdisciplinary collaboration as the way forward. In Part IV, I discuss how bilingual community service providers can work hand-in-hand with mental health professionals to

234 bridge the cultural gap between the helpers and the helped. My suggestions regarding different collaboration projects will enhance the cultural competence of mental health services to the Chinese community. In Part V, I demonstrate to public health educators how this research helps to embrace cultural diversity at a global level.

9.1. Subjective/Personal View: ‘Feeling not well’

Self-awareness of depressive symptoms and contributing causes

In Chapter 2 (Literature Review), I discussed the issues surrounding somatisation by the Chinese. I found that ‘insomnia, mood not good, anxious and tense, social withdrawal’ are among the most troubling symptoms nominated by depressed low- acculturated Chinese. As recent cross-cultural studies demonstrate (Kirmayer, 2001;

Simon et a; 2001), initial somatisation seems to serve the purpose of a ticket to enter primary care. One implication is for GPs to probe for psychological complaints if patients do not volunteer such information. It would also be appropriate for doctors to ask

Chinese patients about their own explanatory models (EMs) for their somatic/physical symptoms. The survey results indicate that Chinese and non-Chinese subgroups nominated common as well as culturally specific explanations for their depressive episodes. Being sensitive to a patient’s ‘emic’ expression (idioms of distress) will enhance early detection of depression. Validated screening measures with sound psycholinguistic equivalence (e.g. the DMI-10 Chinese version) will prove useful in identifying patients at risk of clinical depression. However, respecting a patient’s cultural beliefs and practices is the first step towards cultural competency. Discussion on the patient’s personal view of the depressive experiences and the implications for patient management are sketched out below.

235 9.1.1. Self-nominated most troubling symptoms

(a) Culturally salient symptoms

The survey revealed that for those who had experienced previous depressive

episodes, the six most troubling symptoms nominated by Chinese subgroups and

Australian controls were comparable. However, the individual rankings were

different, suggesting variations in saliency across cultures. These findings point to

the fact that while Low-Acc and High-Acc Chinese were concerned primarily with

the somatic symptom ‘insomnia’, they were also troubled by their ‘depressed mood’

or ‘mood not good’ which is the classic depressive symptom (See Chapter 5, Table

5.3). This result is similar to that of Parker et al.’s (2001) study comparing Chinese-

Malaysian and Australian depressed patients. The notion that Chinese typically

somatise their symptoms is still deeply entrenched in many Western-trained

psychiatrists’ minds, despite recent cross-cultural studies commissioned by WHO

that suggest that somatisation is ubiquitous (Simons et al 1999). This biased view

may lead to (a) GPs misguidedly looking for somatic symptoms among Asians or

(b) making diagnoses prematurely without asking Asian patients about specific

psychological symptoms.

(b) Lack of differentiation between mind and body

The fact that Chinese participants complain of both somatic and non-somatic

symptoms has been previously reported. Cheung (1995) and Ying (2002) are two

Chinese mental health researchers among others to advance the concept of body-

mind integration, an observation that was also apparent in my focus groups. Chinese

236 informants talked about insomnia and other somatic symptoms such as body ache

and weight loss; they also mentioned their cognitive symptoms such as ‘irritation’

and ‘mood not good’. In one particular example, the phrase ‘feeling not well’ was

used, and this could be physical as well as psychological. But in all examples

psychological symptoms were also nominated.

9.1.2. State Depression as measured by DMI-10

In Chapter 6, I report the mean DMI-10 scores of the two Chinese subgroups and the High-Acc Chinese and the Australian controls. The findings showed no significant difference whereas the Low-Acc Chinese (who completed DMI-10 Chinese version) returned a significantly higher mean score when compared with the Australians. The implications of these results are now explored.

(a) Are Chinese denying emotional distress?

The higher mean score of the Chinese DMI-10 suggests that the Low-Acc Chinese do not deny their emotional distress. While cross-cultural validation of the Chinese DMI-10 is in progress, the scores of the different language versions cannot be compared directly.

However, when given a list of 10 common depressive symptoms of cognitive nature,

Low-Acc Chinese did acknowledge the presence of these symptoms. The close resemblance of the mean DMI-10 scores between the High-Acc Chinese and Australian controls also counters any notion of denying emotional distress.

(b) Does ‘emic’ expression of affective states follow the rules of ‘social grammar’?

In this study, semantic translations using Chinese idiomatic expressions were given preference over literal translations. Low-Acc Chinese responded well to these idioms of

237 distress which convey meanings that could readily be identified by them. In the Chinese focus groups the majority of informants used words/phrases containing the ‘heart’ (‘xin’) radicals when describing their emotions. This observation confirmed Tung’s (1994) posit vis-à-vis ‘body-mind link’ via body-metaphor. It is worth noting the use of ‘negation’ +

‘positive attribute’ throughout informants’ discussions, e.g. the preference for the word combination ‘not happy’ (bù + kā-xìn; literally meaning ‘not+ open heart’) over the negative attribute ‘sad’ (shāng xìn; literally meaning injured heart). This rule of

‘negation + salient attribute’ is a distinctive feature in Chinese grammar (Shi and Hueng,

1993). In Chapter 2, I argue that expression of emotions follows the ‘social grammar’

(culture). This is a vivid example of the intermingling of language, emotions and culture.

9.1.3. How well are symptoms recognised from a given list?

The experience of a depressive episode is also reflected in how Chinese recognise common depressive symptoms (see Chapter 7). I elaborate my arguments below.

(a) Acculturation and recognition of depressive symptoms

Applying the concept of ‘culture’ as a form of ‘social grammar’, it becomes obvious that the Low-Acc Chinese would more readily recognise ‘concrete’ bodily symptoms whereas High Acc Chinese would more readily recognise the ‘abstract’ non-bodily symptoms (applying the Chinese ‘negation + salience feature’ rule here). The link between acculturation and the recognition of somatised experience can be conceptualised by the equation below:

E1 - [acculturation intensifies non-somatisation].

238 In other words, as Chinese become more acculturated, their degree of subscription to the

TCM notion of ‘body-mind whole’ attenuates and they are more likely to recognise ‘non- somatised’ experience.

In the survey findings of this research, while those Chinese in the low acculturation subgroup were statistically more likely to recognise somatic symptoms than the high acculturation subgroup (see Chapter 7, Table 7.1, the analyses on somatic symptoms), the differences between each Chinese subgroup and Australian Controls were statistically insignificant, i.e. the Australian subgroup was positioned between the Chinese subgroups in terms of recognising somatic symptoms1. Theoretically, Australians, being completely acculturated, should be least likely to recognise somatic symptoms among the three subgroups. So recognition of somatic symptoms may not be a simple function of acculturation. Other factors such as severity, may play a part. The link with degree of severity is reported in a study undertaken by Cape (2001) on primary care patients in London who found that those who were mildly emotionally distressed presented only somatic symptoms.

(b) Previous depressive experiences and recognition of symptoms

When the total sample was further divided into ‘never depressed’ and ‘previously depressed’ subgroups, the latter scored higher than the former. These findings suggest that participants might have been projecting their own experiences when answering the questions on the 35 depressive symptoms. Chinese at different acculturation levels, with a previous history of depressive episodes, were as good as the Australian participants when

1 Referring to Table 7.1, the respective somatic scores for the Low-Acc Chinese, High-Acc Chinese and Controls are: 7.0 ; 5.7, 6.2 . The comparison between the two Chinese subgroups at different level of acculturation was significant (7.0 Vs 5.7) but the Control group with a mean value of 6.2 (positioned between the two Chinese subgroups) did not differ significantly from either groups.

239 it came to recognising common depressive symptoms. Figure 9.1 is a diagrammatic representation of the recognition of depressive symptoms by the Chinese. People who have already experienced depression, regardless of cultural background and acculturation level, have higher mental health literacy in general. Their experience could usefully come to be viewed as an ‘asset’. Instead of being viewed as mental health ‘consumers’, they could be seen and come to see themselves as lay mental health educators who possess knowledge about ‘what it is like to be depressed’. Such a paradigmatic shift in their thought processes would have a positive therapeutic effect, for example, it would help to overpower their negative thoughts. This could be an effective strategy to combat stigma over mental health issues in the Chinese community.

Figure 9-1 Recognition of depressive symptoms among Low-Acc and High-Acc Chinese

Somatic Insomnia, heaviness in symptoms chest, body-aches and pain etc Salient to Low-Acc Chinese Chinese Recognition Depressed, loss of Core of symptoms interest, lack of symptoms motivation, and helplessness

Non-somatic Suicidal thoughts, feelings of (cognitive) worthlessness symptoms Salient to High-Acc Chinese

240 WHO designated the year 2001 as the International Year for Mental Health. The

World Health Report 2001 (WHO 2001) addressed aspects of consumer rights and education. One of the suggestions made was ‘consumer-run services’. I believe that a proactive approach like the one suggested above will not only empower these so-called

‘consumers’, but will also help them to gain the respect of the community because they can help others deal with their mental illness.

A recurrent theme in my focus group narratives was to suggest that the person in the vignette learn a craft or enroll in a course. Perhaps the therapeutic effect of artistic activities being perceived here is similar to that of ‘art therapy’ in Western psychology.

Certainly this recurrent suggestion from the informants lends support to my emphasis on valuing the consumers’ ability to self-help so that they feel in control again, that in turn boosts their self-confidence and self-esteem. This resonates with Gorman et al.’s (2003) findings that young people from culturally diverse backgrounds in Queensland, Australia, drew on their internal resources to identify their strengths, which reinforced their determination to cope.

9.1.4. Why does this happen to me? (Self-nominated EMs)

Making sense of one’s experiences is of therapeutic significance. Many focus group informants recommended the person in the first vignette seek help from a professional counsellor. By contrast, in the second scenario where signs of mental illness such as ‘dull gaze, walking slowly’ were obvious, informants recommended medical intervention. However, they preferred to introduce the idea of such intervention indirectly, for example meeting for yum-cha to discuss visiting a doctor. Those who had used mainstream mental health services readily suggested seeking professional help. This

241 reflects their bio-medical EMs. However, Chinese usually belong to a complicated web of social relationships. Both Chinese subgroups in the survey frequently nominated

‘family challenges’ as contributing to their distress. This could be due to the emphasis on interdependence in a collective culture (Markus and Kitayama, 1991). Harmonised family relationships are highly valued in collective societies, so any deviation from the optimal state can cause emotional distress. Unlike the Chinese, Australians are more likely to connect their depression to other physical illnesses, reflecting their knowledge on the bio- physiological aspect of depression. However, common themes of ‘life stress’, ‘work stress’ and ‘tension in romantic relationship’ were nominated by all groups, with no significant difference in terms of the relative percentage. Another expected result was that the Low-Acc Chinese experienced more migration-related stress, such as language difficulty and problems associated with adjusting to a new environment. In Chapter 6, I explored the timing of the first depressive episode to illustrate the fact that some Chinese migrants experienced something like depression at different stages of their migration.

These findings were in line with Bhugra’s (2004a) notion of ‘migration stress’ before, during and after the move. The relationship between migration and depression may not have a simple linear relationship; there are multiple contributing factors such as genetic predisposition, personality traits, stressful life events, social support, and coping repertoire, all of which may affect the manifestation of depression.

9.1.5. Implications

It seems obvious that the management of public mental health should target improving mental health literacy among the Chinese. Past research (Thompson et al

2004) has clearly shown that the most endorsed reason for delay in seeking help relates to

242 lack of knowledge about mental illness or available treatment. I outline below a few options to promote better mental health literacy.

(a) If Chinese are good at recognising symptoms how can they be encouraged to report these symptoms to their doctors? Option 1: Bilingual/bicultural health workers could provide psychosocial and mental health education to the community, reinforcing the message that GPs now receive professional training to manage patients’ emotional concerns. The following quote is an example of this suggestion.

If there is a need [to see a psychiatrist], the doctor will refer you! (CS: 139)

Option 2: When interviewing patients from non-Western backgrounds, GPs could ask questions regarding emotional distress sensitively to encourage discussion of their distress, as illustrated with the example below:

If they felt ‘uncomfortable’ to share their emotions with others, you can emphasize the fact that ‘counselling service’ is absolutely confidential. (CV: 107)

(b) If Chinese GPs are considered the first port of call in many depression cases, how can GPs be better equipped to make accurate diagnoses?

Option 1: The revised Chinese DMI-10 will be useful for screening Chinese patients in primary care settings once validation against formal diagnostic tools is complete.

Option 2: GPs have new alternatives. There is the ‘Better Outcome in Mental Health

Care’ program (BOiMHC) to upgrade skills in this area. They are also now able to refer patients to allied health professionals such as psychologists with visits to the latter attracting a Medicare rebate. On 1 Nov 2006, Medicare rebate items were expanded under a new Medicare plan for ‘Better access to Psychiatrists, Psychologists and General

Practitioners’ to enable Australians to access services promptly and economically from a

243 wide range of mental health professionals including those in the pilot BOiMHC program

(Department of Health and Aging, 2007). This option would capitalise on the respect many Chinese informants showed for the expertise of GPs, for example:

The doctor will tell [her] whether she need any medication and assess her situation. (CV: 125)

(c) If Low-Acc Chinese are more likely to talk about emotional distress with Chinese herbalists, how will these herbalists then refer their patients to mainstream mental health services?

Option 1: Communication between the respective professional bodies such as convening seminars and workshops to share expertise would be worthwhile. Some Chinese herbalists from mainland China have received Western medical training; some Chinese

GPs have an acupuncture qualification. Opportunities to share clinical experiences would benefit all parties and help promote understanding and discourage conflict. Chinese informants seem to access Chinese herbal medicine at a early stage:

[I]f you have mild SJSR,... some Chinese herbs can make you sleep better; it can relieve your emotions. (CS: 219)

Option 2: The allied health professionals in the ‘BOiMHC’ could be extended to include accredited Chinese herbalists, for example, members of the Australian Association of

Chinese Medicine. A precedent for this is the inclusion of Aboriginal health workers as allied health professionals in the BOiMHC program. Poliness (2004) reports how

Aboriginal health workers2 play a critical role in facilitating doctors’ understanding of the complex issues patients present with. In the case of the Chinese community, a similar

2 Aboriginal health workers focus on the spiritual and cultural wellbeing of patients. They are indigenous people working with doctors to help bridge the gap between Western medicine and the local communities.

244 policy could certainly be implemented. This would benefit the frequent consumers of

TCM. Participants from different groups in my study mentioned the positive outcomes achieved from uswing Chinese herbs but also that a Medicare rebate was not available for them. For example:

[Some Chinese herbalists] are too far away! There is no [Medicare] rebate! (CS: 249)

(d) Many participants in the focus groups expressed their wish to have more health talks available so they could learn more about clinical depression and its treatment.

Option 1: Deliver mental health talks through Chinese media including newspapers, radio and television. Bilingual mental health professionals could form a centralised education unit to produce quality educational materials for the Chinese community.

Option 2: Bilingual mental health workers could set up stalls during cultural festival events to promote mental health awareness.

Informants from different groups pointed to the need for organised dissemination of mental health information, as illustrated in these dialogues:

… [S]ometimes when we have a stall, there are many pamphlets about our services, all spread across the table… we will then give them out. … (CV: 96)

There has been a lot of work being done… it will take a lot more work. Chinese, basically, are relatively conservative, [we need] to make them feel that it is not a problem to share their emotions. (CV: 101)

But a word of caution: as Thompson et al (2004) point out, people’s thoughts about help- seeking may not translate into action. So evaluation of mental health education programs should be built in as part of the promotion mental health awareness. Also one recurrent theme regarding reaching out for help is the trust between the helper and the helped.

Early recognition of symptoms may depend upon a trusted family member, close friend,

245 or a respected migrant settlement worker in the community broaching the subject with the depressed person.

9.2. The first port of call: “You first talk to your GP…”

(CS: 136)

Protective factors like cultural values, family connectedness, social capital and self-control are likely explanations for lower incidences of depression. In the focus group discussions, informants attributed ‘social stigma on mental illness’ and ‘the Chinese tradition of discouraging expression of emotions publicly’ as reasons for the low percentage of Chinese consulting GPs for emotional distress. It seems crucial to provide

GPs (especially bilingual GPs) with the knowledge (that awareness of cultural nuances and indigenous concepts of mental illness will build a trustful relationship with their

Chinese patients. One approach might be to restore balance in the bio-medical model of depression, i.e. to find a framework that make sense to low acculturated Chinese. As focus groups narratives suggest, highly acculturated Chinese are more aware of their emotions and willing to utilise the available resources, for example they have better mental health literacy. Rather than waiting for Chinese patients to report psychological symptoms, doctors must be more sensitive to the idioms of distress expressed by their patients. The following paragraphs provide an overview of the findings within these primary care settings.

246 9.2.1. Are Chinese as susceptible to depression as their Australians Counterparts?

In Chapter 6, I compared the extent to which non-depressed Chinese of low and high acculturation levels draw on their cultural values for strength in times of hardship.

The non-depressed High-Acc group reported a high level of subscription to Chinese family values. For them, family values worked as a protection against depression; social support tended to reduce any likelihood of getting depressed. However, it is not clear whether endorsing Western cultural values increased ‘admitting’ to previous depressive episodes or the actual increased susceptibility to clinical depression.

Points to note are:

(a) While Chinese may suffer emotional distress equally as Australians, the former may not refer to it as ‘depression’. Participants from different language focus groups all commented on the vignettes as cases frequently observed among their friends and relatives. However, while Chinese informants from low acculturation groups acknowledged the depressed state of those in the vignettes, they failed to label the ‘mood not good’ condition as warranting medical attention.

(b) Even in the second vignette where psychomotor retardation was obvious, some elderly Chinese informants insisted that it was to do with personal determination and setting realistic goals rather than a condition or illness that required professional help.

Unique to Chinese informants from both low and high acculturation groups was the fact that they frequently talked about drawing on Chinese values for inner strength.

(c) Cultural understanding on the part of the therapist was important to the High-Acc

Chinese. Informants stressed the need for having psychologists who understood the subtle nuances of Chinese culture and saw it as an important aspect of psychotherapy. Some

247 Chinese informants were very keen to seek help from their GPs to relieve somatic symptoms. High-Acc Chinese who grew up biculturally, frequently talked about the dilemma of hybridity, i.e. being caught between two cultures. This is what Werbner

(1997) describes as ‘cultural hybridity’. Those caught between two cultures can be ambivalent towards both, finding them a mix of the familiar and the perplexing.

Subjective feelings of self-identity (Chinese vs Australian) seem to provide a quantifiable measure for acculturation. By asking a Chinese person to rate his/her self-identity, he/she objectifies a subjective ‘attribute’ for statistical analysis. In all subgroups there were participants well outside the normal range and the unique context of each of them may require closer examination. In Chapter 2, I tabulated both the protective and risk factors for Chinese of different acculturation levels. Here I post the same table (Table 9.1), adding insights gained from my findings.

A large-scale epidemiological study using formal diagnostic interviews to establish the prevalence rate of clinical depression among the Chinese would be a costly exercise. Should funding for such a project be secured, concerns over the use of Western diagnostic tools to assess people from non-Western cultures remain. As mentioned in

Chapter 4, the challenges of establishing psycholinguistic equivalency have been taken up more seriously by mixed-method research, in particular the importance of striking an

‘etic’ and ‘emic’ balance.

9.2.2. Are Chinese less likely to report emotional distress to GPs?

In Chapter 6, I compared the different subgroups’ rates of raising emotional concerns with their GPs. The differences between the Australian and the two Chinese subgroups were significant (see Table 6.8 for the Chi-square statistics). Chinese were less

248 likely to talk to GPs about their psychological problems. Qualitative data explain the phenomenon as ‘most people consult their GP for organic disease’. While Chinese may generally be more inclined to see doctors trained in Western medicine as suppliers of medication, informants raised other relevant factors.

249 Table 9.1: Research findings supporting ‘protective’ factors against depression and confirming ‘risk’ factors (in bold). Text in italics has been outlined in Table 1.1 as views extracted from earlier literature.

Low acculturation Chinese High acculturation Chinese 1. Motivation to Low – associate mainly with in-group (separation) High – attract racial discrimination due to frequent acculturate reduced chances of inter-group conflict. inter-group contact (assimilation).

Strong Chinese identity, more Chinese social Family support negatively correlated with DMI-10 support than local support, but majority wished score, stronger Australian than Chinese identity. to integrate into mainstream culture. Further Further research needed to examine ‘identity research into possible integration barriers is dissonance’ required. 2. Language skills Poor English language skills lead to acculturation High level of English competence. stress – limited ability to acquire new language skills. English competence is not correlated with SL-ASIA, in line with Laroche’s (1993) results: linear Recurrent theme in Chinese focus groups: relationship plateaued. Language skills needed for language skills vital for daily function; rely on basic needs; once that point is reached, other factors adult children to communicate with mainstream take over, e.g. self-identity society in English. 3. Social resources Rely on community organisations and Chinese Easy access to mainstream services. media. Informants cited access to Internet, media, work, Focus group participants involved in activities and education systems to learn about mental health run by community organizations these serve as literacy. important sources of information about mainstream culture, government regulations and social resources.

250 Low acculturation Chinese High acculturation Chinese 4. Self identity Strong stable ethnic identity: well-defined self. Self-identity can be in dissonance Generally have a stronger Chinese than The outward physical characteristics drove them, Australian identity. willingly or unwillingly, to embrace their ethnic identity. 5. Family Strong family values and social support. Role Torn between interdependence, i.e. family expectations relationship switching and loss of authority due to reliance on (collectivism) and personal aspirations for children’s better English skills to connect to independence (). mainstream society . The ‘never-depressed’ acknowledged family values Chinese values are mentioned at focus groups as as a major source of help when facing hardships. providing the inner strength required to fight negative emotions. In the survey, 40% of In light of these results, family values may well participants cited Chinese values as helpful in serve as protective factors. dealing with adversity. 6. Hierarchy of help- Provide healing in familiar contexts may delay Second generation Chinese may approach Chinese seeking: seeking Western medical help. medicine as one of the ‘alternative therapies’. professional, lay helpers and Chinese perceive herbalists as more suited to the Survey findings indicate individuals in this indigenous healing disclosure of ‘body-mind’ related symptoms, but subgroup were equally as likely as the Low-Acc due to the current Australian medical system, Chinese to consume herbal remedies. Informants seeing herbalists may be more expensive in the were more aware of services provided by long term. psychologists, and school counsellors, and were less concerned about ‘losing face’. 7. Cultural beliefs Major source of moral/spiritual support. Chinese socialisation competes with Western formal (Confucian, Taoist) education. A recurrent theme in the focus groups as well as English more fluent than Chinese yet they strongly reported by survey participants. retain the sense of ‘shame and guilt’. This observation is in line with research into ‘linguistic socialization’ (Freeman and Habermann 1996).

251 Some stressed the importance of building up a good relationship with their friends before they would encourage them to consult a GP. High levels of trust were required before disclosing emotional distress, even to friends because the Chinese culture has long discouraged overt expression of negative emotion. Others were concerned that the mismatch between their cultural backgrounds and that of their helper could lead to misdiagnosis. A study undertaken in Canada suggests that language barriers are the most important reason why people with poor English skills utilise health professionals of a matching ethnic group (Leduc and Proulx, 2004).

9.3. Cultural Interpretation: “his psychological state is out of balance?”

(CB: 458)

The Chinese conceptualisation of the depressive experience

An understanding of the lay Chinese conceptualisation of the depressive experience serves two significant purposes:

(a) To understand how and why Chinese seek one form of help and not another.

(b) To help health professionals understand the role of stigma in service utilisation.

Karasz (2005) found two different conceptualisations of depression in her qualitative study: for South Asian migrant women the model was depression-as-feeling and for

White European Americans it was depression-as-disease.

So, 1. Do less acculturated Chinese attribute their emotional distress more to

physical/non-psychological causes compared to the more acculturated Chinese?

And, 2. How do Chinese explain their depressive experience and mental illness?

An Australian informant talked about the ‘wellness model of mental health’. This resonates with an English-speaking Chinese informant’s comment on ‘mental hygiene’ in

252 Taiwan. Another informant cited a Chinese idiom which reminds Chinese to ‘nurture life’. All of these terms serve to focus on the positive aspect of maintaining mental health as part of a total health care package.

In Chapter 8, I addressed the body-mind integration and lay concepts of illness found among the Chinese. Mental health promotion programs could readily integrate these concepts into their educational messages. To be effective, joint effort is needed so that key concepts are reinforced. It cannot be left to one particular health professional.

The concepts of imbalance of brain chemicals and imbalance of emotions could be integrated. Campaigns to fight stigma will only be successful if the mechanism of depression can be explained clearly in a language that is easily understood by a lay person. Professionals should not exaggerate the ‘magical’ power of anti-depressants. For example, bau-yau-jie, literally meaning ‘resolve hundreds of worries’ appears in the

Chinese translation of the drug ‘Prozac’. But it fails to explain the likely side effects the approximate length of a course of treatment, and the time-lag before the medication takes effect (see Fergusson et al. 2005; Healy 2006; Lucire, 2004 and Whitaker, 2005). A summary of the side effects of SSRIs is provided in Appendix 9-1. Some Chinese, bothlay persons and professionals, have nick named antidepressants ‘happy pills’. Such a label does not explain the true mechanism at work and in its flippancy is doing the medication a disservice. Mental health literacy, like any kind of knowledge, is not acquired instantly. Knowledge accumulates with experience. During focus group discussions, Chinese people of all ages and acculturation levels found the discussions a rare opportunity to vent their negative emotions and to grow in mental health literacy by sharing experiences. This was indeed an added bonus for the participants. As many focus

253 group informants implied, stigma is the consequence of ignorance and, though often unintended, it has a detrimental impact on the mentally ill. Sartorius and Schulze (2005) note that there are three vicious cycles of stigma: self, family and professional. Fighting stigma is everybody’s business: every member of a community has to become involved.

With the advances in information technology, depression literacy websites such as

‘BluePages’ and ‘MoodGYM’ offer psycho-education. Christensen, Griffiths and Jorm

(2004), evaluating the effectiveness of these interactive websites in providing cognitive behaviour therapy, found they had a positive impact. Both resources are effective in reducing symptoms of depression. One of the concerns raised by the Chinese informants was the gossip that permeates the tight-knit social circles within the community. This is a likely deterrent to seeking help early. The delivery of mental health literacy via the

Internet could be welcomed by the Chinese as users can remain anonymous and passwords guarantee confidentiality. Plans to translate some of the current Black Dog

Institute fact sheets into Chinese are underway. Research into the application and effectiveness of these Internet-delivered mental health literacy materials can be valuable for two reasons: (a) they will provide access to the available e-mental health services conveniently and speedily when compared with the lengthy waiting time for specialist consultation, and (b) access anonymity will help to reduce the ‘shame and guilt’ perceived by service consumers.

254 9.4. An integrating model: “Go and find some Chinese community organisations’ (CS: 138)

Under-utilisation of mainstream mental health services and high involuntary admissions by Chinese-Australians reflect a large gap in service delivery. Earlier studies of primary care services in Australia and Canada have consistently revealed a low rate of consulting specialist psychiatrists but a high percentage of mental health cases in the hands of bilingual GPs. Without exception, Chinese GPs are stretched to the limit in terms of time and resources in trying to manage low-acculturated Chinese patients vulnerable to clinical depression. Both the survey and focus groups findings of the current study point to the need for better collaboration between primary care doctors, counsellors, psychologists and specialists. Other community services such as migrant settlement programs and women’s groups are also important sources of socio-cultural support to depressed Chinese. Many Chinese consult traditional Chinese herbalists for

‘unease’ that may not be satisfactorily treated by Western medicine; emotional distress is in this category. An alliance between the different service sectors and cross-referrals would be useful.

In Chapter 8, I proposed the model of a nine-piece jigsaw puzzle to symbolise the help-seeking behaviours of the Chinese focus group participants. The four corner pieces represent help from lay persons or non-professional/non-medical sources. In fact, help from self, family and Chinese cultural values is centred on the important doctrines of

Confucius. The following is a list of Chinese sayings cited in the survey and by focus group participants as what they brought to mind when facing adversity.

• Tiān-wú-jéju-rén-zhī-l ù (Heaven will not impede a person’s way);

255 • Bù-rú-yì-shì-cháng-bā-j ù (80 to 90 per cent of events are unpleasant);

• Chuán-dào-qiáo-tóu-zì-rán-zhí (Cross your bridges when you get to them) • Tiān-tā-xià-lái-zuò-gài-bèi (If the sky falls down, use it as a blanket)

These sayings may sound fatalistic, but within their belief in Heaven or the cosmos, individuals find room to be speculative, even optimistic, about what Heaven has in store for them. Chinese will exert self-control to work hard but at the same time trust that their fellow ‘in-group members’ will be able to offer help in times of need. At an even higher level, they can draw strength from their cultural values and the cosmos. Tu (1999) explains the ultimate value of human existence within the doctrines of Confucius. The

Confucian humanity (jen) has a transcendental sense: to reach this high standard, a human must transform him/herself into the ‘divine self’ of a Confucian. Though

Confucianism has always been considered a philosophy, Taoism (established around the same time by Lao Tzu and Zhuang Tzu, and also a philosophy) has incorporated many legends and is now practised as a religion in many parts of the world. Yeo and Meiser

(2003) outline the importance of integrating the belief systems of Confucianism,

Buddhism and Taoism into the cognitive therapy and treatment of depressive symptoms in the Chinese.

The essence of integrating Western medical models and Chinese cultural values into a therapeutic setting is trying to find common ground wherein both the helpers and the helped feel comfortable and safe. For the former, the environment has to be optimal for providing sound and effective treatment. For the latter, it has to enhance the communication of deep emotional concerns. As cited in Chapter 8, one Low-Acc Chinese participant’s reason for not seeking help was that she was ‘not sure whether an English-

256 speaking specialist could treat her’. This type of statement is often taken to refer simply to the language barrier. However, the preference of an English-speaking High-Acc informant for a psychologist with some understanding of her Chinese cultural background revealed the concern of a deeper cultural gap. In reality, while there is a substantial workforce of Chinese-speaking GPs practising in Sydney (see the Australian

Chinese Medical Association website, http://www.acma.org.au/), along with a growing number of bilingual psychologists and counsellors (see the Australian Psychological

Society website – http://www.psychology.org.au/psych/referral_service/Default.aspx), the number of bilingual psychiatrists remains limited (RANZCP, 2006 pers. comm.).

Collaboration between bilingual GPs and other mental health professionals is crucial. In the section that follows, I suggest a few possible collaborations between different medical and non-medical professionals, drawing on Australian and overseas examples.

9.4.1. Referrals from primary to specialist services

Previous studies of somatization among the Chinese were based on subjects recruited from venues offering Western medical services. In the current research, a sub- sample of participants was recruited from Chinese herbalists’ rooms. It became apparent that within this sub-sample, participants were more willing to talk about their emotional distress with their herbalists (41.2%) than with their GPs (11.8%). While exclusive utilisation of either Western medicine or TCM is rare, Chinese migrants in America showed a preference for consulting herbalists for chronic illness (Ma, 1999). If patients see their herbalists for continued management of a chronic illness, the herbalists presumably will have established good rapport with their patients. This was the impression I gained from recruiting participants at Sydney herbalists’ rooms. The

257 herbalists appeared to have loosened the professional boundary between ‘doctor’ and patient. This phenomenon was also observed by Ito and Maramba (2002) in a qualitative study undertaken at an Ethnic-Specific Clinic for Mental Health in the US. Patients treated culturally-matched therapists as ‘family members'. The authors describe a constant negotiation of role and status by the therapist, who takes a more professional stance while at the same time allowing a degree of informality. This type of therapeutic relationship might be the optimal one for both patients and therapists to work productively.

To support my argument, I illustrate here the TCM historical text of the basic

‘diagnostic interviewing skills’. In TCM the herbalist uses four techniques: look ǰ

(wàng), listen Ϊ (wén), ask Ŋ (wèn), feel the pulse Ƣ (qiē) (Wèi and Niè 1994).

Reported in a new magazine Arts + Medicine, American GP Dr Rita Charon, Professor of

Clinical Medicine at the Columbia University of Physicians and Surgeons, talked about practising ‘narrative medicine’ (Hui, 2005). Instead of ‘interrogating’ the patient for his/her medical history, she says ‘Tell me what you think I should know about your situation’ (p.40). For her the essence of narrative medicine is its capacity to ‘unify rather than fragment patients’. This typifies the holistic approach employed by Chinese herbalists that makes it so much easier to raise sensitive topics such as emotional distress.

The World Health Report (WHO 2001, p. 52) cites Saeed et al’s (2000) studies in many

African and Asian countries showing that approximately 40% of the clients of traditional healers suffer from mental illness. These findings suggest the importance of the prescribed social roles of the professional helpers. Patients were more likely to report psychological symptoms to a GP if the doctor-patient relationship was an on-going one

258 (Simons et al., 1999). Whitley, Kirmayer and Jarvis (2004) provide a summary of different models of culturally competent mental health services in various countries

(Whitley et al 2004):

1. Britain: specialist services are being provided in the voluntary sector in the UK

(Bhui and Sashidharan, 2003)

2. Australia: ethnic matching of clients and clinicians (Ziguras et al 2003)

3. Canada: cultural consultation (Kirmayer, Groleau, Guzder et al 2003)

4. America: clinician-patient racial pairing (Rosenheck, 1995).

More research in this area will be needed before the most cost-effective model can be established. A program called the Bridge Project has been established in New York targeting Chinese-Americans in New York and involving mediating personnel between patients and medical professionals (Chen, Kramer and Chen 2003). A team in Boston replicated the program with encouraging outcomes (Yeung, Kung, Chung et al 2004).

Before the implementation of the Bridge Project, Yeung et al. noted that Asian

Americans viewed mental health services as a last resort. With the Bridge Project in place, psychiatrists work together with a case manager (a mental health nurse) resulting in a hybrid ‘consultation and ethnic-specific’ model linking low-SES Chinese-American patients from primary care physicians to psychiatric services. Many clients using this service subsequently made positive comments about the on-site psychiatric evaluation and treatment. I certainly see the potential for such a project to be launched in an

Australian setting.

259 9.4.2. Collaboration between GPs and psychologists

Both my survey results and the focus group narratives indicate that Chinese at various acculturation levels consider psychologists and counsellors experts in managing social relationships. High-Acc Chinese showed a higher tendency to seek help from psychologists. Low-acculturated Chinese in the focus groups also talked about the availability of counselling services offered by bilingual workers. The Australian government recently announced the provision of funding to establish facilities for psychologists to work alongside GPs, to better manage patients with mental health concerns (Senate of Australian Parliament House, 2006a and 2006b). In the USA, the issue of psychologists needing to become more culturally competent when managing clients from culturally diverse backgrounds has been taken up boldly by the American

Psychological Association (APA). One of the stated aims is to promote racial equity and social justice (Constantine and Sue 2005). Indeed, psychologists may have more time to interact with their clients than GPs.

9.4.3. Linking the community /social worker to mental health professionals

Another important source of professional help comes in the form of the community/social worker. A project undertaken by the National Mental Health strategy

(Mihalopoulos et al 1999) found that many community health centres play an important role in offering mental health services to consumers from non-English backgrounds and their families. Often bilingual counsellors or mental health workers are employed to provide these services. Centres are usually located in areas with large numbers of people of CALD background, with staff sensitive to their particular needs (Mihalopoulos,

260 Pirkis, Naccarella et al, 1999). In fact, all Chinese-speaking focus groups were held at community centres serving the low acculturated Chinese. The recurrent theme of a high level of trust being required for a Chinese person to voice his/her emotional concerns suggests that symptoms are more likely to be recognised by close family members or friends, or a respected migrant settlement worker. Thus bilingual community workers/social workers could be an agent for change, reinforcing the idea of seeking professional help early. As mentioned earlier, the success of the Bridge Project is built on the ‘bridge’ established between helpers and helped. Without a liaison person who shares a language between the helper and the person being helped, communication and trust can be hijacked by language discrimination. This is what happened with Spencer and Chen’s

(2004) representative sample of Chinese Americans. Negative attitudes towards mental health professionals, resulting from language-based discrimination, acted as a deterrent to using mental health services and led to a greater reliance on informal assistance: seeking help from friends, relatives and informal services for emotional problems. The focus group narratives of this study revealed a similar trend (see Chapter 6).

The mental health crisis teams attached to major Sydney hospitals also provide case managers to follow-up cases that come in contact with mental health services through involuntary admission. While multicultural health workers based at a particular community facility provide general information regarding access to the health care system, ethnically-matched case managers play a vital supporting role when the person becomes a mental health case. It would be ideal if collaboration between the community and health sectors was enhanced, e.g. if community workers could refer vulnerable individuals to bilingual case managers before they become cases for the crisis team.

261 Underutilisation of mental health services is widely recognised in the field. It is not just a matter of lack of knowledge or poor English as discussed earlier: it is a matter of trust, as portrayed in the words of the Mandarin-speaking informant who asked ‘How do I know the doctor can really help me with my problems?’ Thus, promoting mental health among

CALD communities requires a more proactive approach. Mental health professionals need to reach out to the community and deliver their services to the Chinese in a culturally competent way. An example of this is my proposal for the hybrid programs

‘Parenting Teenagers’ and ‘Mental Well-being’ which I put forward as an innovative approach to promoting mental health (Chan 2003).

Providing a non-hostile atmosphere in which Chinese can enjoy cultural interaction with other Australians is vital for their mental health. In a recent program on

Australian values entitled Aussie Rules aired on SBS’s Insight series (SBS 2006), the then Deputy Mayor of Ashfield Council described how many migrants felt greater affinity for their country of origin and were slow to integrate. Ashfield is a Sydney residential area with a high ratio of Chinese migrants. A well-known comedian disagreed and advocated embracing and accommodating the new people. The Deputy Mayor then shouted from his seat, 'Integration. We need integration. We need everyone to feel

Australian!’ He did not seem to realise that such pressure to integrate/acculturate threatens the ethnic self-identity of the newcomers. The results of the subjective self- rating of Chinese and Australian identities by the participants in this research illustrate that the concept of ‘cultural-hybridity’ is highly prevalent. Neither is this sense of multiple-identity restricted to people of distinctively different cultural backgrounds. In an era of rapid international travel, high migration and advances in information technology,

262 it is hard to find individuals with a single identity, for example one American-born informant in the English-speaking focus group still felt her American identity strongly after living in Australia for over 20 years.

9.4.4. Centralised collaboration network

The strongest message delivered by the research findings is that there is a pressing need to adopt a more collaborative model. Australia’s three different mental health services sectors, namely the health system, the psychological service, and socio-cultural support should be of equal weight. There should be substantial overlap between the different sectors indicating the importance of collaborative work and inter-disciplinary knowledge (see Figure 9.2). The involvement of the Chinese herbalists is lacking at the time of writing due to unresolved registration issues and scepticism regarding the efficacy of herbal ingredients. However, WHO has developed expertise and guidelines to help its member states to explore legal avenues to practise Traditional Medicine and

Alternative/Complementary Medicine (WHO, 2002a), and to this end the outlook regarding herbalists is at least hopeful. With more evidence-based medical research into various Chinese medicines being undertaken at reputable universities (Johnston, 2003;

Lee, Yang, Huh et al, 2001; Tang, Zhan and Ernst, 1999), the role of TCM in effectively managing depressive illness will eventually gain recognition. Yuen and Lin (2000) urge other researchers to adopt an interdisciplinary approach to TCM to facilitate the discovery of herbal remedies.

Merson (2004) also advocates more interdisciplinary research in order to foster better health care but the current narrow disciplinary interests of those controlling access to research funding may render the path to such projects thorny. In the next section, I

263 outline how the findings of this research can be extended to address global concerns about clinical depression.

Figure 9-2: Implications for ‘culturally competent psychiatry’

ʥƙdžƧ ǀɃřɋĊĵ Culturally competent psychiatry ¤ͥĊĵ Health system (doctors,

hospitals, etc) Chinese GPs & herbalists referral

Ư Psychotherapy ŧŮdžƧɗƍ counselling, Socio-cultural CBT* & Family support therapy family & friends

ŧļDžΊĊĵ Support groups & community services

*CBT – Cognitive Behavioural Therapy

264 9.5. Public health at a global level: Population mental health

‘…how do we integrate and encourage more connection in our community …’ (AK:160)

The concept of population health has long been applied to the prevention of physical illness, e.g. infant immunization programs. In recent years it has also been applied to mental health as in ‘public mental health’ and the improved mental well-being that is a positive spill-over effect from improved upstream determinants of health

(discussed in Chapter 2). My qualitative data strongly indicates that the concept of population mental health is very relevant to the Chinese community. Although the notion of ‘social capital’ is already part of what is a collective culture where family and kinship are so highly valued, it is under-used in professional services. The individual bio-medical and psychotherapy interventions currently offered to depressed Chinese often lack cultural relevance. Programs that build healthier families, communities and even countries, for example, parenting programs to nurture family connectedness, seem to me to be the more culturally competent options to improve the mental well-being of Chinese people in Sydney and also other ethnic non-western communities in the West. The following are my proposals.

9.5.1. A multi-disciplinary approach

In Chapter 2, I outlined the paradigm shift to population health initiated in the

U.S. (Mrazek and Haggerty 1994) and now endorsed by WHO. This initiative adopts a whole population systematic approach that encourages individuals to focus on improving their mental well-being across the life-course. The Commonwealth of Australia published the first National Mental Health Plan in 1992 and the second in 1998. The most recent

265 plan includes the report Framework for the Implementation of the National Mental

Health Plan 2003-2008 in Multicultural Australia. Researchers and public health campaigners around the world are continuously searching for research evidence to prove the cost-effectiveness of population health promotion in ‘natural experiments’ (e.g. the

WHO website’s feature series: Voices from the Frontline, 2006). The findings pertaining to help-seeking strategies for emotional distress among Chinese-Australians of different levels of acculturation clearly demonstrate the need for a public mental health approach.

Raphael (2000) is confident that such a model could provide a ‘comprehensive, evidence- based and cohesive approach for the optimum provision of mental health care ...’ (p. 1). It would involve a multi-disciplinary approach including input from GPs, psychiatrists, health educators in both the public and private sectors and members of the wider community such as consumers, carers and non-government organizations. Many people needing treatment for clinical depression fail to gain access (see Stuart et al. 1996 and

Klimidis et al. 2005) and more proactive strategies are needed. A public health approach identifies the problems experienced by the total population and fostering resilience and family/social support. It is viewed as the parallel of immunisation for certain infectious diseases. Resilience programs have been introduced to primary school children aged 9 to

13 (Burrows, McQueenie and Newton-John. 2005a, 2005b; NSW Department of Health,

2003a). Wyn and colleagues (Wyn et al. 2000) have launched a pioneer program

MindMatters which provides a framework for national mental health promotion in

Australia’s secondary schools. Its aims are to enhance best practice in a whole-school approach to mental health promotion. Since schools provide almost universal access to young people such programs gain excellent coverage. Positive Parenting Programs

266 advertised along with other Healthy Lifestyle courses offer another example of a population approach (NSW Department of Health, 2003b) that concerned agencies confirm that stable and nurturing environments are essential to the development of intellectually and emotionally sound minds. The emphasis placed on Chinese family values as a means of overcoming adversity in both the survey and focus group discussions endorses such an approach and signals that Chinese-Australians would welcome this type of preventive strategy.

9.5.2. Building social capital to guard against mental ill-health

The four corner pieces in the ‘Help-seeking Puzzle’: family and friends, cultural values, spirituality and the self, can be viewed as the ‘social capital’ of the Chinese community. However, social capital can be an asset or a liability. Family cohesion in cultures that emphasise collectivism enables a person to turn to tight-knit family members for help during crises. So a Chinese person is generally reluctant to seek help outside the family circle because a high level of trust is required for the disclosure of personal information. In this research, the highly acculturated ‘never-depressed’ Chinese nominated ‘family values in the Chinese culture’ as most helpful when facing adversity.

This resonates with Cullen and Whiteford’s (2001) proposition that a higher level of social capital decreases incidence of depression because it reduces certain social stressors, for example social isolation. The links between social capital, health, and mental health are not yet fully explored but there is increasing evidence to support the notion that social capital is vital for sustainable community development as well as poverty alleviation (World Bank, 2006).

267 Resilience in the face of adversity is highly praised in Confucian teaching. It is viewed as honourable to be able to endure hardship through willpower. This was a recurrent theme in the focus groups. A missionary sense of commitment to self-help and a positive belief in the premise that ‘Heaven will not impede a person’s way’ were seen as integral to combating life’s inevitable lows.

9.5.3. Global action to reduce the stigma associated with mental illness

Due to the strong stigma attached to mental illness in the Chinese culture, straightforward early detection and early intervention may not work. This is apparent in the findings that Chinese are as likely as Australians to recognise common depression symptoms but for mild episodes, low-acculturation Chinese often just turn to family and friends without seeking further professional help. A more buoyant approach based on collective action to promote the healthy well-being of all without shaming the psychologically imbalanced few is the preferred tactic for mental health promotion among the Chinese community. Integral to the public mental health approach is acknowledgment of the social factors, e.g. culturally mediated shame and guilt, that contribute to overall individual well-being. I refer to Mental Health First Aid in Chapter

2 and this is another concept linked to a population health approach. The knowledge and confidence of those in the social network with the capacity to help individuals who are prone to depression and suicide are deliberately fostered. I approached the MHFA administrators about the possibility of a future MHFA program in Chinese and learnt that government funding is lacking (Kanowski, pers. comm. 2006).

268 9.5.4. Role of media in reporting mental illness

In all focus groups, informants talked about the role played by the media in forming attitudes towards people with mental illness. In particular, informants recalled news coverage involving physical aggression and suicide. They believed the media have an important part to play in providing accurate information about the different types of mental disorders and the mental health services available. Reporting positive cases rather than skewing towards the negative would help to reduce stigma. The Australian

Government has published a guideline Achieving Balance for media to follow when covering this type of news (Pirkis, Blood, Francis et al., 2002). The World Psychiatric

Association in their campaign on stigma reduction (Sartorius and Schulze, 2005) invited journalists to meet people with mental illness to unveil the myths and attempted to enhance communication between psychiatrists and the media. Such measures are an important component in public mental health promotion.

9.5.5. E-mental health

The theme of self-help was prevalent in all focus groups. Informants perceived the Internet as the best tool to allow those in distress to remain in control and capable of exploring the services available (i.e. websites on depression) and what action to take.

Certainly the web promotes a sense of empowerment: consumers are given the upper hand in choosing the goods and services. International collaboration to translate the

Depression and Bipolar Disorder fact sheets, currently available on the Black Dog

Institute website, into Korean and Chinese is underway (Parker and Mitchell 2006-

March-31 pers. comm.). These represent the initial steps taken to ‘indigenize e-mental health’. However, certain issues including confidentiality, ethical responsibility and

269 liability are yet to be spelt out clearly and systematically. With Internet use becoming so popular and increasingly affordable, and providing responsible monitoring of high quality health information is in place, I see a huge potential for so-called e-mental health among the Chinese. Kirkby (2005) calls for more vigilant planning in promoting reputable mental health websites and providing culturally competent backup services.

9.5.6 The value of transcultural research

With globalisation and international migration taking off at incredible speed, major hospitals around the world find themselves caring for patients from diverse language and cultural backgrounds. So both the emotional distress measurement tools described in

Chapter 4, originally developed in English and now being translated and validated systematically by a mixed-method research design, will prove useful. More importantly, throughout the validation process, mental health professionals and academics are being provided with the opportunities to reflect on the values of transcultural research. In essence, researchers walk along the bridges that connect culture and emotions while at the same time explore the science of discovering meaning. Thus they make contributions to epistemological knowledge and gain insights into the nature of the links between depression and culture. I list below some of the highlights of such a journey.

1. The most fundamental and generic skills required in eliciting answers to important

research questions from participants are: respecting the individual’s own explanatory

models (EMs) during the initial interview, which in turn enhances accurate diagnoses

and effective intervention. However, making sense of mental distress is not simple

rational deduction, it is a process shaped by culturally-coded interpretations.

270 2. The varying intensity of emotions attached to particular language by bilingual speakers, though subjective and not quantifiable, reveals itself to be open to systematic analysis.

3. Translation of one language into another may never be perfect, even after carefully planned cross-validation. Hence the importance of developing emic constructs in diagnostic instruments as illustrated in the tools used in the current research. Local adaptations must be taken seriously by researchers working with heterogeneous ethnic groups such as the Chinese. Managing linguistic diversity remains one of the central challenges of cross-cultural researchers; a clear specification of the presumptions would prove useful. By breaking down barriers to explore specific topics in a foreign culture, cross-cultural researchers are able to observe the phenomena in their own cultures from a new platform, i.e. an anthropological perspective.

4. Developing cultural knowledge about a specific ethnic group does not equate to stereotyping, e.g. Chinese somatise, a myth or a fact? Theoretically, researchers can acquaint themselves with generic skills such as respecting cultural differences and taking a non-judgemental stand. Practically, they can ask patients about their worldviews and then reflect on their own viewpoint to eliminate any presumptions.

Treating patients as partners in the process of mental health management will in turn facilitate medication concordance and enhance cultural competency.

5. Collaboration between health professionals will undoubtedly augment communication at the level of expert knowledge and ‘emic’ meanings. This will benefit patients from non-Western backgrounds and mainstream mental health

271 consumers by fostering a pluralistic approach, making a variety of treatment options

available. I present below a synopsis of what has been learned from the research

findings:

Table 9.2: Summary of survey results and focus group discussions

Survey Focus group discussions Prevalence of Greater prevalence with higher level of Admitted having had similar experience to self-reported acculturation the scenario. depressive Comments that both scenarios were episodes common, not denying depressive moods. DMI-10 Among subjects answering English Informants talked about emotional distress measure questionnaire: similar level of mean DMI-10 but only sought medical help in severe cases (emotional/cogni scores but different rate of admitting to Sought counselling services or confided in tive distress) lifetime depression when compared to the close friends in case of mild-moderate Australian Controls. emotional distress. Symptoms Chinese most worrying symptoms included Most salient symptoms mentioned were (similar or ‘insomnia’ and ‘anxious and tense’ ‘insomnia’, ‘dull gaze’. different) suggesting ‘body-mind’ holistic view. Chinese expressions used for ‘heart-radical’ Regarding the 35-symptom checklist : body-mind link: xin-faan, bu-kai-xin, faan- Chinese and Australians equally good at mun, mun-mun-bu-lok, kwai-xin. recognising core symptoms. Limited to the scenarios i.e. repeated the Low-Acc Chinese more likely to recognise major problems of the vignettes. somatic symptoms; High-Acc Chinese, psychological symptoms. EMs Chinese frequently nominated ‘family Talked about ‘family dynamics’, conflicts’ (collective culture orientation, ‘relationship’ (young mother vignette) interdependence in social roles) More acculturated Chinese were aware of Common EMs: relationship breakdown, life the bio-medical model. stress, work stress Unemployment, unrealistic expectation Australians – physical health problems, (unemployed male vignette). induced depression. Help-seeking For mild episodes, most Chinese seek help Nominated sources of non-medical help. from family and friends. For severe cases: suggest professional help For persistent episodes about 40% would through indirect means e.g. engage in an consult a GP. unrelated activity as a means of raising the topic. Described reasons for consulting GP as somatic complaints. Cultural values Draw upon cultural values to deal with Tapping into one’s cultural values for adversity. Both Chinese subgroups described strength to combat hardship was a recurrent

272 cultural values as helpful in dealing with theme in the Low-Acc Chinese focus groups. adversity. Acculturation According to language preference, Chinese Mandarin- & Cantonese-speaking level were grouped into ‘Low’ and ‘High’ informants matched with Low-Acc group, Acculturation subgroups. English-speaking informants with High-Acc group

9.6 Summary of implications

To close the final chapter of my thesis, I now summarise what I perceive to be the most important implications for this mixed method transcultural research into the depressive experiences of Chinese-Australians in Sydney.

9.6.1 Depressive experiences

From the findings of the survey it is apparent that while Chinese and Australians have similar core depressive symptoms, culture shapes their differing attentiveness to, interpretation and presentation of these symptoms, for example as somatic or psychological. The notion of ‘linguistic saliency’ is widely documented in language development. Children living at the North or South Poles, for example, acquire rich vocabularies for different forms of ice and snow. I transfer this concept to the area of human emotions and their verbal expression as guided by their ‘cultural saliency’. Chinese children are negatively reinforced to talk about their negative emotions but positively reinforced to express them using body metaphors, for example ‘I have an angry liver’ instead of ‘I am angry’. Chinese adults are more likely to talk with someone who has a cultural understanding of what s/he means by ‘gan huo ǖ’ (literally ‘liver fire’). The fact that highly acculturated Chinese-Australians voiced their preference for therapists with a good grasp of Chinese cultural nuances may sound like ‘stating the obvious’. But it is in fact a quest for cultural competency among the mental health professionals. The inappropriate use of the term ‘cultural competency’ can cause discomfort among Anglo-Celtic and other mainstream health professionals, for example when it is confused with being politically correct (Lester, 1998). To appreciate the real significance of cultural competency we need only imagine if cultural competency had not been incorporated into mental health care. Misdiagnoses resulting in delayed treatment or

273 malpractice has obvious, serious consequences, for example fatality from suicide. It was commonly agreed by both Chinese and Australian informants in this research that trust was the ticket to accessing sensitive information. One aspect of cultural competence is what health professionals call ‘social competence’ in history taking, a skill that is fundamental to establishing a rapport during any diagnostic interview. Lacking rapport, patients may feel misunderstood or disrespected which undermines an optimal therapeutic relationship. Early termination of or refusal to seek treatment may be the outcome. This can happen to any patient irrespective of cultural or linguistic background.

9.6.2. Concepts of illness

If illness experiences are shaped by culture, so too are concepts of illness. Prevalent among the low acculturated Chinese were the concepts of ‘hot/cold imbalance’, ‘emotional imbalance’ and ‘psychological imbalance’. They can be traced back to the cultural belief in external yin/yang forces in the cosmos and the internal yin/yang balance of qi in the body. The Chinese commonly make an association between Human and Nature and over the course of their history, cultural/mythical/spiritual elements that emerged over 5,000 years ago have become intertwined with this connection. The influence of Confucianism, Buddhism, Taoism and Christianity together with geographic, social, political and economic changes such as the Cultural Revolution have added vibrancy to the explanatory models Chinese use for their experiences of suffering. This is illustrated in the focus group narratives. The stories told by the highly acculturated Chinese-Australians reflected the reality of those straddling two cultures. The non- Chinese groups represent the worldviews of those who grew up in Australia. An understanding of their lay concepts of illness made it easier for me to interpret the observed help-seeking strategies employed by the Chinese to deal with their emotional distress. I conceptualise the findings from the survey and the focus groups using a ‘Help- seeking Puzzle’. If mainstream health professionals believe that consultation with a psychiatrist should be the ‘centre piece’ of care, the pressing task is for them to collaborate with bilingual Chinese GPs and psychologists to refer patients to the most appropriate specialist care. But from my point of view as a bilingual, bicultural medical anthropologist, it is preferable to describe the different options available to a depressed

274 Chinese and indicate that different individuals in similar circumstances may well opt for different forms of help. The action taken will depend on the severity of the case and how one makes sense of the circumstances. Sometimes more than one form of help is required to deal with the complex mechanisms governing human emotions. I believe in providing as much support as possible once the person has decided where to start or who to approach first. It is evident that I am thus not only advocating a pluralistic non- discriminatory approach but also an integrated approach that acknowledges that a person may be facing difficult circumstances that cannot be fixed by medicalising either the somatic or psychological symptoms.

9.6.3 Bridging services

Throughout this discussion, I have made suggestions regarding different forms of services at various levels from personal, professional through to community. I want to emphasise that under-utilisation of mental health services by Chinese-Australians is an issue beyond access. Common structural hurdles to services like ‘inconvenient opening hours of clinics’ or ‘long waiting time to see specialists’ did not emerge in the focus group narratives. However, this does not imply the non-existence of these hurdles but rather reflects a more serious problem:

Is there actually something to access?

Are existing services culturally sensitive or appropriate for the Chinese communities?

I have cited quite a few examples of models used in other countries with a predominately Western or Anglo-Celtic culture facing an increasingly diverse ethnic composition similar to the Australian context. Earlier research findings strongly suggest that there are obvious language difficulties and a hidden cultural gap in the services. The next step is to implement programs to bridge identified service gaps. The ‘Bridge Program’ in New York (Chen et al. 2003) provides a sound model. This program could work very well in Australia if bilingual and bicultural mental health workers are available to act as the ‘bridge’. But, what about other ethnic groups in which bicultural health workers are less readily available? Since the use of both bio-medical Western and traditional medical

275 systems is very common among the Chinese, an integrated model that blends indigenous healing practices, primary care and specialist care could also work well. The indigenous healers would provide holistic care that treats both the body and the mind. During the course of treatment, the patient’s primary physician would be kept closely updated on progress and if the condition requires more acute medical intervention, the doctor could then refer the patient to a psychiatrist. An open dialogue between Western doctors and the traditional healers would serve as a bridge to enhance cultural competency in patient care.

A more direct approach would be for clinicians to become the bridge between patients and medical services, i.e. all Western trained doctors learn the generic skills required to manage patients from diverse cultural backgrounds. The new undergraduate medical program at UNSW is a relevant example. Since 2004 the curriculum3 has incorporated ‘cultural competence’ into the teaching and learning process through all its phases and domains. Multicultural Mental Health Australia provides an on-line resource to help mental health workers raise their ‘cultural awareness’ (A Cultural Awareness Tool Kit, Multicultural Mental Health Australia, 2002). Some overseas examples include the U.S. Office of Minority Health’s online courses (Office of Minority Health, 2006) and ‘A Family Physician’s Guide to Cultural Competence Care’ where GPs can earn credits towards their Continuous Medical Education (CME). The American Medical Student Association (2006) has posted on its website different scenarios to share cultural competence with fellow students. These initiatives acknowledge that:

Rather than being insulted by another culture's perspective, culturally competent providers welcome collaboration and cooperation.

9.6.4 Cultural competence

Culturally competent mental health care for Australia’s multicultural communities is the ultimate goal; the highest standard. To many mainstream mental health workers it

3 The new curriculum commenced in 2004. Through small group tutorials students are given opportunities to engage in discussions aiming at linking cultural issues with indigenous, rural and remote themes. Collaborations with NGOs and consumer groups are given much weight to make possible a wide exposure to practicum and internships with ethnic communities such as Migrant Resource Centres and inter-agency networks.

276 may seem remote. Meeting the demands of heavy caseloads has already put workers’ own mental health at risk, without adding the challenge of cultural competency. Pressing for additional government funding for more staff and resources requires not only the advocacy of consumers and carers at grass roots level, but also evidence-based research to support the claim of existing service gaps. As outlined earlier, stakeholders in research funding in 2000 perceived scientific investigation into mental health in CALD communities as a low priority (Jorm et al, 2002). The remaining option is for CALD consumer and carer groups to agitate more forcefully. I cannot speak for other CALD communities but allusions made during the focus groups to concepts like ‘advocacy’ and

‘assertiveness’ sounded foreign to the Chinese informants. Apart from the language hurdle, the cultural hurdle seems enormously difficult for them to jump over.

Internationally, UNESCO’s Declaration of Cultural Diversity (UNESCO, 2001) affirms that the cultural rights of people of every background should be respected. A group of dedicated public health campaigners in South East Health (SEH) have published a tool kit entitled Four Steps Towards Equity (Equity Project Team, SEH, 2003) with the aim of assisting health professionals and organisation managers to embed the concept of equity at all levels of health services. Its goal is to help to make culturally competent health care more achievable.

9.7 Future directions of research regarding ethnicity

9.7.1 Group heterogeneity

Chinese are not a homogenous group: they are linguistically diverse. Focus groups were conducted mostly in Mandarin and Cantonese. English language groups

277 attracted highly acculturated bilingual Chinese. Thus it is important for researchers to acknowledge the diversity of ethnic groups and make a concentrated effort to manage that heterogeneity.

9.7.2 Self-identification

For the Chinese participants, I used the criterion of ‘self-identification’. However, among non-Chinese migrant participants, those who had lived in Australia for more than

20 years and were able to complete an English questionnaire did not necessarily self- identify as Australians. The reason for the discrepancy in criteria for Chinese and

Australians was to ensure the ‘Controls’ represented people who had lived in Australia for a considerable time and represented the multicultural aspect of Sydney. I suggest that future cross-cultural researchers would benefit from a set of well-defined criteria for their target ethnic group in accord with their study objectives.

9.7.3 Generalisability

Recruiting subjects from bilingual Chinese GP clinics the sample may have resulted in a high tendency among individuals to subscribe to Western medicine. As indicated by the sub-sample recruited from the Chinese herbalists’ rooms, there are Chinese who consider their Chinese herbalist to be their primary family physician. Future research may consider recruiting from a community sample in order to better generalise.

9.8 Future research in clinical depression among non-Western communities

9.8.1 Mental health literacy

In the next phase of the Black Dog Institute (BDI) research, I have developed a questionnaire which addresses mental health literacy. This includes direct questions

278 regarding stigma, like asking participants about whether they view consulting a psychiatrist as admitting to (a) ‘personal weakness’; (b) ‘insanity’; or (c) ‘family history of mental illness’.

In the interests of exploring Chinese resiliency and in connection with the next phase of the BDI project, a second questionnaire has been developed to further delineate whether the observed lower self-reported prevalence of depression among the Chinese is merely a reporting bias or a true difference related to culturally-specific coping strategies.

Thirteen coping strategies frequently mentioned by subjects in this survey and focus groups have been identified and will be added to the questionnaire to explore the Chinese coping repertoire.

9.8.2 Role of religions in help-seeking

Studies have been undertaken on the role of religious beliefs in help-seeking

(Abe-Kim, et al. 2004; Halliburton, 2004). However, further qualitative study using in- depth interviews may illuminate the exact impact of religion on mental illness in the

Chinese. If funding is available, longitudinal studies to examine the relationship between emotional distress and spirituality may overcome the constraints in retrospective reporting (Abe-Kim, Gong and Takeuchi 2004).

9.8.3 Qualitative enquiry

Future research using in-depth interviews to collect qualitative data regarding help-seeking as expressed by the different voices (Chinese and Australians) pertaining to their ‘depressive experiences’ will best serve the purpose of reporting ‘negative cases’

(those differ greatly from a ‘typical case’). For example, among the Australian-born

Chinese ‘ABC’, there were two survey participants who preferred to complete Chinese

279 questionnaires (c.f. the norm for other ‘ABC’ – very limited Chinese reading comprehension). They also had low level acculturation as indicated by their SL-ASIA scores. Such deviations from a typical ‘ABC’ will require closer examination within the individual’s unique context.

9.8.4 Gender differences

Researchers have always been keen to try to explain female preponderance in clinical depression. Due to the focus on clarifying conceptual differences in depression between the Chinese and Western cultures, the study design is not deemed suitable to conduct statistical analysis of gender differences. However, the current study has established strong evidence to support the notion that culture shapes emotional experiences. If the two genders are treated as cultural categories this study endorses a place for gender role socialisation in the experience of depression. If future cross-cultural studies in clinical depression are to help explore gender differences, consensus on an operational definition of clinical depression across cultures will be needed.

9.8.5 Management of mental health cases by Chinese GPs

In the past, focus has been on raising the public’s awareness of mental health issues including the symptoms of depression. But this is only half of the help-seeking story. When patients, especially those of different cultural backgrounds, consult their doctors and report their non-somatic concerns, do GPs detect the early signs of depression? Do they recognise the cultural nuances of their patients’ emotional distress?

Some Canadian research suggests that Chinese-speaking GPs there are ‘less disposed to diagnosing mental health problems or referring their patients to specialist care’ (Chen and

280 Kazanjian, 2005: 51). The Canadian experience may not apply unreservedly to Sydney but there are some strong contextual Chinese/mainstream culture parallels. In a study undertaken in Melbourne, Klimidis, Minas and Kokanovic (2005, 2006) found that GPs not registered with Better Outcome in Mental Health Care (BOiMHC) have more difficulty referring patients to specialist care and getting assistance from interpreters and translated materials. The relative effectiveness of the clinical management of mental health cases by bilingual and monolingual GPs requires further investigation.

9.9 Conclusion

This chapter draws together the findings from both the survey and the focus groups to propose a systematic approach to implement culturally competent mental health services to the Chinese community in Sydney. The principles underpinning my proposal are built upon a population mental health paradigm which can be extended to other non-

Western communities with the necessary adaptations.

The initial awareness of depressive symptoms and the interpretation of contributing factors from a personal perspective form the basis of subsequent help-seeking behaviour.

Public health campaigns targeting mental health literacy such as Mental Health First Aid can be viewed as a long term commitment to enriching lay people’s knowledge about clinical depression and its treatment. The desirable outcomes will be early recognition and intervention. When individuals recognise the warning signs of depression, their first port of call is usually a GP. Education programs to equip bilingual (Chinese-speaking)

GPs with the necessary skills and adequate specialist support will no doubt improve services to low acculturated Chinese. Beyond the obvious language barrier, cultural

281 barriers exist for both clients and clinicians. A basic understanding of the Chinese conceptualisation of emotional distress and mental illness is the key to unlock the stereotypes surrounding Chinese patients and the myths about Traditional Chinese

Medicine. Keeping an open-mind does not have to equate to endorsing non-Western beliefs on the clinician’s part. What it does is to allow Chinese patients to feel respected and to establish a better rapport with the treating clinician. I cannot emphasise enough that a high level of trust is required before Chinese patients will disclose deep emotions to health professionals. I have made recommendations for Western-trained doctors to facilitate an optimal communication exchange with their emotionally distressed patients.

The findings revealed a call for collaboration among the helping professions in my model of culturally competent psychiatry. Participants made clear that by strengthening the referrals between primary care personnel, in this case Chinese GPs and herbalists, and between primary care personnel and specialists, that quality services will be delivered in a timely manner. Given the collective orientation of the Chinese culture and the rich social capital within the Chinese community, linking community services to mental health professionals will ensure that the target population of Chinese vulnerable to clinical depression is more appropriately reached.

Finally, a population mental health approach fits well with the Confucian emphasis on social capital: promoting the mental well-being of ALL rather than shaming the emotionally distressed few is a worthy global guideline to combat clinical depression.

Building upon this principle using a multi-disciplinary team from the health, social work and education sectors, children and adults alike learn resilience against stressful life events and are encouraged to have an optimistic outlook. This contributes to establishing

282 healthier countries as in the example of Scotland. Reducing the burden of clinical depression is an achievable goal for Planet Earth in the years to come.

Capturing Dr. Martin Luther King’s commitment to human rights and Dr. Martin

Seligman’s optimism, I close this chapter with a dream,

I have a dream! One day the long-standing language and cultural hurdles in accessing mental health services will be removed.

I have a dream! One day all Australians regardless of cultural and linguistic background will enjoy top-quality health care by culturally competent service providers.

*****************************************************

Endnote

To be a Chinese man ‘jun-zi’ ́ů, Confucius said,

“Do not impose upon others, what you would not like them to do to you”. ŹÜƄȇ, ƦɌýŋ ( ji- sou-bu-yu, wu-shi-yu-ren’).

Analects 15:22

To be culturally competent, an American medical student was advised,

“Do not treat the patient in the same manner you would want to be treated.”

American Medical Student Association (2006)

As a Chinese-Australian, I would like to be asked, in either Chinese or English, “How do you want to be treated?” Bibiana Chi-Wing Chan

***************************************************

283 Appendix 2-1 Additional Notes on Male-Female Difference vis-à-vis Depression

1. ‘The Three Subordinations and the Four Virtues’ [ŗƝȜ’] Chinese women are still expected to follow ‘The Three Subordinations and the Four Virtues’ [ȳŤŶ] (Centre for Chinese Cultural Studies, 2002). A recent encyclopaedia of ‘Knowledge about sex’ which describes the dominant approach to sex and gender difference after 1949 (the establishment of the People Republic of China) states: “Normal male behaviour is outwardly expressive and evident whereas in the female it is hidden and shy. This signifies a difference between the active and initiating male and the passive female, a difference that is determined by sexual physiology and psychology (Wang Peng, 1993: 97 cited in Evans 1997: 33).

2. Adinoff et al (2003) claim to be the first research team to demonstrate gender-specific responses in limbic activation following a provocative pharmacologic stimulus (Procaine) which could have clinical significance. Although the sample size is small (15 in each gender group), Adinoff et al propose that different limbic structures in men and women can be activated using the same pharmacologic agent. A point to note is regardless of their gender, participants reported similar subjective experiences.

3. With recent advance in radio-imaging technology, George et al (1996) reported that their female participants activated a considerable wider portion of the limbic system than did men during self-induced transient sadness even though these mentally and physically healthy men (n = 10) and age-matched women (n = 10) reported similar changes in mood.

4. Parker and Brotchie (2004) argue for a diathesis-stress model that post-pubertal women are at risk due to influences of sex hormones which may activate a diathesis, and interacts with gender role factors to generate the female preponderance in depressive disorders.

284 Appendix 2-2 Best Practice Psychiatrist Liaison Model

Since Nov, 2006, RANZCP published the latest revised ‘Best Practice Psychiatrist Liaison Model’ to provide guidelines for psychiatrists concerning GPs’ referrals. The new procedure required a psychiatrist to clarify with the referring GP on issues surrounding future management of the patient. The aim of this initiative is to encourage private psychiatrists to see more new patients, and to refer on to psychologists and GPs those patients whose needs can be met by these clinicians, thereby improving access to appropriate mental health care.

GP Mental Health Care Plan involves the GP assessing the patient, identifying needs, setting and agreeing management goals, identifying any action to be taken by the patient, selecting appropriate treatment options and arrangement for ongoing management of the patient, and documenting this in the plan.

To view full document, see Royal Australian and New Zealand College of Psychiatrists (RANZCP) website.

RANZCP (2006). Best Practice Psychiatrist Liaison Model [Available: http://www.ranzcp.org/pdffiles/gpliaison/BestPracticeBrochure2006.pdf] Accessed: 10- Dec-2006]

285 Appendix 2-3 Building Social Capital

The Melbourne, Australia ‘Together We Do Better’ (2001) seeks to increase community awareness of the benefits of strong, connected and supportive communities. For each of us, participation in a range of community-based activities is a way of connecting with our fellow human beings. It provides us with opportunities to build mutually supportive relationships. And we all have a role to play to ensure all people have access to these opportunities. (For more information go to: http://www.togetherwedobetter.vic.gov.au/ )

Towards a Healthier Scotland (1999) includes a commitment to improve mental health services, challenge stigma, reduce suicide and improve mental health and wellness. (For more details see the website: http://www.scotland.gov.uk/library/documents- w7/tahs-02.htm)

286 Appendix 3-1a Survey Forms for Chinese participants preferring English language

PROFILE MEASURE (Chinese participants)

Section I: BACKGROUND INFORMATION

1a) Your Age ______

1b) Your age at migration (if applicable) ______

1c) Which year did you migrate to Australia? (if applicable) ______

2. Sex: Male / Female (Please circle)

3. Country of Birth: ______

4a. Language spoken at home: please specify if not English. ______

4b. Please indicate whether you have taken part in the following situations: If yes, please rate how easy or difficult each was for you.

(1 - very difficult, 2 – difficult, 3 - manageable i.e. neither easy nor difficult, 4 -easy, 5 - very easy )

Yes/No ___ Asking questions at a seminar, parent-teacher interview or other public meeting, Yes/ No ___Talking to neighbours about issues, Yes/No ___ Making telephone enquires about information you need, Yes/No ___ Discussing work-related issues with colleagues,

5. Marital status: (Please circle) 1 – single 2 – married 3 – separated 4 – divorced 5 – widowed

6a. What is your present state of employment? (Please circle)

1- full-time employment 2-part-time employment 3- home duties 4- full-time student 5- pensioner/sickness benefits 6- retired 7 - unemployed

6b. What is your level of education? (Please circle) 1- Postgraduate degree 2- Bachelor degree 3- Diploma or Advanced Diploma 4- Senior High school (e.g. completed Year 12) 5- Junior High School (e.g. completed Year 10) 6- Primary School 7- Other, please specify: ______287 7a. Your current (or most recent) job was : (Please circle the relevant or closest category.)

1- managerial/administrator 2- professional/paraprofessional/technical 3- tradesperson 4- sales/retail/hospitality 5- clerical/administrative support 6- labouring/manual work 8- Other, please specify: ______

Please answer question 7b & 7c if you were not born in Australia or you have worked overseas.

7b. Your last job before migration / overseas job * (please circle) was ______.

Please circle the relevant or closest category.

1- managerial/administrator 2- professional/paraprofessional/technical

4- tradesperson 4- sales/retail/hospitality 6- clerical/administrative support 6- labouring/manual work 7- Other, please specify: ______

7c. Please indicate whether there was a loss in seniority in your current job compared to your last job before migration / before your return to Australia *. (* Please circle)

Yes / No (please circle)

8. In general terms, I like everyone that I know. Yes / No (please circle)

9a. When I need some physical help (family matters, problems with the house, garden, car, mail etc.) I will ask …………

Tick the most relevant option Always Sometimes Rarely Never

1 – Chinese friends ______

2 - Chinese neighbours ______

3 – English-speaking friends ______

4 - English-speaking neighbours ______

5- Family members ______

288 9b. When I need some professional services (taxation, legal, medical etc.) I will ask recommendations from ….. Tick the most relevant option Always Sometimes Rarely Never

1 – Chinese friends ______

2 - Chinese neighbours ______

3 – English-speaking friends ______

4 - English-speaking neighbours ______

5- Family members ______

9c. When I feel ill at ease, I will share my concerns with ... Tick the most relevant option Always Sometimes Rarely Never

1 – Chinese friends ______

2 - Chinese neighbours ______

3 – English-speaking friends ______

4 - English-speaking neighbours ______

5- Family members ______

10. In general terms, I am always nice to people. Yes / No (please circle)

11a. How often do you read Australian (English) Newspapers/Magazine? (Please circle) 1 - daily 2- at least once a week 3 - occasionally 4 - rarely 5 - never 11b. How often do you read Chinese Newspapers/Magazine? (Please circle) 1 - daily 2 - at least once a week 3 - occasionally 4 - rarely 5 – never

12a. How often do you watch/listen to Australian (English) programmes (including news, videos, DVD) on TV or radio? (Please circle) 1 - daily 2 - at least once a week 3 - occasionally 4 - rarely 5 - never 289 12b. How often do you watch/listen to Chinese programmes (paid TV , SBS , news, videos, DVD) on TV or radio? (Please circle)

1 - daily 2 - at least once a week 3 - occasionally 4 - rarely 5 - never 13a. When was the last time you visited your (or your parent’s) country of origin? _____

13b. How often do you visit your (or your parent’s) country of origin? (Please circle)

1- at least once a year 2 -between one to three-year interval 3 - more than a 5-year interval 4 - rarely 5 - never

14a. Have you ever received any Chinese Herbal remedy for emotional distress? Yes / No (please circle) If yes, is it 1 - Self-prescribed 2 - Prescribed by a Naturopath 3 - Prescribed by a Traditional Chinese herbalist .4 - Other, please specify ______14b. Have you ever seen a doctor for emotional unease? (e.g. stress, depression, anxiety, etc)? Yes / No (please circle)

14c. Have you ever received antidepressant medication? Yes / No (please circle)

15. As I remember, I never broke any rule my parents expected me to follow. Yes / No (please circle)

16a. Do you have any religious beliefs or practice any religious rituals? (e.g. go to church, temple, shrine and other places of worship.) Yes / No (please circle) If yes, please specify: ______

16b. Do you practice spiritual traditions. Yes / No (please circle)

1- ‘Ancestor worship’ 2- Joss-sticks 3- Feng Shui 4- Meditation

17a. Please write down some Chinese/Western values that have had the most impact in your life, especially when facing an unhappy event. In not more than 3 sentences, give an example to illustrate how these helped.

______

290 17b. Please mark an ‘ X ’ on each line provided: (i) “How Chinese do you feel?”

l______l Not at all Completely Chinese Chinese

(ii) “How Australian do you feel?”

l______l Not at all Completely Australian Australian

(iii) “How would your neighbours or colleagues feel about your ‘identity’?”

l______l

Completely Completely Chinese Australian

18a. Do you have a family doctor? Yes / No (please circle)

If your answer to 18a. is ‘Yes’, please answer 18b. & 18c. If your answer is ‘No’, please skip to Session II.

18b. Is your family doctor an ethnic Chinese? Yes / No (please circle)

\ 18c. Does he/she speak ______? (You can circle more than one answer) 1- English 2 - Cantonese 3 - Mandarin 4 – Other language: ______

291 Section II. Symptoms of Depression The following is a list of symptoms people may have when they are emotionally distressed. For each item, please tick the appropriate box to indicate, in your opinion, whether someone experiencing ‘Depression’ would be likely to show such a symptom. Symptoms Definitely Sometimes /to Not at all some degree 1. Looking sad and depressed 2. Feeling helpless 3. Think too much 4. Feeling guilty 5. Less able to laugh 6. Fatigue 7. Feeling angry 8. Poor concentration 9. Feeling life is not worth living 10. Slowed physically 11. Feeling withdrawn 12. Loss of appetite 13. Feeling bad about self 14. Loss of essence and energy 15. Heaviness in the chest 16. Feeling anxious and tense 17. Headaches 18. Disturbing dreams 19. Bored and unhappy 20. Having decrease in their self-esteem 21. Thoughts of death 22. Feeling like giving up and hopeless 23. Feeling suicidal 24. Feeling agitated and having to keep moving

25. Unable to look forward to things 26. Loss of weight 27. Having loss of self-confidence 28. Body aches and pains 29. A lack of interest in doing things 30. Easily irritated 31. Inability to sleep 32. Feeling everything is not under control 33. Talking very softly 34. Breathlessness 35. Feeling depressed

292 Section III: Emotional Distress

1. Over their lifetime, everyone experiences some degree of stress. Some people may feel significantly depressed, easily cross and feel lost. Some may feel worthless and hopeless, lose motivation in doing things and loss of energy and not be able to cope as well as usual. Have you ever experienced something similar for a period of at LEAST TWO WEEKS? Yes / No (please circle) If ‘no’, please skip to Section III i) If ‘yes’ how old were you for any first episode? ______ii) In four to five words, write down the cause or causes of this episode:

______iii) Give the 3-4 symptoms that troubled you the most: ______

2. How long was your longest episode (in months)? ______

3. Has it ever prevented you from______? (please circle)

1- going to work 2- being able to work around the home

3- going to school 4- Other: (please specify) ______

4. Looking back at any such episode experienced, do you judge that what your experience was: (please circle)

1 only “normal blues” to be expected over one’s lifetime 2 at times, a distinct disorder (i.e. above and beyond what could be viewed as “reasonable distress” given my circumstances) 3 always a distinct disorder

5. For any such episode, have you ever consulted a: (You can circle more than one answer) 1 – general practitioner 2 – psychologist 3 – psychiatrist 4 – traditional Chinese herbal doctor

5 – other; please specify ______

293 Section IV: SYMPTOMS OF DISTRESS

Please circle the closest/most relevant item.

1. To the extent that you currently feel stressed at all, do you view your stress level as:

1- to be completely expected, given all my circumstances 2 - somewhat above what might be expected from my circumstances 3 - quite above what might be expected from my circumstances

2. Fatigue, sleep problems and loss of appetite are common. When you develop fatigue, which of the following reasons or explanations are you most likely to give:

1- I’m emotionally exhausted or discouraged 2 - I’ve been over-exerting myself or not exercising enough 3 - There is a medical cause (e.g. Anaemia)

3. When you have trouble sleeping, which of the following reasons or explanations are you most likely to give: 1- There is likely to be a physical reason 2 - I’m just not tired 3 - I’ve been worrying too much or must be stressed about

4. When you lose your appetite, which of the following reasons or explanations are you most likely to give:

1 - My body doesn’t need as much food (or energy) at the moment

2 - I am emotionally stressed

3 - I have a physical problem (e.g. Stomach ulcer)

294 SUINN-LEW ASIAN SELF-IDENTITY ACCULTURATION SCALE (SL-ASIA) Adopted for use in Australia. INSTRUCTIONS: The questions which follow are for the purpose of collecting information about your historical background as well as more recent behaviours which may be related to your cultural identity. Choose the one answer which best describes you.

1. What language can you speak?

1. Chinese only (for example, Cantonese, Mandarin, Hakka, Hopkin, etc. 2. Mostly Chinese, some English 3. Chinese and English about equally well (bilingual) 4. Mostly English, some Chinese 5. Only English

2. What language do you prefer?

1. Chinese only (for example, Cantonese, Mandarin, Hakka, Hokkien, etc. 2. Mostly Chinese, some English 3. Chinese and English about equally well (bilingual) 4. Mostly English, some Chinese 5. Only English

3. There are many different ways in which people think of themselves. Which ONE of the following most closely describes how you view yourself?

1. I consider myself basically a Chinese person. Even though I live and work in Australia, I still view myself basically as a Chinese person.

2. I consider myself as a Chinese-Australian, although deep down I always know I am a Chinese.

3. I consider myself as an Chinese-Australian, I have both Chinese and Australian characteristics and I view myself as a blend of both.

4. I consider myself as an Chinese-Australian, although deep down I view myself as an Australian first.

5. I consider myself basically an Australian. Even though I have a Chinese background and characteristics, I still view myself basically as an Australian.

4. Which identification does (did) your mother use?

1. Oriental 2. Asian 3. Chinese 4. Chinese-Australian 5 Australian

5. Which identification does (did) your father use? 1. Oriental 2. Asian 3. Chinese 4. Chinese-Australian 5 Australian

295 6. What was the ethnic origin of the friends and peers you had, as a child up to age 6? 1. Almost exclusively Chinese, Chinese-Australians, Asians 2. Mostly Chinese, Chinese-Australians, Asians 3. About equally Chinese groups and Australian groups 4. Mostly Australians or other non-Chinese ethnic groups 5. Almost exclusively Australians or other non-Chinese ethnic groups

7. What was the ethnic origin of the friends and peers you had, as a child from 6 to 18? 1. Almost exclusively Chinese, Chinese-Australians, Asians 2. Mostly Chinese, Chinese-Australians, Asian 3. About equally Chinese groups and Australian group 4. Mostly Australians or other non-Chinese ethnic group 5. Almost exclusively Australians or other non-Chinese ethnic groups

8. Whom do you now associate with in the community? 1. Almost exclusively Chinese, Chinese-Australians, Asians 2. Mostly Chinese, Chinese-Australians, Asian 3. About equally Chinese groups and Australian group 4. Mostly Australians or other non-Chinese ethnic group 5. Almost exclusively Australians or other non-Chinese ethnic groups

9. If you could pick, whom would you prefer to associate with in the community? 1. Almost exclusively Chinese, Chinese-Australians, Asians 2. Mostly Chinese, Chinese-Australians, Asian 3. About equally Chinese groups and Australian group 4. Mostly Australians or other non-Chinese ethnic group 5. Almost exclusively Australians or other non-Chinese ethnic groups

10. What is your music preference? 1. Chinese-language songs. 2. Chinese-language songs mostly. 3. Equally Chinese /English-language songs . 4. Mostly English-language songs 5. English only

11. What is your movie preference? 1. Chinese-language movies only. 2. Chinese-language movies mostly. 3. Equally Chinese/English-language movie. 4. Mostly English-language movies only 5. English-language movies only

12 What generation are you? (Circle the generation that best applies to you)

1. 1st Generation = I was born in Asia or country other than Australia 2. 2nd Generation = I was born in Australia, either parent was born in Asia or country other than Australia. 3. 3rd Generation = I was born in Australia, both parents were born in Australia and all grandparents born in Asia or country other than Australia. 4. 4th Generation = I was born in Australia, both parents were born in Australia and at least one grandparent born in Asia or country other than Australia and one grandparent born in Australia. 5. 5th Generation = I was born in Australia, both parents were born in Australia and all grandparents also born in Australia.

296 13. Where were you raised? 1. In Asia only 2. Mostly in Asia, some in Australia 3. Equally in Asia and Australia 4. Mostly in Australia, some in Asia 5. In Australia only

14. What contact have you had with Asia? 1. Raised one year or more in Asia 2. Lived for less than one year in Asia 3. Never resided in Asia, occasional visits only 4. Never resided in Asia, occasional communications (letters, phone calls, e-mails, etc.) with people in Asia 5. No exposure or communications with people in Asia

15. What is your food preference at home? 1. Exclusively Chinese food 2. Mostly Chinese food and some Western food 3. About equally Chinese and Western (Non-Chinese) food 4. Mostly Western (non-Chinese) food 5. Exclusively Western (non-Chinese) food

16. What is your food preference in restaurants? 1. Exclusively Chinese food 2. Mostly Chinese food some Western food 3. About equally Chinese and Western (non-Chinese) 4. Mostly Western (non-Chinese) food 5. Exclusively Western (non-Chinese) food 17. Do you 1. Read only Chinese language? 2. Read Chinese language better than English? 3. Read both Chinese and English equally well? 4. Read English better than Chinese language? 5. Read only English? 18. Do you 1. Write only Chinese language? 2. Write Chinese language better than English? 3. Write both Chinese and English equally well? 4. Write English better than Chinese language? 5. Write only English?

19. If you consider yourself a member of the Chinese group (Asian, Chinese, Chinese-Australian, etc., whatever term you prefer), how much pride do you have in this group? 1. Extremely proud 2. Moderately proud 3. Little pride 4. No Pride but do not feel negative toward group 5. No pride but do feel negative toward group

20. How would you rate yourself? 1. Very Chinese 2. Mostly Chinese 3. Bicultural 4. Mostly Westernized 5. Very Westernized

297 21. Do you participate in Chinese occasions, holidays, traditions, etc.?

1. Nearly all 2. Most of them 3. Some of them 4. A few of them 5. None at all

22. Rate yourself on how much you believe in Chinese values (e.g. about marriage, families, education, work.):

1 2 3 4 5 (do not (strongly believe believe) in Asian values)

23. Rate your self on how much you believe in Western values:

1 2 3 4 5 (do not (strongly believe believe) in Western values)

24. Rate yourself on how well you fit when with other Chinese of the same ethnicity:

1 2 3 4 5 (do not (fit very well) fit)

25. Rate yourself on how well you fit when with other Australians who are non-Chinese (Westerners):

1 2 3 4 5 (do not (fit very well) fit)

26. How do you identify yourself?

1. Oriental 2. Asian 3. Chinese 4. Chinese-Australian 5 Australian

Thank you for completing the questionnaire. This will help the researchers to develop more culturally appropriate medical services to the Chinese population in Sydney.

298 Appendix 3-1b Survey Forms for Chinese participants preferring Chinese language [ ɫŃ˥ɵ[![͑ŋɗϡ[ [ [ 8[̛šʻǏ![ [[[[666666666[ [ 9[̛ɥȿϤšʻǏcʭƖɌ![ [ [ 666666666[[ [ :[̛ɒ'Ńʻɥȿ@ȶɺš"cʭƖɌ[ 666666666[ [ [ [[Ô̩![ [[[ϢÔ[[[ŮÔ[[[[[ccŦŖǸ̐Ɩʕš@ [ [ [ [[Ǹɋʞ!66666666666666666666666666666[ [ [ 8[ΞȹÜȑϟʑ!cʭΞȹ̍Ɍϟ0ƪ˾ϟŦĄÜɌϟ666666666666666666[ [ 9[ŦƔĄΠ̹ǶȭǨŘšʒͿƫĹ[0ʀǸ̛˹κͿƫĹšͻ΅°Œ![ [ [[ [[[ [ 6666[ ʟζţŮΞƟŮØƞɚŮƬŚǨ˾ϟ'Ŋ[ [ [ 6666[[ yȑ˾ϟšƛªţŭ3¥[ [ [ 6666[[ Ɍ˾ϟ˰ʝɧɌÜ9šɗϡ[ [ [ 6666[ yʍ3Ǩ˾ϟŀàŸ̚ŚšŊÂ[ [ [ [[ŮȇœĹ![cŦŖǸ̐Ɩʕš@ [ [ [ [[̪[[ [[ʍª[ [źŮ[ [[ơª[ [[¶Ů[ [[̤ĥ[[[ [[[ [ 8[[ɖNjš͑ŰœĹ!cŦŖǸ̐Ɩʕš@ [ [ [ [[ɼ}Ÿ̚[ [ [[͛}Ÿ̚[ [ [[ȲɃΞĵ[ [ [[ɼϤÔ͑Ǻ[ [ [ [[>gėǏØξWɽ [ [ [ [[÷ɮ[ [ [[ȠŰØȡŰ[ [

299 [ 9[̛źͱ˃šǺȭɒ![666666[[[[cŦŖǸ̐Ɩʕš@ [ [ [ [[[ǺūǨŚɗ[ [ [ [[ǺūǺ̇[ [[[ [ [[džǿØė•džǿ[ [[ [ [[ėƅɍŰ[cͱ˃ɫŔŊL[ [[[ [ [[ƓƅɍŰcͱ˃ɫŔL[ [ [ [[ųǺɍŰ[ [[[ [[[QǬ[ŦĄ!6666666666666666666666666666666666[ [ [ [ 8[̛ɖNjØ̐Ƙ΢šŸ̚ɒǖý'ŃŚ̩"cŦŖǸ̐Ɩʕš@ [ [ [

[ ʭĐ̛ʟ/ȞǸɋØΠʟ/ȞŸ̚Ŧʛ@9[[y:[OÂŊÂ[ [ [ 9[̛[[ɥȿNj[ʟ/ȞϤ[[[c[[ŦŖǸƖɌų[šŸ̚ɒǖ'ŃŚ"[ [[[ [ [ cŦŖǸ̐Ɩʕš@ [ [ [ [

[ [ [ :[̛ɖNjšŸ̚ɟɥȿNj[[ʟ/ȞϤc[ŦŖǸƖɌų[̐ȥŃɵŸ̚[ʟ}•ŚˎŘ̮ď"[[[ [[[[[[ [[[[[[[ˎ[[[[[̹[[[[[[cŦŖǸ̐Ɩʕš@  [ [[Ń»@ϥ[Β̣ȯκŃ͑Βϡĭšŋ[[ [ [[[[[[ɒ[[[[[̹[[[[[[cŦŖǸ̐Ɩʕš@ [

300 [ [ [8[ƽ̛9̎ŋǃ`̯cʭΞƅͥ3ÚȒ΢͕ƈĜƵਤϋ΢͕yˇ'Ʈɱ;[ ŮʓŘʀ'Śŋǫλ̯{"[ [ [[[[[[[[[[[[[[[[[[[  [ [[[[[[[[[[[[[[Ƕƌ[[ [[[[[[[[[[[[[[Ôƅ[[[[[[[[[[[[[[[[[[ȠƷ[ [[[[[[[[[[[[[[[[[Ɲ@ϊˎ[ [ [[[nȴċƮ[ [ [ [ [[[nȴƛª[ [ [ [ [[[ȑ˾ϟšċƮ[ [ [ [ [[[ȑ˾ϟšƛª[ [ [ [ [[ΞŋØʛƷ[ [ [ [ [ [ [ 9[ƽ̛9ɲ̎ŹŰŀϤcʭ4ĵĴȣ¤ͥ;[ŮŦŘʀ'ŚŋǫƠƗɷ{"[ [ [[[[[[[[[[[[[[[[[[[[  [[[[[[[[[[[[[[Ƕƌ[[ [[[[[[[[[[[[[[Ôƅ[[[[[[[[[[[[[[[[[[ȠƷ[ [[[[[[[[[[[[[[[[[Ɲ@ϊˎ[ [[[nȴċƮ[ [ [ [ [[[nȴƛª[ [ [ [ [[[ȑ˾ϟšċƮ[ [ [ [ [[[ȑ˾ϟšƛª[ [ [ [ [[ΞŋØʛƷ[ [ [ [ [ [

301 :[ƽ̛ǀƫƠͨØǎ;Ϥ[ŮʓŘʀ'Śŋǫü™{"[ [  [ [ [ [ [ [[[[[[[[[[Ƕƌ[[ [[[[[[[[[[[[[[Ôƅ[[[[[[[[[[[[[[[[[[ȠƷ[ [[[[[[[[[[[[[[[[[Ɲ@ϊˎ[ [[nȴċƮ[ [ [ [ [ [[[nȴƛª[ [ [ [ [[[ȑ˾ϟšċƮ[ [ [ [ [[[ȑ˾ϟšƛª[ [ [ [ [[ΞŋØʛƷ[ [ [ [ [ [[[Ń»@ϥΒ˹κ͑ŋ˧ʍÄʫ[[[[[[[ɒ[[[[[[[[̹[[[[[[cŦŖǸ̐Ɩʕš@ [ [[ [ 8[̛ˎǶƌƱɀȶɺ˾dž̼˽Ø·Ϟď"[cŦŖǸ̐Ɩʕš@ [ [[[ [[[ [[κNJ[ [ [ [[κ¼̐ƷŃ˓[ [ [[Ôƅ[ [ [ [[JƷ[ [ [[Ɲ@ϊˎ[ [ 9[̛ˎǶƌƱ3L  [ɀƅdž̼˽Ø·Ϟď"[cŦŖǸ̐Ɩʕš@ [ [ [ [[κNJ[ [ [ [[κ¼̐ƷŃ˓[ [ [[Ôƅ[ [ [ [[JƷ[ [ [[Ɲ@ϊˎ[ [ [  8̛ˎǶƌˇȻØˇʾ˾ϟǯɖcǽɄȶɺʝȘʝŽšǯɖťΪˍ‘ƍØ[ [[[[[[[‘ͷď"cŦŖǸ̐Ɩʕš@ [ [ [ [[κNJ[[[ [κ¼̐ƷŃ˓[ [ [[[Ôƅ[ [ [ [[JƷ[ [ [[Ɲ@ϊˎ[ [ [  9[[[̛ˎǶƌˇȻØˇʾŗǵϟǯɖcǽɄˎĭʝȘʝŽ[ØȿǤʝȘʝŽšǯɖ[ťΪ[[[[[[[[[[ ˍ‘ƍؑͷď"cŦŖǸ̐Ɩʕš@ [ [ [ [[κNJ[ [ [ [[κ¼̐ƷŃ˓[ [ [[Ôƅ[ [ [ [[JƷ[ [ [[Ɲ@ϊˎ[ [ [

302  8[[̛˹ŚŃ˓ƾʾ̛Ø̛ǘȾšǸɋʞɒ'Ńʻ"666666666666666[ [ [  9[̛ˎǶƌÃƗ̛Ø̛ǘȾšǸɋʞď"cŦŖǸ̐Ɩʕš@ [ [ [ [[̐ƷκʻŃ˓[ [ [ [[κ˓ʼʖŃʻ˷ŗʻ[ [ [[κ˓ʼʖƎʻØǨŚ[ [ [[JƷ[ [ [[ [[Ɲ@ϊˎ[ [ [  8[̛ˎ<Ɍɲ̎ƅĠǨįyƫΣƄʴď"[ [[[[[[[ˎ[[[[[[[̹[[[[[[cŦŖǸ̐Ɩʕš@ [ [ [ʭ@‘ˎ‘̛ɒ![cŦŖǸ̐Ɩʕš@ [ [ [ [[˶Źϔ§[[ [[ [[ɏ˶ͥĴ¤γălj[[[ [[ɏƅ¤ălj[[ [[ [ [QǬ[cŦɁ̚[6666666666666666666666666666666666666[ [ [  9[̛ˎʚʑƫΣ͒;ˮʾ̃¤ď"[ [[[[[[ˎ[[[[[[[̹[[[[[[cŦŖǸ̐Ɩʕš@ [ [ [ [[[  :[̛ˎĊɌɸΔΥːĠď"[ [[[[[[ˎ[[[[[[[̹[[[[[[cŦŖǸ̐Ɩʕš@ [ [ [  [ʟÞȃƅΒƝ@ϊˎɴưǘȾ;ǰΒʽʲšʽj[ [ [[[[[[[ɒ[[[[[[[̹[[[[[[cŦŖǸ̐Ɩʕš@ [[[ [[[ [[ [[[ [ [  8[̛ˎƮŠɲ̎¢ǚØľζ¢ǚRʼcNjÃǚŠŒʱØQǬţŠšʞljď"[[ [[[ [[[[[[[ˎ[[[[̹[[cŦŖǸ̐Ɩʕš@ [ [[[ [ [ [[[ [[[ ʭ@ˎŦĄ̛š¢ǚ!66666666666666666666666666[ [ [  9[̛ˎ˴́ǨŘšʆƻØfRď"[ [ ˎ[[[[̹[[cŦŖǸ̐Ɩʕš@ [ [ [ [[cȉʿȏŃ͑ØǨŚš@ [ [ [ȸɤzɻ[ [ [ɇ*̹͘[[ ˄̵Ǖ[ [ [Ȳ͜͝Ń[ [ [ [

303 [ [ [ [ 8[ŦɌŗOșɉ@Ψ?ϥĄŃ4‘Ơ̏̐ȩšƅ̃ljȨŃ[yU͆ʰ[ƸQɒ[ [[[[[[[['4̛̝̯̯˹õ˜š[ [ 666666666666666666666666666666666666666666666666666666666666666666666666666[ [ 666666666666666666666666666666666666666666666666666666666666666666666666666[ [ 666666666666666666666666666666666666666666666666666666666666666666666666666[ [ 9[ŦʟŘʀȡĭŚǻŚ‘/’Ȧ![ [[ [c@̛ƪƛ˶Źˎ͛˂[“ƅŗƧ”"[ [ [[l______l

[c@@[̛ƪƛ˶Źˎ͛˂[“ȶɺƧ”"[ [ l______l

[ [c@@@[̛šƛªØʍ3˹̛šɵˎ̎ʾĴ"[ [ [[l______l

[ [ 8[̛ˎ€£šΞε¤ɋď"[ [ [ˎ[[[̹[[[[[[[cŦŖǸ̐Ɩʕš@ [[ [ [[[ ğʭ̛8[š@ ɒ‘ˎ’[Ŧƙǫʛ@9[y:[ʭ@[[‘[̹[’ŦɢYɫŊ˥ɵ[[[[ [[[ [ 9[̛š¤ɋɒnȴšď"[[[ [ ɒ[[[[[̹[[[cŦŖǸ̐Ɩʕš@ [ [ :[[ǬʬŮϥ'Ϳϟ"cȉʿȏŃ͑ØǨŚš@ [ [ [ [ [˾ϟ[ [ǵϟ[ [ŗϟcΗ˗ɉ[[[[[[ [QǬ6666666666666666[[

304 ɫŊ˥ɵ “ΥːYœ” “ ”

/

1. ΢Á¥ƨ 2. łƪ̯ 3. Ńƛƴʥ 4. łYƛŠ 5. ŔǨÒæŭŠ 6. ΢ĀZ̀ 7. łY¤ȧ 8. તઠŔǨãƅ 9. łYɋȉɠ 10. ķ̚į̌ 11. łƪʩ΅ˎŀùϡȂɚ 12. ̷Ƅϑ 13. àˇ˶Ź 14. ŀ΋+π 15. ­ũπ̩ˎʷ̐qšłƪ 16. łY–yΙƕ 17. ˨ 18. 'ͦˤ 19. ͨͨƄÏ 20. ˶͏ǀ̮̝ 21. Πˎ“ ˕ţ”šŀÊ 22. ˶Â˶ǽ 23. Ńɸ˶͐- 24. ͜ɝƄʴ 25. Ƅɾ2Ãɲ̎3Œ 26. ɿ̩Ř̮ 27. ȠȈ˶Ʈ 28. ¼Ė 29. 33˧΄Ƅîǒ 30. Ơ͗Āȧ 31. Ĵō͵ 32. łYŒ 33. ϥɉǦŒΚĭľη 34. łƪ#ƶ(Ś#ƄƿŘ#) 35. łYĺ̤ [[[[ [

[[[ [[[

305 ɫŗ˥ɵɫŗ˥ɵ[[[[[[ƫΣ͒;ƫΣ͒;

[ʟŃɋȹκ͑ŋ˧ŮǶȭɜ3țš̐Œ[ ˎ4ŋŮłYɹqšƫΣ̝ȕƪƛȠŀ΢Āø͗ ˎ4ŋŮƪƛ˶ŹƄƅɌłYȠǰ[ તȲƝ ˹|ƙ3ŒȠȈʃƂyłYɋʂ̐ŒŔǨ̠ǩ[ ̛Π̹ˎŚ̗šǶȭɲO͑ɓ΢ØǨŚď"[ [ [[[[[[[ˎ[[[[[[[[[[̹[[[[[[[[[[cŦʿȏ̐Ɩʕš@ [ [ ğʭ̛š@ ɒ‘ˎ’[Ŧƙǫʛ@ǨŘʒȂŊÂ[ ğʭ̛š@ ɒ‘[̹’[ŦɢYɫcȜ˥ɵ[ [ [ c[ʭĐ̛Πˎ˕Śɿɽ̛ɫŃ˓ˎ˕ŚłƪϤ̛šʻǏɒ66666[[[ [ [ c [ɂɌŃOșɉq̚Ǽ˰˕͑ƫĹšͪʚ![ [ 666666666666666666666666666666666666666666666666666666666666666666666 [ 6666666666666666666666666666666666666666666666666666666______6666666666[ [ [[ [ c [ŦʀǸŗ˷Ȝ͑̐ȓ̛™–šYœ![ [[ [ 66666666666666666 666666666666666666 66666666666666666 6666666666666666666[ [ [̛̐ƟšŃ˓ɿɽȽǫʼnʥƷ͑nj"[[[66666666666666666666666666666666[ [ [˕Śšɿɽˎ‘Ơ̏šNJƌŸ̚ď"cŦʿȏ̐Ɩʕš@ [ [ [ [ [Ƅ°ŚL[[ [ [Ƅ°ŚǺ[ [ [ [ [Ƅ°ȲɃΞĵ[[ [QǬ!cŦĄ[[66666666666666666666666666666666[ [[ [[ʛŃ̛ǨÚɿɽ[ǨŘ'Ńè̐°ͼ̛̚ƽϤšœĹ"cŦʿȏ̐Ɩʕš@ [ [[ [[ȕɒɋʂƅƌˎšƫΣ̝ȕ[ [ [ÔƅŮˎĄɹôXšłƪc̳ɒϥΚƽϤȌʰš͡˜ʚ̐Ήʟƛ̛š[ [ [[[[ƫĹźƄ̪ɒŃ»šƫΣ͒;[ [ [ϤƌˎĄɹôXšłƪ[ [[ [ʟ̛ǨÚɿɽȹΠ̹ʓŘʀŹŰŋǫλ̯"cȉʿȏŃ͑ØǨŚš@ [ [ [Ξε¤ɋ[ [ [ [[ǀɃŹΞ[ [ [[તઠˍ¤ɋ[ [ [[ƅ¤γ[ [ [[QǬ[[[[[ŦĄ6666666666666666666666666666666666666666666666666666[

306 [[[ [[[ [[[ ɫȜ˥ɵɫȜ˥ɵ!!!XĹɃȾXĹɃȾXĹɃȾ[[[ [[[ [[[ [͑ɖNjłišɋʂ̐Œ[̛ϡʑ˕4̐Œš3ț[[[cŦʿȏ̐Ɩʕš@ [ [[ [[ǨɄϤš[͡˜@ϥɒͱɼȉǨʣϡƛYš[ [ [ [ǨΒɄϤš͡˜@ϥɒǒʣ΢šŭʼnŃ4[ [ [ [ǨΒɄϤš͡˜@ϥɒǒʣ΢šŭʼnȠʥ[ [ [ [ɸțZ̖Ƞhy̷ƄϑɒƌšɄƽ̛łYɸțZ̖Ϥ[ [[[[ǨŘ'Ń͑Ⱦƹ̐°ϥĄ̛šƫĹ[cŦʿȏ̐Ɩʕš@ [ [ [[ΒłYǀŒɤǁyˢǀĺ̤[ [ [ [Βɸɵȑ̖[ŖšǦɮķ[ [ [ [ˎɋɃØXɃʚ[cʭˎ̀[ [ [ [ƽ͵hƄʴϤ̛Ů΄>ǨŘ'Ń͑ͪʚØȾƹ![[[[[cŦʿȏ̐Ɩʕš@ [ [ [[ȉ°ɒɏýɋɃͪʚ[ [ [ [Βϊˎ͵ŀØƄƴZ̀[ [ [ [Βˎƴʥ™–[ØiYȠŭ̐Œ[ [ [ [ƽ̷ƄϑϤ̛Ů΄>ǨŘ'Ń͑ͪʚØȾƹ!cŦʿȏ̐Ɩʕš@ [ [[ [[[[[[[ [ [ΒšɿƄ9̎ƴʥ̷ŒØ°Æ[ [ [ [ΒšƫΣiYȠŭ̐Œ[ [ [ [ΒˎQǬɋɃØXɃŊÂc[ʭ˧åͬ

307 ˶Βϡʍ˶Βϡʍ[[[[ydžƧƖ̠ÆƔydžƧƖ̠ÆƔ[[[[[[ *, %%%%#.[*#.[* %[*#%[*# %+ +0[,#+,)+ &%[*# (Chinese version)

308 309

310 311 Appendix 3-1c Survey Forms for non-Chinese participants

Section I : BACKGROUND INFORMATION

1a) Your Age ______

1b) Your age at migration (if applicable) ______

1c) Which year did you migrate to Australia? (if applicable) ______

2. Sex: Male / Female (Please circle)

3. Country of Birth: ______

4a. Language spoken at home: please specify if not English. ______

4b. Please indicate whether you have taken part in the following situations: If yes, please rate how easy or difficult each was for you.

(1 - very difficult, 2 – difficult, 3 - manageable i.e. neither easy nor difficult, 4 -easy, 5 - very easy )

Yes/No ___ Asking questions at a seminar, parent-teacher interview or other public meeting, Yes/No ___ Talking to neighbours about issues, Yes/No ___ Making telephone enquires about information you need, Yes/No ___ Discussing work-related issues with colleagues,

5. Marital status: (Please circle) 1 – single 2 –cohabitating 3 - married 4 – separated 5 – divorced 6 – widowed

6a. What is your present state of employment? (Please circle)

1 - full-time employment 2-part-time employment 3- home duties 4 - full-time student 5- pensioner/sickness benefits 6- retired 7 - unemployed

6b. What is the level of education you have completed? (Please circle) 1- Postgraduate degree 2- Bachelor degree 3- Diploma or Advanced Diploma 4- Senior High school (e.g. completed Year 12) 5- Junior High School (e.g. completed Year 10) 6- Primary school 7- Other, please specify: ______

312 7a. Your current (or most recent) job was: (Please circle the relevant or closest category.)

1 -managerial/administrator 2- professional/paraprofessional/technical 3 - tradesperson 4- sales/retail/hospitality 5- clerical/administrative support 6- labouring/manual work 7- Other, please specify: ______

Please answer question 7b & 7c if you were not born in Australia or you have worked overseas.

7b. Your last job before migration/overseas job (Please circle) was ______.

Please circle the relevant or closest category.

1- managerial/administrator 2- professional/paraprofessional/technical

3- tradesperson 4- sales/retail/hospitality 5- clerical/administrative support 6- labouring/manual work 7- Other, please specify: ______

7c. Please indicate whether there was a loss in seniority in your current job compared to your last job before migration/before your return to Australia . ( Please circle)

Yes / No (please circle)

8. In general terms, I like everyone that I know. Yes / No (please circle)

9a. When I need some physical help (family matters, problems with the house, garden, car, mail etc.) I will ask ………… Tick the most relevant option Always Sometimes Rarely Never

1 – Friends from another language/cultural background ______

2 – Neighbours from another language/cultural background ______

3 – Friends ______

4 - Neighbours ______

5- Family members ______

313 9b. When I need some professional services (taxation, legal, medical etc.) I will ask recommendations from: Tick the most relevant option Always Sometimes Rarely Never

1 – Friends from another language/cultural background ______

2 – Neighbours from another language/cultural background ______

3 – Friends ______

4 - Neighbours ______

5- Family members ______

9c. When I feel ill at ease, I will share my concerns with ……. Tick the most relevant option Always Sometimes Rarely Never

1 – Friends from another language/cultural background ______

2 – Neighbours from another language/cultural background ______

3 – Friends ______

4 - Neighbours ______

5- Family members ______

10. In general terms, I am always nice to people. Yes / No (please circle)

11a. How often do you read Australian (English) Newspapers/Magazine? (Please circle) 1 - daily 2 - at least once a week 3 - occasionally 4 - rarely 5 - never

11b. How often do you read Newspapers/Magazine in a language other than English? (please circle) 1 - daily 2 - at least once a week 3 - occasionally 4 - rarely 5- never

314 12a. How often do you watch/listen to Australian (English) programmes (including news, videos, DVD) on TV or radio? (Please circle)

1 - daily 2 - at least once a week 3 - occasionally 4 - rarely 5 – never

12b. How often do you watch/listen to programmes in a language other than English (paid TV , SBS , news, videos, DVD) on TV or radio? (Please circle)

1 - daily 2 - at least once a week 3 - occasionally 4 - rarely 5- never

13a. When was the last time you visited your (or your parent’s) country of origin (if applicable)? ______

13b. How often do you visit your (or your parent’s) country of origin? (if applicable, please circle) 1 - at least once a year 2- between one to three-year interval 3 - more than a 5-year interval 4- rarely 5 - never

14a. Have you ever received any Chinese Herbal remedy for emotional distress? Yes / No (please circle) If yes, is it 1 - Self-prescribed 2 - Prescribed by a Naturopath 3 - Prescribed by a Traditional Chinese herbalist .4 - Other, please specify ______

14b. Have you ever seen a doctor for emotional unease? (e.g. stress, depression, anxiety, etc)? Yes / No (please circle)

14c. Have you ever received antidepressant medication? Yes / No (please circle)

15. As I remember, I never broke any rule my parents expected me to follow. Yes / No (please circle)

16a. 16a. Do you have any religious beliefs or practice any religious rituals? (e.g. go to church, temple, shrine and other places of worship.) Yes / No (please circle) If yes, please specify your religion: ______16b. Do you practice spiritual traditions. Yes / No (please circle)

(You can circle more than one answer.)

1- Ancestor worship’ 2 Joss-sticks 3 - Feng Shui 4 - Meditation

315 17a. Please write down some Chinese/Western values that have had the most impact in your life, especially when facing an unhappy event. In not more than 3 sentences, give an example to illustrate this.

17b. Many Australians and their parents were born overseas and consider themselves as someone with an ethnic background. If you feel you are one of them, how do you feel about your identity? Please mark an ‘ X ’ on each line provided: (Please write down your ethnic identity e.g. Italian, Greek, Irish etc. in the space between the brackets.)

l______l

Not at all Completely ( ……………… ) (……………….) l______l Not at all Completely Australian Australian

(iv) “How would your neighbours or colleagues feel about your ‘identity’?” (Please write down your ethnic identity e.g. Italian, Greek, Irish etc. in the space between the brackets.)

l______l

Completely Completely (………………) Australian

18a. Do you have a family doctor? Yes / No (please circle)

If your answer to 18a. is ‘Yes’, please answer 18b. & 18c. If your answer is ‘No’, please skip to Session II.

18b. Is your family doctor from a cultural background different to yours? Yes / No

18c. What language(s) does he/she speak? (You can circle more than one answer.) 1- English 2 - Cantonese 3 - Mandarin 4 – Other language: ______

316 Section II. Symptoms of Depression The following is a list of symptoms people may have when they are emotionally distressed. For each item, please tick the appropriate box to indicate, in your opinion, whether someone experiencing ‘Depression’ would be likely to show such a symptom. Symptoms Definitely Sometimes /to Not at all some degree 1. Looking sad and depressed 2. Feeling helpless 3. Think too much 4. Feeling guilty 5. Less able to laugh 6. Fatigue 7. Feeling angry 8. Poor concentration 9. Feeling life is not worth living 10. Slowed physically 11. Feeling withdrawn 12. Loss of appetite 13. Feeling bad about self 14. Loss of essence and energy 15. Heaviness in the chest 16. Feeling anxious and tense 17. Headaches 18. Disturbing dreams 19. Bored and unhappy 20. Having decrease in their self-esteem 21. Thoughts of death 22. Feeling like giving up and hopeless 23. Feeling suicidal 24. Feeling agitated and having to keep moving

25. Unable to look forward to things 26. Loss of weight 27. Having loss of self-confidence 28. Body aches and pains 29. A lack of interest in doing things 30. Easily irritated 31. Inability to sleep 32. Feeling everything is not under control 33. Talking very softly 34. Breathlessness 35. Feeling depressed

317 Section III: Emotional Distress

1. Over their lifetime, everyone experiences some degree of stress. Some people may feel significantly depressed, lost, and become easily cross. Some may experience feelings of worthlessness, hopelessness as well as loss of energy, and may lose motivation to do things, and not be able to cope as well as usual. Have you ever experienced something similar for a period of at LEAST TWO WEEKS? Yes / No (please circle) If ‘no’, please skip to Section IV i) If ‘yes’ how old were you for any first episode? ______ii) In four to five words, write down the cause or causes of this episode: ______

iii) Give the 3-4 symptoms that troubled you the most: (1)______(2)______(3)______(4)______

2. How long was your longest episode (in months)? ______

3. Has it ever prevented you from______? (please circle)

1- going to work 2- being able to work around the home

3- going to school 4- Other: (please specify) ______

4. Looking back at any such episode experienced, do you judge that what your experience was: (please circle)

8- only “normal blues” to be expected over one’s lifetime 9- at times, a distinct disorder (i.e. above and beyond what could be viewed as “reasonable distress” given my circumstances) 10- always a distinct disorder

5. For any such episode, have you ever consulted a: (You can circle more than one answer) 1 – general practitioner 2 – psychologist 3 – psychiatrist 4 – traditional Chinese herbal doctor

5 – other; please specify ______

318 Section IV: SYMPTOMS OF DISTRESS

Please circle the closest/most relevant item.

1. To the extent that you currently feel stressed at all, do you view your stress level as:

1- to be completely expected, given all my circumstances 2 - somewhat above what might be expected from my circumstances 3 - quite above what might be expected from my circumstances

2. Fatigue, sleep problems and loss of appetite are common. When you develop fatigue, which of the following reasons or explanations are you most likely to give:

1- I’m emotionally exhausted or discouraged 2 - I’ve been over-exerting myself or not exercising enough 3 - There is a medical cause (e.g. Anaemia)

3. When you have trouble sleeping, which of the following reasons or explanations are you most likely to give: 1- There is likely to be a physical reason 2 - I’m just not tired 3 - I’ve been worrying too much or must be stressed about

4. When you lose your appetite, which of the following reasons or explanations are you most likely to give:

1 - My body doesn’t need as much food (or energy) at the moment

2 - I am emotionally stressed

3 - I have a physical problem (e.g. Stomach ulcer)

Thank you for completing the questionnaire. This will help the researchers to develop more culturally appropriate medical services to the Chinese population in Sydney.

319 Appendix 3-1d Screening of ‘Depression for the medically- ill’ (English and Chinese version)

MEDICAL ILLNESS IMPACT QUESTIONNAIRE

Please consider the following questions and rate how true each one is in relation to how you have been feeling lately (i.e. in the last three days) compared to how you usually or normally feel.

Tick the most relevant option

Not True Slightly True Moderately Very True True 1. Are you stewing over things?

2. Do you feel more vulnerable than usual?

3. Are you being self-critical and hard on yourself?

4. Are you feeling guilty about things in your life?

5. Do you feel as if you have lost your core and essence?

6. Are you feeling depressed?

7. Do you feel less worthwhile?

8. Do you feel hopeless or helpless?

9. Do you feel more distant from other people?

10. Do you find that nothing seems to be able to cheer you up?

320 ƫΣœĹŊd DMI-10 Chinese version[[ [ [[[[[[[[ [ ŦǪɺƱɀǨŘκȂŊÂ[ ȥʟȋ̯ljƛʿǸ̐ƿƘ̛ɸȈOŗƲǨ@šƫΣœĹʿȏ@ ϤŦǨŃʓ ØȽƌšłiy̐Ƙš̚ǒɨ[ [[[[[[ [ [

[[ [ c[ c[ c [ (3) [[[[ [̛łY͈æǀ3ď" [[[[[[[ [[[[[[[ [[[ [[[[[[[[[[[[[[[ [[[[ [̛ƪƛ˶ŹšłƫɨȫƌĀiþΝď? 2 [[[[[[[[[[[[[[[[ [[[[ [̛˹˶Ź̎λȠė, Ϥƌ̚˶ΒΝ‘ď? 3 [ [[[[ [̛˹ɋʂŚɜ43ƫłYƛŠď" 4 [[ ̛łYŀ΋+πď"[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[ [[[[[[[ [[[[ [[[[[[[[[[[[[[[[[[[[[[[[[[[[[[ [[[[ [̛łYƫΣ̝ȕ[cØTΥːU[[[[ď" 6 [[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[ [[[[̛ƪƛ˶ŹƄƅɌ[cͳ ˕Ɍm[ď"[[[[ [[[[[[[ [[[[ [[ [[[[ [̛łYϊˎ;ǰ[Ø̯ď" 8 [[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[[ [[[[ [̛ƄśŀɟQǬŋŧɤď" 9 [[[[[[[[[[[[[[[[[[[ [̛łYϊˎƑN°ȓ̛Òǀî@ď"[[[[[[[[[ [[[[ [ [ [

321 Appendix 3-2 Focus group scenarios and semi-structured questions

Scenario I A friend of yours recently was very unsettled emotionally. She frequently became irritated for no reasons. Last week she told you that the situation was getting worse. She not only felt the ‘blues’, she was not keen to do anything. In addition, she often reported difficulties with sleep and fatigue. It seemed to her that she could not manage the everyday house chores, driving the two children to school and after school activities. There was no one to help. Her relationship with her husband was not very good. She confided this to you because she treated you as her good friend. She asked you for advice about what to do. She reminded you not to tell anyone about this, because she was concerned about people gossiping. (1) How do you feel? (2) What do you think her major problems are? Why? (3) How would you help your friend? Scenario II Your distant relative migrated from China to Sydney a few years ago. He could not find any work. Recently, you saw him at a distance; he had this dull gaze and walked very slowly along the street. He seemed to have lost a lot of weight. You walked towards him to greet him. He spotted you and then he turned around and walked away in the opposite direction. Later, you talked with another relative on the phone to find out that this unemployed relative was not leading an easy life. He was very keen to find himself a job at first but as times went by, he lost the motivation. He started to believe he was worthless and that he would never find a job in Sydney. Everyday, he just walked aimlessly on the streets and turned down all of his friends and relatives’ offers of help. His wife and children could not help very much because he seldom talked about this matter at home. (1) How do you feel? (2) What do you think his major problems are? Why? (3) How would you help your friend?

Additional discussion questions

1. What is your personal views on depression?

2. Would you consider depression as a mental illness?

3. Do you believe people in general discriminate against people with depression?

4. Where do you think the knowledge or stigma of people with depression would have come from?

322 Focus group scenarios and semi-structured questions -Chinese version

̛ˎŃ̇ċƮ̐ƘƫΣȠƄĉ£ ǶƌͪɊ'`# ʬŚɓ΢ɟ̛΄Ư ʬšƫĹ«@«αƄ̘ǀƫǎ; ˹ɲ̎3ƫ˧΄ƄîǒɾǻŚǶƌȠhɿŵƈ΢ĀZ̀ Ń»ΞĵʭƿôO͑ȈůŚǺyʒÄŨȞʂķŠʫʽ̠ǩƄ@ϊˎŋ°̝ʬ ወΕःȲƆ͛ɭȩȾȷƂǂʬŃʓŽ̛ʑʬšʫċƮ Ɓʓ̛ü™ Ŋ̛̠ɀȫÄĢʬE̩΄˄̛Ƅ̎ʓQǬŋ΄Ư̥ƛŋΞÕÕϟ

ŃȻʼn˕Äšͣɓ ̛ˎʧNư̠"

Ŋ ̛ϡʑʬšǤ̎ŊÂʟ'ȹ"

ŗ̛ŮȫÄ̝̯ʬ{"

̛ˎŃ̇ÚʛƷ ɥȿYȶɺˎʫ͛ʻ ǬŃŤΜƄYŸ̐̚Ƙ̛ʟ‰ŚǘYǬ ǬÿʼnȠʥɖɸ̼͉ ķ̚į̌ŃNjɟǬȲ͑åuȫϡǬdž˨Ãưljʓʼnȥ@̛ɟȔŃ̇ʛƷ ˗ʝɉťɰ˕͑ȠŰʥʻšʛƷɋʂŃŤƄƴʫ Ǭȹ@ŠȠɠŵΜŸ̚ ȥ@͑ǀȑʼn ҘʼƮ˶ŹƄƅɌɁƄȉ°ʟȶɺΜYŸ̚ʼnǬɾNJ ʈʈʟ‰ŚˣÅ Å ŃȻʼn˕Äšͣɓ ̛ˎʧNư̠"

Ŋ ̛ϡʑʬšǤ̎ŊÂʟ'ȹ"

ŗ̛ŮȫÄ̝̯ʬ{" Å ŊÂàŭ!

1. ̛͑ŋ˹ΥːYšʾĴȫÄ"

2. ̛ϡʑ˕ɒતઠXšŃͿď"

3. ̛ʼƮŃ»ŋ˹ΥːYXųʰˎīØĤŽď"

4. ̛ϡʑŃ»ŋ˹ΥːYXųšʼnȾy€£ΆʽɒƝ'ȹ@š"

323 Appendix 3-3 Coding Procedures

1. I first coded the transcript of one Cantonese-speaking group (Group A).

2. The transcript of an English-speaking control group (Group B) was then coded, which also served as a distracter before the second coding of the transcript of Group A.

3. I then coded Group A as new.

4. The transcript of Group B was again coded as if it was a new document.

5. The codes of the two sets of documents were examined to check any discrepancies.

Explicit descriptions of inclusion-exclusion criteria were written to eliminate any likely confusion. The memos written during the coding process were found to be very useful in developing the list of criteria. The in-built coding retrieval capacity of the NVivo 2 allowed easy access to quick reference.

6. I then coded all the remaining 14 sets of transcript (including the two used for initial set up) following the inclusion-exclusion criteria strictly.

324 Appendix 4-1 Chinese Characters and corresponding phonetic transcriptions

(in alphabetical order of transcriptions)

ƄƅɌ (bù zhōng yòng)

ưđ ( cuì ruò)

κͤ (cuò zhé)

łƫ (găn-qíng)

ėʃ gāo-xíng)

Òǀ (kāi-xín)

ϊˎU͆ (méi-yǒu jià-zhí)

ͳɪɪ (mo mat yòng)

ƛŠ (nèi-jiù)

ঘđ ( ruăn ruò) iþ Ν (shòu-shāng-hài

ɏ (shū-yuăn),

325 Appendix 4-2 Differential response pattern of some MDEMS items.

Evenly distributed responses: Responses clustered between midpoint to the ‘not at all likely’ end Infection Wrong behavior when menstruating Brain Damage or head injury A spirit who was angry because someone did something wrong. Having had an accident The person’s soul leaving the body temporarily or becoming scattered. Someone wanting to hurt the person and Someone unwittingly casting a spell. casting a spell. The person had a bad or ominous sensation. The person had a bad or ominous dream Being Hot (but not from fever or weather) Birth control against the religion and Non-Western/Naturalistic culture The person coming into contact with something or someone taboo. The person coming into contact with something or someone ‘dangerous’ or unclean or contaminated or contagious or polluted. Doing the wrong thing during pregnancy Someone wanting to hurt the person and engaging a witch/shaman to cast a spell. Failure to properly observe rituals after giving birth

326 Appendix 4-3 Third Iteration of MDEMS before test-retest

તઠ͒;˃ʚūɧ (Mental Distress Explanatory Model Schedule Chinese version)

ŦĤ‚ˎŒ̛š˩Λɗϡ(ŊÂ)! ˕ƔɒƄÞʔš ̛ƄɌĤ‚™ʔ

ĤƔNJ΢!______

ʻǏ!______

̛š}Ű!______

¢ǚƮɳ!______

ΞƅÜȑϟ!______°ȑɲ̎QǬϟ!______̛ǸɋšŗΞØǴȩ!______ʭʟȶɺǨȞʞljǸɋɫŃ˓òȶšʻɵɒ!______̛ǘʛǸɋšŗΞØǴȩ!

ʭʟȶɺǨȞʞljǸɋǬɫŃ˓òȶšʻɵɒ!______̛ȾʛǸɋšŗΞØǴȩ!

ʭʟȶɺǨȞʞljǸɋʬɫŃ˓òȶšʻɵɒ!______

ʟŃɋƅȠʥŋ˧Πξiતઠ͒;˕4ƫĹȉŭȉųƄʍšŋŮˎƄʍšત ઠ͒;ǶȭØǨƄʍšΆʼ@ƔɲˎϤǬ͊ŮłYͧþ ؙ–ˎϤŮłYŒ̠ǩ ŖØųˎϤǬ͊Ůy|ƙ3Œʍǯ

Ǭ͊ØŮʰˎÑɎšÊ˨ ˎϤǬ͊š́ʑŮɲƛ·ö˽; ȉ°Ů˹ŋ˹ŹʰˎƄ üʓ κ͑ŋ˹તઠ͒;šȾƹ˧ƄʍΒ͊;ǰťɰ̛˹Řʀʒèતઠ͒;˃ʚšʾĴ ̛ȉǨʟȡĭŚšɲ̎Ń*ŚÞȦ@ϥĄ ǨŘκŃè̚ʑǼ˰તઠ͒;šȉ°Ôʑ̎"(̐ȨŀƔɚTȉ°Ôŵ̝U̐ȋ ŀƔɚTȉ°ÔŵėU)˕ȹ0ϊˎR˹SØRˉSš@ ͑Ή̛ƄƴŽ£ ŠŦ̛ʛ@κŃȂŊ Ŧ˗ŀΚ̛šŀ‚ʟκèšȡĭŚόό

327 ǨŘʒèɒȉ°Ǽ˰તઠ͒;š˃ʚ!

1. 9ʻ ŵƄʭŀšǶȭ ………………. 2. ƙǬŋɊŀþΝɿ……………….. 3. ƙiɻ̍ØǀɃȲ̨……………….. 4. Ń»šɋʂ̐ŒØ̔þ……………… 5. ɄǮɋʂš(Ώʾ)ǯǹ………………. 6. ͗ï (̘ƪ'ïØƲ#!ï)………….. 7. i̵Ø#ɼšķʓ‘Ȍ……………… 8. ϊˎŤšƞˊ…………………… 9. ɿšઠǶˎǓXÜ˰……………… 10. ʻˬÜ˰………………………... 11. ɺuØXɵłə………………….. 12. ˂úšš˸……………………… 13. ζɋ͏@š(ɻƲÔš) …………….. 14. ˉϤ¾̷ʼnɟȹŋɿžʼŚš̷Œ…… 15. ˕ŋšɿȠū ( ). 16. ɋɃX ……………………….. 17. Ȑ˥šƧǺ˃ɵȠū ……………... 18. ( ) ………………………………………… 19. ƙiŀȞ ………………………. 20. ȠŰ ………………………….. 21. ƙiƭɮ̘ƄǽɄƲɃÜ£š~ɮ …. 22. æȣϤɅʼnΊʠ …………………. 23. ɟʛƮšů™Ü˰…………………

328

24. ƘʛØʫƮ˛Ǡƿî (ʭƯÊʛŋ)……... 25. ɊůȥȺˎʽ́úɵʆƻ…………... 26. Ȑ˥iŞØ˨˥i̔………………... 27. ˂ư¢ǚƮɳ Øúɵˮ˴́ǯ ………. 28. njǶ@âɅʼnǣΊ………………….. 29. ƲɃ~ɮ………………………… 30. Ĭ(ɏý˕ŋNjɋØNjǠÜɠ˵’Ø ϧ)... 31. ΄«Ě…………………………. 32. ʚˎŋɅˉˮÒǾʼnĚJ ( )...... 33. ʛJ ǸɿØJ̶ǏΓ………………... 34. ɥȿɎ&………………………… 35. ˕͑ŋƿƫʼnɜ4ɅʼnΊʠšŋØŒ...... 36. / / / . 37. ĢʼnŃ4ŧŮ/džƧ̵ƻÜƄ΢š3ƫ…… 38. Ÿ̚ɸ̖ØɀɌǼɸț…………….. 39. ʷŋŀƅŘʼnsϟ(ʭȲųŋ) ………. 40. ɜŋˎǀŘs@þΝ˕ŋ(ʭ̮˨) ……...

41. Ξεo‹ØɠńȠǛ ……………….. 42. ɜŋˎǀþΝ˕ŋŦ@ͽγŘʼnsϟ….. 43. ˕͑ŋˎƄ ØƄડšłƪ…………... 44. ˕͑ŋ'ͦˤØƄડšˤ…………….. 45. ˕͑ŋʾȻYłƪYƄડšʣɺ ….

̛ϣˎŃYQǬšͪʚ ď " ______

______

329 Mental Distress Explanatory Model Schedule Please fill in the following background questions. Do not fill in your name – the schedule is anonymous. Today’s date: ______Age (years): ______; Sex: ______Your occupation: ______Spritual or religious background: ______Preferred language spoken at home: ______Other languages spoken: ______Your town and country of birth: ______If born outside Australia, year of first arrival: 19_____ Father’s town and country of birth: ______If born outside Australia, year of first arrival: 19 __ Mother’s town and country of birth: ______If born outside Australia, year of first arrival: 19__

Many people suffer mental distress at some time in their lives. Such distress can be mild or severe. People can experience and manifest mental distress in many ways. Sometimes they feel sad or anxious. Sometimes they are unable to cope. Or sometimes they are out of touch with what is going on around them. They may have experiences of strange beliefs. Sometimes their behaviour becomes disorganized. They may become destructive towards themselves or others.

People explain mental distress in a variety of ways. Some are listed below. We would like to learn what you think can cause people to suffer mental distress.

How likely is it that each of the following could contribute. There is no right or wrong answer. Please mark the appropriate point for each item (from ‘not at all likely’ to ‘highly likely’). You should respond to every item even if you are not sure. Please feel free to write any comments you like on the dotted line alongside any item.

Mental distress can be caused by the following:

1. Bad experiences during childhood Not at all likely |______| Highly likely

2. Being physically harmed (intentionally) by another person Not at all likely |______| Highly likely

3. Exposure to a fright or shock Not at all likely |______| Highly likely

4. General life stress or trauma (e.g. grief) Not at all likely |______| Highly likely

5. The pace of ‘modern life’ Not at all likely |______| Highly likely

6. Being hot (but not form fever or weather) Not at all likely |______| Highly likely

7. Movements of ‘wind’ or ‘drafts’ or ‘gas’ or ‘milk’ or currents of air flowing Not at all likely |______| Highly likely

8. Not having enough money Not at all likely |______| Highly likely

9. Bad ‘nerves’ in the body Not at all likely |______| Highly likely

10. The effects of old age Not at all likely |______| Highly likely

11. Infection Not at all likely |______| Highly likely

12. Genetic or inherited defect Not at all likely |______| Highly likely

13. Being born this way (e.g. inheriting ‘bad/weak/low/cold blood’) Not at all likely |______| Highly likely

14. Eating food which is ‘‘wrong’ for that person (but not socially forbidden food) Not at all likely |______| Highly likely

15. The person’s body being out of balance or harmony (e.g. yin/yang, hot/cold, wind, fire, water, earth) Not at all likely |______| Highly likely

16. Physical illness Not at all likely |______| Highly likely 17. Chemical imbalance’ in the brain 330 Not at all likely |______| Highly likely 18. One or more of the person’s ‘vital organs’ being disrupted (e.g. ‘liver’, or ‘blood’, or vital fluids, or bone displacement) Not at all likely |______| Highly likely

19. Having had an accident. Not at all likely |______| Highly likely

20. Unemployment Not at all likely |______| Highly likely

21. Bad luck or chance (but not including astrologically determined fate) Not at all likely |______| Highly likely

22. Doing the wrong thing during pregnancy Not at all likely |______| Highly likely

23. Conflict with family or friends Not at all likely |______| Highly likely 24. Death of a relation or close friend Not at all likely |______| Highly likely

25. Failure to properly observe rituals after giving birth Not at all likely |______| Highly likely

26. Brain damage or head injury Not at all likely |______| Highly likely

27. Birth control against the religion or culture Not at all likely |______| Highly likely

28. Wrong behaviour when menstruating Not at all likely |______| Highly likely

29. Astrological destiny Not at all likely |______| Highly likely

30. The person’s karma (what happened to him/her in previous lives or incarnations) Not at all likely |______| Highly likely

31. A dangerous, unprovoked spirit Not at all likely |______| Highly likely

32. A spirit who was angry because someone did something wrong (e.g. someone failed to honour it properly) Not at all likely |______| Highly likely

33. The person’s soul leaving the body temporarily or becoming scattered Not at all likely |______| Highly likely

34. Migration to a new country Not at all likely |______| Highly likely

35. The person coming into contact with something or someone taboo Not at all likely |______| Highly likely

36. The person coming into contact with something or someone ‘dangerous’ or unclean’ or ‘contaminated’ or ‘contagious’ or ‘polluted’ Not at all likely |______| Highly likely

37. Doing something forbidden by social/cultural rules Not at all likely |______| Highly likely 38. Too much work or study Not at all likely |______| Highly likely

39. Someone unwittingly casting a spell e. g. the evil eye Not at all likely |______| Highly likely

40. Someone wanting to hurt the person and casting a spell e. g. the evil eye Not at all likely |______| Highly likely

41. Breakup of family, or a failed relationship Not at all likely |______| Highly likely

42. Someone wanting to hurt the person and engaging a witch/shaman to cast a spell Not at all likely |______| Highly likely

43. The person had a bad or ominous sensation Not at all likely |______| Highly likely

44. The person had a bad or ominous dream Not at all likely |______| Highly likely 45. The person seeing, hearing or feeling something ominous Not at all likely |______| Highly likely

Are there any other causes you want to tell us about? ______331 Thank you very much for completing this schedule. Appendix 5-1 Comparison of demographics and depression variables between retained and excluded participants.

Low-Acc Chinese High-Acc Chinese Australians Mean X √ X √ X √ t-test t-test t-test (n = 32) (n = 256 ) (n = 14 ) (n = 129 ) (n = 14) (n =143 ) Age 44.4 42.4 0.7 35.6 30.6 1.5 31.2 41.4 2.2* Age at 34.1 31.4 1.0 12.1 13.5 0.4 NA NA Migration SL-ASIA 2.05 2.07 0.2 2.72 2.95 1.5 NA NA DMI-10 9.7 12.3 2.2* 6.1 7.1 0.5 9.4 7.0 1.1

Percentage Out In χ 2 Out In χ 2 Out In χ 2 Male 38.5% 43.0% 38.5% 45.7% 33.3% 47.2% 0.33 0.25 1.05 Female 62.5% 57.0% 61.5% 54.3% 66.7% 52.8% Life time Depressive experience Yes 29.0% 29.0% 23.1% 37.6% 53.8% 49.5% 0.00 1.01 0.16 No 71.0% 71.0% 76.9% 62.4% 46.2% 50.5% X – Excluded in the sample; √ – Retained in the sample; * - p < 0.05.

Notes: 1. The phenomenon of ‘responding indiscriminate’ was observed in all subgroups, the respective rates for Low-Acc Chinese, High-Acc Chinese and Australians were 11.1%, 9.8%, 8.9%.

2. Although the DMI-10 of the Low-Acc Chinese excluded in the sample had a significantly lower mean DMI -10 score than those retained, differences in all the other variables were insignificant. Establishment of the psycholinguistic equivalence of the Chinese DMI-10 was still in progress at the time of the survey. As a result, the mean score for the Low-Acc Chinese was deemed not suitable for direct comparison with the other subgroups.

3. The mean age of those Australian excluded was significantly lower than those retained. However, there was no significant difference in the percentage of male/female and the rate of life time depressive experiences. Perhaps the ‘younger’ generation in this sample had higher mental health literacy and recognised all the symptoms listed as commonly experienced by people suffering from depression and thus responded to the 35 symptoms indiscriminately.

332 Appendix 5-2 Demographics of all Chinese and Australians

Variables All Chinese Controls n = 256 n = 143 % % Tertiary Education (post-high school) Bachelor 44.2 27.1 Degreeor above χ 2 = 13.7 (p High School or 40.0 47.9 =0.001) diploma Junior high 15.8 25.0 school or below Current Jobs Managerial 8.2 14.2 Professional/Para 29.0 29.8 -profession Sales/Services 26.6 35.5 χ 2 = 41.8 (p < Labour/blue 0.001) collar 7.9 11.3

Not in work force 28.2 9.2

333 Appendix 5-3 Demographics of the low acculturated Chinese and Australians

Variables Low-A Chinese Controls n = 256 n = 143 % % Tertiary Education (post-high school) Bachelor Degree 36.9 27.1 or above High School or 42.5 47.9 χ 2 = 3.90 (N.S.) diploma Junior high 20.6 25.0 school or below Job Managerial 4.6 14.2 Professional/Para 21.4 29.8 -profession Sales/Services 26.1 35.5 χ 2 = 41.8 (p < Labour/blue 0.001) collar 10.1 11.3

Not in work force 37.8 9.2

334 Appendix 5-4 Comparison between Highly Acculturated Chinese and Australians

Variables High-A Chinese Controls Chi-square n = 129 n = 143 % % Tertiary Education (post-high school) Bachelor Degree 58.6 27.1 or above High School or 35.2 47.9 χ 2 = 32.9*** diploma Junior high 6.3 25.0 school or below Job Managerial 15.0 14.2 Professional/Para 43.3 29.8 -profession Sales/Services 27.6 35.5 9.5 (N.S.) Labour/blue collar 3.9 11.3

Not in work force 10.2 9.2

335 Appendix 5-5 Comparison between Low and Highly Acculturated Chinese Subgroups

Variables Low-A Chinese High-A Chinese Chi-square n = 256 n = 129 % % Tertiary Education (post-high school) Bachelor Degree 36.9 58.6 or above High School or 42.5 35.2 χ 2 = 21.3*** diploma Junior high 20.6 6.3 school or below Job Managerial 4.6 15.0 Professional/Para 21.4 43.3 -profession Sales/Services 26.1 27.6 χ 2 = 50.7*** Labour/blue collar 10.1 3.9

Not in work force 37.8 10.2

Last Job Managerial 11.8 13.1 Professional/Par 30.3 29.7 a-profession Sales/Services 17.1 27.1 χ 2 = 6.45 (N.S.) Labour/blue collar 1.3 3.53.9

Not in work force 39.5 26.6

336 Appendix 5-6 Education levels and Job categories of Chinese and Australians Focus Group Participants

Variables Low-Acc Chinese High-Acc Australians Chinese n = 143 Mandarin Cantonese English % % % % Education Bachelor degree 14/17 6/18 (33.3%) 9/26 (34.6%) 10/23 (43.5%) or (82.4%) above High School or 9/18 (50%) 11/26 (42.3%) 3/17 (17.6%) 9/23 (39.1%) diploma Junior high school 3/18 (16.7%) 6/26 (23.1%) Nil 4/26(17.4%) or below Current Jobs Managerial Nil 1/22 (4.5%) 2/17 (11.8%) 1/22 (4.5%) Professional/P 10/22 4/14 (28.6%) 5/22 (22.7%) 5/17 (29.4%) ara-profession (45.5%) Sales/Services 2/14 (14.3%) 3/22 (13.6%) 2/17 (10.8%) 3/22 (27.3%) Labour/blue collar 1/14 (7.1%) 1/22 (4.5%) 1/17 (5.9%) Nil

Not in work 12/22 force 7/14 (50.0%) 7/17 (41.2%) 5/22 (22.7%) (54.5%)

337 Appendix 7-1 Factor Analysis of common symptoms of depression

For the Factor Analysis, an imposed 3-factor analysis was performed using ‘Unweighted Least Squares’(ULS) extraction and OBLIMIN ROTATION. There were 5 components with Eigen values over 1 and the Scree Plot ‘elbowed’ after component 3. Factor 1 represent the ‘core symptoms’ factor, Factor 2 is a ‘cognitive’ factor and Factor 3 is a clear somatic factor.

Table A: Total Variance Explained

Rotation Sums of Squared

Factor Initial Eigenvalues Loadings(a)

Total % of Variance Cumulative % Total

1 15.325 43.786 43.786 14.808

2 2.433 6.952 50.738 1.930

3 1.311 3.745 54.483

4 1.088 3.110 57.592

5 1.007 2.878 60.470

6 .958 2.737 63.207

34 .193 .551 99.570

35 .150 .430 100.000

Extraction Method: Unweighted Least Squares. a When factors are correlated, sums of squared loadings cannot be added to obtain a total variance.

338 Table B: Pattern Matrix (All Subjects)

Factor 1 2 3 loss of essence and energy .781

less able to laugh .691 feeling withdrawn .665 helplessness .644 feeling guilty .640 think too much .600 feeling everything is not under control .573 can't concentrate .565 .258 feel bad about self .557 -.412 feeling anxious and tense .555 having decrease in their self-esteem .509 -.358 loss of confidence .490 -.353 fatigue .483 .260 look sad .478 loss of interest in doing things .478 unable to look forward to things .458 -.449 loss of appetite .457 feeling depressed .446 -.401 bored and unhappy .425 heaviness in the chest .409 .289 slowed physically .408 feeling angry .382 inability to sleep .367 .261 easily irritated .364 .314 feeling suicidal -.917 feeling like giving up and hopeless -.771 thoughts of death -.753 live not worth living .291 -.640 body aches and pains .748 headaches .576 breathlessness .576 talking very softly .284 .464 disturbing dreams .449 feeling agitated and having to keep moving .259 .363 loss of weight -.315 .326 Extraction Method: Unweighted Least Squares. Rotation Method: Oblimin with Kaiser Normalization. a Rotation converged in 15 iterations.

339 Appendix 7-2 Support Groups identified by the focus groups

1. Speranza Club – one lady sold cakes for 20 cents – opens up channels to talk about the ‘taboo’ topic of depression/ suicide. SPERANZA means "hope" and it also stands for Suicide Prevention, Education, Research, Australia & New Zealand Action. It is the first Australian suicide consumer alliance and was established in 1994.

2. Chinese support group at Surry Hills (established for 5 years) – develops individual talents and encourages people to live with their ‘mental illness’ and at the same time to develop their talent.

3. Mother’s group – open up, share one’s emotions, put into broader perspective.

4. Informal Support Group – Chinese gather at each other’s homes sharing ‘real experiences’.

5. Migrant Group - under a different umbrella but providing vital support for each other.

340 Appendix 9-1 Issues surrounding the side effects of SSRI antidepressants

Teicher (1990) first warned that Prozac (Fluoxetine, the first Selective Serotonin Reuptake Inhibitor SSRI) could cause suicidal behaviour in the American Journal of Psychiatry: At the present time we recommend that this drug be used cautiously and that the practitioner be attentive to the possible emergence of suicidal ideation, even in those patients without a previous history of suicidal thoughts or actions.

The next year, King (1991) reported a similar phenomenon that happens in children. Yet, drug companies fiercely denied any such risk for over a decade. The Food and Drug Administration (FDA) of the United States convened an advisory committee in 1991 to conclude “there is no credible evidence” that Prozac increases the risk of suicide. The close financial ties of these committee members to Eli Lilly (the drug company which manufactures Prozac) were never questioned. This approval became the watchword of the pharmaceutical industry and the new SSRIs skyrocketed to worth $17 billion. In October, 2002, the BBC-Panorama produced and aired an investigative report on the human casualties who had been prescribed Seroxat/Paxil. BBC not only exposed the irresponsible prescribing of the drug and drug company’s unscrupulous marketing tactics to the public, but also revealed the indifference of regulatory bodies to a serious hazard to public wellbeing. Despite the worldwide publicity resulting from the BBC broadcast, senior FDA officials tried to suppress a report by FDA’s internal safety officer, Mosholder (Alliance for Human Research Protection 2004, Mosholder's embargoed report March, 2004) which confirmed a twofold suicidal risk in SSRI use among paediatric population. Later that year, under intense pressure from parents whose children became suicidal after an SSRI was prescribed and U.S. Congress applied pressure on the FDA, warnings of suicidality were added to these drugs’ label. GlaxoSmithKline (GSK) acknowledged ‘suicidality’ in kids, but not suicide. In May 2006, GSK admits the drug is associated with increased risk of suicide attempts in young adults (note 1). Subsequently, GSK changed the warnings section in the labels for PAXIL (paroxetine HCl) and PAXIL CR (paroxetine HCl Controlled-Release Tablets) to include the followings:

341 young adults, are at an increased risk of suicidal thoughts or suicide attempts, and should receive careful monitoring during treatment. with fine print to state that the higher frequency observed in the younger adult population may extend beyond the age of 24. It is difficult to conclude a causal relationship.

Despite GSK’s acknowledgement of the suicide risk, the company still tries to persuade healthcare professionals to continue to prescribe their drugs: "GSK continues to believe that the overall risk-benefit of paroxetine in the treatment of patients with Major Depression Disorders(MDD) and other non-depressive disorders remains positive…"(GSK 2006).

Note: 1. In May, 2006, GlaxoSmithKline (GSK) has submitted documents to the FDA and other regulatory agencies, contradicting its decade long denial that its antidepressant drug, paroxetine (Paxil / Seroxat) increased the risk of suicidal behaviour in the company’s controlled clinical trials,. http://www.gsk.com/media/paroxetine_adult.htm

342 References:

Abbott, M.W., Wong, S., Williams, M., Au, M., and Young, W. (1999). Chinese migrants' mental health and adjustment to life in New Zealand. Australian New Zealand Journal of Psychiatry, 33, 13-21. Abe-Kim, J., Gong, F., and Takeuchi, D. (2004). Religiosity, spirituality, and help-seeking among Filipino Americans: Religious clergy or mental health professionals? Journal of Community Psychology, 32, 675-689. Abu-Lughod, L. (1991). Writing against culture. In R. Fox (Ed.), Recapturing Anthropology (pp. 137-161). New York: School of American Research. Academic Resources at Colorado State University (2007) Clifford Geertz, “Description: Toward and Interpretive Theory of Culture,” The Interpretation of Culture, (NY: Basic Books, 1973), Chapter 1 Retriedved on July 11, 2007 from http://academic.csuohio.edu/as227/spring2003/geertz.htm ACCA (2004). 30th Year Anniversary Book. Sydney: Australian Chinese Community Association Adinoff, B., Devous, M.D.S., Best, S.E., Chandler, P., Alexander, D., Payne, K., Harris, T.S., and Williams, M.J. (2003). Gender differences in limbic responsiveness, by SPECT, following a pharmacologic challenge in healthy subjects. Neuroimage, 18, 697-706. Alliance for Human Research Protection (2004). Mosholder's embargoed report (March 2004) and the accompanying FDA memos. Retrieved December 19, 2006 from http://www.ahrp.org/risks/SSRImosholder/index.php American Institutes for Research (2005). Executive Summary: A Patient-centered guide to implementing language access services in health organizations. Retrieved July 2, 2006 from http://www.omhrc.gov/Assets/pdf/Checked/HC-LSIG-ExecutiveSummary.pdf American Medical Student Association (2006). Cultural Competence in Medicine. Retrieved July 2, 2006 from http://www.amsa.org/programs/gpit/cultural.cfm American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders Washington, D.C.: American Psychiatric Association American Psychological Association (2003). Guidelines on multicultural education, training, research, practice and organizational change for psychologists. American Psychologist, 58, 377-402. Andrews, G. Hall, W. Teesson M. Henderson S. (1999) The mental health of Australians. Mental Health Branch, Commonwealth Department of Health and Aged Care. Ata, A. and Morrison, G. (2005). [Guest Editorial] Health care providers, bereavement and ethnocentric pedagogy: Towards a sense of otherness. Australian e-Journal of the Advancement of Mental Health, 4(3). Retrieved June 28, 2006 from http://www.auseinet.com/journal/vol4iss3/atamorrisoneditorial.pdf Australian and Chinese Community Association (2006). Family and Counselling Service, [electronic source]. Retrieved March 20, 2006 from http://www.acca.org.au/section_1.asp?sectionid=7 Australian Broadcast Corporation (ABC) (2005). Second Opinions: What is Traditional Chinese Medicine? Off-air recording, 10 May, 2005. Australia Broadcast Corporation (2006), PM - Mental health high on COAG's list, [electronic source]. Retrieved February10, 2006 from http://www.abc.net.au/pm/content/2006/s1561162.htm Australian Bureau of Statistics (ABS) (2002a). 2001 Census Basic Community Profile and Snapshot, [electronic source]. Retrieved November 20, 2002 from http://www.abs.gov.au Australian Bureau Statistics(2002b) Social Capital and Social Well-being. Canberra: ABS

343 Australia Bureau of Statistics (ABS) (2003). National Health Survey: Mental Health, Australia. Canberra: ABS Australia Bureau of Statistics (2006). Australian Health Survey 1983. Retrieved November 15, 2006 from http://www.abs.gov.au/websitedbs/D3310114.nsf/89a5f3d8684682b6ca256de4002c809b/ 56c3d82cb3a5e90bca257203002381e6!OpenDocument Australian Chinese Medical Association (2005). ACMA E-News Magazine and Website. Retrieved August 8, 2006 from http://www.acma.org.au. Australian Psychological Society (2006). Find a psychologist. Retrieved January 20, 2006 from http://www.psychology.org.au/psych/referral_service/Default.aspx Baldwin, J.D., and Baldwin, J.I. (1978). Behaviourism on Verhesen Vs Erklaren. American Sociology Review, 43, 335-347. Ballenger, J.C. (2001). Focus on transcultural issues in depression and Anxiety. Journal of Clinical Psychiatry, 62(S13), 3. Bao, D.N ,. (1991). Family Roles [ ]. Beijing: Zhongguo Huaqiao Press ] (in Chinese). Barlow-Stewart, K., Yeo, S.S., Meiser, B., Goldstein, D., Tucker, K., and Eisenbruch, M. (2005). Towards cultural competence in cancer genetic counselling and genetics education. European Journal of Human Genetics, 13 (S11), 73. Barnes, L. (1998). The psychologising of Chinese healing practices in the United States. Culture, Medicine and Psychiatry, 22, 413-443. Barnes C. (1992). Qualitative research: valuable or irrelevant? Disability, Handicap and Society, 7, 115-124. BBC (2002). Panorma: The secrets of Seroxat. TV, BBC 2002 Oct 13. Transcripts available electronically. Retrieved November 25, 2006 from http://news.bbc.co.uk/2/hi/programmes/panorama/2310197.stm Beardsley, L. (1994). Medical diagnosis and treatment across cultures. In W.J. Lonner, and R.S. Malpass (Eds.), Psychology and Culture (pp. 279-284). Boston: Allyn and Bacon. Beiser, M. (2003). Why should researchers care about culture? Canadian Journal of Psychiatry, 48, 154-160. Benedict, R. (1934). Patterns of Culture Boston: Houghton Mifflin Berry, J.W., Poortinga, Y.H., Segall, M.H., and Dasen, P.R. (2002). Cross-cultural psychology: Research and applications Cambridge: Cambridge University Press Berry, J. W and Sam, D (1997). Acculturation and Adaptation. In Berry, J., Segall, M. and Kagitcibasi, G (Eds.) Handbook of Cross-Cultural Psychology, Vol. 3 Social Behavior and Application (2nd ed.), (pp. 291-326), Boston: Allyn and Bacon. Betancourt, J. (2004). Cultural competence - Marginal or mainstream movement? New England Journal of Medicine, 35, 953-955. Beyondblue (2004). Our History, [electronic source]. Retrieved September 29, 2004 from http://www.beyondblue.org.au/index.aspx?link_id=2.22 Beyondblue (2006) What is depression? Retrieved July 20, 2007 from http://www.beyondblue.org.au/index.aspx?link_id=89 Bhugra, D. (2003). Migration and depression. Acta Psychiatrica Scandinavica, 108 (S 418), S67- 72. Bhugra, D. (2004a). Migration, distress and cultural identity. British Medicine Bulletin, 69, 129- 141. Bhugra, D. (2004b). Migration and mental health. Acta Psychiatrica Scandinavica 109: 243-258. Bhugra, D. (2005). Cultural identities and cultural congruency: a new model for evaluating mental distress in immigrants. Acta Psychiatrica Scandinavica, 111, 84-93.

344 Bhugra D and Mastrogianni A (2004) Globalisation and mental disorders: Overview with relation to depression. British Journal of psychiatry 184, 10-20 Bhui, K., Mohamud, S, Warfa, N., Craig, T.J. and Stansfeld, S.A. (2003). [editorial] Cultural adaptation of mental health measures: improving the quality of clinical practice and research. British Journal of Psychiatry, 183,184-186. Bhui, K. and Sashidharan, S.P. (2003). Should there be separate psychiatric services for ethnic minority groups? British Journal of Psychiatry, 182, 10-12. Black Dog Institute (2005), [electronic source]. Retrieved October 23, 2005 from http:// www.blackdoginstitute.org.au Black Dog Institute, (2006). Hear Professor Parker talk about depression, [electronic source]. Retrieved 2006, Feb 29, 2006 from http://webqem.mmresellers.breezecentral.com/p64795487/ Bloor, M., Frankland, J., Thomas, M. and Robson, K. (2001). Focus group in social research London: Sage Bond, M.H. (1996). Chinese Values. In M.H. Bond (Ed.), Chinese Psychology (pp. 208-226). Hong Kong: Oxford University Press. Bowlby, J. (1997). Attachment and Loss. London: Pimlico Brown, G.W., Andrews, B., Harris, T., Adler, Z. and Bridge, L. (1986). Social support, self- esteem and depression. Psychological Medicine, 16, 813-831. Burrows, G., McQueenie, M. and Newton-John, P. (2005a). [Abstract for The Royal Australian and New Zealand College of Psychiatrists Joint CINP/ASPR Scientific Meeting, Brisbane, Australia, 7-9 December.] A preventive program in resiliency and wellbeing training for young Australians. Australian and New Zealand Journal of Psychiatry, 39(S), A89. Burrows, G., McQueenie, M. and Newton-John, P. (2005b). [Abstract for The Royal Australian and New Zealand College of Psychiatrists JointCINP/ASPR Scientific Meeting, Brisbane, Australia, 7-9 December.] Resiliency training for young people as prevention of psychiatric disorders and substance abuse. Australian and New Zealand Journal of Psychiatry, 39(S), S 89. Bush, R, and Baum, F. (2001) 'Health, Inequities, Community and Social Capital', in The Social Origins of Health and Wellbeing (Eds) Eckersley, R., Dixon, J., and Douglas, B. Cambridge: Cambridge University Press, pp. 189-204. Cai, X.-Q. [ , Lai, B. , and Xia, Y.H. [ (1994). Analects of Confucius [ Beijing: Sinolingua [ (in Chinese and English). Canadian Mental Health Association (1992). Bridging the Gap. Toronto: Canadian Mental Health Association. Canadian Mental Health Association (2004). Annual Report 2004: Making Connections. Toronto: Canadian Mental Health Association. Retrieved July-30, 2006 from http://www.cmha.ca/bins/content_page.asp?cid=7-15-133&lang=1 Cape, J. (2001). How general practice patients with emotional problems presenting with somatic or psychological symptoms explain their improvement. British Journal of General Practice, 51, 724-729. Caspi, A., Sugden, K., Moffitt, T.E., Taylor, A., Craig, I.W., Harrington, H., McClay, J., Mill, J., Martin, J., Braithwaite, A., and Poulton, R. (2003). Influence of Life Stress on Depression: Moderation by a Polymorphism in the 5-HTT Gene. Science, 301, 386-389. Carr, L.T. (1994). The strengths and weakness of quantitative and qualitative research: what method for nursing? Journal of Advanced Nursing, 20, 716-721. Cartwright-Jones, C. (2002). The functions of childbirth and Postpartum Henna traditions, [electronic source], Retrieved April 17, 2004 from http://www.hennapage.com/henna/encyclopedia/pregbirth/postpart.pdf.

345 Casino, G., Lewis-Fernandez, R. and Bravo, M. (1997). Methodological Challenges in Cross- cultural Mental Health Research. Transcultural Psychiatry, 34, 163-184. Centre for Chinese Cultural Studies (2002). The Three Subordination and the Four Virtues [ , [electronic source]. Retrieved June 18, 2006 from http://hk.chiculture.net/1002/html/b02/1002b02.html (in Chinese). Chan, B. (unpublished ) 'Cross-cultural issues in Clinical Depression and the implications for multicultural health polices in Australia'. 2002 Master thesis, Macquarie University, Sydney. Chan, B. (2003). 'Healthy family, a cross-cultural perspective' an innovative project to promote mental health to the Chinese community, Diversity in Health. Sydney, October 27-29: Multicultural Mental Health Australia and Diversity Health Institute (Abstract). Chan, B. and Parker, G. (2004). Some recommendations to assess depression in Chinese people in Australasia. Australian and New Zealand Journal of Psychiatry, 38, 141-147. Chan, B., Parker, G., and Eisenbruch, M. (2005). Depression through Chinese eyes and the implications for Australian multicultural health policy, The First International Congress of Qualitative Inquiry. Urbana-Champaign: University of Illinois. Retrieved June 4, 2005 from http://www.qi2005.org/papers/chan.pdf Chan, D.W. (1991). The Beck Depression Inventory: What difference does the Chinese Version Make? Psychological Assessment, 3, 616-622. Chan, E.A., Cheung, K., Mok, E., Cheung, S., and Tong, E. (2006). A narrative inquiry into the Hong Kong Chinese adults' concepts of health through their cultural stories. International Journal of Nursing Studies, 43, 301-309. Chen, A.W., and Kazanjian, A. (2005). Rate of mental health service utilization by Chinese immigrants in British Columbia. Canadian Journal of Public Health, 96, 49-51. Chen, C.-N., Wong, J., Lee, N., Chan-Ho, M.-W., Lau, J.T.-F. and Fung, M. (1993). The Shatin Community Mental Health Survey in Hong Kong: II. Major Findings. Archives of General Psychiatry, 50, 125-133. Chen, H., Kramer, E.J., and Chen, T. (2003). The Bridge Program: A Model for Reaching Asian Americans. Psychiatric Service, 54(10), 1411-1412. Chen, I.G., Roberts, R.E. and Aday, L.A. (1998). Ethnicity and adolescent depression: the case of Chinese Americans. Journal of Nervous and Mental Disease, 186, 623-630. Chen , M.M. (1989). Analyzing the teachings from the ‘Doctrines of the Mean’. Taipei: Wén Jīn (in Chinese) Cheng, A.T. (1995). Mental illness and suicide. A case-control study in east Taiwan. Archives of General Psychiatry, 52, 594-603. Cheng, A.T.A. (2001). [Editorial] Case Definition and culture: are people all the same? British Journal of Psychiatry, 179, 1-3. Cheng, T.A. (1989). Symptomatology of minor psychiatric morbidity: a cross-cultural comparison. Psychological Medicine 19, 697-708. Cheng, A.T.A., and Chang, J.C. (1999). Mental health aspects of culture and migration. Current Opinion in Psychiatry, 12, 217-222. Cheng, A.T.A., Tien, A.Y., Chang, C.J., Brugha, T.S., Cooper, J.E., Lee, C.S., Compton, W., Liu, C.Y., Yu W.Y. and Chen, H.M. (2001). Cross-cultural implementation of a Chinese version of the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) in Taiwan. British Journal of Psychiatry, 178, 567-572. Cheung, C. and Bagley, C. (1998). Validating an American scale in Hong Kong: The Center for Epidemiological Studies Depression Scale (CES-D). The Journal of Psychology, 132, 169-187. Cheung, F.M. (1982). Psychological symptoms among Chinese in urban Hong Kong. Social Science and Medicine, 16, 1339-1344.

346 Cheung, F.M. (1985). Psychological Symptoms Among Chinese in Urban Hong Kong. Social Science and Medicine, 16, 1339-1344. Cheung, F.M. (1987). Conceptualization of psychiatric illness and help-seeking behavior among Chinese. Culture, Medicine and Psychiatry, 11, 97-106. Cheung, F.M. (1989). The indigenization of neurasthenia in Hong Kong. Culture, Medicine and Psychiatry, 13, 227-241. Cheung, F.M. (1995). Facts and Myths about Somatization among the Chinese. In T.Y. Lin, W.S. Tseng and E.K. Yeh (Eds.), Chinese societies and Mental Health (pp. 156-166). Oxford: Oxford University Press. Cheung, F.M. (1996). The assessment of psychopathology in Chinese societies. In M.H. Bond (Ed.), Chinese Psychology (pp. 393-411). Hong Kong: Oxford University Press. Cheung, F.M., Lau, B.W.K. and Wong, S.W. (1984). Paths to psychiatric care in Hong Kong. Culture, Medicine, and Psychiatry, 8, 207-228. Chi, I., Yip, P.S.F., Chiu, H.F.K., Chou, K.L., Chan, K.S., Kwan, C.W., Conwell, Y. and Caine, E. (2005). Prevalence of Depression and Its Correlates in Hong Kong's Chinese Older Adults. American Journal of Geriatric Psychiatry, 13, 409-416. China Press (1968). The Encyclopedia of Chinese Phrases aipei: The China Press (in Chinese). China-Taiwan History (2000) [electronic source], Retrieved, December 20, 2005 from http://www.pbs.org/newshour/bb/asia/china/china-taiwan.html Chiu, E. (2004). Epidemiology of depression in the Asia Pacific region. Australasian Psychiatry, 12(S), S4-S10. Choa, G. (1967). Chinese traditional medicine and contemporary Hong Kong. In T.H.K.B.O.T.R.A. Society (Ed.), Weekend Symposium: Some traditional Chinese ideas and concepts in Hong Kong social life today (pp. 31-35). Hong Kong: The Hong Kong Branch of the Royal Asiatic Society. Chong, M-Y., Chen, C-C., Tsang, H-Y., Yeh, T-L., Chen, C-S., Lee Y-H., Tang, T-C. and Lo, H- Y. (2001). Community study of depression in old age in Taiwan. British Journal of Psychiatry 178, 29-35. Christensen, H., Griffiths, K. and Evans, K. (2002). e-Mental Health in Australia: Implications of the Internet and Related Technologies for Policy. ICS Discussion paper No. 3. Canberra: Commonwealth Department of Health and Aging [electronic source]. Retrieved June 24, 2006 from http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/mental- pubs/$FILE/emh.pdf Christensen, H., Griffiths, K.M. and Jorm, A. (2004). Delivering interventions for depression by using the internet: randomised controlled trial. BMJ 2004;328;265 http://bmj.com/cgi/content/full/328/7434/265 Christensen, H., Griffiths, K., Wells, L., and Kljakovic, M. (2006). Models of mental health delivery: efficacy, support and policy. Canberra: Australian Primary Health Care Research Institute (APHCRI). Chung, R.H.G., Kim, B.S.K. and Abreu, J.M. (2004). Asian American Multidimensional Acculturation Scale: Development, Factor Analysis, Reliability, and Validity. Cultural Diversity and Ethnic Minority Psychology, 10, 66-80. Clement, R. and Noels, K. (1992). Towards a situated approach to ethnolinguistic identity: The effects of status on individuals and groups. Journal of Language and Social Psychology, 11, 203-232. Clement, R., Noels, K. A. and Deneault, B. (2001). Interethnic Contact, Identity, and Psychological Adjustment: The Mediating and Moderating Roles of Communication. Journal of Social Issues, 57, 559-577. Cochrane, R., and Bal, S.S. (1987). Migration and schizophrenia: an examination of five hypothesis. Social Psychiatry and Psychiatric Epidemiology, 22, 180-191.

347 Coleman, J.S., (1988) 'Social capital in the creation of human capital.' American Journal of Sociology, 94, 95-120. Comino, E.J., Silove, D., Manicavasagar, V., Harris, E. and Harris, M. (2001). Agreement in symptoms of anxiety and depression between patients and GPs: the influence of ethnicity. Family Practice, 18, 71-77. Commonwealth Department of Health and Aged Care (2000). National Action Plan for Depression. Canberra: Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged Care. Confucius, (1996). The Analects Trans. A. Waley, A. Hertfordshire: Wordsworth Constantine, M.G. and Sue, D.W. (2005). The American Psychological Association's guidelines on multicultural education, training, research, practice, and organizational psychology: Initial development and summary. In M.G. Constantine and D.W. Sue (Eds.), Strategies for building multicultural competence in mental health and educational settings. New Jersey: Jon Wiley and Sons. Cook, T.D. (1985). Post-positivist critical multiplism. In R.L. Shortland, and M.M. Mark (Eds.), Social science and social policy (pp. 21-62). Thousand Oaks, CA: Sage. Cooper, L.A., Roter, D.L., Johnson, R.L., Ford, D.E., Steinwachs, D.M., and Powe, N.R. (2003). Patient-Centered Communication, Ratings of Care, and Concordance of Patient and Physician Race. Annals of Internal Medicine, 139, 907-915. Coyne, I.T. (1997). Sampling in qualitative research. Purposeful and theoretical sampling; merging or clear boundaries? Journal of Advanced Nursing, 26, 623-630. CRUfAD (2003). Overview: Better Outcome in Mental Health Care. Retrieved December 27, 2006 from Clinical Research Unit for Anxiety and Depression website http://www.crufad.com/phc/overview.htm. Cullen, M. and Whiteford, H. (2001). The Interrelations of Social Capital with Health and Mental Health Discussion Paper. Canberra: Commonwealth of Australia [electronic source]. Retrieved June 24, 2006 from http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/mental- pubs/$FILE/intsocial.pdf Culture and Recreation Portal, Australian Government (2005) The Australian Gold Rush. Retrieved December 20, 2005 from http://www.cultureandrecreation.gov.au/articles/goldrush/ Cyranowski, J.M., Frank, E., Young, E., and Shear, M.K. (2000). Adolescent Onset of the Gender Difference in Lifetime Rates of Major Depression: A Theoretical Model. Archives of General Psychiatry, 57, 21-27. D' Andrade, R. (1984). Cultural meaning systems. In R. Shweder, and R. Le Vine (Eds.), Cultural Theory, Essays on Mind Self and Emotion (pp. 88-119). Cambridge: Cambridge University. Davison, K.P., Pennabaker, J.W. and Dickerson, S.S. (2000). Who Talks? The social psychology of illness support groups. American Psychologist, 55, 205-217. De Jong, J. and Van Ommeren, M. (2002). Toward a culture-informed epidemiology: combining qualitative and quantitative research in transcultural contexts. Transcultural Psychiatry, 39, 422-433. De Vos, G., Marsella, A.J., and Hsu, F.L.K. (1985). Introduction: approaches to culture and self. In A.J. Marsella,G. De Vos and F.L.K. Hsu (Eds.), Culture and Self: Asian and Western Perspective (pp. 2-23). New York: Tavistock. Denzin, N.K. (1978). The Research Act, A Theoretical Introduction to Sociological Methods (2nd ed.) New York: McGraw Hill Dew, M.A., Bromet, E.J. and Penkower, L. (1992). Mental health effects of job loss in women. Psychological Medicine, 22, 751-764.

348 Department of Health and Ageing (2004). National Neuroscience Consultative Taskforce Established. Retrieved January 31, 2007 from http://www.health.gov.au/internet/ministers/publishing.nsf/content/health-mediarel- yr2004-ta-abb142.htm?OpenDocument&yr=2004&mth=8Available

Department of Health and Aging (2007). Better Access to Mental Health Care Retrieved January 12, 2007 from http://www.health.gov.au/internet/wcms/publishing.nsf/Content/C972FCCDAC5928A8C A257201007C3E6F/$File/Better%20Access.pdf Department of Immigration and Cultural and Indigenous Affairs (DIMIA) (2003). Abolition of the 'White Australia' Policy. Fact sheet No. 8. Canberra: Australia Government. DIMEA (2005). Living in Harmony Initiative. Retrieved August 8, 2005 from http://www.harmony.gov.au/media-room/ Dorfman, S. (2000). Preventive interventions under managed care: Mental health and substance abuse services. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Eastwood, H.L. (2000). Complementary therapies: the appeal to general practitioners. The Medical Journal of Australia, 173, 95-98. Eisenberg, L. (1995). The social construction of the human brain. American Journal of Psychiatry, 152, 1563-1575. Eisenbruch, M. (1990). Classification of natural and supernatural causes of mental distress: Development of a Mental Distress Explanatory Model Questionnaire. Journal of Nervous and Mental Disease, 178, 712-719. Eisenbruch, M. (1991). From post-traumatic stress disorder to cultural bereavement: diagnosis of Southeast Asian refugees. Social Science and Medicine, 33, 673-680. Eisenbruch, M and Handelman, L. (1989). Development of a Cambodian Mental Distress Explanatory Model Questionnaire. Journal of Refugee Studies, 2, 243-248. Eisenbruch, M., Yeo, S.S., Meiser, B., Goldstein, D., Tucker, K. and Barlow-Stewart, K. (2004). Optimising clinical practice in cancer genetics with cultural competence: Lessons to be learned from ethnographic research with Chinese-Australians. Social Science and Medicine, 59, 235-248. Eisenbruch, M., Chan, B. and Parker, G. (2005). The meaning of suffering - a Chinese explanatory model tool for depressive episode (Abstract). Australian and New Zealand Journal of Psychiatry, 39(S2), A51. Ekblad, S. and Baarnhielm (2002). Focus group interview research in transcultural psychiatry: reflection on research experiences. Transcultural psychiatry, 39, 484-500. Elias, N. and Blanton, J. (1987). Dimensions of ethnic identity in Israeli Jewish families living in the United States. Psychological Reports, 60, 367-375. Equity Project Team South East Health (2003). Four steps towards equity, [electronic source] Retrieved February 2, 2006 from http://www.health.nsw.gov.au/pubs/f/pdf/4-steps- towards-equity.pdf Escobar, J.I. (1998). Immigration and Mental Health: Why are immigrants better off? Archives of General Psychiatry, 55, 781-782. Evans, H. (1997). Women and Sexuality in China. Cambridge: Polity Press Evans, R. (1997). Deng Xiaoping and the making of Modern China. London: Penguin Fergusson, D., Doucette, S., Glass, K.C., Shapiro, S., Healy, D., Hebert, P., and Hutton, B. (2005). Association between suicide attempts and selective serotonin reuptake inhibitors: systematic review of randomised controlled trials. BMJ, 330, 653. Flaskerud, J., and Nguyen, T.A. (1988). Mental health needs of Vietnamese refugees. Hospital and Community Psychiatry, 39, 435-437.

349 Flatau, P., Petridis, R. and Wood, G. (1995). Immigrants and Invisible Underemployment. Canberra: Bureau of Immigration Multicultural and Population Research, Australian Government Publishing Service. Foliaki, S. (1997). Migration and Mental Health: The Tongan Experience. International Journal of Mental Health, 26, 36-54. Fonseca, M. (2002). Alternative medicine gets a boost, radio program, September 16, ABC Radio Sydney, [electronic source]. Retrieved March 7, 2005 from http://www.abc.net.au/pm/s677696.htm Foucault, M. (1980). The politics of health in the Eighteenth Century. In C. Gordon (Ed.), Power/Knowledge: Selected Interview and Other Writings 1972-1977 (pp. 166-182). Brighton: Harvester. Freeman, N.H. and Habermann, G.M. (1996). Linguistic socialization: A Chinese perspective. In Bond, M.H. (Ed.), The Handbook of Chinese Psychology (pp. 79-92). Hong Kong: Oxford University Press Friedli, L. (2005). [Guest Editorial] Promoting mental health in the United Kingdom: a case study in many parts. Australian e-Journal of the Advancement of Mental Health, 4(2), [electronic source]. Retrieved June 25, 2006 from http://www.auseinet.com/journal/vol4iss2/friedlieditorial.pdf Furnham, A. and Bochner, S. (1986). Culture Shock London: Routledge Furnham, A. and Li, Y.H. (1993). The Psychological Adjustment of the Chinese Community in Britain, A Study of Two Generations. British Journal of Psychiatry, 162, 109-113. Gao, M.C.F. and Liu, X. (1998). From Student to Citizen: A Survey of Students from the People's Republic of China (PRC) in Australia. International Migration 36, 27-48, doi: 10.1111/ 1468-2435.00032 Garza, G. (2005). The science of qualitative research: validity and reliability re-framed in terms of meaning, The First International Conference of Qualitative Inquiry. Champaign- Urbana: University of Illinois, [electronic source]. Retrieved May 10, 2005 from http://www.qi2005.org/papers/garza.pdf Geertz, C. (1973). Thick description: Toward an interpretative theory of culture, The Interpretation of Cultures (pp. 3-30). New York: Fontana. George, M., Ketter, T., Parekh, P., Herscovitch, P., and Post, R. (1996). Gender differences in regional cerebral blood flow during transient self-induced sadness or happiness. Biological Psychiatry, 40, 859-871. Gilbert, P. and Allan S. (1998). The role of defeat and entrapment (arrested flight) in depression: an exploration of an evolutionary view. Psychological Medicine, 28, 585-598. Glaser, B. and Strauss, A. (1967). The discovery of grounded theory Chicago: Aldine Glaser, B.G. (1978). Theoretical sensitivity Mill Valley, California: Sociology Press. Glaser, B.G. (1992). Basics of grounded theory analysis Mill Valley, California: Sociology Press. Goldberg, D. and Huxley, P. (1980). Mental Illness in the Community: The Pathway to Psychiatric Care. London: Tavistock Publications. Goldberg, D. and Huxley, P. (1992). Common Mental Disorders – A Bio-social Model. London, Routledge Goldney, R.D., Fisher, L.J., Dal Grande, E. and Taylor, A.W. (2005). Changes in mental health literacy about depression: South Australia, 1998 to 2004. Medical Journal of Australia, 183, 134-137. Goldney, R.D., Fisher, L.J., and Wilson, D.H. (2001). Mental health literacy: an impediment to the optimum treatment of major depression in the community. Journal of Affective Disorders, 64, 277-284. Good, B (1992) Culture and psychopathology: directions for psychiatric anthropology. In T. Schwartz, M.W. White, C.A. Lutz (Eds), New Directions In Psychological Anthropology (pp 181-205). Cambridge: Cambridge University Press.

350 Good, B., and Kleinman, A. (1985). Epilogue: Culture and depression. In A. Kleinman, and B. Good (Eds.), Culture and Depression (pp. 491-505). Berkeley: University of California Press. Good, B.J., Del Vecchio Good, M.-J. and Moradi, R. (1985). The interpretation of Iranian depressive illness and dysphoric affect. In A. Kleinman and B. Good (Eds.), Culture and Depression (pp. 369-428). Berkeley: University of California Press. Gorman, D., Brough, M. and Ramirez, E. (2003). How young people from culturally and linguistically diverse backgrounds experience mental health: Some insights for mental health nurses. International Journal of Mental Health Nursing, 12, 194-202. Grace, J., Lee, K.K., Ballard, C. and Herbert, M. (2001). The relationship between post-natal depression, somatisation and behaviour in Malaysian women. Transcultural Psychiatry, 38, 27-34. Green, G., Brandby, H., Chan, A., Lee, M., and Eldridge, K. (2002). Is the English National Health Service meeting the needs of mentally distressed Chinese women? Journal of Health Service research and Policy, 7, 216-221. Green, G., Brandby, H., Chan, A., and Lee, M. (2006). "We are not completely Westernised": Dual medical systems and pathways to health care among Chinese migrant women in England. Social Science and Medicine, 62, 1498-1509. Greene, J.C. (2005). Mixed method social inquiry: possibilities and strategies, First International Congress of Qualitative Inquiry. University of Illinois, Urbana-Champaign. Greene, J.C., Caracelli, V.J. and Graham, W.F. (1989). Towards a conceptual framework for mixed-method evaluation designs. Educational Evaluation and Policy Analysis, 11, 255- 274. Greenfield, S., Borkan, J. and Yodfat, Y. (1987). Health beliefs and hypertension: a case-control study in a Moroccan Jewish community in Israel. Culture, Medicine and Psychiatry, 11, 79-95. GSK (2006). Important prescription information, [electronic source]. Retrieved November 15, 2006 from http://www.gsk.com/media/paroxetine/adult_hcp_letter.pdf. Halliburton, M. (2004). Finding a fit: psychiatric pluralism in South India and its implications for WHO studies of mental disorder. Transcultural Psychiatry, 41, 80-98. Hankin, B.L. and Abramson, L.Y. (1999). Development of gender differences in depression: description and possible explanations. Annals of Medicine, 31, 312-319. Hannah, M. (2002). With Health in Mind: Improving mental health and wellbeing in Scotland. Edinburgh: The Scottish Public Mental Health Alliance Harkness, S. (1987). The cultural mediation of . Medical Anthropology Quarterly, 1, 194-209. Hassett, A., George, K. and Harrigan, S. (1999). Admissions of elderly patients from English- speaking and non-English speaking backgrounds to an inpatient psychogeriatric unit. Australian and New Zealand Journal of Psychiatry, 33, 576-582. Hawthrone, L. (1994). Labour Market Barriers for Immigrant Engineers in Australia Canberra: Bureau of Immigration and Population Research, Australian Government Publishing Service. Healy, D. (2006). Did regulators fail over selective serotonin reuptake inhibitors? BMJ, 333, 92- 95. Heilscher, S., and Somerfield, J. (1985). Concepts of illness and the utilization of health care services in a rural Malain village. Social Science and Medicine, 21, 469-481. Heine, S.J. and Lehman, D.R. (1999). Culture, self-discrepancies, and self-satisfaction. Personality and Social Psychology Bulletin, 25, 915-925. Helman, C. (1986). Communication in primary care: The role of patient and practitioner explanatory models. Social Science and Medicine, 23, 923-931. Helman, C.G. (2000). Culture, Health and Illness (4th Ed). London: Wright.

351 Henningsen, P., Jakobsen, T., Schiltenwolf, M. and Weiss, M.G. (2005). Somatization Revisited: Diagnosis and perceived causes of common mental disorders. Journal of Nervous and Mental Disease, 193, 85-92. Hernandez, D.J. and Charney, E. (1998). From Generation to Generation: The Health and well- being of Children in immigrant families. Washington, D.C.: National Academy Press. Hickie, I.B., Groom, G.L., McGorry, P.D., Davenport, T.A., and Luscombe, G.M. (2005). Australian mental health reform: time for real outcomes. MJA, 182, 401–406. Higgins, E. (1999). Self-discrepancy: A theory relating self and affect. In R.F. Baumeiser (Ed.), The Self in Social Psychology. (pp. 150-181). Philadelphia: Psychology Press. Hilton, T., Parker, G., McDonald, S., Heruc, G.A., Olley, A., Brotchie, H., Friend, C., and Walsh, W. (2006). A validation study of two brief measures of depression in the cardiac population: the DMI-10 and DMI-18. Psychosomatics, 47, 129-135. Hinshaw, S.P. and Cicchetti, D. (2000). Stigma and mental disorder: conceptions of illness, public attitudes, personal disclosure, and social policy. Development and Psychopathology, 12, 555-598. Historical Museum for Medicine of the Shanghai Academy of Chinese Medicine (1985). The Struggle for and against a Belief in Fate in the Medicine of Our Land. In P.U. Unschuld (Ed.), Medicine in China: A History of Ideas (pp. 340-352). Berkeley: University of California Press. Ho, C.U. (1999). The Chinese in South-East Asia, [electronic source]. Retrieved December 22, 2005 from http://www.minorityrights.org/Profiles/profile.asp?ID=16 Ho, D.Y.F. (1996). Filial Piety and Its Psychological Consequences. In M.H. Bond (Ed.), Chinese Psychology (pp. 155-165). Hong Kong: Oxford University Press. Hofstede, G. (2001). Cultural Consequences: Comparing Values, Behaviours Institutions and Organizations Across Nations (2nd ed). Thousand Oaks: Sage Holtz, T. (1998). Refugee trauma versus Torture trauma: a retrospective controlled cohort study of Tibetan refugees. Journal of Nervous and Mental Disease, 186, 24-34. Hon, H.C. and Coughlan, J.E. (1997). The Chinese in Australia: Immigrants from the People's Republic of China, Malaysia, Singapore, Taiwan, Hong Kong and Macau. In J.E. Coughlan and D. McNamara, J, (Eds.), Asian in Australia, Pattern of Migration and Settlement (pp. 120-170): McMillan Education Australia. Hong D.G. [ (2002). The Common Origins of Food and Herbal Therapies Hong Kong: Cosmos Book Limited (in Chinese) Hong Kong Observer (1981). Pressure Points. Hong Kong: Summerson Education Research Centre Hong, M. , and Wang, H.L. [ ] (2002). Faults in family education leading to anxiety for examination among high school students: Analysis and solution. [ ]. Psychological Science [ ], 25, 753-755 (in Chinese). Hsu, F.L.K. (1971). Psychosocial homeostasis and Jen: Conceptual tools for advancing psychological anthropology. American Anthropologist, 73, 23-44. Hsu, F.L.K. (1978). Passage to understanding. In G. Spindler (Ed.), The Making of Psychological Anthropology (pp. 142-173). Berkeley: University of California Press. Hsu, F. (1985). The Self in Cross-cultural Perspective. In A. J. Marsella, G. De Vos, and F.L.K. Hsu (Eds.), Culture and Self, Asian and Western Perspectives (pp. 24-55). New York: Tavistock. Hua, M., C. Rissel, Orr, N. and Li, MW. (2002). "Effectiveness of a resource on the Australian health care system among the Sydney Chinese-speaking community." Promotion and Education 9: 98-100.

352 Hui, J.-A. (2005). Plot Heavy - interview with Dr. Rita Charon, Professor Clinical Medicine and director of Narrative Medicine, Columbia University, Arts + Medicine pp. 39-41. Hwu, H.-G., Chang, I.-H., Yeh, E.-K., Chang, C.-J. and Yeh, L.-L. (1996). Major depressive disorder in Taiwan defined by the Chinese Diagnostic Interview Schedule. The Journal of Nervous and Mental Disease, 184, 497-502. Hwu, H-G., Yeh, E-K. and Chang, L-Y. (1989). Prevalence of psychiatric disorders in Taiwan defined by the Chinese Diagnostic Interview Schedule. Acta Psychiatrica Scandinavica, 79, 136-147. Ito, K.L. and Maramba, G.G. (2002). Therapeutic beliefs of Asian American therapists: views from an Ethnic-Specific Clinic. Transcultural Psychiatry, 39, 33-73. Jack, D.C. (1999). Silencing the self: inner dialogues and outer realities. In T. Joines, and J. Coyne (Eds.), The Interactional Nature of Depression (pp. 221-246). Washington, DC: American Psychological Association. Jacka, T. (1997). Women's Work in Rural China. Cambridge: Cambridge University Press Jacobs, D.G. (1995). National Depression Screening Day: educating the public, reaching those in need of treatment, and broadening professional understanding. Harvard Review of Psychiatry, 3, 156-159. Johnston, G. (2003). Dietary Chemicals and Brain Function. Journal and Proceedings of the Royal Society of New South Wales, 135, 57-71. Johnson, R.L., Roter, D., Powe, N.R. and Cooper, L.A. (2004). Patient race/ethnicity and quality of patient-physician communication during medical visits. American Journal of Public Health, 94, 2084-2090. Jorm, A.F. (2000). Mental health Literacy. British Journal of Psychiatry, 177, 396-401. Jorm, A., Christensen, H. and Griffiths, K.M. (2005). The impact of beyondblue: the national depression initiative on the Australian public's recognition of depression and beliefs about treatments. Australian and New Zealand Journal of Psychiatry, 39, 248-254. Jorm, A.F., Griffiths, K., Christensen, H. and Medway, J. (2002). Research Priorities in Mental Health - ANU Centre for Mental Health Research, Canberra: Commonwealth of Australia Jorm, A.F., Korten, A.E., Jacomb, P.A., Christensen, H., Rodgers, B. and Pollitt, P. (1997). "Mental health literacy": a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia, 166, 182- 186. Jorm, A.F., Medway, J., Christensen, H., Korten, A.E., Jacomb, P.A. and Rodgers, B. (2000). Public beliefs about the helpfulness of interventions for depression: effects on actions taken when experiencing anxiety and depression symptoms. Australian and New Zealand Journal of Psychiatry, 34, 619-626. Jorm, A.F., Nakane, Y., Christensen, H., Yoshioka, K., Griffiths, K.M. and Wata, Y. (2005). Public beliefs about treatment and outcome of mental disorders: a comparison of Australia and Japan. BMC Medicine, 3:12. Joyful (Mental Health) Foundation (2004). Joyful (Mental Health) Foundation - about the organization [electronic source]. Retrieved November 20, 2005 from http://www.jmhf.org/abs_bg.htm Kadri, N., and Sartorius, N. (2005). The Global Fight against the stigma of schizophrenia. PloS Medicine, 2(7): e136(7). Karasz, A. (2005). Cultural differences in conceptual models of depression. Social Science and Medicine, 60, 1625-1635. Katon, W. and Kleinman, A. (1981). Doctor-patient negotiation and other social science strategies in patient care. In L. Eisenberg, and A. Kleinman (Eds.), The relevance of social science for medicine (pp. 253-279). Dordrecht: Reidel.

353 Kovacs, M., Obrosky, D.S., and Sherrill, J. (2003). Developmental changes in the phenomenology of depression in girls compared to boys from childhood onward. Journal of Affective Disorders, 74, 33-48 Kessler, D., Lloyd, K., Lewis, G. and Pereira, D. (1999). Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care. British Medical Journal 318, 436-439. Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., and Walters, E.E. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602. Kessler, R.C., McGonagle, K.A., Swartz, M., Blazer, D.G., and Nelson, C.B. (1993). Sex and depression in the National Comorbidity Survey I: Lifetime prevalence, chronicity and recurrence. Journal of Affective Disorders, 29(2-3), 85-96. Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H.U, and Kendler, K.S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8-19. Khan, M.E. and Manderson, L. (1992). Focus groups in tropical diseases research. Health policy and Planning, 7, 56-66. King, R.A., Riddle, M.A., and Chappell, P.B. (1991). Emergence of self-destructive phenomena in children and adolescents during fluoxetine treatment. Journal of American Academic Child & Adolescent Psychiatry, 30, 179-186. Kirkby, K. (2005). [Abstract for The Royal Australian and New Zealand College of Psychiatrists Joint CINP/ASPR Scientific Meeting, Brisbane, Australia, 7-9 December.] Support networks promoting E-health in youth. Australian and New Zealand Journal of Psychiatry, 39(S), A30. Kirmayer, L. (2001). Cultural Variations in the Clinical Presentation of Depression and Anxiety: Implications for Diagnosis and Treatment. Journal of Clinical Psychiatry, 62 (S 13), S22- 28. Kirmayer, L.J., Groleau, D., Guzder, J., Blake, C. and Jarvis, E. (2003). Cultural consultation: a model of mental health service for multicultural societies. Canadian Journal of Psychiatry, 48, 145-153. Kirmayer, L., and Minas, H. (2004). The future of cultural psychiatry: An international perspective. Canadian Journal of Psychiatry, 45, 438-446. Kirmayer, L.J., Robbins, J.M., Dworkind, M., and Yaffe, M.J. (1993). Somatization and the recognition of depression and anxiety in primary care. American Journal of Psychiatry, 150, 734-741. Kitchener, B.A. and Jorm, A.F. (2002). Mental Health First Aid Manual. Canberra: Centre for Mental Health Research Kitchener, B.A. and Jorm, A.F. (2005). [Abstract for The Royal Australian and New Zealand College of Psychiatrists Joint CINP/ASPR Scientific Meeting, Brisbane, Australia, 7-9 December.] Mental Health First Aid training in the workplace. Australian and New Zealand Journal of Psychiatry, 39(S), A37. Kitzinger, J. (1999). The methodology of focus groups: the importance of interaction between research participants. In A. Bryman and R.G. Burgess (Eds.), Qualitative Research (pp. 138-155). London: Sage. Kleinman, A. (1977). Depression, somatisation, and the new cross-cultural psychiatry. Social Science and Medicine, 11, 3-10. Kleinman, A. (1980). Patients and healers in the context of culture: An exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley: University of California Press.

354 Kleinman, A. (1982). Neurasthenia and depression: A study of somatisation and culture in China. Culture, Medicine and Psychiatry, 6, 117-190. Kleinman, A. (1986). Social origins of distress and disease: Depression, neurasthenia, and pain in modern China. New Haven, CT: Yale University Press Kleinman, A. (1987). Anthropology and psychiatry: The role of culture in cross-cultural research on illness. British Journal of Psychiatry, 151, 447-454. Kleinman, A. (1995). Writing at the Margin. Berkeley: University of California Press Kleinman, A. (1998). Seminar on Health, Culture and Change: Lessons for Australia in the Asia Pacific Region., 26-March-1998. Melbourne: Victorian Health Promotion Foundation. Kleinman, A. (2004). Culture and Depression. New England Journal of Medicine, 351, 951-953. Kleinman, A. and Cohen, A. (1997). Psychiatry’s Global Challenge. Scientific American, March, 74-77. Kleinman, A., and Kleinman, J. (1999). The transformation of everyday social experience: what a mental and social health perspective reveals about Chinese communities under global and local change. Culture, Medicine and Psychiatry, 23, 7-24. Klimidis, S., and Minas, H. (1995). Migration, culture and mental health in children and adolescents. In C. Guerra, and R. White (Eds.), Ethnic minority youth in Australia (pp. 85-100). Hobart: National Clearinghouse for Youth Studies. Klimidis, S., Minas, H. and Kokanovic, R. (2005).[Abstract] Ethnic minority community patients and the Better Outcomes in Mental Health Care initiative, Diversity in Health 2005; it's everybody's business. Melbourne. Klimidis, S., Minas, H. and Kokanovic, R. (2006). Ethnic minority community patients and the Better Outcomes in Mental Health Care initiative. Australasian Psychiatry, 14, 212-215. Klimidis, S., Stuart, G., Minas, I.H. and Ata, A.W. (1994). Immigrant status and gender effects on psychopathology and self-concept in adolescents: A test of the migration-morbidity hypothesis. Comprehensive Psychiatry, 35, 393-404. Koenig, H.G. (2001). Religion and Medicine II: Religion, mental health and related behaviors. International Journal of Psychiatry in Medicine, 31(1), 91-109. Kovacs, M., Obrosky, D.S., and Sherrill, J. (2003). Developmental changes in the phenomenology of depression in girls compared to boys from childhood onward. Journal of Affective Disorders, 74, 33-48. Koven, M. (2004) Getting 'emotional' in two languages: Bilinguals' verbal performance of affect in narratives of personal experience. Text, 24: 471-515. Kuper, A. (1999) Culture - The anthropologists' account. Cambridge: Harvard University Press. La Trobe University and Museum of Chinese Australian History (2003). Brief History of the Chinese in Australia, [electronic source]. Retrieved December 2, 2005 from http://www.chaf.lib.latrobe.edu.au/education/history.htm Landy, D. (1983). Medical Anthropology: A critical appraisal. In J. Ruffini (Ed.), Advances in Medical Social Science. New York: Gordon and Breach. Lai, J. and Linden, W. (1993). The smile of Asia: Acculturation effects on symptom reporting. Canadian Journal of Behavioral Science, 25, 303-313. Larkin, P.J., de Casterle, B.D., & Schotsmans, P. (2007) Multilingual translation issues in qualitative research: reflections on a metaphorical process. Qualitative Health Research, 17, 468 - 476. .Retrieved on July 5, 2007 from http://qhr.sagepub.com/cgi/content/abstract/17/4/468 Laroche, M., Kim C., Hui K and Tomiuk M., (1998). Test of a nonlinear relationship between linguistic acculturation and ethnic identification. Journal of Cross-cultural Psychology, 29, 418-434.

355 Lazarus, R.S. and Lazarus, B. N. (1994). How biology and culture affect our emotions. In R.S. Lazarus, and B. N. Lazarus, Passion and Reason (pp. 174-197). Oxford: Oxford University Press. Leduc, N. and Proulx, M. (2004). Patterns of Health Services Utilization by Recent Immigrants. Journal of Immigrant Health, 6, 15-27. Lee, D.T.S., Yip, S.K., Chiu, H.F.K., Leung, T.Y.S., Chan, K.P.M., Chau, I.O.L., Leung, H.C.M. and Chung, T.K.H. (1998) Detecting postnatal depression in Chinese women. Validation of the Chinese version of the Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 172:433-437. Lee, M.S., Yang, K.H., Huh, H.J., Kim, H.W., Ryu, H., Lee, H.S. and Chung, H.T. (2001) Qi therapy as an intervention to reduce chronic pain and to enhance mood in elderly subjects: a pilot study. American Journal of Chinese Medicine, 29, 237-245. Lee, S. (1997). Unity and hybridity: the transformation of mental health problems in Chinese Society. Transcultural Psychiatry, 34, 265-286. Lee, S. (1998). Estranged bodies, simulated harmony, and misplaced cultures: Neurasthenia in contemporary Chinese society. Psychosomatic Medicine, 60, 448-457. Lee, S. (2002). Socio-cultural and global health perspectives for the development of future psychiatric diagnostic systems. Psychopathology, 35, 152-157. Lee, S., Chiu, M.T.L., Tsang, A., Chui, H., and Kleinman, A. (2006). Stigmatizing experience and structural discrimination associated with the treatment of schizophrenia in Hong Kong. Social Science and Medicine, 62, 1685-1696. Lee, S. and Kleinman, A. (1997). Mental illness and social change in China. Harvard Review Psychiatry, 5, 43-46. Lee, S. and Wong, K. (1995). Rethinking neurasthenia: the illness concepts of "shenjing- shuairuo" among Chinese undergraduates in Hong Kong. Culture Medicine and Psychiatry, 19, 91-111. Leong, F.T.L., and Lau, A.S.L. (2001). Barriers to providing effective mental health services to Asian Americans. Mental Health Services Research, 3, 201. Lester, N. (1998). Cultural Competence: A Nursing Dialogue Part Two. Continuing Education. American Journal of Nursing, 98, 36-42. Levy, R.I. (1984) Emotion, knowing and culture. In R.A. Shweder and R.A.L. Vine (Eds), Culture Theory: Essays on Mind, Self and Emotion. (pp 214-237). Cambridge: Cambridge University Press. Li, P.L., Logan, S., Yee, L. and Ng, S. (1999). Barriers to meeting the mental health needs of the Chinese community. Journal of Public Health, 21, 74-80. Liang, S.-M. [ ](1987). Chinese Cultural Highlight [ ]. Hong Kong: Joint Publishing (in Chinese). Liao, H.-Y., Rounds, J., and Klein, A.G. (2005). A test of Cramer's (1999) help-seeking model and acculturation effects with Asian and Asian American College Students. Journal of Community Psychology, 52, 400-411. Lim, A. and Bishop, G. (2000). The role of attitudes and beliefs in differential health care utilization among Chinese in Singapore. Psychology and Health, 14, 965-977. Lin, T.Y. (1985) Mental disorders and psychiatry in Chinese culture: characteristic features and major issues. In W.S. Tseng and Y.H. Wu (Eds), Chinese Culture and Mental Health (pp 369-394). Orlando, Fla: Academic Press. Ling, C.S. (1997). Back to the future - herbal tea shops in Hong Kong. In G. Evans and M. Tam (Eds.), Hong Kong: the anthropology of a Chinese metropolis (pp. 51-73). Surrey: Curzon. Lifton, R. (2005). Americans as Survivors. New England Journal of Medicine, 352, 2263-2265. Littlewood, R. and Lipsedge, M. (1997). Aliens and Alienists: Ethnic Minorities and Psychiatry. London: Routledge

356 Liu, X.C., Ma, D.D., Kurita, H. and Tang, M.Q. (1999). Self-reported depressive symptoms among Chinese adolescents. Social Psychiatry and Psychiatric Epidemiology, 34, 44-47. Lock, M. (1987). DSM-III as a cultural-bound construct: Commentary on culture-bound syndromes and International Disease Classifications. Culture, Medicine and Psychiatry, 11, 35-42. Loring, M. and Powell, B. (1988). Gender, race, and DSM-III: A study of the objectivity of psychiatric diagnostic behavior. Journal of Health and Social Behavior, 29, 1-22. Lu, L. [ ], Huang, M. S. ], Sun, X. L. [ ], Shu, F. [ ], Liu, Z. Z. [ ], Zhang, D. P. [ ] and Yin, H. F. [ ] (1998). The study of emotional disorders in department of internal medicine [ ]. (1998). Chinese Journal of Psychiatry [ ], 31, 234-236 (in Chinese). Lucire, Y. (1996). PhD Thesis, Ideology and Aetiology: RSI, an epidemic of Craft Palsy, School of Science and Technology Studies. Sydney: University of New South Wales. Lucire, Y. (2003). Constructing rsi: Belief and desire. Sydney: UNSW Press Lucire, Y. (2004). SSRIs - Do they cause ? [Available: http://www.lucire.com.au/documents/pps/Do-SSRIs-cause-Suicide.pps] Retrieved on 15- Sept- 2006]. Lutz, C. (1983). Depression and the translation of emotional worlds. In A. Kleinman, and B. Good (Eds.), Culture and Depression (pp. 63-100). Berkeley, CA: University of California Press. Lutz, C. and White, G.M. (1986) The anthropology of emotions. Annual Review of Anthropology, 15: 405 436. Ma, G. (1999). Between two worlds: the use of traditional and western health services by Chinese immigrants. Journal of Community Health, 6, 421-437. Madriz, E. (2000). Focus groups in feminist research. In N.K. Denzin, and Y.S. Lincoln (Eds.), Handbook of Qualitative Research (pp. 835-850). Thousand Oaks: Sage. Mak, A., and Chan, H. (1995). Chinese family values in Australia. In R. Hartley (Ed.), Families and Cultural Diversity in Australia (pp. 70-95). Melbourne: Allen Unwin. Mak, A.S. (2001). Relocating Careers: Hong Kong Professionals and Managers in Australia. Hong Kong: Centre of Asian Studies, University of Hong Kong. Markus, H.R. and Kitayama, S. (1991). Culture and the self: Implications for cognitions, emotion and motivation. Psychological Review, 98, 224-253. Marsella, A. (2001). Cultural diversity and cultural well-being: Nuances of a complex relationship [Abstract]. Diversity in Health, Sharing Global Perspective: a landmark conference on multicultural health and well-being, Sydney. Marsella, A.J. (2003). Cultural aspects of depressive experience and disorders. In D.L.D. W. J. Lonner, S. A. Hayes, and D. N. Sattler (Ed.), Online Readings in Psychology and Culture, (pp. Unit 9, Chapter 4). Bellingham, Washington USA: Center for Cross- Cultural Research, Western Washington University, [electronic source]. Retrieved, October15, 2005 from http://www.ac.wwu.edu/~culture/Marsella.htm Marsella, A.J., Sartorius, N., Jablensky, A., and Fenton, F. (1985). Cross-cultural studies of depressive disorders: An overview. In A. Kleinman, and B. Good (Eds.), Culture and Depression (pp. 299-324). Berkeley: University of California Press. Martin, N. (2006). What do we know about the genetics of depression? [Abstract], The Australasian Society for Psychiatric research Annual Conference - Brainwaves (p. 23). December 7-9, 2006, Sydney Mathers, C.D., and Loncar, D. (2006). Projections of Global Mortality and Burden of Disease from 2002 to 2030. PLoS Medicine, 3, 11, e442.

357 McLaren, C. (2003). Prozac Nations: How does mental illness differ cross-culturally? An interview with Lawrence Kirmayer [electronic source]. Retrieved June 24, 2006 from http://www.stayfreemagazine.org/archives/21/lawrence_kirmayer.html McLean, C.A. and Campbell, C.M. (2003). Locating research informants in a multi-ethnic community: ethnic identities, social networks and recruitment methods. Ethnicity and Health, 8, 41-61. McNair, B.G., Highet, N.J., Hickie, I.B. and Davenport, T. (2002). Exploring the perspectives of people whose lives have been affected by depression. Medical Journal of Australia, 176, S69-S76. Mental Health Council of Australia (MHCA) (2005). Not a failure of policy: it's a failure of implementation and delivery, [electronic source]. Retrieved February 10, 2006 from http://www.mhca.org.au/documents/MHCASub-SenateInquiryintoMentalHealth.pdf Mental Health Foundation of New Zealand (2005). Mindful Schools: Mentally Healthy Schools. Retrieved August 3, 2006 from http://www.mentalhealth.org.nz/page.php?123 Merson, J. (2004). Epistemic Capture: The Science and Politics of Stress-related Illness. PhD thesis. Sydney: University of New South Wales. Miller, G. (2006). China: Healing a metaphorical heart. Science, 311, 462-463. Mezzich, J., Kirmayer, L.J., Kleinman, A., Fabrega, H., Parron, D.L., Good, B.J., Lin, K.-M. and Manson, S. (1999). The place of culture in DSM-IV. The Journal of Nervous and Mental Disease, 187, 457-464. Mihalopoulos, C., Pirkis, J., Naccarella, L. and Dunt, D. (1999). The role of general practitioners and other primary care agencies in transcultural mental health care. Melbourne: Australian Transcultural Mental Health Network. Minas, I.H. (1990). Mental health in a culturally diverse society. In J. Reid, and T. P. (Eds.), The Health of Immigration Australia: a Social Perspective (pp. 250-287). Melbourne: Harcourt Brace Jonanovich. Morse, J.M. (1991). Strategies for sampling. In J.M. Morse (Ed.), Qualitative nursing research: a contemporary dialogue (pp. 127-145). Newbury Park, California: Sage. Mrazek P.J. and Haggerty R.J. (1994) Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. National Academy Press: Washington Muhlbauer, S.A. (2002). Navigating a storm of mental illness: phases in the family's journey. Qualitative Health Research, 12, 1076-1092. Multicultural Mental Health Australia (MMHA), (2004). Framework for the implementation of the National Mental Health Plan 2003-2008, [electronic source]. Retrieved February 27, 2006 from http://www.mmha.rog.au/Policy/framework.pdf Multicultural Mental Health Australia (MMHA), (2002). Cultural Awareness Tool: Understanding Cultural Diversity in Mental Health Canberra: Commonwealth of Australia. Retrieved May 3, 2006 from http://www.mmha.org.au/MMHAPublications/Store/cat.pdf Murdock, G., Wilson, S. and Frederick, V. (1978). Cultural illness and health Washington, DC: American Anthropological Association. Murphy, H.B.M. (1977). Migration, culture and mental health. Psychological Medicine, 7, 677- 684. Murray, C.L.J. and Lopez, A.D. (1996). Evidence-based health policy - lessons from the Global Burden of Disease Study. Science, 274, 740-743. Nakane, Y., Jorm, A., Yoshioka, K., Christensen, H., Nakane, H. and Griffiths, K.M. (2005). Public beliefs about causes and risk factors for mental disorders: a comparison of Japan and Australia. BMC Psychiatry, 5:33. Nazroo, J.Y. (2001). Exploring Gender Difference in Depression, Vol. XVIII, Issue 3 Psychiatric Times, [electronic source]. Retrieved June 18, 2006 from http://www.psychiatrictimes.com/p010343.html

358 Nazroo, J.Y., Edwards, A.C. and Brown, G.W. (1997). Gender differences in the onset of depression following a shared life event: a study of couples. Psychological Medicine, 27, 9-19. Nazroo, J.Y., Edwards, A.C. and Brown, G.W. (1998). Gender differences in the prevalence of depression: artefact, alternative disorders, biology or roles? Sociology of Health and Illness, 20, 312-330. National Multicultural Advisory Council (NMAC), (1999). Australian multiculturalism for a new century: Towards inclusiveness. Canberra: Commonwealth of Australia. NSW Department of Health (2003a). NSW School-Link initiative, [electronic source]. Retrieved June 28, 2006 from http://www.health.nsw.gov.au/pubs/s/pdf/well_school-link.pdf NSW Department of Health (2003b). NSW Parenting Program for Mental Health, [electronic source]. Retrieved June 28, 2006 from http://www.health.nsw.gov.au/pubs/p/pdf/well_parenting.pdf New South Wales Transcultural Mental Health Centre (NSWTMHC) (2001). Working in Partnership: Key Achievements 1997-2000. Parramatta: NSW Transcultural Mental Health Centre. Ng-Tse, T. (2001). Development of a questionnaire to assess the impact of mental illness on Chinese women. Hong Kong Journal of Psychiatry, 11, 9-16. NHMRC (2005). Cultural Competency in Health: A guide for policy, partnerships and participation. [electronic source]. Retrieved December 11, 2006 from http://www.nhmrc.gov.au/publications/_files/hp19.pdf Noels, K.A., Pon, G. and Clement, R. (1996). Language, identity and adjustment, the role of linguistic self-confidence in the acculturation process. Journal of language and social psychology, 15, 246-264. Nussbaum, M. (1999). Sex and Social Justice. New York: Oxford University Press Nvivo Version 2 (2004). Melbourne: QSR International Pty. Ltd. Oates, M., Cox, J.L., Neema, S., Asten, P., Glangeaud-Freudenthal, N., Figueiredo, B., Gorman, L., Hacking, S., Hirst, E., Kammerer, M., Klier, C., Seneviratne, G., Smith, M., Sutter- Dallay, A.L., Valoriani, V., Wickberg, B., Yoshida, K. and TCS-PND (2004). Postnatal depression across countries and cultures: a qualitative study. British Journal of Psychiatry, 184, S10-S16. Office of Minority Health (2006). A family physician's guide to cultural competence care: Department of Health and Human Services, [electronic source]. Retrieved July 2, 2006 from https://cccm.thinkculturalhealth.org/ Olioff, M. (1991). The application of cognitive therapy to postpartum depression. In M. Vallis, J. Howes, and P. Miller (Eds.), The Challenge of Cognitive Therapy (pp. 111-133). New York: Plenum Press. Oppedal, B., Roysamb, E., and Heyerdahl, S. (2005). Ethnic group, acculturation and psychiatric problems in young immigrants. Journal of Child Psychology and Psychiatry, 46, 646- 660. Ots, T. (1990). The angry liver, the anxious heart and the melancholy spleen: the phenomenology and perception in Chinese culture. Culture, Medicine and Psychiatry, 14, 21-58.

Owen, S. (2001). The practical, methodological and ethical dilemmas of conducting focus groups with vulnerable clients. Methodological Issues in Nursing Research, 36, 652-658. Panorma: The secrets of Seroxat (2002) TV, BBC 2002 Oct 13. Transcripts available electronically. Retrieved November 25, 2006 from http://news.bbc.co.uk/2/hi/programmes/panorama/2310197.stm Parker, G.B. and Brotchie, H.L. (2004). From diathesis to dimorphism: The biology of gender differences in depression. Journal of Nervous and Mental Disease, 192, 210-216.

359 Parker, G. and Chan, B. (2004). Depression in Australian Chinese. How acculturation informs us about the detection and manifestation of clinical depression, XXIV CINP Congress (Abstract). Paris: International Journal of Neuropsycho-pharmacology. Parker, G, Chan, B., Tully, L. and Eisenbruch, M. (2005) Depression in the Chinese: the impact of acculturation. Psychological Medicine, 35:1475-1483. Parker, G., Gladstone, G. and Chee, K.T. (2001). Depression in the planet's largest ethnic group: the Chinese. American Journal of Psychiatry, 158, 857-864. Parker, G., Hilton, T., Bains, J., and Hadzi-Palovic, D. (2001). Screening for depression in the medically ill: the suggested utility of a cognitive-based approach. Australian and New Zealand Journal of Psychiatry, 35, 474-480. Parker, G., Cheah, Y.-C. and Roy, K. (2001). Do the Chinese somatise depression? A cross- cultural study. Social Psychiatry and Psychiatric Epidemiology, 36, 287-293. Parker, G., and Gladstone, G. (2004). Capacity of the 10-item Depression in the Medically Ill screening measure to detect depression 'caseness' in psychiatric out-patients. Psychiatry Research, 127, 283-287. Parker, G., Hilton, T., Bains, J. and Hadzi-Palovic (2002). Cognitive-based measures screening for depression in the medically ill: the DMI-10 and the DMI-18. Acta Psychiatrica Scandinavica, 105, 419-426. Parker, G., Hilton, T., Hadzi-Palovic, D. and Irvine, P. (2003). Clinical and personality correlates of a new measure of depression: a general practice study. Australian and New Zealand Journal of Psychiatry, 37, 104-109. Parker, G. and Parker, K. (2003). Influence of symptom attribution on reporting depression and recourse to treatment. Australian and New Zealand Journal of Psychiatry, 37, 469-474. Parsons, C. (1990). Cross-cultural issues in health care. In J. Reid, and P. Trompf (Eds.), The Health of Immigrant Australia: A Social Perspective (pp. 108-153). Sydney: Harcourt Brace Jonanovich. Parsons, C. and Wakeley, P. (1991). Idioms of distress: Somatic responses to distress in everyday life. Culture, Medicine and Psychiatry, 15, 111-132. Paykel, E.S. (2001). The evolution of life events research in psychiatry. Journal of Affective Disorders, 62, 141-149. Paykel, E.S. (2003). Life events and affective disorders. Acta Psychiatrica Scandinavia 108 (S 418): S61-S66. Paykel, E.S., Hart, D. and Priest, R.G. (1998). Changes in public attitudes to depression during the Defeat Depression Campaign. British Journal of Psychiatry, 173, 519-522. Paykel, E.S., Tylee, A., Wright, A., Priest, R.G., Rix, S. and Hart, D. (1997). The Defeat Depression Campaign: psychiatry in the public arena. American Journal of Psychiatry, 154, 59-65. PBS (2000). China-Taiwan History, [electronic source]. Retrieved December 22, 2005 from http://www.pbs.org/newshour/bb/asia/china/china-taiwan.html Phan, T., Steel, Z. and Silove, D. (2004). An Ethnographically Derived Measure of Anxiety, Depression and Somatization: The Phan Vietnamese Psychiatric Scale. Transcultural Psychiatry, 41, 200-232. Phil, R., Prior, L. and Wood, F. (2001). Lay attitudes to professional consultations for common mental disorder: a sociological perspective. British Medical Bulletin, 57, 207-219. Phillips, D.L. and Clancy, K.J. (1972). Some effects of "Social Desirability' in Survey Studies. American Journal of Sociology, 77, 921-940. Phinney, J.S. (1990). Ethnic identity in adolescents and adults: Reviews of research. Psychological Bulletin, 108, 499-514. Phinney, J.S. and Alipuria, L. (1990). Ethnic identity in college students from four ethnic groups. Journal of Adolescence, 13, 171-183.

360 Pillsbury, B.L.D. (1978). 'Doing the Month': Confinement and Convalescence of Chinese women after childbirth. Social Science and Medicine, 12, 11-12. Pirkis, J., Blood, W.R., Francis, C., Putnis, P., Burgess, P., Morley, B., Stewart, A. and Payne, T. (2002). The Media Monitoring Project: A Baseline Description of how the Australian Media Report and Portray Suicide and Mental Health and Illness. Canberra: Australian Department of Health and Aged Care. Pleto, P.J. and Pleto, G.H. (1997). Studying knowledge, culture, and behavior in applied Medical Anthropology. Medical Anthropology Quarterly, 11, 147-163. Ponzio, V. (2006). Utilisation of mental health services by people from Mainland China. Australian Rotary Health Research Seminar: Mental health issues and access to care among migrants from mainland China. Jan, 2006 Sydney. Poortinga, Y.H. (1989). Equivalence of cross-cultural data: an overview of basic issues. International Journal of Psychology, 24, 737-756. Putnam, R.D. (2000) Bowling Alone: The Collapse and Revival of American Community. Simon and Schuster, New York. Putnam, R.D. (1993) Making Democracy Work, Civic Traditions in Modern Italy. Princeton University Press, Princeton, New Jersey. Rack, P.H. (1988). Psychiatric and social problems among immigrants. Acta Psychiatrica Scandinavia, S 144, 167-173. RANZCP (2006). Best Practice Psychiatrist Liaison Model, [electronic source]. Retrieved December 20, 2006 from http://www.ranzcp.org/pdffiles/gpliaison/BestPracticeBrochure2006.pdf RANZCP (2006). Social and Cultural Psychiatry Conference: Influencing social determinants of mental health and well-being in rural, indigenous and island peoples. Sept, 2006, Cairns. Retrieved December 28, 2006 from http://www.ranzcp.org/publicarea/public.asp Raphael, B. (2000). A population health model for the provision of mental health care Canberra: Commonwealth of Australia, [electronic source]. Retrieved June 24, 2006 from http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/mental- pubs/$FILE/pophm.pdf Rebhun, L.A. (1993). Nerves and Emotional Play in Northeast Brazil. Medical Anthropology Quarterly, 7, 131-151. Rebhun, L.A. (1994). Swallowing Frogs: Anger and illness in Northeast Brazil. Medical Anthropology Quarterly, 8, 360-362. Regier, D.A., Hirschfield, R.M.A., Goodwin, F.K., Burke, J.D., Lazar, J.B. and Judd, L.J. (1988). The NIMH Depression Awareness, Recognition, and Treatment Program: Structure, aims and scientific basis. American Journal of Psychiatry, 145, 1351-1357. Reidfield, R., Linton, R., and Herskovits, M.J. (1936). Memorandum for the study of acculturation. American Anthropologist, 38, 149-152. Ren, P. [ ], (2004). Zhong Guo Min Jian Jin Ji [Traditional Chinese Cultural Taboos Beijing: China Social Science [ ], (in Chinese). Richards, L. (1999). Using NVivo in Qualitative Research. London: Sage Rissel, C. (2005). The Bangkok Charter for Health Promotion in a Globalised World: What is it all about? N S W Public Health Bulletin, 16(9-10), 156-158. Ritchie, J. (2001). Not everything can be reduced to numbers. In C.A. Buerglund (Ed.), Health Research (pp. 149-173). Oxford: Oxford University Press. Ritchie, J. and Herscovitch, F. (1995). From Likert to love it: engaging blue collar workers in focus group inquiries. Journal of Occupational Health Safety - Australia and New Zealand, 11, 471-479.

361 Rowling, L. (2002). Mental Health Promotion. In L. Rowling, G. Martin, and L. Walker (Eds.), Mental Health Promotion and Young People Concepts and Practice (pp. 10-23). Sydney: McGraw Hill. Rowling, L. (2003). School mental health promotion research: Pushing the boundaries of research paradigms. Australian e-Journal for the Advancement of Mental Health 2(2)[electronic source]. Retrieved July 30, 2006 from http://www.auseinet.com/journal/vol2iss2/rowling.pdf Rowling, L. and Rissel, C. (2000). Intersectoral collaboration for the development of a national framework for health promoting schools in Australia. Journal of School Health, 70 (6), 248-250. Robinson, N. (1999). The use of focus group methodology — with selected examples from sexual health research. Journal of Advanced Nursing, 29, 905-913. Rosaldo, R. (1983) Grief and the headhunters' Rage. In E.Bruner (Ed), Play, Text and Story (pp 178 195). Washington, DC: American Ethnological Society. Rosenheck, R., Fontana, A. and Cottrol, C. (1995). Effect of clinician-veteran racial pairing in the treatment of posttraumatic stress disorder. American Journal of Psychiatry, 152, 555-563. Rosenthal, D.A., Bell, R., Demetriou, A. and Efklides, A. (1989). From collectivism to individualism? The acculturation of Greek immigrants in Australia. International Journal of Psychology, 24, 57-71. Rosenthal, D.A. and Feldman, S.S. (1996). Crossing the Border: Chinese Adolescents in the West. In S. Lau (Ed.), Growing Up the Chinese Way (pp. 281-319). Hong Kong: Chinese University Press. Rudmin, F. and Ahmadzadeh, V. (2001). Psychometric critique of acculturation psychology: The case of Iranian migrants in Norway. Scandinavian Journal of Psychology, 42, 41-56. Russell, J.A., and Yik, M.S.M. (1996). Emotions among the Chinese. In M.H. Bond (Ed.), The Handbook of Chinese Psychology (pp. 166-188). Hong Kong: Oxford University Press. Ryan, G.W., and Bernard, R.H. (2000). Data management and analysis methods. In N.K. Denzin, and Y.S. Lincoln (Eds.), Qualitative Research (2nd ed.) (pp. 769-802). Thousand Oaks: Sage. Ryder, A., Alden, L. and Paulhus, D. (2000). Is acculturation unidimensional or bidimensional? A head-to-head comparison in the prediction of personality, self-identity and adjustment. Journal of Personality and Social Psychology, 79, 49-65. Said, E.W. (1979). Orientalism New York: Random House, Vintage Books Salant, T. and Lauderdale, D.S. (2003). Measuring culture: A critical review of acculturation and health in Asian immigrant populations. Social Science and Medicine, 57, 71-90. Sale, J., Lohfeld, L., and Brazil, K. (2002). Revisiting the qualitative-quantitative debate: Implications for mixed-methods research. Quality & Quantity, 36, 43-53. Saluja. Gitanjali, Iachan, R., Scheidt Peter C., Overpeck, M.D., Sun Wenyu, & Giedd, J.N. (2004). Prevalence of and Risk Factors for Depressive Symptoms Among Young Adolescents. Archives of Pediatric Adolescenct Medicine, 158, 760-765. Sandelowski, M. (1995). Focus on qualitative methods: sample size in qualitative research. Research in Nursing and Health, 18, 179 -183. Sartorius, N. and Schulze, H. (2005). Reducing Stigma of Mental Illness: a report from a Global Programme of World Psychiatric Association Cambridge: Cambridge University Press Schulze, B., and Angermeyer, M.C. (2003). Subjective experiences of stigma. A focus group study of schizophrenic patients, their relatives and mental health professionals. Social Science and Medicine, 56, 299-312. Schumaker, J. and Ward, T. (2001). Cultural Cognition and Psychopathology. London: Praeger Scottish Office (1999) Towards a Healthier Scotland – A White Paper on Health. Retrieved May 8, 2006 from http://www.scotland.gov.uk/library/documents-w7/tahs-02.htm

362 Seligman, M.E.P. (1975). Helplessness: On Depression Development and Death. San Francisco: Freeman and Co. Senate, Australia Parliament House (2006a) First Report- tabled on 30 March 2006 published, [electronic source]. Retrieved April 30, 2006 from http://www.aph.gov.au/SENATE/committee/mentalhealth_ctte/report/index.htm Senate, Australia Parliament House (2006b) Final Report- tabled on 28 April 2006, [electronic source]. Retrieved April 30, 2006 from http://www.aph.gov.au/SENATE/committee/mentalhealth_ctte/report02/index.htm Shen, Y.C., Zhang, M.Y., Huang, Y.Q., He, Y.L., Liu, Z.R., Cheng, H., Tsang, A., Lee, S. and Kessler, R.C. (2006). Twelve-month prevalence, severity, and unmet need for treatment of mental disorders in metropolitan China. Psychological Medicine, 36, 257-267. Shi, Y., and Hueng, G. (1993). Marked adjectives and unmarked adjectives. Chinese Language Zhogguo Yuwen [ 6, 401-409, (in Chinese). Simon, G.E., Goldberg, D., Tiemens, B.G., Bedirhan, T., and Üstün, T.B. (1999). Outcomes of recognized and unrecognized depression in an international primary care study. General Hospital Psychiatry, 21, 97-105. Simon, G.E., Von Korff, M., Piccinelli, M., Fullerton, C. and Ormel, J. (1999). An International Study of the Relation between Somatic Symptoms and Depression. New England Journal of Medicine, 341, 1329-1335. Simon , G.E., Goldberg, D.P., Von Korff, M. and Üstün, T.B . (2002). Understanding cross- national differences in depression prevalence. Psychological Medicine, 32 585-594. Smith, P. B. and M. H. Bond (1999). Social Psychology Across Cultures. Boston: Allyn and Bacon. Special Broadcast Station (SBS), (2006). Insight: Aussie Rules, Off-air recording, 25th April, 2006. Spencer, M.S. and Chen, J. (2004). Effect of Discrimination on Mental Health Service Utilization among Chinese Americans. American Journal of Public Health, 94, 809-814. Sperber, A.D., Devellis, R.F. and Boehlecke, B. (1994). Cross-cultural translation: methodology and validation. Journal of Cross-Cultural Psychology, 25, 501-524. Spiro, M.E. (1961). Social system, personality, and functional analysis. In B. Kaplan (Ed.), Studying personality cross-culturally (pp. 93-128). Evanston: Row, Peterson. SPSS 13.0 for Windows (2004). Chicago: SPSS Inc. Steel, Z., McDonald, R., Silove, D., Bauman, A., Sandford, P., Herron, J., and Minas, I.H. (2006). Pathways to the first contact with specialist mental health care. Australian and New Zealand Journal of Psychiatry 40, 347-354. Stevenson, H., C. S. Chen, et al. (1994). Chinese Families. In J. Roopnarine and B. Carter (Eds), Parent-Child Socialization in Diverse Cultures. New Jersey: Ablex. Stuart, G.W., Minas, I.H., Klimidis, S. and O'Connell, S. (1996). English language ability and mental health service utilization: a census. Australian and New Zealand Journal of Psychiatry, 30, 270-277. Sue, D.W. and Sue, D. (2000). Counselling the Culturally Different. New York: Wiley. Suinn, R.M. (1998). Measurement of Acculturation of Asian Americans. Asian American Pacific Islanders Journal of Health, 6, 7-12. Suinn, R. M., C. Ahuna and Khoo G. (1992). The Suinn-Lew Asian Self-identity Acculturation Scale: concurrent and factorial validation. Educational and Psychological Measurement, 52: 1041-1046. Super, C., and Harkness, S. (1994). The Developmental Niche. In W.J. Lonner, and R.S. Malpass (Eds.), Psychology and Culture (pp. 95-99). Boston: Allyn and Bacon. Swartz, L. (2005). Intergenerational Issues. Synergy, 3, 4-7.

363 Swartz, L.P., and Dick, J. (2002). Managing chronic diseases in less developed countries: healthy teamworking and patient partnership are just as important as adequate funding. British Medical Journal, 325, 914-915. Tabora, B.L. and Flaskerud, J.H. (1997). Mental health beliefs, practices, and knowledge of Chinese American immigrant women. Issues in Mental Health Nursing, 18, 173-189. Takeuchi, D.T., Chung, R.C., Lin, K.-M., Shen, H., Kurasaki, K., Chun, C.-A., and Sue, S. (1998). Lifetime and Twelve-Month Prevalence Rates of major Depressive Episodes and Dysthymia Among Chinese Americans in Los Angeles. American Journal of Psychiatry, 155, 1407-1414. Tan, B.C.H. (1998). The Chinese Community in Australia: A 27 years retrospective, Chung Wah Association, [electronic source]. Retrieved December 22, 2005 from http://www.nw.com.au/~ysyow/chungwah/85/bobtan.html Tang, J.L., Zhan, S.Y. and Ernst, E. (1999) Review of randomised controlled trials of traditional Chinese medicine. BMJ, 1999; 319, 160-161 Tang, J.-Y. [ ] (2003). Chinese Cultural Ideology and Moral reasoning [ ]. Taipei: Student Book (in Chinese). Tashakkori, A. and Teddlie, C. (1998). Mixed Methodology. London: Sage Tata, S.P. and Leong, F.T.L. (1994). Individualism-collectivism, network orientation, and acculturation as predictors of attitudes towards seeking professional psychological help among Chinese Americans. Journal of Counseling Psychology, 41, 280-287. Teicher, M.H., Glod, C., and Cole, J.O. (1990). Emergence of intense suicidal preoccupation during fluoxetine treatment. American Journal of Psychiatry, 147, 207-210. Temple, B., & Edwards, R. (2002). Interpreters/translators and cross-language research:Reflexivity and border crossings. International Journal of Qualitative Methods, 1(2). Retrived on July 5, 2007 from http://www.ualberta.ca/~iiqm/backissues/1_2Final/pdf/temple.pdf Thakker, J. and Ward, T. (1998). Culture and classification: The cross-cultural application of the DSM-IV. Clinical Psychology Review, 18(5), 501-529. Thompson, A., Hunt, C. and Issakidis, C. (2004). Why wait? Reasons for delay and prompts to seek help for mental health problems in an Australian clinical sample. Social Psychiatry Psychiatric Epidemiology, 39, 810-817. Thompson, S., Manderson, L., Woelz-Stirling, N. and Cahill, A. (2002). The social and cultural context of the mental health of Filipinas in Queensland. Australian and New Zealand Journal of Psychiatry, 36, 681-687. Tippett, V., Elvy, G., Hardy, J. and Raphael, B. (1994). Mental Health in Australia: A Review of Current Activities and Future Directions. Canberra: Australian Government Publishing Services To, C.-Y. [ ], Kwan, C.-H. ] and Tong, W.K. [ ] (2004). Classics of Traditional Chinese Medicine [ ]. Hong Kong: Commercial Press (in Chinese). Tsai, J. H. (2003). Contextualizing immigrants' lived experience: the story of Taiwanese immigrants in the United States. Journal of Culture Diversity, 10, 76-83. Tu, W.-M. (1993). Way, Learning and politics: essays on the Confucian intellectual. Albany: State University of New York Press Tung, M. (1994). Symbolic meanings of the body in Chinese culture and "somatisation". Culture, Medicine and Psychiatry, 18, 483-492. UNESCO (2001). Cultural Diversity [electronic source]. Retrieved June 12, 2005 from http://portal.unesco.org/culture/en/ev.php Unschuld, P.U. (1985). Medicine in China: A history of ideas. Berkeley: University of California Press

364 Unschuld, P.U. (1992). Epistemological Issues and changing Legitimization: Traditional Chinese Medicine in the Twentieth Century. In C. Leslie, and A. Young (Eds.), Paths to Asian Medical Knowledge (pp 44-61). Berkeley: University of California Press. Üstün, T. B. and N. Sartorius, Eds. (1995). Mental Illness in General Health Care: An international study. Chichester, John Wiley and Sons. Van de Vijver, F., and Leung, K. (1997). Methods and Data Analysis for Cross-cultural Research. Thousand Oaks: Sage. Van Ommeren, M., Sharma, B., Thapa, S., Makaju, R., Prasain, D., Bhattarai, R., and De Jong, J. (1999). Preparing instruments for transcultural research: Use of the translation monitoring form with Nepali-speaking Bhutanese refugees. Transcultural Psychiatry, 36, 285-301. Van Ommeren, M. (2003). Validity issues in transcultural epidemiology. British Journal of Psychiatry, 182, 376-378. Vickery, D.M., Kalmer, H., Lowry, D., Constantine, M., Wright, E., and Loren, W. (1983). Effect of a self-care education program. Journal of the American Medical Association, 250(21), 2952-2956. Victorian Government Health Information VGHI (2006). Victoria’s Mental Health Services, [electronic source]. Retrieved May 8, 2006 from http://www.health.vic.gov.au/ Vic Health (2001) Together We Do Better . Retrieved May 8, 2006 from http://www.togetherwedobetter.vic.gov.au/ Vinokur, A.D., Schul, Y., Vuori, J. and Price, R.H. (2000). Two years after a job loss: Long-term impact of the JOBS program on reemployment and mental health. Journal of Occupational Health Psychology, 5, 32-47. Walker, M.L. (1991). Rehabilitation service delivery to individuals with disabilities: A question of cultural competence. OSERS News in Print, 4(2), 6-11. Wang, H.T. [ ], (2004). The Emperor’s book of internal medicine: contemporary version [ ]. Bejing: Ren Min Shu Sheng Press [ ], (in Chinese). Wadesworth, Y. (1997). Everyday Evaluation on the Run (2nd ed) Sydney: Allen and Unwin Ward, C. (2001). The A, B, C's of acculturation. In D.R. Matsumoto (Ed.), The handbook of culture and psychology (pp. 411-445). New York: Oxford University Press Ward, N. (1998). Sociosomatics and Illness Course in Chronic Fatigue Syndrome. Psychosomatic Medicine,, 60: 394-401. Werbner, P. (1997). Introduction: the dialectics of cultural hybridity. In P. Werbner and T. Modood (Eds.), Debating Cultural Hybridity: Multi-cultural Identities and the politics of anti-racism (pp. 1-26). London: Zed Book. Weber, M. (1930). The Protestant Ethic and the Spirit of Capitalism; London; Boston: Unwin Hyman. E-book by the University of Virginia American Studies Program 2001, [electronic source]. Retrieved December 27, 2006 from http://xroads.virginia.edu/~HYPER/WEBER/toc.html. Weber, M. (1968). Economy and Society: An Outline of Interpretive Sociology. New York: Bedminster Press Wèi, Z.-X. [ ] and Niè, L.-F. [ ], (1994). Chinese traditional Medicine and Hygiene [ ] .Taipei: Taiwan Commercial Press [ ] (in Chinese). Weiss, M. (1997). Explanatory Model Interview Catalogue(EMIC): Framework for comparative study of illness. Transcultural Psychiatry, 34, 235-263. Weiss, M., Sharma, S., Gaur, R., Sharma J. S, Desai A. and Doongaji D. R. (1986). Traditional concepts of mental disorder among Indian psychiatric patients: preliminary report of work in progress. Social Science and Medicine, 23, 379-386. Weng, A.E.A. (1996). Controlled study of the family environment, intimacy and adaptation. Chinese Mental Health Journal, 10, 148-150.

365 Werbner, P. (1997). Introduction: the dialectics of cultural hybridity. In P. Werbner and T. Modood (Eds.), Debating Cultural Hybridity: Multi-cultural Identities and the politics of anti-racism. (pp. 1-26). London: Zed Book. Westermeyer, J. and Janca, A. (1997). Language, culture and psychopathology: conceptual and methodological issues. Transcultural Psychiatry, 34, 291-311. White, G.M. (1990). Moral discourse and the rhetoric of emotions. In C.A. Lutz and L. Abu- Lughod (Eds.), Language and the politics of emotion (pp. p. 46-68). Cambridge: Cambridge University Press. Whitehead, M. (1990). The concepts and principles of equity and health. Geneva: WHO, Regional Office. Whitehead M, D.G., Evans T. (2001). Equity and health sector reforms: can low-income countries escape the medical poverty trap? Lancet, 358, 833-836. Whitley, R., Kirmayer, L.J. and Jarvis, G.E. (2004). [Letter to the editor] Cultural consultation in psychiatric practice. British Journal of Psychiatry, 185, 76. Wilhelm, K., Kotze, B., Waterhouse, M., Hadzi-Pavlovic, D. and Parker, G. (2004). Screening for Depression in the Medically Ill: A Comparison of self-report measures, clinician judgment, and DSM-IV diagnoses. Psychosomatics, 45, 461-469. Wilhelm, K.A.Y., Mitchell, P.B., Niven, H., Finch, A., Wedgwood, L., Scimone, A., Blair, I.P., Parker, G. and Schofield, P.R. (2006). Life events, first depression onset and the serotonin transporter gene. British Journal of Psychiatry, 188, 210-215. Whitaker, R. (2005). Anatomy of an epidemic: Psychiatric drugs and the astonishing rise of mental illness in America. Ethical Human Psychology and Psychiatry, 7, 23-35. Whittaker, A., and Connor, L. (1998). Engendering Stress in Australia: The embodiment of social relationships. In L. Manderson (Ed.), Australian Women's Health: Innovations in Social Sciences and Community Research, (pp. 97-115). Sydney: Haworth. WHO (1946). World Health Organization, Constitution of the World Health Organization, 1946. Geneva: WHO, [electronic source]. Retrieved July 12, 2006 from http://w3.whosea.org/aboutsearo/pdf/const.pdf. WHO (1978). Declaration of Alma-Ata: International Conference on Primary Health Care. Geneva: WHO. WHO (1986). Ottawa Charter for Health Promotion First International Conference on Health Promotion. Geneva: WHO, [electronic source]. Retrieved July 12, 2006 from http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf WHO (1997). Jakarta Declaration on Leading Health Promotion into the 21st Century. Geneva: WHO, [electronic source]. Retrieved July 12, 2006 from http://www.who.int/hpr/NPH/docs/jakarta_declaration_en.pdf WHO (2000). Women's Mental Health: An Evidence Based Review, [electronic source]. Retrieved August 6, 2006 from http://whqlibdoc.who.int/hq/2000/WHO_MSD_MDP_00.1.pdf. WHO (2001a). Mental health: strengthening mental health promotion (Fact sheet No. 220). Geneva: WHO, [electronic source]. Retrieved August 6, 2006 from http://www.who.int/mediacentre/factsheets/fs220/en/print.html WHO (2001b). The World Health Report 2001: Mental Health: New Understanding, New Hope, [electronic source]. Retrieved May 17, 2002 from http://www.who.int/whr/2001/en/whr01_en.pdf. WHO (2002a). The World Health Report 2002 - Reducing Risks, Promoting Healthy Life, [electronic source]. Retrieved December 3, 2004 from http://www.who.int/whr/2002/Overview_E.pdf WHO (2002b). WHO Traditional Medicine Strategy 2002-2005, [electronic source]. Retrieved March 7, 2006 from http://whqlibdoc.who.int/hq/2002/WHO_EDM_TRM_2002.1.pdf WHO (2003). Investing in Mental Health, [electronic source]. Retrieved April 30, 2004 from http://who.int/mental_health/en/investing_in_mnh_final.pdf

366 WHO (2004a). World Health Report 2004: Changing history, Geneva: WHO, [electronic source]. Retrieved January 11, 2007 from http://www.who.int/whr/2004/en/ WHO (2004b). Prevention of Mental Disorders: Effective Interventions and Policy Options. Geneva: WHO, [electronic source]. Retrieved June 24, 2006 from http://www.who/int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf WHO (2004c). Promoting Mental Health: Concepts, Emerging Evidence, Practice: A Summary Report. Geneva: WHO, [electronic source]. Retrieved June 24, 2006 from http://www.who/int/mental_health/evidence/en/promoting_mhh.pdf WHO (2005). The Bangkok Charter for Health Promotion in a Globalised World: WHO, [electronic source] Retrieved July 12, 2006 from http://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/ WHO (2006a) Gender difference. Geneva, WHO, [electronic source]. Retrieved June 26, 2006 from http://www.who.int/mental_health/media/en/242.pdf WHO (2006b) Feature Series: Voices from the Frontline, [electronic source]. Retrieved July 12, 2006 from http://www.who.int/social_determinants/advocacy/feature_chilesolidario/en/index2.html World Bank (2006). Social Capital, [electronic source]. Retrieved 24 August, 2006 from http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTSOCIALDEVELOPME N Wu, Y. [ ] (1998). Neo- Taoism Explained [ ]. Taipei: Sam-min [ ] (in Chinese) Wyn, J., Cahill, H., Holdsworth, R., Rowling, L. and Carson, S. (2000). MindMatters, a whole- school approach promoting mental health and wellbeing. Australian and New Zealand Journal of Psychiatry, 34, 594-601. Wynaden, D., Chapman, R., Orb, A., McGowan, S., Zeeman, Z. and Yeak, S.H. (2005). Factors that influence Asian communities' access to mental health care. International Journal of Mental Health, 14, 88-95. Yao, S.-C. ( 2002) Confucius Capitalism. London: Rutledge. Yee, L. and Au, S. (1997). Chinese Mental Health Issues in Britain – Perspectives from the Chinese Mental Health Association. London: Mental Health Foundation. Yen, C.-F., Chen, C.-C., Lee, Y., Tang, T.-C., Yen, J.-Y. and Ko, C.-H. (2005). Self-Stigma and Its Correlates Among Outpatients With Depressive Disorders. Psychiatric Services, 56, 599-601. Yen, S., Robins, C. and Lin, N. (2000) A Cross-Cultural Comparison of Depressive Symptom Manifestation: China and the United States. Journal of Consulting and Clinical Psychology 68, 6, 993-999 Yeo, S.S. and Meiser, B. (2003). Cross-cultural cognitive therapy for the treatment of depressive symptoms in Chinese clients: integrating the beliefs systems of Confucianism, Buddhism and Taoism. In W.O. Phoon and I. Macindoe (Eds.), Untangling the threads: perspectives on mental health in Chinese communities (pp. 300-317). Sydney: Transcultural Mental Health Centre. Yeo, S.S., Meiser, B., Goldstein, D., Tucker, K., Barlow-Stewart, K. and Eisenbruch, M. (2005). Understanding community beliefs of Chinese-Australians about cancer: Initial insights using an ethnographic approach. Psycho-Oncology, 14, 174-186. Yeung, A., Howarth, S., Chan, R., Sonawalla, S., Nerenberg, A.A. and Fava, M. (2002). Use of the Chinese version of the Beck Depression Inventory for screening depression in primary care. Journal of Nervous and Mental Disease, 190, 94-99. Yeung, A., Kung, W.W., Chung, H., Rubenstein, G., Roffi, P., Mischoulon, D. and Fava, M. (2004). Integrating psychiatry and primary care improves acceptability to mental health services among Chinese Americans. General Hospital Psychiatry, 26, 256-260.

367 Ying, Y. (1990). Explanatory models for major depression and implications for help-seeking among immigrant Chinese-American women. Culture, Medicine and Psychiatry, 14, 393- 408. Ying, Y.-W. (1995). Cultural orientation and psychological well being in Chinese Americans. American Journal of Community Psychology, 23, 893-911. Ying, Y.-W. (2002). The conception of depression in Chinese Americans and Its Implications for Treatment. In K.S. Kurasaki, S. Okazaki and S. Sue (Eds.), Asian American Mental Health: Assessment Theories and Methods (pp. 173-183) New York: Kluwer. Ying, Y. -W., Lee, P, Tsai, J., Yeh, Y.-Y. and Huang, J. (2000) The conception of Depression in Chinese American College Students in Cultural Diversity and Ethnic Minority Psychology, 6,2,183-195 Ying, Y., and Miller, L. (1992). Help-seeking behavior and attitude of Chinese Americans regarding psychological problems. American Journal of Community Psychology, 20, 549- 556. Young, A. (1976). Some implications of medical beliefs and practices for social anthropology. American Anthropology, 78, 5-24. Young, A. (1982). The anthropologies of illness and sickness. Annual Review of Anthropology, 11, 257-285.Yuan, R. and Lin, Y. (2000). Traditional Chinese medicine: an approach to scientific proof and clinical validation. Pharmacology and Therapeutics, 86, 191-198. Yuan, R., and Lin, Y. (2000). Traditional Chinese medicine: an approach to scientific proof and clinical validation. Pharmacology and Therapeutics, 86, 191-198. Zhang, A.Y., Yu, L.C., Yuan, J., Tong, Z., Yang, C. and Foreman, S. (1997). Family and cultural correlates of depression among Chinese elderly. International Journal of Social Psychiatry, 43, 199-212. Zhang, M. Y. (1989). The diagnosis and phenomenology of neurasthenia: a Shanghai Study. Culture Medicine and Psychiatry, 13, 147-161. Zhang, W. X., Shen, Y. C. and Li, S. R. (1998). Epidemiological investigation on mental disorders in seven areas of China. Chinese Journal of Psychiatry, 31, 69-71. Zheng, Y., Liang, W., Goa, L., Zhang, G. and Wong, C. (1988). Applicability of the Chinese Beck Depression Inventory. Comprehensive Psychiatry, 29, 484-489. Zheng, Y.P., Xu, L.Y. and Shen, Q.J. (1986). Styles of verbal expression of emotional and physical experiences: a study of depressed patients and normal controls in China. Culture, Medicine and Psychiatry, 10, 231-243. Ziguras, S., Klimidis, S., Lewis, J. and Stuart, G. (2003). Ethnic Matching of Clients and Clinicians and Use of Mental Health Services by Ethnic Minority Clients. Psychiatric Services, 54, 535-541.

Personal Communication:

Bashir, M (2005) Multicultural Mental Health Policy (2005-April-15) Berijiklian, G. M. Discussion on thesis findings. (2006-June-24) Burton, C, (2006) Findings from depression research among Chinese in Sydney and the implications for mental health policy. (2006-May-31) Eisenbruch, M (2004) Mental Distress Explanatory Model Schedule Chinese Translation (2004- Apri-l30) Human Research Ethics Committee – University of New South Wales (HREC-UNSW 2006) Response to research application. (2006-May-22) Kanowski, L. (2006) Mental Health First Aid – Chinese project. (2006-February-6). Lee, S (2004) Help-seeking strategies among Chinese in Hong Kong. (2004-July-19)

368 Parker and Mitchell (2006) Collaboration with China to translate Black Dog Institute Fact Sheets available on the website. (2006-March-31) RANZCP (2006) Chinese-speaking psychiatrists in Sydney (2006-December-13)

369