Filial Piety and Mental Health in Asian American Families

Over the last four months, I have supported my mother and extended family in caring for my father just before his recent passing. In that time, I’ve taken the opportunity to reflect on my family and my identity as a Taiwanese-American and practicing psychiatrist, and particularly how that identity has impacted my own recent experiences with grief. This contemplation has illuminated for me how cultural traditions, expectations, and values can significantly impact one’s mental health.

I was born in Taiwan and came to the U.S. when I was 10 years old. Given my age when my family moved, I grew up straddling two very different worlds—traditional Asian values and Western cultural norms. It wasn’t until I studied Chinese in college to fulfill a language requirement that I learned of many Asian customs and traditions. And now that I’m married to a white woman, we’ve come to realize the importance of family traditions and are looking to raise our children with the best of both cultures.

Source: cottonbro/Pexels

In July we observed National Minority Mental Health Awareness Month, and I found myself even more aware of, and interested in, a better understanding of some of the reasons behind underlying disparities in mental health among multicultural communities compared to Caucasians. In my opinion, the most significant difference, especially for those with a similar cultural background to mine, is the impact stigma and cultural norms can have on a person.

In the U.S. today, 23.8 million Americans identify as Asian American or Pacific Islanders (AAPIs), making up more than 7% of the U.S. population.[1] And that number is only growing as Asian Americans accounted for the fastest-growing racial and ethnic group in the country between 2000 and 2019. Despite the common use of ‘Asian American,’ it is important to note that the term refers to many communities—approximately 50 subpopulations, which vary in terms of culture, religion, history, and language. However, one thing is consistent: AAPIs have the lowest help-seeking rate for mental health services of any racial or ethnic group.

And I believe that for many Americans of East Asian descent like myself, this is rooted in filial piety, the fundamental virtue in traditional Chinese and other East Asian cultures defined as respect for one’s parents, elders, and ancestors. This concept is rooted in a commitment to maintaining a hierarchical power structure within families and society. It certainly has its place in our culture, but if taken to the extreme, filial piety can be considered authoritarian and can create a familial culture that isn’t healthy.

By expecting children to pay deep reverence to their elders and parents, children may develop unconscious challenges as adults when relating to their own family. Rather than creating open lines of communication between generations, children are told to obey their parents at all times—it’s a sign of respect. If a child does correct an elder, they are often seen as ungrateful and made to feel ashamed for upending this system.

In many AAPI households, children are expected to control or hide their emotions to prevent being perceived as someone who complains too much and can’t solve challenges for themselves. This can translate to family environments where silence is a sign of strength and feelings aren’t likely shared.

It can also result in a lack of communication within AAPI communities about any kind of emotional or mental distress. In particular, younger generations may feel misunderstood and even become at odds with their own emotions or suffering to live up to the filial ideal. In this hierarchical system, any decision-making, including the decision to seek care for mental illness, is determined by the interests of the family as a whole. Since mental illness is still often perceived as a flaw, failure, or weakness for the whole family, accessing timely mental health care may not occur, potentially exacerbating trauma or crises for all involved.

When my father was diagnosed with pancreatic cancer in 2018 and later took a turn for the worse, I could never have anticipated the intrafamilial struggles I would have with my own mother as I upset our traditional dynamics. Even as a doctor, my mother wanted to remain in control of my father’s care and disregard my professional opinion. She frequently disregarded my opinions, because, as she sees it, I am still the child.

In similar cultures beyond AAPI communities, a person may feel they are unable to confront their parents, set appropriate boundaries, or engage in family therapy. As such, when individuals from non-Anglo-Saxon-American backgrounds reach out for support from a mental health provider, it is important to consider these traditions in view of treatment.

Health Essential Reads

Are Women Really Better Doctors?

How Healthy Is Healthy Enough?

Physicians, psychologists, social workers, and nurse practitioners working closely with patients should educate themselves on how the nuances of a person’s identity might affect therapeutic approaches and their outcomes. There are educational resources, from organizations such as the National Alliance on Mental Illness, that discuss identity and cultural dimensions across races, ethnicities, disabilities, or sexual orientations to learn more about certain considerations. While awareness of multicultural barriers alone will not solve the challenges of caring for people across cultural communities, it is a critical first step in understanding why it may be so hard for some people to seek therapeutic approaches that make sense for them.

For many, belonging to a family with close relationships across generations can be a significant source of personal strength. But it can also be a source of trauma when bonds or traditional values like filial piety are disrupted. Importantly, for many Americans who are caught between two cultures like myself, the pressure to uphold family expectations while staying true to oneself can cause real, significant mental distress.

Although I considered my own upbringing as largely Western and non-traditional, I’ve seen how deeply rooted and even unconscious family values and cultural norms can run. Opening up to a family member may not be an option for members of some communities, and mental health professionals should be considerate of this issue. Mental health providers should educate themselves on cross-cultural differences and how cultural traditions or values may impact the patients they are treating. Each individual’s care should be tailored to all the nuances of their identity—be it culture, gender, or sexual orientation—to treat the person as a whole. It is important to remember that anyone should be able to receive help for their mental health or illness, especially for those who overcome cultural stigmas by seeking assistance at all.