Mental-Health Professionals’ Advice on Dealing with Difficult Family Dynamics of Depression, Isolation and Abuse
As a child of a nisei man who had suffered from long-term depression, a mid-life existential crises that led to a nervous breakdown and late-diagnosed Narcissistic Personality Disorder, I have long reflected on how we handle mental wellness in the Japanese settler community of Hawai‘i. A decade and a half after my brother, husband and I buried this “difficult” parent, after closely arranging elderly care in my dad’s last years, I remain haunted by the cultural dilemmas that pit public image and reputation against family care and wellness, struggles that seem without easy solutions:
In our insular, private households, when we Nikkei notice that things are not emotionally okay within our families, how do we cope?
When we see others in our neighborhoods and social networks who seem to struggle with mental-health challenges, what do we do?
And who cares for the caregivers — those who watch over and tend to family or community members who need others’ support to maintain their health?
These persistent thoughts informed the questions I posed to three professional public-health and social workers who are connected through their dedicated efforts towards mental-health literacy for Hawai‘i residents. Unsurprisingly, all three are associated with Project Dana, the lauded, groundbreaking, community-based elderly-care program in Mö‘ili‘ili. Speaking with them validated the take-away of my own experience: that caring for küpuna, dealing with their healthcare and end-of-life issues, cannot help but make one look closely at older dynamics in family history, including uncomfortable decades-long patterns — which we try not to speak of (too loudly) if they are about others, which we tend to grit our teeth and bear if they are about our own relatives.
Introspective Solitude, and Sometimes Still Shame
This article is about how and when we choose to care for others. Expected caregiving in the “normal” life course of a partner, parent or grandparent aging through physically challenging health conditions can prove meaningful, however difficult. For example, retired social worker Mel Hayase, who once worked at the state’s mental-health department and offered counseling at the Samaritan Counseling Center Hawai‘i, took care of his wife after she was diagnosed with Parkinson’s disease. The locally raised, sansei Buddhist helped that spouse, a haole from Montana, with this progressive nervous-system disorder, until she passed away last August.
A former freelance resource person for Project Dana and a longtime mental-health specialist, Hayase found it odd when others praised him for his family work. He asserts humbly that caring for someone you love is not a Japanese value but a cross-cultural one. He looks back, somewhat critically, on the local community’s response to his experience: “People complimented me [for caring for my spouse], but I thought this was normal; there was no need to be congratulated. It was a natural transition in our relationship for me to take care of her.”
The Japanese American community at large, though, still seems split on how to deal with tough healthcare challenges that seem to depart from members’ “conventional” life plans, especially when it comes to facing emotional and mental difficulties in the home. Responses differ between those who are relatively Americanized — where the orientation is “more matter-of-fact; you have mental illness, then go get help,” according to Hayase — and those who still hold on to the shame-based culture of many issei immigrant ancestors.
Hayase speculates, “(W)e are third or fourth generations and still carry out the values of our grandparents and great-grandparents from Meiji Japan (which are not even the same as values they have with the current generation in Japan today!). I am not sure, though, that the notion of shame is as strong [with them] as it was for their grandparents … [Japanese] once had to do that, to protect ourselves and our community; immigrants had to protect each other from the outside, so shame was a factor in that. You could not be a rotten kid, or it would shame your community. But that carries over to mental health, to suicide, that kind of thing.”
This cultural response to mental-health challenges might be in part due to spiritual worldviews. “… Buddhism, compared to the Middle Eastern religions (Christianity, Islam, Judaism),” evaluates Hayase, ”… is more introspective, about how to deal with problems and issues. If I am depressed, I go introspectively first; we are less open to getting outside help fast.”
Project Dana Executive Director Cyndi Osajima, a cheerful Nikkei from Los Angeles with a Masters in Public Health, agrees with her colleague Hayase during my two-person Zoom interview. When Project Dana staff sometimes encounter elders who are depressed, she says, “I suggest wanting to see a specialist or therapist. In a few cases, they go, ‘I’m not crazy; there is nothing wrong with me.’
“Hopefully they get introspective; they will look at themselves first. Maybe they will seek help,” ponders Osajima aloud. Trained by co-founders of Project Dana Rose Nakamura and Mrs. Shimeji Kanazawa, the executive director, who has been with the organization since 1993, took the reigns in 2017 after Nakamura’s retirement. The U.S.-continent-raised Osajima, who cut her teeth in elderly care at Project Dana, works to balance a more critical mainland perspective with decades of insight into the subtleties of local (especially Hawai‘i Japanese) culture. “It might be generational; I do not know if much of that older generation will seek help,” she admits.
I think of Japan, a status-oriented country with a complex socio-historical and spiritual relationship with suicide, where public-health workers struggle to create viable systems to identify and successfully intervene in people’s depression. In 2018, the country experienced the sixth-highest suicide rate out of members of the Organization for Economic Cooperation and Development (data.oecd.org/healthstat/suicide-rates.htm); last year, Japan made global headlines when the number of suicides in October surpassed its COVID-19 deaths for the whole year (see for instance insider.com/japan-more-suicide-deaths-in-october-than-from-covid-19-in-2020).
My mind turns, not for the first time, to the strangely alienating nature of this “harmonious,” group-based society.
“Buck Up!” Versus Inclusive Cultural Solidarity
Humorously to the point, Mernie Miyasato-Crawford, a former licensed clinical social worker for the federal government who grew up in O‘ahu and California, summarizes a common Japanese cultural response towards the emotional or mental challenges of community members: “Buck up!”
“How you see in the old … samurai movies, they say to a dying person, ‘buck up!’ as they are bleeding out of their jugular veins,” explains the LCSW wryly. ‘Oh, buck up!’ Somehow, it is not ‘get help!’ This readily transfers to emotional traumas and distresses: It’s also not “You need help,” but instead are seen as character flaws if you dare to need it [emotional support]. ‘What’s wrong with you, that you cannot pick yourself up?’”
The retired sansei gerontologist got her MSW degree at Case Western University then went through a 19-year stint at Kuakini that ended in her heading its medical social-work department for a decade before she found similar healthcare team-leadership employment with the government. Over phone and (follow-up) email interviews, she shares her reflections on how being raised in a Honolulu AJA household and neighborhood had taught her about the community’s approach to mental wellness:
“I remember my mom [when I was uncomfortable and in pain from, say, cramps or a headache] would say, “You are just under the weather. You’ll just make yourself feel worse lying around! Just get up, just go!’ That whole thing I took to be very much a rule; you are not allowed to not feel 100%. Then fast forward, and as our generation aged, and got into the 1970s and high school, where there was an infusion of drug culture and addiction — [then the] tendency was to lay the ‘blame’ on some kind of character flaw, or seen as, ‘Oh my god, there is something wrong with the [that person’s] family!’ That is the bubble [evaluative framework] against which these things are held. Not something blatant or overt, just part and parcel of how things are seen.”
Though mental-health literacy has now improved with younger generations such as yonsei and gosei, when Miyasato-Crawford was a child in the 1960s-1970s, emotional and mental difficulties were still kept hidden from outside the family. “To the extent that we had mental-health issues in our own families, it was ‘hush hush’; we never really talked about it. It was just not something commonly acknowledged or discussed. I do remember times during family gatherings when allusions would be made about this or that person who ‘had some issues.’ But who knows? Perhaps that person was simply unique and went against societal norms versus having something that [we would today say] was diagnosable. It was always so amorphous, unidentified and mysterious,” she describes.
The more I hear Miyasato-Crawford’s informed professional perspective, the more I wish someone like her had been around during my childhood in Wailuku’s Japanese-settler community. I am certain others in our diverse Nikkei population have had similar experiences of being part of a family with that “oddball” member whom everyone else talked about — or of carefully regarding that person from the outside, trying to make sense of her or his behavior beyond the trite constraints of community gossip. At any rate, we might have benefited from someone who could distinguish between simple cultural deviance versus emotional or mental-health issues.
Miyasato-Crawford similarly recalls, “We grew up with mostly other AJA families. In one neighborhood … everyone would identify a member of one of the neighbor households as ‘crazy.’ Based on years and years of living as neighbors, observed behaviors clearly pointed to there being some kind of severe mental illness. But we judged this [SMI] as, ‘What’s wrong with them? Why can’t they control [their family member]? Why don’t they do something?’
“Only now, much later, as adults,” Miyasato-Crawford looks back, “could I have the awareness to have conversations saying, ‘Living with mental illness is horrible – not just for the individual, but for the entire family. There is no forced treatment; you cannot lock someone away; laws and policies governing mental health treatment limit what can be done without consent …’ Only as an adult (and likely due to [my] clinical experience [as a medical social worker]) can I see this situation with compassion and empathy — and frustration that there are no easy answers.”
She contrasts this relative inability, in earlier generations of the JA community, to train its young members to identify those who need emotional or mental support and show them compassion, with how the Okinawan community (of which she is a member on the side of her father, a “full-blooded Uchinanchu”) handles such issues. The strength and continuity of Okinawan culture, the powerful bonds between Hawai‘i Uchinanchu and those in Okinawa, absolutely has an effect on people’s mental wellness, she believes. The emotional-health specialist cites the sheer volume of active clubs within the Hawaii United Okinawan Association as an example of high levels of community engagement for that ethnic group which makes community members feel comparatively emotionally supported.
“This [cultural solidarity] was brought home to me when my daughter and I went to one of the taikais [mass homecomings to Okinawa of thousands of diasporic Uchinanchu from around the world, all at once] after my father died; it was awesome! What is unique about Uchinanchu is that it is definitely true that if you have even 1 oz. of that blood, you are of them, in your bones; no matter how far you are on the planet, you are embraced. It is an absolute identification.” [The last taikai drew about 8,000 people from 27 countries abroad, of which 1,800 were from Hawai‘i, according to the Ryukyu Shimpo in english.ryukyushimpo.jp/2020/09/04/32630/.]
The connection across the Pacific also cuts across time. The granddaughter of one of the seven original “Pigs from the Sea” Uchinanchu in Hawai‘i, whose courage and commitment had helped re-generate the porcine population (and thus food supply) of Okinawa after its wartime devastation of 1945, Miyasato-Crawford marvels at how her own granddaughter was valued for coming from Hawai‘i. When her granddaughter performed in the “Pigs from the Sea” play in Okinawa, says the appreciative grandparent, she realized that “Till this day, when Okinawans in Okinawa know you are from Hawai‘i and are Uchinanchu, even young bloods not alive back then will say, ‘Thank you very much’; it [sending the pigs over] was literally life-saving.”
She compared the resiliency of Okinawans to other groups that have survived colonization. “Okinawans just had this resiliency, this strength — whatever comes, we can handle it. At a broad population level, it does find evidence in people’s mental health and wellness; it does matter where the ability to withstand things is part of the
culture of ways to handle stress,” she says of one of the longest-living ethnic populations of the world, with Okinawans having a 40% greater chance of living to 100 than people from mainland Nippon (for more, see bbc.com/future/article/20190116-a-high-carb-diet-may-explain-why-okinawans-live-so-long).
“This [cultural resiliency] approach is different from ‘buck up,’ or where you see things only as a matter of individual character,” she sums up.
A Continuum Of Observation and (Thoughtful) Care
A proponent of holistic community-care who has consulted for Project Dana, Miyasato-Crawford reveals that even before COVID-19, the nonprofit was making one of its goals the treatment of social isolation. This takes an all-hands-on-deck approach of casual service-monitoring, of unsystematic but regular data-gathering.
“[We felt that] If we can prevent this [isolation], we can help prevent a full force of mental-health problems, including major depression and other things,” she said. “Even with other social-service type activities [i.e., not explicitly mental-health ones], all serve a mental-health function; for example, if you are a Meals On Wheels delivery person, even if it is five minutes a week delivering seven days of frozen meals to a homebound client, you can see a little bit of what is going on [with the elderly or disabled people you are serving] and you notify people.”
She advises making the gathering of information from such services, seamless so that there is a “continuum of [observation and] care” in order to sense and act upon any signs of social isolation: “Healthy communities support healthy individual citizens,” notes the retired LCSW. Such informal data collection can open the door for a medical social worker to visit then ask, “So how are you doing? Who do you live with? What do you do everyday?” she explains.
This gathering of information is key, as one of the most diagnosed yet unrecognized problems among the elderly is depression, Miyasato-Crawford states. Family can do their own version of information-collection: “To the extent that you know your mother or grandma, pay attention; be attuned to their ‘temperature’; know what is atypical in terms of how they are feeling, both emotionally/mentally as well as physically,” she urges. “Know each other; recognize when things are wrong.”
Careful observations, and thoughtful analyses of what is going on at home beneath the surface, also covers complex living situations where hidden mental-health issues might include PTSD and/or abuse. Mel Hayase explains that for some family households, trauma might characterize a person’s emotional state: “Trauma is not only for when you are in the military but when something happens suddenly, like an accident or wartime experience.
“The reaction can come from any kind of long-term trauma — for instance, from long-term marital abuse when you have been together a while. Then the abuser might die, and you go on with life, but you may still have PTSD; when you come across something that reminds you of that, you are going to be reminded of it [so you react as if it is still occurring],” he explains.
Hayase gives the example of an old man being abusive to his wife at home. “We wear different hats depending on how we are,” he says philosophically. “Publicly [for example], I am nice and fun; one guy I knew was [similarly] nice, considerate, grateful. But at home, apparently, he was an abuser! He was calling his wife all kinds of terrible things!” Hayase had also witnessed this same dynamic in counseling venues; for instance, a person complaining about his spouse had called her stupid privately, Hayase remembered.
Cyndi Osajima also recalls witnessing an older couple where the husband was disabled and the son was on the mainland; thus, the wife had to care for her spouse. One day, Osajima heard the wife saying “Ow!” and asked what had happened. The wife admitted her husband had pinched her; the husband then told Osajima she [the wife] is stupid. So instinctively, being from the mainland, Osajima informed him to never pinch your wife again. She also asked the wife, does he always pinch you? She said yes, so Osajima told the husband that she has an obligation as a mandated reporter to report any abuse.
She held staff meetings to discuss this situation, but she and her team realized that nothing would help the couple if the staff were to call Adult Protective Services on them; that this was [likely] an issue of control and power, which the husband was trying to assert due to his loss of power [being disabled] and [thus] “saving face” in the relationship – which the wife perhaps understood. So instead, Osajima told the wife to call her if you ever need help; she never got a response. She hopes that by saying she could report him, that might have gotten the husband to understand what he was doing is wrong. However, she worries that this kind of dynamic might repeat inter-generationally, to the children and their partners.
Though Hayase considers that education will help people understand and be less inclined to abuse others, Osajima, in an observation mirroring the intimate partner violence literature, notes that sometimes even highly educated people do it. “Another guy called his wife stupid and crazy, because she had dementia. He was a highly educated engineer who had attended a workshop where we talked about aging,” she points out.
“He was in his 80s at the time, and the wife, too, was in her 80s. He wanted to know why they don’t have sex any more,” she recounts.
For those knowing families challenged by mental or emotional problems, both Osajima and Hayase recommend hearing its members out, without proffering solutions or judgment. “You cannot be in a situation where you are afraid of getting into a conversation where you end up not talking any more,” advises Hayase pragmatically. “So do not go to the extreme where it feels you [they] are being attacked personally and vice versa (in talking about family abuse, anxiety, depression, etc.). Talk about it to each other, but do not get into too personal things where it severs your relationships.”
Osajima adds, “Do not point fingers at anyone, but do talk about it.”
“My tendency is try to solve the problem,” admits Hayase, “but do not do that unless they ask you specifically for a solution. Don’t go there. A lot of people when they start talking about a problem don’t need you solving it; just hear them, let them talk it out, encourage them to share. Not ‘Hey sister, do that!’ — don‘t go there, as sometimes, you cause more problems. Just hear them out.”
“Listen to them; be a good listener. Eventually they’ll come up with their own answers,” recommends Osajima.
Mernie Miyasato-Crawford wraps up these discussions by asserting, “Let’s increasingly not think of mental health and mental-health breakdowns as isolated, separate occurrences … Breakdowns — as evidenced by suicidal ideations, suicide attempts and tragically, completed suicides — don’t ‘just happen.’ These are the most concerning manifestations of emotional pain and suffering. What can we each as individuals do to support each other in our own little circles of life to protect each other?”
Note: For often stressed-out caregivers (especially of elderly people 60 years or older), Project Dana has run a “caring for the caregivers” type program out of Honpa Hongwanji Mission of Hawai‘i, Hawai‘i Betsuin, for 20 years (and also out of the Hongwanji Buddhist Temple, Waipahu). Caregiver Support Group Coordinator Maria Morales, a counselor, currently administers it virtually via Zoom for 2-3 sessions/month including regular education sessions (with guest speakers) and rap sessions, as well as occasional outing sessions (now socially distanced) every few months or so.