Culture gap

In other countries, symptoms of mental illness vary, with treatments that American doctors are just beginning to appreciate

Cambodian immigrant Heap You continues to use the traditional "cupping" treatment she learned in her homeland, believing it allows harmful "excess wind" to escape her body. Mental health professionals have long been skeptical of such techniques, but some are becoming more open to including them along with Western treatments. With cupping, a small heated glass is placed upside-down on the skin. As the air inside it cools, it creates a vacuum that draws some of the skin into the cup, leaving a welt. (Globe Staff / George Rizer)

LOWELL - Heap You's doctors thought she was crazy. The Cambodian immigrant kept saying her neck was going to explode, though an examination showed nothing physically wrong. One hospital put her on antipsychotic medication.

But eventually, the mother of five was referred to Dr. Devon Hinton, a psychiatrist with a clinic in this city's struggling downtown. She arrived in his office one spring day 10 years ago with her neck upright and rigid, even as she sobbed about her troubled family life. She told Hinton that she didn't want to move her neck because excessive "wind," bottled up in her body, might surge through her neck, break blood vessels, and kill her.

Hinton realized the patient was not out of her mind. The Harvard assistant professor, who specializes in treating Southeast Asian patients, knew that some Cambodians believe that the circulation of wind throughout their bodies maintains their health, and poor circulation from an ill body can cause a dangerous strokelike explosion of wind.

Hinton, speaking in You's native Khmer language, told her to taper off her antipsychotic medications, according to his records, and handed her prescriptions for two other drugs - one to help her sleep, another to control her anxiety attacks. He urged her to continue her traditional Cambodian practices to help "wind" flow.

After regular therapy sessions with Hinton, You's emotions stabilized. And she trusted these words from him: You're not going to die from your neck vessels bursting.

Hinton was one of the first foot soldiers in a national push to offer more culturally sensitive mental health care to immigrant groups, often in small clinics in urban areas. These clinicians are part cultural anthropologists, part psychiatric professionals, part medical detectives. A key part of their work is properly diagnosing mental illness that patients often first articulate as body pain, headaches, or stomach ailments.

"You often see emotions expressed as a bodily symptom," said Dr. Glenn Saxe, a psychiatrist at Children's Hospital Boston who has helped develop a new mental health clinic for Somalian refugees.

Among newcomers to this nation - one in eight Americans is now foreign-born - mental illness can be an alien, stigmatizing term, and many immigrants from Latin America, Africa, and Asia are far more likely to talk initially about physical ailments than seek psychiatric services.

Over the past several years, top mental health specialists have begun a number of new initiatives to improve psychiatric care for immigrants. The Massachusetts Department of Mental Health, along with a team of researchers, are educating primary care doctors around the state about what physical symptoms might be signs of mental disorders.

Primary care clinics in Somerville and Cambridge, run by the Cambridge Health Alliance, are going a step further, installing computerized educational programs in Portuguese, Spanish, and Creole, aimed at teaching immigrants how fatigue, intestinal complaints, and other physical ailments, as well as intense homesickness or loneliness, can be signs of depression.

Researchers say cross-cultural psychology was once relegated to the margins of mental health practice, viewed as a kind of exotic sideshow to mainstream medicine. But ever since a 1999 surgeon general's report on mental health found the impact of culture has been "historically underestimated," a growing number of clinics focused on immigrants' needs have opened. Many have blended traditional practices from patients' homelands with conventional Western treatments, and have hired translators and staff who share the patients' immigrant roots.

Like many other clinicians, Hinton, who practices at Arbour Counseling Services, in Lowell, is careful not to overgeneralize about any ethnic group. Not every Cambodian with anxiety disorders, for instance, will focus on neck pain. And some neck pain is just that - and needs an X-ray follow-up. But after working with Southeast Asian refugees for more than two decades, Hinton has identified more than 400 Cambodian patients who complained about neck ailments while being diagnosed with panic and anxiety disorders. In research papers he has published, he calls the phenomenon "sore-neck syndrome."

Hinton said each immigrant group has a particular "ethnophysiology," or the way in which they perceive their body's inner workings. He said English and German culture often raise "heart-focused" complaints when conveying anxiety, while Latin American cultures refer to attacks of "nerves."

Hinton said many Cambodians believe in the importance of wind, and that this wind must exit regularly through their feet and hands. But when their extremities become cold, perhaps because of an involuntary physical response to stress, they worry that the wind is becoming trapped in their torso.

As a result, Hinton said, they develop culturally rooted fears about the trapped wind suddenly bursting through the neck. He sees it as his job to reverse this type of snowballing, disastrous thinking - which can lead some doctors, unfamiliar with Cambodian culture, to mistakenly think the patient is psychotic.

During Hinton's sessions with You, he asked her to rotate her neck repeatedly while he was present, a way of convincing her that she would not die from such movement. He encouraged her to use native treatments to help alleviate her stress, such as "cupping," in which a person places a suction cup on the forehead for several minutes to help the wind flow. When the cup is removed, it leaves a red circular mark that looks like a raised welt, which can remain for days.

"It helps me suck my headache out," the 50-year-old You said in an interview in her Lawrence home. Her therapy with Hinton has convinced her she will not die of "wind overload," she said, and she no longer has the overwhelming worries that she once did.

But, at home now and then, she still uses the "cupping" technique, which she learned from her grandparents in Cambodia, and has since encouraged her children to use it as well. She also continues to take what she calls "Dr. Hinton's medicine," including a sleep medication and an antidepressant.

Hinton believes that his encouragement of "cupping" practice helped build You's trust in him, and explains in part why she continues to confide in him about her family and financial struggles.

Ultimately, Hinton diagnosed Heap with depression and a panic disorder common among Cambodian refugees, particularly those who lived through the brutal Khmer Rouge regime, responsible for killing more than 1 million Cambodians in the late 1970s.

Dr. Francis Lu, a specialist in cultural diversity with the American Psychiatric Association, who is familiar with Hinton's work, said the typical American clinician may find it a daunting task to understand the nuances of all the culturally diverse groups in this country.

"We don't know all the intricacies of hundreds of cultures, but that doesn't mean we throw up our hands," Lu said. "There's a certain body of knowledge that we're collecting. And at least we should know what we don't know."

Patricia Wen can be reached at wen@globe.com.