Abstract
We explore the dynamics of mental health, family, and migration within the experiences of United States–based South Asian immigrants with severe mental illness (SMI) diagnoses and their family members. We utilized a grounded theory approach to understand emerging unique cultural aspects (i.e., on economic hardship, racial discrimination) that have not been previously identified. Semi-structured interviews were conducted with 21 South Asian patients with an SMI diagnosis, 11 family members of South Asian patients with an SMI diagnosis, and four clinicians. Thematic analysis was used to interpret the data with a specific focus on family relationships, migration experiences, and South Asian cultural influences. We identified three themes: “Stories of Isolation,” “Complexities of Care,” and “Dynamics of Gender, Illness, and Family.” These themes reflect the complex dynamics involved in migration, family, and mental health for South Asian immigrant families in the United States. Furthermore, we expanded the notion of familial vulnerability by focusing on how structural vulnerabilities induce widespread distress within a family unit and affect multiple kinds of gendered relations within a family.
Keywords
Asian Americans are the fastest-growing racial or ethnic group in the United States and are projected to become the largest immigrant group by the middle of the century (Budiman & Ruiz, 2021). South Asians are currently the second largest subgroup compared with East Asians (Rico et al., 2023). South Asian immigrants are those who migrated from South Asia and settled in the United States, and their descendants. They include people from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka (Demographic Snapshot of South Asians in the United States, 2019). We also include those whose ancestors migrated from South Asia to other regions (e.g., Caribbean, Africa) but who are newly arrived in the U.S. New York City (NYC) is home to one of the largest populations of South Asian immigrants, which also includes Indo-Caribbean immigrants, descendants of laborers from the Indian subcontinent who came to the Caribbean under the indentured system by the British, Dutch, and French during the colonial era (1838–1917; Pillai, 2019).
The heterogeneity of U.S. South Asians is further shaped by their intersectional experiences, such as immigration status, generational status (i.e., first-generation immigrants born in another country, and second-generation children born in the United States), socioeconomic status, ethnicity, language, cultural/religious beliefs, gender, and acculturation (Contractor et al., 2023; Islam et al., 2014; Masood et al., 2009; Mohsin et al., 2024; Rumbaut, 2004). Considering the variations of these factors within the South Asian population illuminates the diverse range of lived experiences, levels of social mobility, identity formations, family and community dynamics, and health outcomes. Among South Asians, health conditions and experiences further differ by other intersectional identities. Few studies have explored how these variations affect mental health outcomes and experiences, including for severe mental illness (SMI) diagnoses such as severe depression, bipolar disorder, and schizophrenia.
In recent years, mental health has come to be recognized as an urgent issue among many immigrant groups, including South Asians in the United States (Gany et al., 2019; Karasz et al., 2019). A national study found a 20.8% lifetime prevalence for affective, anxiety, or substance use conditions among U.S. South Asians (Masood et al., 2009). Another national study reported a 24.5% lifetime prevalence among U.S. South Asians for mood, anxiety, or substance use conditions (Lee et al., 2015). In NYC, a recent Asian American community needs assessment reported that 11% of South Asians were at risk of depression (Misra, Wyatt, et al., 2020). A community-based study ascertained that 9.4% of South Asian older adults experienced mild or moderate depression symptoms (Ali et al., 2021). These experiences further vary among South Asian immigrants. In the United States, some studies have explored the dynamics of intersectional experiences and mental health in religion and gender (Chowdhury & Okazaki, 2020), legal status (Barajas-Gonzalez et al., 2021), generation (Sharma, Shaligram and Yoon, 2020), and gender (Tummala-Narra, 2013). For SMI, one study in the United Kingdom found that differences in religious beliefs shape help-seeking, particularly service utilization, for mental illnesses (Ineichen, 2012). For instance, British Bangladeshi Muslims seem to be more accepting of psychosis symptoms and are less likely to seek clinical care compared with other ethno-religious immigrant groups in the study (Pote & Orrell, 2002). Another U.K.-based meta-analysis (Bourque et al., 2011), which includes a substantial number of South Asian participants, reported that the risk of psychosis is higher among second-generation immigrants than first-generation immigrants. However, more research is needed to understand the role of migration-related challenges in familial tensions that shape U.S. South Asian immigrants’ experiences with psychological distress.
Because family life plays a central role in the South Asian American experience, the family environment has been consistently highlighted as a significant contributing factor that shapes psychological functioning within the population (Masood et al., 2009). While intergenerational tension is common among South Asians, the strength of these ties may vary from family to family. More research is needed on how intergenerational conflict, in particular, is shaped by various factors such as migration pathways, socioeconomic status, and gender dynamics (Badrinath & Seto, 2024). Others have broadly explored the significance of a wide range of factors (gender, religion, generation, socioeconomic status, and nationality) on psychological distress (Badrinath & Seto, 2024; Karasz et al., 2019; Sharma et al., 2020). However, a specific and deeper focus on SMI experiences in this population in the United States is needed.
This analysis draws on data from an exploratory qualitative research study that focused on the experiences of U.S.-based South Asians with SMI diagnoses and their family members. The project aimed to understand the perceptions of structural, cultural, and social factors on these experiences and identify cultural assets and capabilities that can be leveraged to promote recovery and reintegration within clinical care and in the community (Mohsin et al., 2024). The present analysis emerged from this initial analysis and focuses more specifically on how the dynamics of family and migration shape the mental health experiences of South Asian immigrants.
The Dearth of Research on SMI Among U.S. South Asians: Findings From the United Kingdom and Canada
Immigrants and ethnic minorities experience persistent inequities in SMI (e.g., incidence, severity, and treatment)—not due to biological differences but due to structural, social, and cultural factors (Morgan et al., 2019). U.K.-based data confirm that South Asian groups also experience these inequities (Z. Islam et al., 2015; Kirkbride et al., 2012). While immigrants and ethnic minorities in the United States usually report lower rates of common mental illnesses (Breslau et al., 2005), available data imply the potential for higher rates of SMI (Olbert et al., 2018). These groups also experience inequities in the course and treatment of mental illnesses (Ihara et al., 2014; Yang et al., 2020).
Currently, there are no data on the prevalence of SMI among South Asians in the United States. However, research in Canada and the United Kingdom, where more data on South Asians with SMI diagnoses exist, notes the significant role of the family in an individual’s experience and understanding of their illness. For instance, a Canadian study on the mental illness severity among Chinese and South Asian patients found that greater illness severity among these populations is most likely due to a combination of patient/family and health system/provider factors (Chiu et al., 2016). Another Toronto-based qualitative study that explored the community participation and recovery experiences of South Asians with schizophrenia highlighted varying degrees of family relations that were often a source of additional stress for participants (Virdee et al., 2017). This stress led some to maintain a distance from family members (Virdee et al., 2017). A U.K. study on the stigma experiences of British South Asians born to immigrant parents showed the considerable role families played in the stigmatization of participants (Vyas et al., 2021). Previous U.K. studies have shown how stigma from within the family can discourage help-seeking (Z. Islam et al., 2015; Penny et al., 2009). U.K.-based studies on psychosis early intervention programs found that working with families is integral because between 60% and 70% of individuals experiencing psychosis live with their families after the first episode (Penny et al., 2009). Research has shown that this proportion is higher in South Asian communities, which aligns with the U.S.-based research on the importance of family-based interventions in improving mental health outcomes for South Asian Americans (Inman & Tewari, 2003; Masood et al., 2009; Shaligram et al., 2022). While research in the United Kingdom and Canada provides some key insights into South Asian patients’ and families’ perspectives regarding SMI, the United States’s distinctive health care system and cross-cultural contexts present differing SMI experiences and family dynamics (Mohsin et al., 2024).
The Impact of Immigration on South Asian Family Relations
Though South Asian immigrants are diverse regarding immigration status, socioeconomic status, ethnicity, language, cultural/religious beliefs, gender, and acculturation (Contractor et al., 2023; F. Islam et al., 2014; Masood et al., 2009; Mohsin et al., 2024), they share similar norms, practices, and beliefs about family (Mehrotra & Calasanti, 2010; Shariff, 2009; Tummala-Narra, 2001). The family unit in South Asian cultures is central to identity development and is typically multigenerational, with extended family providing critical social support (Tummala-Narra, 2013). After migration, such familial norms and values become more significant, especially as individuals adjust to differences in sociocultural environments (Inman & Tewari, 2003). Families typically try to maintain South Asian cultural norms and values influenced by patriarchal characteristics, such as well-defined, structured, and hierarchical roles based on gender, age, birth order, and socioeconomic status, which affect family relations (Inman & Tewari, 2003). Immigration brings about changes to the family structure that can lead to conflict. For instance, immigration patterns consistently lead to more nuclear family formations, and subsequently, individuals can experience a loss of support and guidance from extended family (Tummala-Narra, 2013). While rapid urbanization has also contributed to the growth of nuclear families in major cities in South Asia (Hussein, 2022), the relatively greater physical distance involved in transnational migration renders support from extended families almost inaccessible.
The impact of the lack of extended family support is emphasized in several areas of psychological literature concerning identity development, such as changing gender relations and the intergenerational tension between first-generation parents and their second-generation children. Regarding gender, increased reliance on the nuclear family often means that both men and women are contributing to their families’ well-being in different ways across gendered lines (Tummala-Narra, 2013). For example, in a study that examined changing gender dynamics within Indian immigrant families, when men take on domestic duties that women usually do, the male participants redefined these duties as part of their caregiving role as husbands (Mehrotra & Calasanti, 2010). Female participants who worked outside the home characterized their employment as a way to support their husbands, thus an extension of their responsibilities as wives (Hari, 2018; Mehrotra & Calasanti, 2010). However, women remain primarily responsible for socializing their children and are burdened with ensuring their children forge cultural ties. This is especially salient for immigrants who may feel disconnected from their culture of origin (Akhtar, 2011). Thus, the continued high amount of family labor for women without support from extended family may lead many women to experience stress and conflict with other family members (Mehrotra & Calasanti, 2010).
Many parents double down on maintaining cultural norms and values due to the isolation of child-rearing without extended family and the fear of depriving their children of cultural beliefs that provide a sense of connection to the homeland. This creates intergenerational tension with their children (Inman & Tewari, 2003). These differences in cultural adaptations lead to the “acculturation gap” (Tummala-Narra, 2013). The intergenerational difference also maps onto perceptions of mental health and help-seeking. First-generation parents may enforce the idea that problems should be private and kept within the family, discouraging mental health care. In turn, second-generation children may not share their experiences, including the use of mental health services, with their parents because of their disapproval (Arora et al., 2016). For SMI, a U.K. study highlighted instances in which intergenerational differences in cultural perspectives prevented second-generation South Asian immigrant participants with SMI diagnoses from sharing their diagnoses with their families (Vyas et al., 2021). Family, both near and far, plays a significant role in how families approach mental illness and care for those experiencing SMI. Thus, the different kinds of family and gender relations shaped by South Asian norms and values, and the potential conflict from adapting to a new environment, were concerns that influenced the direction of this analysis.
Using Familial Vulnerability to Understand Mental Health Experiences in South Asian Families
Like many other immigrants from the Global South, after leaving loved ones behind, South Asians must contend with learning a new language, building new social networks, and working long hours to support themselves and family members back home through remittances (Sangaramoorthy & Carney, 2021). Furthermore, in societies like the United States, they are consistently exposed to exclusionary immigration policies and racism that also affect their mental health (Misra et al., 2021; Sangaramoorthy & Carney, 2021). However, much of the mental health research on South Asian American families to date focuses on the influences of interpersonal dynamics within families and the central role of varying identity developments on psychological functioning. Some research has investigated how interpersonal racism and discrimination affect South Asian identity development and mental health (Bhatia & Ram, 2009; Tummala-Narra, 2013). But the research on how structural forms of discrimination in health, employment, and education can place additional strain on U.S. South Asians is limited (Misra et al., 2021). Also, none focus on the structural impacts on the family unit who are together adjusting to a new society. This is partly due to the Model Minority Myth, which upholds a reductive and inaccurate perception of South Asians as a successful ethnic group based on the high economic success of a subset of prominent Indian professionals (Shams, 2020). U.S. South Asians are much more diverse and have immense income inequality, with 10% living in poverty; some groups (e.g., Bangladeshis and Nepalis) have the lowest median household incomes of all Asian American subgroups (Demographic Snapshot of South Asians in the United States, 2019). In addition to masking structural challenges, because the Model Minority Myth is associated with high academic achievement and socioeconomic status, seeking mental health care may be perceived as failing to meet the expectations of such a “positive” stereotype (Goel et al., 2023; Yip et al., 2021).
Recent research on health inequities has highlighted how structural racism has a negative indirect and direct impact on health outcomes in immigrant groups (Misra et al., 2021), including South Asians in the United States (Misra et al., 2022). Racialized state violence against immigrants includes political exclusion via immigration policy and citizenship status, disproportionate immigration enforcement and criminalization, and economic exploitation and disinvestment (Misra et al., 2021, p. 334). This violence was especially heightened for South Asians following 9/11 (Misra et al., 2022). Inequities in language access for non-English speakers further exacerbate access to resources for which immigrants would otherwise be eligible. A study on Bangladeshi immigrant parents and their children in NYC found that parents with more legal vulnerability (unauthorized legal citizenship status) experience more stressors in employment, lower utilization of social services, and other legal status-related challenges. These stressors directly or indirectly affect their mental health and subsequently that of their children (Barajas-Gonzalez et al., 2021). In addition, many South Asian immigrants hail from non-English speaking backgrounds and often face language barriers to critical resources, information, and services. Investment in addressing these barriers for South Asian immigrants, which involves more translation services in health care, is often limited and does not consider the diversity of South Asian languages. Certain South Asian dialects, such as Sylheti for Bangladeshis and Mirpuri for Pakistanis, are underrepresented, adding an additional communication barrier for these populations (Ahmed et al., 2015). Together, migration places immigrants in what anthropologists term “structural vulnerability,” which is the embodiment (e.g., physical and mental health) of dynamics such as economic exploitation, political marginalization, and social discrimination (Carruth et al., 2021; Quesada et al., 2011; Stuesse, 2018). Structural vulnerability is a type of subjective experience that leads to physical and emotional suffering by fostering a sense of individual and collective “unworthiness” (Larchanché, 2012; Quesada et al., 2011).
Structural vulnerability is useful for exploring an individual’s subjective experience that includes mental health challenges stemming from a marginalized position in their host society. However, anthropologists have suggested a related concept, “familial vulnerability,” which better captures intersubjective experiences of oppression and marginalization at the family level. Logan et al. (2021) introduced familial vulnerability to show how structural vulnerabilities experienced by one individual also affect the family unit as a whole. Specifically, they applied the concept to illustrate how the precarious legal immigration status of at least one individual in a family has a deleterious effect on the mental health of everyone in the family. For South Asian immigrants, family is often the only reliable source of support in challenging times (Ayika et al., 2018; Masood et al., 2009; Tummala-Narra, 2013), yet experiences with structural racism can disrupt even the strongest family bonds, causing additional stress for both patients and their families (Abrams et al., 2022; Löbel, 2020; Rahman, 2023). Different bodies of literature on U.S. South Asian mental health have shown how interpersonal dynamics (within and outside of the family) and structural racism affect individual psychological health (Bhatia & Ram, 2009; Misra et al., 2021; Tummala-Narra, 2021). However, the interdependence of racism and interpersonal dynamics has received little attention at both the familial and individual levels. While familial vulnerability, a relatively novel concept that has been studied within U.S. Latino immigrants, it has not yet been explored in the context of mental health in South Asian families. Thus, we argue that specifically for those experiencing SMI, this concept can help illuminate the complexities of family dynamics when addressing mental illness within the context of migration and expand the evidence base that is currently focused on interpersonal dynamics and acculturative processes.
Current Study
The present study was conducted as a follow-up to prior work by our team to understand the perceptions of structural, cultural, and social factors on these experiences. We also sought to identify cultural assets and capabilities that can be leveraged to promote recovery and reintegration within clinical care and in the community (Mohsin et al., 2024). In our prior work, the use of modified grounded theory (Charmaz, 2014) led to three significant new insights that motivated the analysis in the present paper. First, though some participants were recruited as family members of individuals who were diagnosed with SMI, many of these participants divulged their own struggles with mental illness while providing care to other family members who were diagnosed with SMI. The second insight was that many participants attributed poor mental health to social and cultural reasons, often contributing to familial conflict. The third insight was that many of these social and cultural factors were experienced by multiple family members. Essentially, interpersonal conflict within the family was very much tangled in their mental illness experiences. Thus, the analysis presented here aimed to understand the shared stresses and widespread distress across both patient and family member participants and why familial relations seemed to cause additional stress to both kinds of participants.
Method
This article draws on data from an exploratory qualitative research interview-based project that focused on the experiences of U.S.-based South Asians with SMI diagnoses and their family members. Semi-structured interviews were conducted with adult patients and their family members through an outpatient psychiatry department of a large NYC municipal hospital that helps people from across the city and accepts patients with Medicare/Medicaid and those without insurance. To generate and report new insights about an understudied topic, the project utilized modified grounded theory (Charmaz, 2014) and thematic analysis for the interview data (Fereday & Muir-Cochrane, 2006), following the COREQ Checklist (Tong et al., 2007) and APA Style JARS-Qual (Journal Article Reporting Standards; Levitt et al., 2018). Methods for the original study have been described in further detail elsewhere (Mohsin et al., 2024).
Typically, studies on SMI among U.S. immigrants only include family caregivers due to the perceived challenges in recruiting and interviewing people with SMI diagnoses (Hernandez et al., 2019; S. Lopez et al., 2009). Therefore, we sought to specifically include the perspective of patients with lived experiences in the present study. Furthermore, multi-perspective studies in qualitative research in health can cultivate a richer understanding of the needs of patients and their families, potentially improving services, especially for those experiencing health inequities (Kendall, 2009). Triangulation across multiple sources (e.g., patients and family members) strengthens our analysis by identifying the similarities and differences across both perspectives (Kendall, 2009). Across both types of participants, we identified similar interdependent experiences of illness, family, and migration that were not specific to the SMI diagnosis, leading us to combine the data for the analysis in this article.
Positionality Statement
Two co-principal investigators led the study: a clinical PI and a non-clinical PI. The study team consisted of three graduate students (one of whom is the first author) and one community health worker. Including the PIs, everyone acknowledged being of South Asian descent, with each having more specific identities within the immense ethnic, linguistic, and religious diversity of South Asians in the United States. Throughout data collection and analysis, during debrief meetings, team members reflected on and discussed how their identities and experiences might shape their understandings of mental health experiences within South Asian immigrant communities.
Participants
Recruitment
Semi-structured interviews were conducted with 21 South Asian adult patients with an SMI diagnosis, 11 adult family members of South Asian patients with an SMI diagnosis, and four clinicians (not included in this analysis). Participants were recruited via clinical referral. The clinical co-primary investigator (PI) held group presentations and individual meetings with clinicians in the hospital’s Psychiatry Department and followed up with multiple email reminders during recruitment. The clinical co-PI directly referred participants and confirmed the eligibility of participants referred by colleagues. After confirming the participant’s interest in participation and permission to be contacted by the research team, a trained interviewer followed up by phone to schedule an interview. To protect patient confidentiality, the clinical co-PI was blinded from all data collection, debriefing, and analysis until data were de-identified and aggregated.
Patients
Inclusion criteria for patients included (a) 18 years or older; (b) primary diagnosis in medical charts of Schizophrenia and related disorders (ICD-10 code F20), Schizoaffective Disorder and subtypes (F25.9), severe Major Depressive Disorder (F33.3-33.4), Bipolar Disorder and subtypes (F31), or complex Post-Traumatic Stress Disorder (F43.12); (c) not actively symptomatic; (d) self-identify as South Asian (trace ancestry to Bangladesh, Bhutan, India, Nepal, Pakistan, Sri Lanka, the Maldives, or elsewhere in diaspora, that is, Caribbean and Africa); and (e) speak English, Bangla, Hindi, or Urdu. Exclusion criteria included being unable to complete a 10-item cognitive assessment immediately prior to the start of the interview after three attempts.
Family Members
Inclusion criteria for family members included: (a) first-degree relative of an individual with a primary diagnosis living in the United States; (b) self-identify as South Asian (trace ancestry to Bangladesh, Bhutan, India, Nepal, Pakistan, Sri Lanka, the Maldives, or elsewhere in diaspora, that is, Caribbean and Africa); and (c) speak English, Bangla, Hindi, or Urdu. Patients and family members did not have to be recruited together; however, verbal consent was obtained from patients prior to approaching family members. We did not intend to recruit dyads of patients and family members, and thus, most patient and family participants were not related to each other; when we do have shared data from relatives, we note this in the analysis. The sample size for family member participants is smaller because it was easier to approach patients, considering the study setting. In addition, COVID restrictions were still in place during the study and limited family member presence.
Procedure
An interview guide was first developed for individuals with an SMI diagnosis (see in Supplemental Material), then adapted for family members and clinicians and translated into Bangla, Hindi, and Urdu by bilingual study team members. The interview guide built on a literature review on causal beliefs, stigma and discrimination, and family involvement in South Asian populations (Bhikha et al., 2015; Chaudhry & Chen, 2019; Karasz et al., 2019; Masood et al., 2009; Mirza et al., 2019; Virdee et al., 2017), and the guides from two prior studies focused on the experiences of schizophrenia among immigrants in the United States (Misra, Johnson, et al., 2020); L. H. Yang & Singla, 2011). After asking for demographic information, including family history of mental illness, the main sections included (a) experiences of distress and diagnosis; (b) impact on family relationships; (c) cultural influences; (d) gender influences; (e) experiences of stigma and discrimination; and (f) experience of support and recovery/reintegration. The interviewers did not introduce any new topics but did probe further for issues introduced by the participant. The interview was intended to take 60 to 90 minutes for patients and family members and 45 to 60 minutes for clinicians. Verbal informed consent was obtained from each participant before the interview. Patients and family members were compensated with a $75 gift card; no compensation was provided to clinicians.
Data Collection and Analysis
Data were collected between January and September 2021. Due to the COVID-19 pandemic and the anticipated technological abilities of our target population, all data collection was completed virtually by telephone. Interviews were conducted by three trained research team members who self-identified as South Asian and spoke at least one of the included languages, ensuring that each participant was interviewed in their preferred language. Given gender norms in South Asian culture, gender concordance between the interviewer and interviewee was attempted when possible. When a patient and their family member both agreed to participate, different interviewers were assigned to each one to minimize bias. Regular debriefing occurred via weekly team meetings, which also informed minor adaptations to the interview guide over time. All interviews were audio recorded and transcribed verbatim into English. Trained research assistants transcribed the English (n = 25), Urdu (n = 1), and Hindi (n = 2) interviews directly to English. The Bangla interviews (n = 8) were directly transcribed into English by a paid bilingual consultant at a local community organization.
Overall, 47 individuals agreed to participate, with 10 withdrawals (four patients and six family members) during the scheduling process. One completed interview with a family member had to be excluded due to failure to audio record it. The final sample comprised 36 participants (21 patients, 11 family members, four clinicians). Table 1 presents the demographic breakdown of the patient and family member participants, immigration generation, and patient diagnosis. While we include patient diagnoses as a reference, this article does not engage with the clinical diagnoses of patient participants because the research question focuses more on the sociocultural and structural dynamics of individuals’ experiences with mental or emotional distress.
Demographic Profile of Study Participants (n = 32).
Complex post-traumatic stress disorder (PTSD).
Major depressive disorder (MDD).
Data analysis was managed in NVivo, and the initial analysis of the original study utilized modified grounded theory, combining inductive and deductive approaches (Charmaz, 2014). First, the research team read the interviews line-by-line to generate an initial codebook (~175 codes) based both on the broad categories of the interview guide and on new themes emerging from the data (notable categories included immigration-related experiences, stressful and traumatic experiences, and religious influences). Using this initial codebook, each transcript was coded by pairs who met periodically to review and reconcile any differences by clarifying individual rationale, reaching a consensus, and then re-coding if necessary. Calibration of the coding process across the two pairs occurred via weekly team meetings, which also informed minor adaptations to the codebook over time (e.g., addition or removal of codes, revisions to definitions of codes, revision to applications of codes). We focused on the most significant and/or frequent concepts identified, merged similar or related codes into more inclusive themes and subthemes, and assessed the relationships between those themes and subthemes. This included looking for similarities and differences within and across all the patient and family member interviews and comparing patterns by other relevant identities (e.g., gender, diagnosis, country of origin, generational status, and religious affiliation).
For the study, saturation was defined as the point at which additional collection no longer yielded new thematic insights about the primary research question. This was assessed through weekly debrief meetings and a collective consensus of all team members. All collected data was subject to thorough analysis and cross-validated themes, and an iterative process was followed that ensured the comprehensiveness of the analysis throughout the study. Through this primary analysis, we observed widespread distress across both patient and family member participants and how and why familial relations seemed to cause additional stress to both kinds of participants.
To explore this phenomenon in further detail, the first author re-examined all the coded transcripts in-depth, focusing specifically on codes in the following categories: family relationships, family history of mental illness, stressful/traumatic experiences, South Asian cultural influences, gender influences, and other relationships/support networks. Codes in other categories were also examined in case they yielded additional insight. The first author then identified instances of familial tension that were organized into themes and subthemes based on shared and distinctive characteristics related to migration, mental health, and experiences. We acknowledge we might not have saturation in these themes given it was not the primary research question but considered saturation for the analysis to be when no new insights were being generated from reading and re-reading the transcripts and original codes.
Results
This article presents results that illuminate our understanding of the unique dynamics of migration, family, and mental health among South Asian immigrants in the United States. Table 2 shows the operational definitions of the three major themes and their subthemes elicited from our data analysis, and Figure 1 presents a thematic map of experiences discussed. Each theme demonstrates how family and migration experiences shape mental health and vice versa.
Operational Definitions of Themes and Subthemes.
Thematic Map for Interdependent Experiences of Illness, Family, and Migration; Displaying Major Themes and Their Subthemes.
Theme 1: Stories of Isolation
The first theme examines the loneliness and isolation in relation to familial relations that many of the participants experienced due to illness and migration-related hardships. Each of the subthemes below focuses on different dimensions of isolation. The first subtheme discusses the social isolation certain participants experience due to navigating their health needs alone and with the intentional exclusion of family support. The second explores the stress of isolation that certain participants feel when they are forced to face adulthood adversities, such as the death of a loved one or the challenges of motherhood on their own, without the support of their close family who remain on the other side of the world. The final subtheme focuses on how a long duration of physical isolation can negatively affect family relationships that become even more palpable when individuals are reunited.
Negotiating Care and Support Without Family
While many of our participants were involved in the care of their family members or had family involved in their care, other participants intentionally decided to navigate their care on their own. For example, P05 and P21 shared very little about their care with their families. While their families know of their diagnoses, they approach their care independently. In addition, these individuals did not seek other forms of support networks. When P21 was asked about support networks outside of family, she answered:
P21: I learned not to rely on those people. In the sense that relying on them can influence their mental health. I have a lot going on in my mental health. Now I am able to understand that other people do too. Regardless of whether I see it. So, I like to make a conscious effort to . . . if I’m going to . . . if I’m going to share something make sure that they are not already dealing with something that this will compound.
P21 no longer shares her emotional struggles with her friends because she fears burdening them. While P05 eventually found an alternative support system of friends, she initially had a difficult time making friends outside of the close-knit community of her family. P14 is a first-generation Indo-Caribbean immigrant who lives with family, but they are unaware that she is receiving care. Because of the tense relationship she has with most of her siblings, she is wary of sharing anything with any family that may leave her vulnerable to judgment. Similar to P21, P14 does not even inform her friends of her diagnosis, although her reason is that she fears they will tell others and misrepresent her experiences. The one friend she does share some confidence with lives abroad and only knows P14 by a nickname. All three participants’ negative experiences with their families in the United States affected their willingness to seek social support elsewhere, leading to receiving little to no support at all.
Experiencing Adulthood Adversities Alone
As the introduction mentions, migrating and leaving behind your existing social networks can be a profoundly lonely experience. These feelings of loneliness become especially overwhelming when individuals are also struggling with their mental health, as life can become almost unbearable during times of adversity. For instance, some of the first-generation South Asian women who became mothers faced the challenges of motherhood without the culturally expected help of family due to long distance. P13 and P15 both had young children who had life-threatening illnesses. For P13, she and her husband left Bangladesh and moved abroad, where their son received major surgeries for his poor health. She shares,
P13: . . . in Bangladesh, after my marriage, my in-laws, I was naïve, so the way I talked, everything, they would insult me. The decisions that I took . . . they did not support this at all. They would say I made my own decisions, never listened to the family. I was taking my husband away from the family. For that reason, because I was taking my husband away from the family, they blamed me for everything [translated from Bangla].
Because of both the long distance and lack of support from family, particularly her in-laws, P13 was taking care of her sick child alone. Even when her child became better, and she began experiencing emotional distress, she could not share her mental health struggles with her family due to fear of judgment.
In addition, P15 was experiencing a great deal of stress from caring for a child with epilepsy and marital issues with her husband, who was her only other family in the United States. She could not share her problems with her family because she felt they would become sad unnecessarily when they lived so far. The examples of this subtheme show how life adversities, such as the illness of a loved one, can become particularly harrowing for individuals when they must face these adversities alone in a new country.
Reunited but Still Apart
Even when reunited with family after a long duration of separation due to migration, some of the participants still felt isolated from their families due to interpersonal tensions. For example, P11 and P01 are distant from their siblings, who eventually immigrated to the United States after them and even live nearby. However, P11 expressed how misunderstood and betrayed she felt by her siblings and her parents. When they were still in Bangladesh, she would send remittances, often sacrificing her comfort. After they joined her in the United States, she says:
P11: Like you know what I feel. . . that they used [me] for when they needed me. Now that there is no need for me, they do not use me. I feel useless all the time. Your mental state becomes weak. Interviewer: And your mental state becomes broken. . . . P11: Yes, broken. Helped them study even in America, their home, food, I provided them with buildings . . . And when they came here, no one gave me anything. They did not even give me mental peace. For that reason, if there was love, if they were next to me, I would not feel anything like this. I always think what I did. I did all these for them and do not have anything myself [translated from Bangla].
When they were reunited, P11 felt that her family was unsupportive, especially when she was struggling with her mental health. P01 has also isolated herself from her siblings even as she grapples with the fear and anxiety of losing her husband. Overall, this subtheme illustrates the enduring impact of separation due to migration on familial bonds to the extent that even when the family eventually arrives close by, the emotional distance created over time still exists, and they cannot be a reliable source of support.
Theme 2: Complexities of Care
The second theme centers on the complexities of providing care and receiving care for both patient and family member participants. Not all family members interviewed were primary caregivers, and not all patients had caregivers. The dynamics of family and care in the context of migration extend beyond just simple expressions of obligation and love. Interpersonal tensions, shared trauma, and generational differences shape the beliefs participants hold about providing and receiving care. Also, this theme of care does not just highlight the challenges caregivers experience but also the complicated feelings of gratitude, resentment, and dissatisfaction of those being cared for. The first subtheme illustrates how certain participants manage their own care and negotiate support from family members who express disapproval of clinical care. The second subtheme highlights the limitation of physical caregiving in the cases of older participants who also desire more emotional understanding. The final subtheme reveals the complicated feelings of compassion and resentment some caregivers, primarily children, experience when caring for a parent with whom they have tense relationships.
No Support Without Understanding
Some participants, usually those who were younger and raised in the United States, often excluded their family from their care due to doubts that they would be supportive given their lack of understanding about mental health. However, family members, usually parents, did try their best to care for the participants from a distance. In these cases, while these family members wanted to be supportive, they disapproved of the participants’ decision to receive clinical care. A common source of tension was medication. In the cases of P21 and P19, their parents were skeptical about the benefits of medication. P21’s mother believed that medication may have negative consequences and even disagreed with P21’s decision to seek therapy. About his father’s response, P19 says:
P19: Um he does um he just really discourages taking the med Interviewer: Why is that? P19: Kind of has trust issues with these symptoms. Um he uh thinks that it’s altering my mind in ways. Doesn’t want me to change, I guess. Interviewer: Right. Does he say he notices something different from you because of these med? P19: Um he doesn’t notice anything different Interviewer: Hmm and why do you think he doesn’t trust—what are the reasons behind his lack of trust? P19: Um I mean he um so when he was younger, I mean when he was like 3 he had an accident his one his legs was unable to move. And he went in for an operation that made it worse. Worsened his condition and its, he’s now almost unable to use both legs and move his fingers. So, its—I kind of understand. It’s the doctors in Guyana did something to make it worse and it was so long ago that looking into it it’s kind of a lost cause. Interviewer: Hmhm right. Wow I see. He has the same perception about the U.S system right or . . .? P19: Yeah. Doctors are doctors, I guess.
P19’s father was wary of his son using medication because he believed the medication may exacerbate his condition or alter him negatively. The father’s wariness also stems primarily from his own experiences with biomedical health care, which caused him further harm in the past. In addition, these parents’ aversion to medication and other forms of seeking care outside of family is also rooted in their belief that emotional challenges were a part of life and not a pathologized condition that needed to be “treated.” As a result, aware of their parents’ persisting disapproval, both P21 and P19 limited their communications about their health and use of health care with their parents. While they acknowledged that their parents’ concern came from a place of love and care, they did not find their parents’ lack of understanding about mental health care to be helpful to their overall well-being.
Cared for but Not Understood
While certain caregiving (attending appointments, medication management, etc.) is critical in ensuring the long-term physical well-being of participants, the importance of emotional support is often overlooked. Several participants were patients who identified as older first-generation Bangladeshi women who felt like their families, typically their adult children, cared for their tangible needs but not necessarily their emotional ones. Their primary caregivers were typically sons, who attended every appointment, communicated with the doctors, and ensured their mothers received their medication. While these participants were appreciative of the care given by their sons, some remained unhappy. One woman, P16, was suffering from the grief of losing her loved ones from COVID-19 and the fear she experienced when two of her adult children who lived in another country became sick. While she was living with her other children who lived in the United States, she expressed:
P16: No, no. My daughter-in-law would say ‘you have become sick and made us sick. Does it feel good for us?’ My son would say ‘why did you have this, what do you think about? You think about your youngest son, so think that he is dead. So do you want to die as well’. They would explain and nag me. Interviewer: They helped you in other words. P16: Yes, and they would nag me. ‘You are staying home all day getting yourself sick and us as well.’ Son and daughter, both would say that. They did not do it for wrong but for good [translated from Bangla].
While she acknowledged their behavior came from a good place, she felt misunderstood by her family, particularly her son, daughter, and daughter-in-law. She felt that her family was impatient with her persisting grief and could not understand why she could not move on. Yet, she was still grateful for the physical expressions of caregiving they provided. The caregivers could occasionally sense their inabilities to offer what their family members wanted. One son who was the caregiver (F18) shared his frustration of not understanding how his mother felt despite his efforts to ensure that her every material need was met. He could not understand why his mother experienced suicidal ideation despite the care he provided her. Both cases are examples of the limitations of physical caregiving, which are appreciated by participants but mask the emotional understanding that many participants need in their recovery process.
Unheard Understandings
For some participants, primarily the adult children of patients, despite the love and obligation that comes with caring for a family member while they are ill, many of these relationships were fraught with tensions and made caregiving even more challenging. Yet these participants were also very compassionate, particularly about the limitations their parents experience due to migration-related stressors. F05 and F06 had tense relationships with their parents who were diagnosed with SMI as both participants experienced abuse from their parents. Though they resented having to care for someone who had mistreated them, they also had a deep understanding of why their parents engaged in negative behavior.
F05 explained that while she did not get along with her mother because of her temper, she ascertained that her mother’s anger stemmed from the anxiety of having a husband with a chronic illness. She shared,
F05: Um so . . . so that’s you know . . . I think that’s the first thing to start within the context of my mom who is the patient um you know she um she and my dad I guess got, got married 30 . . . over 30 years ago. And um you know my mom was really young when she got married. Like 17 essentially. And uh just uh you know came to a new country and what not, but my dad has been like chronically ill like for a very long time. Um so I think that was probably one of the major mental catalysts for her mental illness and kind of depression. Um just because she’s like the primary caretaker of my father right now.
F05 understands the stress her mother experienced as a young wife and mother who suddenly had to become the primary caregiver of her husband (F05’s father), which is even more challenging considering the financial limitations her mother faced as a first-generation immigrant woman.
F06 explicitly expressed how much she resented her father’s mistreatment of her, her siblings, and her mother. But she also explained that her father, as a first-generation immigrant, experienced a loss in status after migration and was deeply disappointed in his perceived lack of success in the United States despite coming from an educated background in India. Unfortunately, his family bore the brunt of his disappointment. Despite such deep understanding for their ill parents, neither participant ever expressed their compassionate feelings to their parents. Such compassion does seem to help them continue to care for their parents despite the tension and can help strengthen bonds frayed by resentment. These cases show how the combined challenges of migration and mental illness complicate family dynamics in which children are taking care of parents whom they resent and love.
Theme 3: Dynamics of Gender, Illness, and Family
The third theme focuses on how experiences of illness shape and are shaped by the gendered ways in which family members are supposed to relate to each other, particularly masculine expectations of being the primary provider and feminine expectations of being the family caregiver. In addition, migration introduces changes in gender dynamics within families, and the tensions arising from these changes are especially palpable during difficult times, such as family members experiencing illness. For instance, the first subtheme discusses the stress experienced by women who must unexpectedly be the primary provider for their families but often do not have the financial means to do so. The second subtheme consists of examples of women becoming the head of their households and being held to gender norms for both men and women within South Asian family structures. The final subtheme centers on men who take on caregiving roles that are traditionally held by women in the family.
Women Who Must Work but Can’t
Many first-generation immigrant South Asian women are raised with the expectation that they will carry out the domestic responsibilities of taking care of a family while their husbands serve as primary financial providers. This dynamic does change post-migration when greater economic demands push some women to work outside the home, becoming secondary providers. However, because many must still fulfill domestic expectations of women, they remain financially dependent on their husbands. Therefore, when husbands fall ill and are unable to work, their wives suffer from anxiety and often resentment.
For instance, P01 believes the root of her depression is the fear she has of losing her husband, who has a debilitating chronic physical illness. She admits she does not have the background or experience to work outside the home, which is where she feels the most comfortable. However, if her husband cannot work, who will take care of her? In contrast, F17 completed her education in India but had depended on her husband to be the primary provider when they moved to the United States. She shared,
F17: Before my husband’s condition worsened, my kids would blame me for everything—since they thought I was alone. I would just listen to everything—I thought this is life. I did not leave my husband because I did not have any financial support and there was no one to look after my kids [translated from Hindi].
F17’s husband was abusive to her and their children, but she remained with him because she was financially dependent on him. She had mentioned that if she had studied in the United States, maybe she could have worked. But that was not possible because she needed to be there for her children. Now, with the onset of his illness, she is not only resentful of him because of his abuse but even more so with his inability to provide.
In sum, along with expectations for women to remain at home and the challenges immigrant women face in the American labor market, many South Asian first-generation women experience a great deal of anxiety, fear, and resentment when their husbands are unable to provide.
Women Who Must Do It All
On the contrary, such challenges push some women to take on the responsibilities usually held by the male head of their households, even when there are other eligible male members. For example, when her father became ill, F06 took on the responsibility of making major decisions that affected the family, such as hospitalizing her father and ensuring that others, like her mother, were taken care of. Another example is F15, whose husband and two other children were diagnosed with bipolar disorder. F15 is the primary provider for her family and the manager of their health affairs. She makes important decisions, such as moving to the United States to provide better care for her husband and daughter.
Both F06 and F15 experience resistance from other family members who may not agree with their decision-making. Some of F06’s family were against the decision to hospitalize her father since they were in the process of receiving their green card, and hospitalization may jeopardize their applications. For F15, she had a difficult experience in convincing her husband to receive care for his condition, resulting in forced hospitalization when his behavior became too much for her. Despite her personal care for her husband, her decision to place him in psychiatric care is disapproved by other family members, such as her mother-in-law, who blames F15 for her husband’s condition. For instance, she said:
F15: My mother-in-law was not helpful. She was very nasty. She was telling because of me; her son got this illness . . . She was very nasty. Yeah. And she was always that because of me . . . because of me.
Because, as women, they are taking on roles usually inhabited by the eldest male in the household, F06 and F15 are often resented by other family members. Thus, their experiences reflect the challenges women leaders in the family face when stressful situations such as illness and immigration change the gendered power dynamics within families.
Men as Caregivers
Caregiving is primarily a domestic responsibility of women in most South Asian cultures, especially when the person being cared for is a woman. Such responsibilities are often shared by members across a large extended family, which changes for South Asian immigrants separated from their extended families. While most of the caregivers in this study identified as women, there were also some instances in which men fulfilled that role.
For example, P13, who was diagnosed with complex PTSD and MDD, described her husband as the primary caregiver. She shared that not only did he ensure she received health care, but he also provided support in other ways such as limiting communications between their respective natal families who were a major source of emotional stress. In addition, he took over domestic responsibilities, such as taking care of their son while working as the primary breadwinner.
Another kind of subversion of gender norms in caregiving was between mothers who were patients and their caregiving sons. Because F18 is the only child of his mother, who is in the United States, he is her sole caregiver. While his wife is also in the same household and as the daughter-in-law is expected to be the primary caregiver, F18 continues to manage almost all aspects of his mother’s care, which includes taking her to appointments and managing her medication. However, he is unsure how she feels when he shares:
F18: And I told my mom—I mean I tried to give her things. Whatever she wants. I try to keep her happy or fulfilled from every corner. I don’t know how much she’s really happy or if she’s fully satisfied uh because it always bother my mind because I know how my mom is like she never try to share 100% whatever in her mind. I can feel it because I know it.
Within most South Asian families, the emotional worlds of men and women remained separate along gendered lines, which may explain why F18’s mother did not confide in her son. But this gendered line becomes blurred for F18 as he struggles to provide his mother with emotional support despite his mother’s resistance. Overall, both cases here show that migration produces contexts in which traditional familial support networks are unhelpful or unavailable and can affect the gendered ways in which families care for one another, such as men fulfilling caregiver roles that are usually filled by female family members.
Discussion
Our analysis of the interdependent experiences of family, migration, and illness of U.S.-based South Asian immigrants diagnosed with SMI and their family members, many of whom shared their own mental health struggles, contributes to an understudied area in U.S. South Asian immigrant mental health. Most studies that include family members primarily focus on their role as caregivers (Bui et al., 2018; Han et al., 2019; Law et al., 2021). Our study contributes to the small body of literature that examines in tandem the experiences of both patients and their family members within the context of family, migration, and mental illness (Lan et al., 2018; Penny et al., 2009). Until recently, mental illness among immigrants has been primarily attributed to acculturative stress experienced by individuals and their families. This overemphasizes the responsibility of the individual or their family in adjusting to a new cultural context and occludes the significant role of structural stressors such as the lack of social support from extended family and economic hardship (Ibañez et al., 2015). The concept of familial vulnerability goes a step further than the acculturative stress model by recontextualizing the experiences of mental illness among South Asian immigrant families within the broader frame of structural factors that place them in a precarious position (Misra et al., 2021; Viruell-Fuentes et al., 2012), leading to emotional and physical suffering.
While not every participant in our study attributed their mental illness to migration-related stress, almost everyone’s experiences were connected to some form of structural vulnerability due to the migration of their families or themselves. At the same time, the family was also identified as an additional source of stress. Familial vulnerability shows how structural vulnerabilities experienced by one individual also affect the family unit as a whole. It provides a more intersubjective dimension of the structural racism experienced by immigrants. In medical anthropological literature so far (Collins et al., 2022; Garcini et al., 2022; Logan et al., 2021; W. D. Lopez & Castañeda, 2022; W. D. Lopez et al., 2022; Payan, 2022), the concept has been utilized to show how the legal precarity of at least one individual in a family has a deleterious effect on the mental health of everyone. The concept aligns with what we observed in the experiences of our participants. Our study findings encompass multiple forms of structural racism beyond legal vulnerabilities, such as economic limitations for women and having limited social networks experienced by multiple members within a family, which intersects with having an ill family member that forces the restructuring of family roles. These dynamics contribute to widespread distress across the entire family. Therefore, we are expanding the concept of familial vulnerability by illustrating how migration and mental health dynamics affect familial bonds, caregiving, and gender relations within South Asian immigrant families.
If Not Family, Then Who?
Like other societies in North America and Europe, mental health theory and treatment practices continue to be individual-focused in the United States (Kirmayer, 2018). Yet for many South Asians, family, more so in the immigration context, shape their illness experiences (Ekanayake et al., 2012; F. Islam et al., 2014; Kirmayer et al., 2011; Masood et al., 2009; Naeem et al., 2019). The concept of familial vulnerability can help us understand why some patients lack the support network critical to recovery by examining how migration experiences affect social bonds within families (Abrams et al., 2022; Garcini et al., 2022; Löbel, 2020). Participants who are undocumented not only experience persistent anxiety, but they are also scared to seek help in case illness becomes another way to criminalize their existence along with lack of citizenship (Asad & Clair, 2018; Hardy et al., 2012; Perreira & Pedroza, 2019; Torres & Young, 2016). Their fear is not unfounded because U.S. immigration policy has a number of health requirements that can potentially invalidate one’s bid for citizenship (Daudi, 2021; Perreira & Pedroza, 2019). For example, in one family, there was disagreement about whether to take the father to the emergency room because of the fear that hospitalization would compromise his and his wife’s green card application. When the father’s situation worsened, one of the adult-aged children hospitalized him, which angered the mother, who experienced feeling betrayed by her child. This illustrates how structural vulnerabilities, such as the struggle to gain legal status, can lead to negative consequences. First, for the father and mother, the fear and anxiety can delay seeking help, potentially worsening the overall health of the individual. In addition, other family members, such as the adult children, made difficult decisions, such as hospitalizing their father, which could lead to feelings of mistrust from other family members disapproving of this decision.
Furthermore, for many South Asian immigrants, their social life is centered around and through family (Kallivayalil, 2004; Karasz et al., 2019; Masood et al., 2009; Samuel, 2005; Shariff, 2009; Tummala-Narra & Deshpande, 2018). The complex dynamics of family relationships within the context of migration that include the impact of familial vulnerability is not only limited to relationships within families but also shapes how individuals develop relationships outside their families (Kandula et al., 2018; Masood et al., 2009). For families where at least one individual experiences visible mental distress, many withdraw from the community from the fear of the stigma of a family member being associated with mental illness. Also, participants were hesitant to seek a support network outside of family because they either did not know how or practiced caution based on their own negative experiences with family—if your own family lets you down, who can you really trust? At the same time, some participants had a strong support network—either within their family or outside of it. One participant shared that though her family could be a source of stress, they understand her seeking therapy and are even receptive to the insights she is learning. Another participant shared that while she will not discuss her mental health struggles with family, she confided in friends about her experiences and found their support helpful.
This section makes several important contributions. First, existing literature on familial vulnerability focuses on how an individual’s emotional or physical suffering due to structural inequalities can affect the health of other individual family members (Cerda et al., 2023; Garcini et al., 2022; Logan et al., 2021; W. D. Lopez & Castañeda, 2022; W. D. Lopez et al., 2022; Payan, 2022). We argue that familial vulnerability should also consider the impact of vulnerabilities on relationships within families. How do such hardships affect how family members relate to one another? Furthermore, the study also contributes to the research on the importance of support networks in recovery from mental illness as understanding how breakdowns in familial bonds due to familial vulnerabilities can affect an individual’s ability or desire to seek support networks that may be helpful to their own recovery.
In addition, there is limited exploration of potential family conflicts outside the parent–child relationship, such as between adult immigrants and their physically distant extended family. While research has highlighted the complicated feelings of guilt and resentment immigrants may feel, particularly about aging parents they have left behind (Tummala-Narra et al., 2013), more studies are needed on how migration shapes relations with other family members, such as siblings, particularly on how individuals communicate (or do not communicate) when they experience psychological distress. This is especially salient in the case of two of the participants (P01 and P11) who had tense relationships with family members who migrated much later, and these tensions further contributed to the isolation they experienced as a part of their illness. This phenomenon of delayed chain migration is also indicative of another way South Asians are marginalized in the United States, as anti-immigrant policies can often prevent even close family members, such as siblings, from immigrating as well. Thus, even when extended families eventually immigrate to the United States, sometimes many years or even decades later, the reunification also produces a cultural gap that may lead to conflict that can affect the psychological functioning of U.S. South Asians. Even in cases where individuals do immigrate alongside other members beyond their immediate family without delay, it is worth better understanding how the precarity of moving to a different sociocultural environment may affect relationships within extended families. Nevertheless, we hope there will be more exploration into how transnational familial relations and delayed chain migrations shape the mental health of South Asian immigrants in the United States.
Rethinking Caregiving
Assessing caregiving within the context of familial vulnerability can help us understand situations in which resentment exists between individuals and their caregivers. Our study provides invaluable insight into the participants’ perspectives on the care they receive, if any, especially since the line between “patient” and family member “caregiver” becomes almost negligible. While we had two distinctive participant groups—patients and their family members—because many of the family members were suffering from their own mental distress, the distinction became blurred. We found that caregiving involves more than just the physical and cognitive labor of engaging with health care (e.g., making appointments, accompanying the patient to appointments, and medication management). It also involves the enumerable emotional burdens of being responsible for the well-being of a loved one. This includes the constant guilt of not doing enough for a loved one and complicated feelings of resentment and compassion when caring for an abusive family member (Bui et al., 2018; Littlewood & Dein, 2016; Penny et al., 2009). The lack of emotional understanding and open communication among family members was a consistent pattern across the participants. Many older Bangladeshi women felt misunderstood by their families, even though they appreciated their physical support. Some South Asian children who were the primary caregivers of their parents often suffered from their own mental health issues. While these shared experiences fostered deep compassion within the children for their parents, resentment and mistrust from parental harms prevented any emotional connection or understanding between the two.
These observations have two significant implications. The first is a contribution to the study of structural vulnerabilities among immigrant groups in the United States. We show how negative mental health due to structural vulnerabilities is not just limited to one family member but widespread within a family, and multiple members are affected (Logan et al., 2021; W. D. Lopez & Castañeda, 2022; W. D. Lopez et al., 2022). Familial vulnerability has been studied within primarily Latino immigrants, and to our best knowledge (W. D. Lopez & Castañeda, 2022; W. D. Lopez et al., 2022), this article is the first to explore this phenomenon in relation to South Asian immigrants and in the context of psychological distress.
Our findings contribute to the body of literature that highlights the importance of social support in mental health (Fasihi Harandi et al., 2017; Lakey & Orehek, 2011). Studies have found that instrumental support (i.e., providing tangible aids such as transportation to appointments) alone does not improve well-being, and emotional support is critical to an individual’s recovery (Carter et al., 2019; Fisher et al., 2021; Fu & Ji, 2020; Guntzviller et al., 2020; Morelli et al., 2015; Rennick-Egglestone et al., 2019; Tzeng et al., 2023). Finally, our findings corroborate the established positive relationship between emotional support and mental well-being by highlighting the importance of providing empathy and understanding in the overall recovery process.
Because family is typically the main source of caregiving support for U.S. South Asians (F. Islam et al., 2014; Masood et al., 2009; Naeem et al., 2019; Penny et al., 2009; Sharma et al., 2020; Tummala-Narra, 2013), this article’s findings further emphasize the importance of family-based interventions for South Asian immigrants with SMI. Currently, most U.S. studies on family-based interventions that include South Asians are primarily in the context of improving outcomes for youth mental health, particularly as preventive measures against substance use and suicide (Tummala-Narra & Yang, 2019). For SMI specifically, family-based intervention practices can potentially alleviate the stigma individuals experience from their families (Sharma et al., 2020; Vyas et al., 2021). The complex family dynamics related to illness and migration can help inform how families can be more supportive, particularly emotionally, of their loved ones who are struggling with SMI.
Engendering Family and Illness
In South Asian families, gender is one of the major organizing principles of social relations. Connecting familial vulnerability to gender shows that while mental distress may be widespread within the family, the impact is not uniform across all members. Gender is one source of this unevenness. For instance, while men are usually considered the head of the family, women are usually responsible for fostering social cohesiveness. As a result, family tensions have a disproportionately negative impact on the mental health of women in the family. Moreover, when an individual family member is ill, caregiving is usually a woman’s domain—and if the woman who is supposed to do the caregiving is the one who is ill, then there is a particularly strong disruption to the family unit.
Because gender dynamics vary across time and place, these experiences are further augmented by the structural vulnerabilities of migration. For instance, South Asian immigrants must negotiate the cultural values and beliefs regarding the gender of their home society against that of American society, which are very different (Inman, 2006; Kaduvettoor-Davidson, & Inman, 2012; Tummala-Narra, 2013; Tummala-Narra & Deshpande, 2018; Varghese & Rae Jenkins, 2009). While gender dynamics and relationships do not remain static in the home countries, they are not as dramatic as the changes immigrants experience in a new country. Tummala-Narra (2013) discusses how immigration introduces changes in the family structure that involve men and women taking roles inside and outside the home. For South Asian women, who traditionally must take care of spouses, children, and extended family, immigration adds the role of working outside the home. For families with limited extended kinship relations in the United States, some South Asian men are grappling with caring for their elderly mothers or wives when female relatives would conventionally fulfill such duties.
In addition, migration introduces another dimension of cultural change that not only affects how men and women relate to each other but also how financial struggles affect relations. Economic hardships are another force of structural vulnerability that directly affects gendered relations in South Asian families. For instance, limited financial opportunities for first-generation South Asian immigrant women leave many of them vulnerable to heightened anxiety, which also affects other family members, such as their children. In two families, the mothers attributed their distress to their husbands, who had debilitating illnesses. Because the husbands were the primary breadwinners, their illnesses left their wives financially and emotionally vulnerable. Whereas in their home countries, the women might have relied on other male relatives. While many studies on mental health and gender among South Asian immigrants focus on women and the impact of South Asian patriarchal elements on their mental health (Anand & Cochrane, 2005; Husain et al., 2006; Ineichen, 2012; Karasz et al., 2019; Masood et al., 2009; Varghese & Rae Jenkins, 2009), other studies also acknowledge that structural factors such as immigration policy and economic limitations, particularly for women, also play a significant part (Badhwar, 2022; Chew-Graham et al., 2002; Hussain & Cochrane, 2004; Millner, 2015; Naeem et al., 2019; Özen-Dursun et al., 2023; Tummala-Narra, 2013). Our study demonstrates that the use of familial vulnerability provides a more complex understanding of gendered relations within family, migration, and mental health.
Strengths, Limitations, and Future Directions
Our article makes significant contributions to studies on immigration, migration, and South Asian mental health in the United States. We specifically contribute to the concept of familial vulnerability in three ways. First, we expand the analytical parameters of the concept to include how structural vulnerabilities not only lead to widespread mental distress but also how social bonds within families are negatively affected in the process. Second, we bring attention to how studying familial vulnerability can expand our understanding of family and caregiving, particularly in the context of immigrant families. Finally, by examining gender and mental illness within the framework of familial vulnerability, we illustrate how migration contributes to the complexity of gendered relations within families that shape illness experience.
In addition to these strengths, limitations to the study must be discussed. First, this article’s analysis focused on the emerging patterns regarding family and migration from data that had been collected based on a different research question. The initial study question sought to better understand the experiences of U.S.-based South Asian immigrants diagnosed with SMI and their family members. Thus, themes do not necessarily show instances of structural vulnerabilities caused by migration-related stress directly, but we are interpreting that the additional stress from the interdependent experiences of illness, migration, and family dynamics as a consequence of the structural vulnerabilities that at least one member of a family is experiencing. Because the consequences of these vulnerabilities are not simply contained in a particular member but affect the psychological function of other family members as well as the relationships among them. Also, while all participants were asked a series of questions about immigration history, family relationships, discrimination and stigma, and the patient’s mental health experience, they were not explicitly asked about migration-related stress, and family members were not asked about their own mental health struggles. Mental health is a sensitive and challenging topic, and while a number of family members in the study discussed their own mental health experiences, we did not directly ask family members about this, so we cannot fully reflect on their experiences. Finally, participants shared a wide range of hardships related to migration that were also rooted in broader structural factors, which were contextualized as such in our analysis. However, because we did not directly ask about migration-related stress, we cannot be sure that those who did not discuss these hardships had not experienced them.
Therefore, our study raises questions for future research. First, considering the centrality of family in immigrant communities, more studies on migration and mental health should examine the shared and individual experiences of multiple members of a family. Furthermore, questions for family caregivers should not solely focus on their role as caregivers or the physical and cognitive labors of caregiving but also on their own experiences outside of being a caregiver. Second, studies on South Asian mental health in the United States need to expand beyond attributing mental and emotional distress among South Asians to acculturative stress. While many cultural differences exist between mainstream American society and South Asian cultures, such differences should not be pathologized. Migration places many South Asian immigrants in precarious positions, resulting in widespread distress that should not be dismissed as individual or familial lack of responsibility for failing to acculturate (Shams, 2020; Viruell-Fuentes et al., 2012). Utilizing structural vulnerabilities and familial vulnerabilities in the South Asian immigrant context will highlight the impact of systemic racism faced by South Asian immigrants, including economic exploitation and exclusionary immigration policies.
Conclusion
We expanded the notion of familial vulnerability by focusing on how structural vulnerabilities induce widespread distress within a family unit and affect multiple kinds of gendered relations within a family. Our findings reflect the complex dynamics involved in migration, family, and mental health for South Asian immigrant families in the United States. We organized these findings into three major themes. The first theme illuminates the isolation experienced by participants due to the cumulative effect of migration-related challenges and illness. The second theme provides the unique perspectives of both caregivers and individuals receiving care, revealing that our understanding of care should expand to examine the complexities of emotional in addition to the physical labors involved in caregiving. The final theme highlights how experiences of illness are constitutive of gender, migration, and cultural change.
Supplemental Material
sj-pdf-1-jcc-10.1177_00220221251389101 – Supplemental material for The Sociocultural Dynamics of Mental Distress, Migration, and Family Among South Asians in the United States
Supplemental material, sj-pdf-1-jcc-10.1177_00220221251389101 for The Sociocultural Dynamics of Mental Distress, Migration, and Family Among South Asians in the United States by Tasfia Rahman, Kathryn L. Lovero and Supriya Misra in Journal of Cross-Cultural Psychology
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this paper was supported in part by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number U54MD000538. The first author’s contribution was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, United States (grant No. 5T32HD049339). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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