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Reading: Healing the Whole Family: A Graphic Story Intervention for AAPI Mental Health

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Healing the Whole Family: A Graphic Story Intervention for AAPI Mental Health

Authors:

Nealie Tan Ngo ,

University of Toledo College of Medicine & Life Sciences, US
About Nealie Tan

MPH

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Grace Chiang,

MA Education, Stanford University, US
About Grace

MBA

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Eunice Y. Yuen

Department of Psychiatry, Yale School of Medicine; Yale Child Study Center, US
About Eunice Y.

MD, PhD

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Abstract

Healing the Whole Family (HTWF) is a graphic novel about Asian American and Pacific Islander (AAPI) intergenerational and mental health. HTWF is a project sponsored by Yale Compassionate Home, Action Together (CHATogether), a research group focused on AAPI mental health. HTWF describes one girl’s struggle with her mental health and her family who, in the beginning, do not acknowledge mental health or illness. The story follows her struggles to understand her family’s dynamics and how intergenerational trauma within her family plays a large role. HTWF aims to: 1) portray a relatable story for AAPI families about mental health and illness; 2) educate AAPI families on topics such as intergenerational trauma, attachment theory, the circle of security, and adverse childhood experiences (ACEs); 3) encourage future conversations about mental health within AAPI families. The audience for HTWF is purposefully multigenerational and includes AAPI teenagers, young adults, and caregivers.

This paper will first introduce HTWF and provide a summary of the graphic novel. Following sections will include a discussion about the intersection of Graphic Medicine and mental health and illness, analysis of visual metaphors (with corresponding excerpts shown from the graphic novel), and clinical implications of arts-based interventions in child and adolescent mental health.

How to Cite: Ngo, N. T., Chiang, G., & Yuen, E. Y. (2022). Healing the Whole Family: A Graphic Story Intervention for AAPI Mental Health. Graphic Medicine Review, 2(1), 3. DOI: http://doi.org/10.5164/gmr.34
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  Published on 29 Nov 2022
 Accepted on 25 Oct 2022            Submitted on 01 Aug 2022

Healing the Whole Family is a graphic novel that follows one teenage girl’s struggle with her mental health and her family, despite seeming to have it all. The graphic novel includes details of parental perspectives as well as the inclusion of “Teaching Points” that aim to educate and encourage reflection among readers on topics such as the circle of security and adverse childhood experiences (ACEs), while providing action-steps to improve child-parent relationships. The graphic novel’s primary audiences are teenagers, young adults, parents, and families. It is a resource helpful for any community, but it may be especially resonant for the Asian American Pacific Islander (AAPI) community.

The graphic novel is a multidisciplinary collaboration between physicians, writers, and visual artists. The unique combination of identities and perspectives of all three authors was purposefully channeled in order to create a graphic novel that reflected their identities as not only AAPI women, but also highlighted their individual strengths as patients, physicians, artists, writers, daughters, and mothers. As a result, the graphic novel has three distinct purposes: (1) create a visually appealing and relatable AAPI story concerning mental health and illness, (2) provide education about mental health, intergenerational trauma, attachment theory, the circle of security, and ACEs, (3) encourage and improve child-parent communication around mental health.

With the illustration of fantastical, often larger-than-life characters throughout the story, the reader is introduced to the various manifestations of the protagonist’s stressors. The decision to illustrate Perfectionism as a powerful, mythical beast (Figure 1) mirror the techniques of using mysticism and lore ancient storytellers and artists have used in many Asian parables and fables in order to convey complex messages and emotions (Leontovich, 2015). The use of a dragon to personify perfection also references the cultural significance surrounding this creature, especially in Chinese culture. Aside from being a personal symbol for the Emperor during imperial China, those who were considered to be excellent, outstanding, and flawless were often compared to a dragon, as reflected in a well-known Chinese idiom: “to hope that one’s child will become a dragon,” 望子成龙 (simplified Chinese), 望子成龍 (traditional Chinese). However, the dragon in this story turns the legend on its head, showcasing the consequences of striving for excellence at all other costs. Perfectionism pushes our protagonist to the edge, causing her freefall, and in the process subsequently pulls the reader along to witness her new journey to self-discovery and recovery, starting at ground zero.

Comic panel one shows the protagonist fighting a dragon. Surrounding the dragon are the words, “You must get a perfect SAT score in one try, 3 perfect SAT II subject tests, 10 perfect AP tests, national awards, club presidency, volunteering experiences…” Protagonist explains, “Because my family and I didn’t know there were illnesses called depression and anxiety…I battled with the pressures of being a perfectionist in school, paranoid that everyone was out to sabotage me—and that I had to do the same to survive.” Comic panel two shows the protagonist stepping backwards and falling off of a cliff. Protagonist explains, “I was constantly on edge, because I was taught that a moment without worry was a moment wasted in idleness. I accepted that I would never be happy—and that’s just the way life was."
Figure 1 

Excerpt 1 from Healing the Whole Family.

The protagonist’s descent forces her to gradually and meticulously start reflecting upon her own childhood, the relationships within her family, and most importantly, her parents. As she discovers the histories her parents harbor and the stories of their struggle, she realizes that her parents were once children, too, forced to grow up too fast in vastly different circumstances than her own. This understanding of familial history is reflected in the depiction of each of her parents’ inner child trapped in cages formed by their current adult selves, unable to break free of the past (Figure 2). As a result, they are unable to connect not only with themselves, but also as a family. A visual representation of both intergenerational trauma and ACEs, the birdcage portrait attempts to visualize how the past may hinder the present and affect one’s personal relationships to themselves and to others. As her parents learn how to confront their past further in the story, these inner children reappear, free from their cages, and actively interact with their adult selves to understand their shared history. Through these visualizations of anxiety, grief, and trauma, the reader is repeatedly forced into the practice of mentalization: the experience of understanding someone else’s mental state and emotions (Association, 2022). This active participation on the part of the reader throughout the graphic novel aims to increase empathy, knowledge, and understanding of these often stigmatized and complex topics.

Comic panel shows two children covered in bandages, each locked inside a birdcage shaped like an adult head. Inside the birdcages are scenes of childhood trauma, such as physical abuse. The children are reaching out towards each other. Protagonist explains, “Raised by neglectful, physically and emotionally abusive parents, my parents had scars they dared not uncover even for themselves to see. No one had ever taught them how to address those traumas and to avoid repeating them when parenting their own children.”
Figure 2 

Excerpt 2 from Healing the Whole Family.

Immigrant parents commonly navigate multiple identities when living at a crossroads of multiple cultures. It is not unusual for their first-or second-generation children to lack meaningful connections to their cultural heritage. This gap can cause a conflict with parental desires to maintain traditional core beliefs, creating what is known as an acculturation gap. This graphic novel depicts the various impacts of the acculturation gap on the relational health of a child-parent dyad, leading to effects such as different academic expectations, perceptions of support and care, and approaches to help-seeking in regards to mental health. Intergenerational trauma, along with language and cultural differences, may become additional barriers for child-parent communication. Such barriers are significant for physicians to understand and to address through education and accessible community resources. Healing the Whole Family serves as one such tool that can fill this gap. The graphic novel can inspire and educate physicians, trainees, and even patients by elucidating the various socio-cultural determinants of mental health as well as providing culturally-sensitive and family-attuned approaches for families, especially minorities and people of color. For example, Healing the Whole Family may provide clinicians a cultural lens with which to understand how mental health is affected by AAPI family dynamics with the portrayal of concepts such as (1) filial piety and how self-harming violates this concept and disrupts familial harmony, and (2) “eating bitterness”, 吃苦 (simplified and traditional Chinese): the cultural belief that adversity can be overcome by merely being tough, which may lead to decreased treatment-seeking behavior and higher distress. The graphic novel additionally includes a chapter formally dedicated to “Teaching Points” (Figure 3). These Teaching Points summarize the main takeaways for readers and include sections explaining definitions and providing resources to learn more about topics such as intergenerational trauma, ACEs, Attachment Theory, and the Circle of Security. They also include action-steps for both caretakers and children, highlighting a collection of communication techniques for families. The aims of the Teaching Points are threefold: (1) educate readers on important mental health topics and provide resources for further understanding, (2) encourage readers to actively reflect on their own experiences, (3) apply lessons learned from the Teaching Points and the graphic novel to increase awareness and understanding of intergenerational factors, initiate conversations related to mental health, and improve intra-and-interpersonal relationships. We include discussion questions (Tables 1, 2) that may be helpful to guide reflection and comprehension of the graphic novel for various readers.

Comic panel shows a blurred out background image of an open mouth getting a routine dental exam. Superimposing text reads, “Teaching Point #4: Breaking the Cycle (for children): Acknowledging the existence of mental health can be the first step in creating a prevention model to addressing intergenerational trauma. Taking care of your mental health starts with paying attention to your emotional wellness. This can include acknowledging your emotions, reaching out for help, and communicating with your friends and families. Mental health is every bit as important as your physical health, and maintaining one’s mental health is like getting your annual physical or going to your dentist every year. Both are halves of the same whole to your overall wellness!"
Figure 3 

Excerpt 3 from Healing the Whole Family.

Table 1

List of Discussion Questions for Readers Who Identify as Parents or Caretakers.


Reflect about the parent-child relationship in the story. What stood out to you?

When I mention the phrase, “mental health” what comes to mind?

What experiences have you had talking about mental health?

In what ways have you noticed that past experiences and relationships affect current ones? You can think of examples from your own personal life, your parents, your siblings, your friends, etc.

Communication goes two ways. How do you commit to changing or learning in order to improve your communication with your child? What do you wish your child could change?

If you were the parent or caregiver in the novel, what would you do similarly or differently?

Table 2

List of Discussion Questions for Readers Who Identify as Teenagers or Young Adults.


When I mention the phrase, “intergenerational trauma” what comes to mind?

Reflect upon your own experience with mental health or a loved one’s experience. What were some things that helped you or your loved ones during the process?

In what ways might your behaviors be influenced by past experiences?

What do you need to feel seen and cared for?

How does talking about your mental health make you feel? If you have not discussed this topic before, how do you imagine it might feel?

How might feelings (like anger, frustration, fear, hope, and sadness) play into your day-to-day behaviors?

What do you think your loved ones would say if you wanted to get treatment for your mental health?

Who do you turn to for support, comfort, and empathy? Is there anything you wished they knew about supporting someone with mental health challenges?

Communication goes two ways. How do you commit to changing or learning in order to improve your communication with your parents or caretakers? What do you wish they could change?

Did this protagonist’s story resonate with you? What would you do similarly or differently?

The medium of a graphic novel helps to facilitate curious, open, and non-defensive conversations when discussing challenging family dynamics during a medical encounter. Preliminary feedback from audiences indicate that the graphic novel is a powerful piece of art and storytelling that may be useful for teenagers struggling with their mental health and who lack social support and for parents who may not understand the mental health challenges of their children. A major clinical application of Healing the Whole Family includes distributing copies of the graphic novel at psychiatrist, therapist, and social work offices, as well as other mental health treatment centers as an intervention to help break down the barriers of child-parent communication. The graphic novel could also be disseminated at primary care, internal medicine, pediatric, and OB/GYN clinics in order to introduce an early-seeking preventive model for children, parents, and even expecting parents. Healing the Whole Family can also be a meaningful resource for educators in school settings, as well as function as a conversational tool for multi-family group discussions during therapy sessions.

In light of the rapid rise of anti-Asian hate, the amount of health disparities during COVID-19, and poor mental health access due to stigma and accessibility concerns, minority mental health is an issue at the forefront of the medical community. With the graphic novel easily accessible online, via various social media outlets, and with the potential to distribute print copies at healthcare and educational facilities, Healing the Whole Family holds promise as an accessible, preventive public health intervention to promote early-help seeking behaviors for mental health.

Funding Information

We acknowledge supports by the Josiah Macy Jr. Foundation President Grant for Medical Education, Yale New Haven Health System Innovation Award and AACAP Advocacy and Collaboration Grant.

Competing Interests

The authors have no competing interests to declare.

References

  1. Association, A. P. (2022). Mentalization. In APA Dictionary of Psychology. https://dictionary.apa.org/mentalization 

  2. Leontovich, O. (2015). The world of Chinese fictional narratives: content, characters and social impact. International Communication of Chinese Culture, 2(3), 301–317. DOI: https://doi.org/10.1007/s40636-015-0026-x 

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