Special Report: Asian American Hate Incidents—A Co-occurring Epidemic During COVID-19

After a day of giving lifesaving medical care during the COVID-19 pandemic, Lucy Li, M.D., leaves the hospital. A man follows her, yelling, “Why are you Chinese people killing everyone? What is wrong with you?” Waiting for a train in St. Paul, Minn., an elderly Asian woman is kicked in the face by three laughing teenagers. At an elementary school, a 10-year-old girl is repeatedly called “coronavirus” until she sobs that she doesn’t want to be Asian anymore. A family is walking in Haleiwa, Hawaii, when a procession of cars slows down and passengers cough upon the Asian American family.

Amid the COVID-19 pandemic, Asian Americans have been hit, spat upon, coughed upon, yelled at, Zoom bombed, and outright assaulted in 44 states and Washington, D.C. Asian Americans have had windows broken, tires slashed, and property graffitied with slurs like “Asian Virus.” In workplaces, Asian Americans have fielded accusations of eating bats, being cruel to animals, and ruining cities. Some have been falsely accused of having the coronavirus and then furloughed.

Over 1,700 cases of anti-Asian incidents have been reported to the Stop AAPI (Asian American and Pacific Islander) Hate online tracker since it was launched on March 19 by the Asian Pacific Policy and Planning Council (A3PCon) and Chinese for Affirmative Action. Indeed, a warning was issued by the FBI about a surge in anti-Asian hate crimes during the COVID-19 epidemic after the March 14 stabbing of a family in Midland, Texas. While two children (aged 2 and 6) and their parents were recovering from stab wounds, the assailant confessed his motive was to stop the Burmese American family from spreading coronavirus.

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Asian Americans Advancing Justice is another group tracking anti-Asian hate activity during the pandemic. One of their reports involved a Zoom bombing with racial epithets during a webinar organized by the Coalition of Asian American Leaders titled “Countering Xenophobia and Anti-Asian Discrimination During COVID-19.” Zoom bombers yelled and chat-boxed obscenities unmentionable here but viewable on their website. “The hate is palpable,” says Russell Jeung, Ph.D., chair of Asian American Studies at San Francisco State University.

Cynthia Choi, executive director of Chinese for Affirmative Action, points out that the 1,800 incidents have occurred while most of the United States has been under orders to stay at home. She expects anti-Asian activity to increase as the country reopens. Making schools, playgrounds, and neighborhoods feel safe again is a task “that I can’t even get my head around,” says Choi.

Asian Americans have long been underserved in terms of mental health care and have encountered cultural barriers to seeking care. Adding to these problems are the difficulties of getting any type of care during the COVID-19 pandemic and the federal government’s new restrictive immigration rules that threaten the deportation of immigrant physicians who serve these populations. Approximately 30% of practicing psychiatrists are international medical school graduates, according to APA, and many have visa statuses potentially in question. Nonetheless, acts of innovation and leadership have been occurring as psychiatrists rise to meet the needs of Asian Americans during this time of tremendous challenge.

Stop AAPI Hate Epidemiology

According to Jeung, who has analyzed data from the Stop AAPI Hate tracker, assaults constitute 14.6% of 1,710 reports between March 19 and April 29, including coughing and spitting during a pandemic. About 10% of reports constitute civil rights violations, such as those of an Asian American woman who was ignored for 45 minutes at the post office while others were called to the counter and a 71-year-old man who was denied use of a public restroom. The vast majority of incidents—69.6%—involved verbal harassment, and 23% involved shunning. Women were about 2.5 times more likely to be harassed than men. About 10% of reports involved elderly people. “They’re targeting the vulnerable,” says Jeung.

Coughing and spitting upon Asian Americans have become categories of hate activity unique to the COVID-19 pandemic. While walking to work, an Asian American woman was called “f***ing Chinese” by an older man who then spit on her coat, scarf, and face. In a grocery store, a woman spat upon an Asian American family after yelling that the coronavirus was their fault.

Thirty-two percent of Americans have witnessed an Asian person being blamed for the coronavirus, according to a survey of 1,001 Americans conducted by the Center for Public Integrity and Ipsos. Among Asian American respondents, 60% witnessed an Asian person thus blamed.

How to Handle an Attack or Threat

For People Who Feel at Risk

The following guidance is for people who feel they are at risk of an attack and for therapists who are advising patients who feel at risk:

• Staying safe is the priority. The perpetrator is, by definition, not thinking about your well-being—so don’t underestimate the danger.

• Remove yourself calmly and inconspicuously from the scene if possible. Leave the perpetrator alone with his or her actions, which, again, are not about you.

• When you are safe, call the police, 911, or management of the facility in which the attack occurred.

• If the attack involved something visible (such as spit), take photographs, which might be useful later.

• If you are by yourself, seek out a trusted authority, family member, or friend. It is best to not stay alone.

• Report the incident to the Stop AAPI Hate online tracker.

Safety should be the immediate priority. During an act of hate is not the time to educate or do good. For example, an Asian American was walking dogs when a stranger shouted racial slurs and “dirty words” from a patio. According to the report filed with Stop AAPI Hate, the victim “responded peacefully and attempted to deescalate.” The man then attacked the Asian American and the dogs with a sharp-ended umbrella. The incident lasted approximately an hour, until police arrived in five patrol cars and intervened. This is an example of the importance of seeking safety first and removing oneself from a scene at the first sign of hate activity. A verbal assault can easily escalate to physical harm.

In contrast, as Li was threatened upon leaving the hospital, she did not confront the man yelling and following her. She sought safety by ducking into a large grocery store. She then called police and the security officers at her hospital, who accompanied her from the scene. Realizing that many of her fellow anesthesia residents and staff are Asian, she texted her colleagues, her program director, and the chair of her department to spread the warning. When she returned to work, she made sure that she was never alone.

For Witnesses

• Assure your safety first.

• Consider calling the police or 911 to assist the victim, who may not be able to call.

• Once the threat is over, check whether the victim needs medical assistance.

• Let the victim know that you witnessed the wrongdoing. Express sympathy and support. The immediacy of this action can make a difference for the victim and for yourself, as it becomes part of the memory of the incident.

Priscilla Marquis, Ph.D., a psychologist and trauma specialist, was walking with her daughter near Chinatown in San Francisco when they witnessed a man yelling racial epithets at an elderly Asian American woman and man. As the two defended themselves, Marquis and her daughter tried to support them but did not engage the man yelling at them. Marquis’s action, because it was immediate, becomes part of the memory of the verbal assault, and thus an important intervention for all.

Around that same time, says Marquis, an elderly Asian American man had been assaulted, and the perpetrators were sentenced only to community service. “We were horrified and traumatized by these events,” says Marquis.

“Being able to feel safe with other people is probably the single most important aspect of mental health,” writes Bessel van der Kolk, M.D., in his book The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. “Safe connections are fundamental to meaningful and satisfying lives.”

PTSD Occurs in Victims and Witnesses

Posttraumatic stress disorder (PTSD) occurs in people who have experienced or witnessed a traumatic event, according to DSM-5. Indeed, while psychological sequelae of war have been long recognized, the diagnosis of PTSD was first described in the aftermath of the Vietnam War—not in Vietnamese, but in American servicemen who had witnessed or suffered violence in Vietnam.

Hate activity is potentially traumatizing to all involved—not just to victims, but to witnesses and the larger community.

Elements of Healing

Exposure Therapy

“Trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body,” according to Van der Kolk. “Trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but also your very capacity to think.”

The Nobel Prize–winning work of Eric Kandel, M.D., shows that memories are not erased and that new learning can occur, such as becoming desensitized to stimuli that trigger memories of trauma. Although trauma itself cannot be erased, Edna Foa, Ph.D., has written extensively that “prolonged exposure” is the most effective way to overcome trauma.

When counseling patients who have suffered an assault or trauma, psychiatrists must help them realize that if new fears or anxieties occur, they are likely a result of the trauma, even if the patients don’t consciously recognize it. Psychiatrists should promote calmness and encourage patients to confront and overcome any new fears. If the level of anxiety is severe, a gradual approach and the use of a hierarchy of fears may be effective.

When Li was verbally assaulted, she felt a sense of panic as she heard the man approaching her and following her. She recalls feeling sad that this was happening and then anger. “He was accusing me of hurting people while I was taking care of patients daily, like many Asian American colleagues.”

In the coming days, Li experienced symptoms that are typical in the aftermath of trauma. “When I returned to work, I’d glance around to see if he was there,” she said. Li experienced hypervigiliance, a typical symptom in the aftermath of a traumatic experience. Avoidance is another common symptom. But Li continued to go to work, using the same route and hospital entrance; however, she put safety first and always went to and from work with a co-resident—never alone.

Li thus confronted the location of the trauma and her memories. With this “exposure,” the anxiety symptoms of hypervigilance and avoidance have lessened. Li says, “It’s gotten better with time, absolutely.”

Cognitive Restructuring

The strategies of cognitive therapy may be especially useful in instances of harassment, shunning, or discriminatory experiences, as well as more aggressive assaults that provoke fear.

The victim may personalize the harassment and feel somehow deserving of it, and inferior, like a second-class citizen. Corrective statements from a therapist might include “The incident says a lot about the perpetrator and virtually nothing about you—except that you happened to be there at the wrong time.”

Overgeneralizing may occur, and the victim may feel that other people will also behave like the perpetrator. A therapist might ask these questions: “How many people did you see that day? How many of them behaved this way? What are the odds that the next person you see will behave that way?”

The victim should become aware of cognitive distortions such as discounting the positive and the positive interactions that have occurred. He or she may have a mental filter and overly focus on the negative incident while discounting other incidents. Constructive statements from a therapist might be “Don’t other people deserve your attention, more than this person?” or “It sounds like this person doesn’t deserve your thoughts, and other people deserve your thoughts more.”

The victim may even catastrophize and feel that the incident ruins the future or that all future incidents will be thus. The therapist can point out a more balanced view and note that the incident was likely isolated.

The victim may jump to conclusions or exhibit emotional reasoning, and make statements like, “I feel like it’s going to happen again—maybe all the time now.” While the therapist can validate the feelings and allow the patient to express these feelings, the therapist can also point out the distorted thinking.

Negative core beliefs might be activated. According to Aaron Beck, M.D., core beliefs tend to be in one of two categories: being unloved or being a failure. Constructive statements from a therapist might include: “Perhaps you feel unwanted by this person. Can you name the people who do want you? How much does this person matter?” or “What’s the evidence that you are a failure? Could it be that this person failed miserably in the way you were treated?”

Narrative Therapies

The victim must also make sense of trauma and integrate it into his or her own world view. For example, Vietnam War veterans have struggled with issues of abandonment and betrayal, along with larger moral issues about the war and why it happened. Rape victims often struggle with questions of good and evil in the world, as do many victims of other trauma.

Perhaps a function of storytelling, which exists universally in all cultures, is to help people make sense of trauma and incongruous life events. Stories tie together disparate views into one narrative, along with many details and complexities. Traditional insight-oriented psychotherapy allows a patient to formulate stories about trauma while also allowing exposure and desensitization to triggers by re-experiencing the trauma in the safety of the therapist’s office. Narrative therapy, art therapy, dance therapy, or the creation of literature or art can help integrate the trauma into the self and into one’s world view.

Understanding Perpetrators

Why does hate activity occur?

Psychodynamic theories center on projection and scapegoating. By blaming another person, the perpetrator finds an object upon whom to unleash emotions while not facing his or her own fears or anger. The perpetrator may delay facing his or her personal situation and responsibility.

According to Jeung, there is no clear demographic pattern among the perpetrators reported to the Stop AAPI Hate tracker. Perpetrators span the demographic spectrum, including teens, the elderly, and all age groups in between and all racial and ethnic groups. A lack of emotional maturity, often due to age, may be a contributing factor.

In economically stressful times, hate activity historically increases. Choi is concerned that this is the most economically challenging time since the Great Depression, which leads her to predict that hate activity will increase.

“I got pushed and slammed to the floor by a neighbor who lost his job,” states a report to Stop AAPI Hate. “He yelled at me, ‘I lost my job cause Asians.’ I got my back, neck, and hand hurt.”

In a political climate that encourages divisiveness and actively targets China, President Donald Trump has called the novel coronavirus the “Chinese virus,” and an unnamed White House official was quoted as using the term “Kung flu,” according to the March 17 Washington Post. Meanwhile, according to Politico, a 57-page memo was issued on April 17 by the firm of top Republican strategist Brett O’Donnell, instructing Republicans to “attack China” as a key campaign strategy for the November election.

The scientific discovery of mirror neurons provides a physiologic basis for why people emulate leaders and others around them. Leadership provides a powerful example in terms of preventing or provoking racist activity.

The Innovators

Robert Hsiung, M.D., and Teresa Lee, M.D., are psychiatrists who wanted to support Asian American therapists during the COVID-19 pandemic. Because Hsiung lives in Chicago and Lee lives in New York, their solution was to offer group sessions through Zoom videoconferencing.

“To help others, you have to first put on your own oxygen mask,” Hsiung explains.

The Asian American Therapist Community Support Group met for three sessions in March and April and had approximately two dozen regular participants. The therapists related their own anxieties of racism while supporting patients who also had anxieties of racism. One therapist had a patient who rushed from place to place, afraid of being identified as Asian at a time of hate crimes toward Asian Americans. Lee says, “If you can survive scapegoating, you are stronger.” She adds a saying from Confucius, “To swallow your own bitter pill is good, but to swallow another’s is divine.” She speaks of the role of the scapegoat as being “honorific” in a “collective trauma” such as COVID-19 upon the United States.

Ben Pu Cheng, M.D., a psychiatrist in Indiana, organized support to over 600 frontline health care professionals in Wuhan from psychiatrists mostly in the United States and Australia through WeChat, an app widely used in China (see Psychiatric News). He now strives to create a way to support Asian Americans during the COVID crisis.

Ravi Chandra, M.D., a psychiatrist and author, wrote a Psychology Today blog, “Calling COVID-19 a ‘Chinese Virus’ or ‘Kung Flu’ Is Racist.” When Chandra posted the blog to a listserv for psychiatrists, he was surprised at fellow psychiatrists who criticized him for detracting from COVID-19, “virtue signaling” and using “identity politics” to “manufacture outrage.” (“Virtue signaling” is a pejorative term for sharing a view to attract praise of one’s moral character or righteousness). Chandra subsequently held free sessions over Zoom titled “Contagious Compassion” in which he taught techniques of mindfulness to manage anxiety and suffering.

Institutions and Leadership

Institutions and diversity officers can play an important leadership role toward the healing and prevention of hate activity, as illustrated by the actions of Joseph Betancourt, M.D., M.P.H., chief equity and inclusion officer of Massachusetts General Hospital (MGH).

After Lucy Li was threatened, Betancourt broadcasted an email on the Mass General and Partners email lists to approximately 100,000 people. The email began:

“A member of our MGH family was leaving the hospital when a stranger unleashed a tirade of anti-Asian sentiment related to the COVID-19 outbreak.”

Betancourt called upon members of the MGH community to be active participants in denouncing such activity. He emphasized, “We cannot stress enough that this type of intolerance and discrimination is not acceptable—ever.”

According to Betancourt, this was an opportunity “to message our values” that MGH is an “environment where we treat everyone with respect and dignity.” Li became a speaker at the Radiology Department’s webinar about xenophobia at the time of coronavirus. Twitter and social media posts resulted in the dissemination of her story. Betancourt also checked on her regularly. Li says that counseling and therapy services were offered to her. She says, “I feel definitely supported and backed up in multiple ways. I am much better.”

Betancourt had already been working on a mechanism for responding to incidents of racism and related microagressions prior to the COVID-19 pandemic. “It’s my life’s work. I care deeply about this,” he says. “One key ingredient is having a radar screen to pick it up.” He had already built this, which is why he heard about Li’s incident from the police and Li’s department chair.

He commended the MGH community: “The community stood up for her.”

“It’s more important than ever for people to denounce these actions and to talk about it,” says Li. “Every time something like this occurs, it should be publicized. It’s more important than ever for people in leadership positions to say this is not OK.”

Li says, “I’m quite impressed with Dr. Betancourt and my institution.”

Can America Heal When Sheltering an Epidemic of Hate?

The COVID-19 pandemic has proven how interconnected we are today, as world citizens. Can America heal from COVID-19 if it shelters an epidemic of anti-Asian hate while relying on Asia for masks, medications, and medical supplies? Can the American economy heal when leaders blame China while asking China to purchase bonds and to help rescue America’s debt? Anti-Asian hate damages Asian Americans and America.

We must heal from two epidemics: COVID-19 and anti-Asian activity. Both are potentially long lasting, with lethal consequences. Yet the epidemic of anti-Asian activity is fully up to us to end, as an American nation. It must stop, for America to heal this season of epidemics. ■