CHATogether: a novel digital program to promote Asian American Pacific Islander mental health in response to the COVID-19 pandemic

CHATogether is consistent with the mental health awareness and prevention goals of Strategic Prevention Framework (SPF) from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). The SPF emphasizes community needs, building, and implementation of evidence-based prevention strategies through grassroots coalition efforts. Moreover, SPF incorporates elements of cultural humility [18] and communities’ values, traditions, distinctive heritage, and social structures [19]. SPF has been applied in several adolescent mental health initiatives [20, 21]. Drawing from the SPF, CHATogether uses approaches centered around the AAPI community needs to promote mental health prevention during the COVID-19 pandemic [19]. The program exemplifies Participatory Action Research (PAR) [22‐24], in which the intended beneficiaries are part of the research effort. PAR in turn incorporates cooperativism, a modified economy model where the program is composed of individuals who are part of a collective member-based ownership [25]. In this cooperative alliance approach, youth and adult volunteers partner based on shared values, goals, and passions to bring positive influences to their communities at a time of crisis [25]. In CHATogether, members draw on their strengths, talents, and interests and use the guiding principle of altruism to help address AAPI mental health and anti-Asian sentiment.

The interactive theater component of the program incorporated elements from the “Theater of Oppressed (TOp)”, which was first developed in Brazil in the 1970s by dramatist Augusto Boal, influenced by the work of educator Paulo Freire and his classic Pedagogy of the Oppressed (1970) [26]. TOp aims to promote social changes in the community by promoting non-hierarchical dialogue between audience and performer [27, 28]. TOp has informed medical education programs [29], public health initiatives on sexual assault [30], and cancer screening awareness [31]. We further adapted its tenets to the AAPI community’s needs during the pandemic.

CHATogether harnesses the potential of storytelling and the arts, leveraging electronic platforms to address the dynamics of family life and to translate the stigmatized language of mental health into stories told through theater, visual arts, and other expressive outlets. CHATogether has six core components: (1) interactive theater; (2) mental health education; (3) research; (4) community peer support; (5) collaboration; and (6) AAPI mentorship (Fig. 1,2, 3 and Table 1). Each component is led by leaders from a pool of 30 to 40 standing members, each of whom contribute their expertise in areas of improv, acting, graphic medicine, visual arts, research, psychotherapy, and community outreach. At a time of strict COVID-19 restriction, including lockdown and shelter-in-place mandates, CHATogether was launched as an interactive, theater-based mental health program disseminated through dedicated social media channels. Members meet biweekly to share project updates and peer supports, as well as gathering and milestone celebrations.

A moderator co-constructs a skit with community participants, in an effort to address a problem in their daily lives. The moderator next engages the audience using “time outs” and “time ins” to “freeze” and “replay” the skit at various points, until a realistic solution to the problem is found [28]. Similar interactive theater models have been used in medical education [29, 33], CHATogether’s interactive theater skit includes three sequential parts:

Twenty individuals (18–30 years old) participated in four different focus groups, each with members with differing levels of seniority and involvement in CHATogether. We summarized participant demographic characteristics in “Appendix”.

We conducted the focus groups in the fall of 2019 and spring of 2020 using synchronous videoconferencing. We obtained institutional review board approval from the Yale Human Investigations Committee (Protocol # 2000028490). At the beginning of each session, participants provided verbal consent for audio recording. We discarded video content and had audio files transcribed by Rev.com (San Francisco, CA and Austin, TX). We de-identified transcripts before analyzing them supported by NVivo 12 software (QSR International, Melbourne, Australia).

The senior author (EC) led four focus group interviews to discuss different aspects of CHATogether and/or COVID-19. Participants in focus group A (“CHATogether as a peer support group during the pandemic”) were asked to describe their relationship with CHATogether, how they first got involved with the group, what (if any) benefits CHATogether had provided (such as a sense of purpose, stability, flexibility, a safe space, and community), thoughts on CHATogether’s ability to provide opportunities for artistic outlets, and how COVID-19 had affected them. Focus group A was mainly conducted with the founding members, as their involvement in the program allowed a deeper reflection on CHATogether’s mission, foundation, implementation, and vision. CHATogether was founded during the peak of the COVID-19 pandemic when anti-Asian hate became a significant concern in the community. Initial codes suggested several significant stressors within the family and community, and thus we expanded those themes through the subsequent focus groups. Participants in focus groups B and C, “Effect of COVID-19 on family harmony” [14], consisted of a mix of founding members, newly joined members, and non-members. We asked them to describe their family dynamics before and during the pandemic, any cultural or communication gaps that occurred and/or were heightened during that time, and whether any coping skills were learned as a result of involvement with CHATogether. In case of non-members, an introduction of CHATogether work (such as skit videos and webinars) was shown before the interview. Focus group D was an expansion of preliminary themes from previous interviews that many participants identified. These themes included racism as a significant stressor during the pandemic. Participants in focus group D (“Racism and stress on AAPI individuals”) were asked to describe their thoughts and experiences with anti-AAPI discrimination before and during COVID-19, the psychological impact of racism at the individual, family and community levels, different ways to communicate about racism and cultural identity with family, and any other support networks.

For this qualitative project we used thematic analysis in an inductive fashion [36], which was rooted in an interpretative phenomenological approach aimed at examining the participants’ personal and subjective experiences [37‐39]. Three authors first worked independently to identify and organize codes. Those raw codes were then shared with the other investigators to triangulate a final codebook. We created a list of overarching domains and underlying themes based on the codebook, each supported by several verbatim quotes. We analyzed data iteratively until reaching theoretical sufficiency [40]. We adhered to accepted guidelines for qualitative research [41, 42].

Many participants identified family conflict as a general stressor. Communication barriers became significant sources of child-parent conflict. Many participants perceived their families as lacking emotional engagement to each other’s feelings and suffering. One participant stated how dismissed they felt, given that:

“Whenever I talk to them about anything that I'm concerned about with my feelings, or if I feel like I don't fit in socially, or challenges that I've had with me and my racial identity, social identity, they just say, ‘Oh, okay.’

Several participants attempted to embrace family harmony by avoiding conflictual communications. One participant stated how:

When I was younger, I thought they [my parents] understood. Now, I realize that they just don't, and they don't want to tell me why. I realize that I do that with them as well.

Moreover, many participants live in a household with older generation or first-generation immigrant family members. They identified that language and generational barriers also forestalled complicated conversations, as well as more intimate conversations requiring emotional support.

Whenever they try to talk to me in Chinese and there's words I don't understand, I find it very difficult to be patient to try to use other words to explain to them.

Several participants noted their families’ experiences with cross-cultural challenges across generations. Differences in cultural expectations in a child-parent relationship at times hindered the development of healthy family dynamics among immigrant families. While acknowledging the broad diversity of Asian culture, Confucianism is a common historical influence on the many Chinese descendants living in countries across most of East Asia and, to a lesser extent, of Southeast Asia, a fact relevant to most study participants. Confucianism focuses on moral values such as filial piety, children’s primary duty of respect, obedience, caring for parents and elderly members of the family [43]. Such concepts highlight some unique aspects of Asian heritage, including hierarchical relationships, a more authoritarian parenting style, and emotionality [32]. Parents may perceive speaking about emotions or personal problems as disrupting family harmony, whereas for children the opposite may be the case. As a result, conflicts among family members were commonly ignored rather than discussed openly. Such discrepancy of cultural values, expectations, and family functioning commonly prevented children from communicating about their struggles when they needed family support the most.

Some participants reported cultural and generational tensions in the understanding of family harmony between parents who grew up in the mainland and their American-raised children: “If a child decides to break the values that a family has set, that is seen as betrayal.” Straying from the family’s traditional values and predefined pathways were seen as a disharmonious affront to their parents’ viewpoint.

Many participants expressed confusion or avoidance of their cultural identity as both Asians and Americans. They noted that first-generation immigrant parents tended to prioritize assimilation and success in the US and impose high expectations on their children, over the role of emotional validation, overall wellbeing, and racial identity development. Some felt pressured to assimilate into the dominant white culture, a process that made them feel ashamed of their Asian heritage:

When I was younger, I claimed myself as an American. I would get into arguments with my grandmother where she would say I was Chinese, but I opposed that: ‘No, I'm American.’ I would refuse to use chopsticks because I would say only Chinese people use chopsticks. I'm not Chinese so I can't use them (Table 2).

Table 2

Domain I: stressors experienced by participants

Theme	Subtheme	Representative quote(s)
1. Individual stressors	Family conflict	My family harmony? It feels like we pretend not to have a conflict. No one wants to talk. And avoidance, I presume is doing something good for each other. But we have zero communication, in our so-called “harmony.” There is a sense of ownership that my parents had. “I feel like I'm not a human to them. I feel like I'm an object that they control.” I feel like they see me as something they have ownership of and that doesn't have their own conscience.”
	Cultural identity	When I was younger, I would only say that I was American. To be frank, I didn't want to tell people that I was Chinese. You want to fit in, you don't understand why you're different, and you hate that you are different, but I think part of growing up is accepting the things that make you different and embracing them and finding places that are special
	COVID-19 pandemic	Being in the same physical space day after day causes extreme conflicts COVID, sort of united the family: feeling the same, sharing similar feeling, and feeling safe to express them
2. Collective stressors	Mental health stigma	The shame and guilt of talking about mental health as a weakness. It's like, “Oh yeah, I have this pain, I have this sneezing. I have the fever. It is like more objective neutral thing to talk. But mental health, that's so stigmatized to talk about that.”
	Uncertainty from COVID	In COVID-19, we are like floating on the ocean, we have no idea what is coming next. And things keep piling up Things that I see on the news make me feel that I am uncertain about what my future holds: “Where should I move to build my family and find the place where I belong?”
	Polarized Society and family conflicts	Issues around injustice, inequality, and racism have been ongoing. [My family and I] are not necessarily in active conflicts, just disagreements, not seeing eye to eye on these issues, and not really talking about them either, because of not much understanding on either side. Instead of bringing up frustration, which ends up being something that I'm okay with, but I think my mom is not. For example. She would rather spend our time to share things that pertain to our individual lives rather than to the broader society

The pandemic exposed and amplified individual problems and pre-existing conflicts: “Being in the same physical space day after day causes extreme conflict.” Identified stressors included financial difficulties and job loss or insecurity. The instability and anxiety from financial difficulties exacerbated family problems, especially during the protracted quarantine and periods of mandated lockdown. Unemployment with no colleagues to interact with and with no physical workplace exacerbated tensions between family members:

I also felt very grateful that I had a job and I have a roof over my head, but also a lot of sadness and anxiety of like, “Oh, what will happen to me? Will I also be in a similar situation [as the less fortunate]?

Despite a lack of personal space, which led to heightened conflicts, family members were also forced to be more emotionally communicative and united in facing the unprecedented challenges imposed by the pandemic. One participant explained how:

COVID-19 has brought us closer together and being a little bit more emotionally expressive. Not quite 100% there yet, but I think that forced my dad to be a little bit more open.

Participants largely agreed that mental health in Asian families and communities is a stigmatized subject of conversation. Perception of weakness and lack of supportive spaces associated with shame and guilt of having mental health struggles were discussed as significant stressors. As one participant explained, “Specifically in Asian immigrant communities, mental health is viewed in a very negative way, like ‘What's wrong with you?’” Another participant highlighted the discrepancy in openness compared to their peers at school:

I know for a lot of my friends at school, they're able to talk with their parents about what's wrong and how their parents can help. But in Asian communities, talking about mental health is so taboo.

The COVID-19 pandemic led to a massive disruption in longstanding social structures and routines, forcing people to adjust to new environments while simultaneously disbanding others. As one participant explained:

It was such an uncertain time and there was so little that any individual could do, and so much of what we were all being asked to do was to not do anything.

Many participants identified the division and polarization of society, especially reflected in the increase of racial violence against Blacks and Asians, as another aspect of pandemic uncertainty. They expressed fear, hopelessness, helplessness, and a lack of control. One participant stated, “Having COVID-19 occur with Black Lives Matter and social movements where we're once again in a situation that’s very uncertain, the feeling of wanting to help and wanting to be able to do something but not being able to do much.” Another participant shared her traumatic experience on “being called Coronavirus” by a fellow high school student. Yet another participant commented how “the murders in Atlanta were a kind of climactic moment where it triggered all these feelings from years, decades of built-up micro-aggressions or macro-aggressions. It was certainly an awakening”. A few other participants experienced concerns over their personal and family safety:

Am I going to get jumped by someone for being who I am?

Contributing to their feelings of anxiety and hopelessness, several participants identified how societal uncertainty further intensified their family conflicts and emotional tension. They expressed how family members could not provide support or agreement due to divergent political opinions, cultural values, and language barriers:

When talking about social issues, I have not even tried to bring that conversation up to my parents, because of what they've been going through, and because we're so far away. Also, my lack of ability to speak in their language, even though they are proficient in English. They don't encounter terms like ‘model minority’, or ‘civic engagement’.

In face of anti-Asian racism, participants expressed frustration to parents’ indifference of the discussion, “My mom came here for graduate school, and on paper being successful, it’s frustrating to me that anti-Asian racism is not a big of a deal to her.”

The personal benefits of unleashing and making use of creativity and talent was identified among several participants. CHATogether’s projects provided a platform to share thoughts and feelings through art and less traditional means of communication. One participant stated how:

We translate languages into action, into word, into video, into something that can be understood by everyone. The conversation becomes more tolerable and acceptable to talk and to express.

Creative expressions enabled stigmatized topics like mental health and racial trauma to become more approachable, intimate, and descriptive. It also provided a healthy coping outlet for developers who were involved in the different component projects. As described by one of them:

It carries incredible value to see effective communication demonstrated as an educational model. It also allows us to interpret our own experiences in possible alternative ways in which they could occur.

Participation in CHATogether created a sense of action and control, which was especially important during the pandemic and its lingering—and ongoing—aftermath. As one participant shared:

Purpose is the main fuel and anchor for productivity.

Many members identified altruism and helping others going through similar struggles as the purpose of this group. Sense of purpose also strengthened participants’ sense of control. Making something out of challenging times taught adaptability, as described by one participant: “It also speaks to the flexibility, the cognitive flexibility, that helps us think outside the box…it can be the silver lining of adversity.” It was also helpful in overcoming the struggles in the ongoing pandemic:

As opposed to the powerlessness and sense of guilt, we expanded CHATogether during COVID. I feel like it gives me the power to put my mind into action as we contribute to something or someone out there (Table 3).

Table 3

Domain II: CHATogether’s benefits to participants

Theme	Subtheme	Representative quote(s)
1. Individual benefits	Expression of creativity and talent	The power of the arts can really transcend a level of conversation where you can connect with others and really be able to convey a sense of unity, compassion, care, and empathy with others. I think it can do so in a way that other modes of communication cannot
	Productivity and sense of purpose	Here we take the experiences that we have and channel them into a certain type of product. Because we do that, which requires a certain level of empathy, mentalization, of thinking around yourself—outside of your own box—for the purposes of helping others. That, combined with the fact that so much of the work we do and the way we do our work has changed with the pandemic, and that the topics we're discussing are related to the pandemic. It's been a really nice way for me to bring reason to what's going on We are not only are united as a group, but also bring it forward to other people, to the community, in a way that we hope can be helpful
	Connection	It's a sense of loss and confusion. You don't know what the next moment is going to be; society adding on more and more, but we have something important to hang on to: we have this group, the cohesiveness of being together
	Mentorship	The different career paths of my senior colleagues affirm that no matter what I end up doing, it is always possible to make time and invest effort for issues we care about. As a young person beginning to venture into the real world, CHATogether is the perfect place for me to hone instrumental life skills like collaboration and speaking up, and it makes me excited for the kind of research and initiatives I hope to pursue
2. Collective benefits	Consistency	“The structure, and the consistency, and the meaning for us to work in CHATogether gives us a lot of hope against what the COVID-19 pandemic is putting upon us.”
	Sense-making through storytelling	“I know so many other people's stories that have shared themes of some of the things that CHATogether hopes to address— or at least even begin to explore, to bring light to some discussions. These conversations allow for new narratives to be created. Healthy narratives that can show that it's possible when things within a family or within an individual feel impossible, when one feels there's no model or no way out. in these situations.”
	AAPI support group	“I think that CHATogether has a very powerful potential to connect AAPI for those who are maybe at different levels of accepting or appreciating their [Asian] heritage. Share their experiences and understand that a lot of things that you feel like and are maybe you're going through on your own are actually quite common, and maybe that brings on a belief and connection to others.”
	Provision of a safe space for stigmatized conversations	The skit allows a medium so that we don't need to talk directly at each other but instead we're talking within the skit or through other artistic outlets. It is a more tolerable, less taboo medium, in which we can discuss things in a culturally sensitive way. I hope that we can expand to many other minorities, not just AAPI. CHATogether has so much potential to bring people together, to let them feel comfortable to talk about mental health.”

The importance of interpersonal connection and teamwork was shared by all participants. These relationships were particularly critical to people who experienced limited or highly suppressed social interactions in their family or community: “Sharing the experience of struggle with somebody who gets it and then laugh about it at the same time is a form of healing.”

CHATogether members include a wide range of passionate individuals in various career developmental stages and disciplines, including the arts, theater, medicine, public health, science, and architecture. Connection through collaborative projects create additional mentorship components in the program. Senior CHATogether members represent a symbol of “cultural pride” for junior members to model after. One participant stated how:

Working with AAPI senior colleagues has shown me what is possible in terms of career paths, possible academic areas to which I can contribute, and AAPI collaboration. The CHATogether environment exemplifies AAPI people supporting one another in the confusing political environment that erases and sometimes destroys our identities.

CHATogether successfully adapted to digital programming during the pandemic, which provided structure and consistency. Members met bi-weekly, led by the program director. Each meeting started with bond-building conversations about timely concerns in the AAPI community, followed by a list of project items on the agenda to discuss progress and future directions. CHATogether also held team workgroups, social events, and holiday and programmatic milestone celebrations between regular meetings: “We are coming from different places in the U.S. and other places. Since the difficult time of pandemic, we are still consistently meeting regularly. We are happy to be doing this meaningful work. We grow so much, are proud of each other, and stay emotionally healthy together.”

Another community benefit that was identified was the power of storytelling in making sense of overwhelming, confusing, strange, and unprecedented times. Sharing personal stories creates a strong bond within the community, especially when sharing relatable experiences:

Being able to hear from other Asian Americans is healing. These are issues that I’ve thought about and struggled with; how you communicate. I wish we were able to talk about them more.

Storytelling allows both tellers and listeners to process the experience from various perspectives through empathy, exchange, and reflection. Sharing stories seemed to allow for sharing a considerable amount of emotional burden. One participant stated how, “Each story is a personal narrative. In the process of sharing it, we're trying to put our mind and feelings into words and actions.”

CHATogether successfully created a collaborative environment that serves as a support group for its members through creative and productive outlets. The cooperative model of CHATogether allows collaboration with people who share similar interests, goals, and vision, all of which create a sense of belonging and empowerment. Some participants identified how members support each other’s projects and progress as healing and therapeutic:

I think that all of our healing is tied together in some ways. I think that the integration, healing, growth that I've experienced, I also longed for that and other people, and other people's growth and perspectives and healing also influences and contributes to my growth.

CHATogether provides a place to openly express ideas and thoughts, as well as a platform to try various methods of artistic expression through which to communicate their thoughts and experiences. One participant described the sense of artistic community that CHATogether created:

The fact that CHATogether is the forum where people connect and talk about these [stigmatized] issues is what I see the most value in. There are not many safe spaces in which you can talk about your feelings, how you feel your racial identity and background really form the way that you experience life is important.