Introduction

Nikkei elders (individuals of Japanese ancestry) often face challenges in accessing quality services because of language and cultural barriers, a mistrust of social service and political systems, and financial reasons (Doi 2003). Psychological barriers, in particular, can adversely affect service utilization, quality, and outcomes of services for Nikkei elders (Machizawa and Lau 2007). For example, Nikkei elders are often reluctant to seek or accept help from formal support systems, even when those services are offered by service agencies in their community (Choi 2001). Oftentimes, they seek services only when they are in crisis situations that require assistance of the police or hospital emergency services (Doi 2003). Elder mistreatment is also seldom reported because of the cultural norm of silent suffering and quiet endurance (Tomita 1998). Developing effective and culturally sensitive interventions for Nikkei elders therefore is imperative. However, few empirical studies have examined the psychological needs and characteristics of this population. Prior research primarily considers Asian American elders as one homogenous category and often does not examine variations within Asian ethnic communities (e.g., Elo 1996; Kim and McKenry 1998; Moon et al. 1998; Tanjasiri et al. 1995). The purpose of this qualitative, interview-based study is to explore the variations in psychological needs among Nikkei elders that may shape their social service and health treatment seeking behaviors. Understanding psychological needs—that is, the emotional conditions necessary to fulfill a sense of wellbeing—will provide a greater insight to practitioners and policymakers in developing more appropriate and effective strategies to serve the Nikkei elderly population.

Heterogeneity within Nikkei elders

Asian Americans are one of the fastest growing racial/ethnic groups in the United States. (Shibusawa and Mui 2001). According to the U.S. Census 2000, the Nikkei population has grown by 36% from 1990 to 2000 (U.S. Census Bureau 2000), primarily due to self-selection of race/ethnicity in the 2000 census and high prevalence of inter-racial marriages. About 21% of the Nikkei population is individuals aged 55 or older. While studying the psychological needs of Nikkei elders, it is important to consider the diversity of this ethnic group. Each Nikkei generational cohort is given a distinct Japanese name that is intended to reflect different cultural values, behaviors, and attitudes. Differences between generations have been attributed to factors related to historical events, acculturation, and assimilation. The first generation of Japanese Americans is called Issei. The first Issei males immigrated to Hawaii or the west coast of the U.S. mainland as contracted laborers followed by their Japanese wives during the late 19th and early 20th century (Hikoyeda et al. 2006). Their ideology was to work hard so that their children could get education and become successful in American society (Hikoyeda et al. 2006). Those who have immigrated to the U.S. relatively recently are called Shin Issei. Most of them have immigrated for business reasons or have been sponsored by their children who live in the U.S. There are also “war brides” of American military personnel who have immigrated to the U.S. after World War II. While most of the Issei have passed away, Shin Issei and war brides constitute small groups of Nikkei elders today.

The second generation, called Nisei, account for the majority of Nikkei elders in the U.S. Most of the Nisei experienced internment camp during World War II (Shibusawa et al. 2001). Many lost their properties and belongings and were separated from family members when they were placed in different camps. Some Nisei individuals, called Kibei (which literary means “return to America”), were sent by their parents to Japan temporary for education at a young age. As a result, they usually speak fluent Japanese and have more exposure to Japanese culture than Nisei who have received education only in the U.S.

The third generation, called Sansei, largely is acculturated into the American society and does not speak Japanese. Even though most Sansei have not experienced the internment camp, they have suffered from discrimination, economic loss and recovery, and reestablishment of Nikkei identity and community because of the anti-Japanese sentiment after wartime (Hikoyeda et al. 2006). While most Sansei have not yet reached old age, they are often the primary informal caregivers for their elderly Nisei parents.

Nikkei community in the greater Chicago area

According to the U. S. Census 2000, the number of Nikkei population in Cook County, where the City of Chicago and its surrounding suburbs are located, is 2,926. The majority of Nisei was born outside of Illinois and left their internment camps to settle in Cook County during World War II. Although the majority (60%) of the Nikkei population lives in the suburbs of Chicago, Nikkei elders living within the City of Chicago tend to be older than elders living in the suburbs. This suggests that Nikkei elders, particularly the oldest of the old, tend to be city dwellers, while the younger elders tend to reside in Chicago suburbs (Doi 2003). Presently, there is only one ethnic-specific, community-based organization, the Japanese American Service Committee, that targets social services to Nikkei elders in the greater Chicago metropolitan area, and one medical clinic located in a suburb area of Chicago, the Nihon Clinic, that specifically outreaches to the Nikkei community. The increasing geographic dispersion among younger elders to suburban neighborhoods poses challenges for providers to serve Nikkei elders effectively (Doi 2003).

The life course perspective

To understand how psychological needs vary among Nikkei elders in the historical and socio-cultural contexts, a life course perspective provides an informative framework. Commonly applied in the field of gerontology, the life course perspective captures intersections of diverse life experiences that contribute to individual differences and similarities in aging and development (Hatch 2000). Individuals’ life courses are shaped by historical and cultural forces, life role transitions, and the timing of these experiences. Additionally, lessons passed on through generations along with shared relationships collectively influence individuals’ behaviors, worldviews, and social development (Elder 1998). For instance, experience with internment camp, relocation, and discrimination during and after World War II affected many Issei and Nisei by engendering mistrust in them toward political and social service systems (Shibusawa et al. 2001). While the majority of current Nikkei elders are born in the U.S., they often embrace cultural and family values originated in Japan during the Meiji period (1868–1912) when Issei left their homeland (Hikoyeda et al. 2006). These values are passed on to subsequent generations but tend to have less impact on the younger generations, thus resulting in more acculturated generations over time. Because psychological needs are shaped by individuals’ values, attitudes, and behaviors, they too are likely formed by life experiences in the cultural and historical contexts.

The current study explores the psychological needs of Nikkei elders through in-depth interviews with multiple community members. By applying the life course perspective, we attempt to understand variations in Nikkei elders’ needs based on their unique life, cultural, and historical experiences in the American society. Findings of this study may help us gain better awareness of Nikkei elders’ psychological needs in socio-cultural and historical contexts and how they may impact their treatment seeking behaviors and service preferences.

Subjects and Methods

Participants

Data for this paper were from an original study that examined general health and safety needs of Nikkei elders, aged 60 and over, who either lived alone in the greater Chicago metropolitan area or lived in a surrounding suburban neighborhood regardless of the cohabitating situations (Machizawa and Lau 2007). The original study focused on this population because elders living alone and those living far away from ethnic specific social service organizations might be especially vulnerable to social and cultural isolation, as well as service underutilization. Because details about subject recruitment and characteristics have been described in an earlier publication (Machizawa and Lau 2007), a brief summary of subject recruitment and characteristics is provided here. The inclusion criteria of the current study sample (i.e., elders’ age requirement and living arrangement), therefore, were the same as those in the original study.

We collected data not only from Nikkei elders, but also from their family, friends, and personal caregivers who were at least 18 years of age, as well as professional care providers who served the Nikkei elderly population. This multi-source approach (Billings and Cowley 1995; Murray and Graham 1995; Finifter et al. 2005) allowed us to obtain a comprehensive overview of the psychological needs based on perspectives of those who experience the needs (Nikkei elders) and those who assist them informally (family, friends, or personal caregivers) and formally (professional providers). Nikkei elders discussed their needs, lifestyles, concerns, and life experiences. Family, friends, and personal caregivers spoke about what they knew about the psychological issues concerning Nikkei elders. Generally, family, friends, and personal caregivers provided similar themes in their interviews. Because of small sample size, we examined their responses collectively as a group but presented their quotes according to the individual’s relationship to the Nikkei elder. Professional providers were asked to address the characteristics and needs of Nikkei elders whom they served in their practices.

The number of study participants included 41 Nikkei elders; 11 family members, friends, or personal caregivers; and 8 professional providers. The average age of the elderly participants was 77 and the majority of them were female and Nisei (see Table 1). About 20% of elders had less than $20,000 annual income, whereas about 17% had more than $50,000 per year. Most elders reported social security and stock or investment as their financial sources. Although the majority of elders were not born in Chicago or its surrounding suburbs, they lived there for an average of 52 years.

Table 1 Characteristics of Nikkei Elders (N=41)
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The average age of family members, friends, or personal caregivers of Nikkei elders was 46 and the majority of them were female, Sansei or Yonsei (fourth generation) Japanese Americans. There were two Filipino personal caregivers and one Caucasian friend (see Table 2). The eight participating professional providers included two internal medicine doctors, one optometrist, one dentist, one nurse, two social workers, and one licensed caregiver. By race and ethnicity, six providers were Nikkei, one was Korean, and one was Caucasian. All of the providers, except for one, practiced in Chicago and the years of practice in their profession ranged from 4 to 40. (Data are not provided in table but available upon request)

Table 2 Characteristics of Family/Friends/Personal Caregivers
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Study design

This study employed a qualitative approach based on the grounded theory (Glaser and Strauss 1967; Jeon 2004), a systematic qualitative methodology to generate theory based on empirical data. Demographic surveys were used to collect participants’ demographic information and semi-structured, open-ended interviews were conducted to obtain in-depth information regarding psychological needs of Nikkei elders. We used the qualitative approach because conducting one-on-one, in-person interviews was necessary to establish a strong rapport with these generally hard-to-access study participants and to discuss personal and sensitive topics.

The interview guides were initially developed based on the existing literature on psychological issues and coping styles of Nikkei elders, as well as findings based on the previous Nikkei community assessment (Doi 2003). While we did not explicitly asked questions about psychological needs, we posed trigger questions about elders’ social, cultural, and family activities (e.g., How has your social and family life changed over the last several years? Would you say you see your friends/family often enough or not enough? What cultural activities do you engage in? What do you like about these activities?), as well as psychological status (e.g., How satisfied are you with your life? Whom do you talk to about your feelings? If no one, do you want to talk to someone about your feelings? Are you hopeful about the future? What do you do to stay happy? If you had a magic wand, what would you wish for and why?). Together, these questions provided us information and insight regarding elders’ psychological needs. Additional probe questions were asked of study participants to speak from their own experiences and provide examples when appropriate.

Drafted interview guides were evaluated and finalized by a seven-member advisory panel of community leaders, which collectively included (not mutually exclusive): two registered nurses, four social workers, one home services coordinator, one adult day services coordinator, one hospice care researcher, two family caregivers, and two Nikkei elders. Using a modified Delphi method (Dalkey et al. 1969), the advisors first individually evaluated the face validity of each question based on its understandability, importance, and cultural appropriateness and then together reached a consensus on the final version of the guide during a three-hour meeting. Both English- and Japanese-version of the interview guides were developed using forward-backward translation methods. Then, the interview guides were pilot tested with one Nikkei elder, one family member, and one professional provider.

Interviewing and recruitment

We advertised our study with the purpose of examining the overall health and safety concerns among Nikkei elders living in the Chicago area. Psychological needs were not explicitly stated upfront with the respondent due to cultural sensitivity concerns. Using a convenient sampling technique, we targeted our recruitment of Nikkei elders, as well as their family and friends, by announcing our study through electronic listserv blasting, handing out flyers in health clinics, postal mailing to various membership lists, and advertisements in local newspapers with high readership among Nikkei individuals. We further asked members of a Chicago-based Japanese American social service agency to participate and provide referrals. To target professional service providers who worked with Nikkei elders, letters of inquiry were sent to professional groups that were associated with the local Japanese American service agency.

Interviews were conducted by an experienced, bilingual researcher. Interviews were held at a location based on the respondent’s preference—at a Japanese American service agency, the home of the elder or family, or the workplace of the professional provider. Interviews on average lasted for 1.5 h and were audio-taped with participant’s consent. Among the 41 elder interviews, 6 were conducted in Japanese and 35 in English. All interviews with family, friends, personal caregivers, and professional providers were conducted in English.

Data analysis

Consistent with the grounded theory approach (Glaser and Strauss 1967; Jeon 2004), transcripts were coded and analyzed simultaneously with data collection. Data were managed and organized using Atlas.ti software (Muhr and Friese 2004). Two investigators initially coded the transcripts independently. Major recurrent themes were identified using an iterative process of comparison and evaluation across interviews. Weekly team meetings were also held to discuss coding strategies and to reach consensus on discrepant codes to ensure analytical consistency. Relationships between categories were identified using a combination of inductive and deductive reasoning. Common themes were further organized and structured to identify the core ideas or key psychological needs of Nikkei elders.

Results

Based on the interviews, we identified five categories of psychological needs among Nikkei elders: 1) independence; 2) cultural connection; 3) social connection; 4) feeling useful; and 5) maintaining face and dignity. Although elders of other racial/ethnic groups might exhibit similar needs, Nikkei elders shared specific historical, cultural, and individual factors that uniquely shaped their psychological needs.

Independence

Nikkei elders had a strong need to feel independent and self-reliant by “aging in place” and continuing to live in the community. Several family members and providers reported how devastating it was for many elders to lose physical abilities that were integral for independence. A family member talked about her Nisei mother who was told to give up driving:

The doctor didn’t want her [my elderly mother] to drive anymore and she just went off the deep end. She wouldn’t get out of bed, she wouldn’t eat, she wouldn’t take her medication, and she screamed at me all the time. I think not driving for most elders is a difficult thing because you take away their independence. (Female)

Furthermore, losing independence seemed to be associated with a sense of shame among Nikkei elders. One family member reported that her elder mother was reluctant to hire a housekeeper because “she doesn’t want anyone to see that she can’t do it anymore.” While Nisei elders expressed need for maintaining independent living, they tended to be reluctant to hire homemaking service, even if they had adequate financial resources or if their children volunteered to pay for these services. There seemed to be feelings of guilt among Nisei elders with using money for homemaking service, which might be partially attributed to their experience with historical trauma, such as internment camp and poverty experience during and after World War II. One provider explained, “Nisei people value frugality. For them paying for homemaking service is luxury,” because they had to live with limited resources. One Nisei elder said:

I don’t want to spend the money to hire someone, and by the same token, I don’t like a dirty house either, so I just manage by myself even though I have a harder time getting on my knees and wiping around the bathroom floor. (Female)

Many Nikkei elders reported that they did not want to depend on their children for assistance if their health declined due to their fear being a burden to the children. One Nisei elder stated:

It’s not that my children wouldn’t help me, but I would rather not be a burden if they’re busy with their own lives and have family to take care of…I’m not going to live my life assuming that that’s how I’m going to be cared for. (Male)

Despite Nikkei elders’ reluctance to ask their children for help, several family members reported that Nikkei elders still expected their children to provide support and care. Family members commented that this expectation might be related to Oyakoko, a Confucian concept of filial piety entailing familial obligation to be good to and care for parents. There were communication gaps between generations because elders were often reluctant to ask for help or express their needs to their children, even if they expected support. Nevertheless, the elders tended to have unspoken expectations that family members should know what they were feeling and thinking without being told. Nikkei elders’ reluctance to explicitly ask for help might have caused frustration for elders and their children. A family member expressed her frustration regarding the difficulty in helping and pleasing her Nisei elderly mother because she seldom verbalized what she wanted.

She always says, ‘I’m okay, everything’s okay. I don’t need anything. I don’t need anyone.’ And then if you bring things, she’d say, ‘Thank you, but I don’t really need all this food.’ But when I backed off, she was upset and said, ‘I have nothing in the refrigerator!’ (Female)

Nikkei elders’ strong need for independence seemed to be less motivated by individualistic needs such as need for personal freedom, but more reflective of cultural values such as fear of being a burden to their children and enryo (hesitance to ask for help or accept something to avoid appearing demanding). For example, one Shin Issei elder said that she moved out from her son’s house because she was no longer able to cook:

I lived with my son and his family. At that time I cooked for them. But it got more and more difficult for me to cut vegetables and cook, and it made me feel uneasy and uncomfortable to live with them. So I moved out. I cannot live with them if I cannot contribute anything. I felt katamigasemai (feel ashamed, feel small). (Female)

In addition, Nikkei elders’ hesitance to ask for help or accept help from their children might be partially due to fear of losing their authority as a parent. A family member reported that that Nikkei elders wanted their children to provide them assistance not because they were frail but out of respect and filial piety.

Cultural connection

Many respondents said that Nikkei elders needed to feel connected to their Japanese heritage. It appeared that their needs for cultural connection and resources varied by life experience, acculturation level, English proficiency, and generation. For example, elders of Kibei, war brides, and Shin Issei showed a stronger preference for Japanese or Asian foods and cultural resources, such as Japanese television programs and newspapers. A family member made the following observation about her Kibei mother:

Being Japanese is something she embraces as hers. She cooks mostly Japanese food. Everything she maintains pretty much is Japanese. Even though she might not be fluent in Japanese, the language that she is most comfortable with is Japanese. Whether it’s friends, the food, the activities, its all Japanese or Japanese American. (Female)

While cultural connection seemed to be a critical part of maintaining quality of life for Nikkei elders, they often reported difficulty in accessing ethnic-specific and Japanese cultural resources. One Kibei elder living in an assisted living reported that she felt very lonely because there was no other Nikkei elder at her facility and meals served in the facility were all American food. Elder immigrants including war brides and Shin Issei expressed strong desire to visit or return to Japan and were nostalgic about Japan. However, returning to their homeland was difficult for some because of economic, family, or health reasons.

Several Nisei elders reported that they reverted back to prioritizing their own cultural identity in later years of their lives. They often engaged in cultural activities to learn about and feel connected with their culture of origin; activities included ikebana (flower arrangement), buyou (Japanese dance), origami, taiko (drum), and sadou (tea ceremony). One Nisei elder said:

I didn’t want to be Japanese when I was younger. Now, I really enjoy the Nikkei community because of its attitudes and values. It’s just very comforting to me to be with other Nisei people. I admire that generation so much. They went through a lot to give me the opportunity to be me and to also have a strong identity to fall back on because of what they did. (Female)

This rediscovery and ethnic pride appeared to be especially common among Nisei elders because they had to define their ethnic identity in changing socio-cultural climates and forces throughout their lives, including pressures to assimilate and identify with American culture during the war era and to move toward cultural pluralism and integration in the post war era. Another Nisei elder said:

The amazing thing to me in this day and age is despite my exposure to as many cultures, I still have my roots in my Japanese upbringing. When you’re younger, you don’t really care. But when you get older, you begin to understand the importance and the value of Japanese qualities. (Male)

Social networks

Nikkei elders reported strong need to maintain interactions with their social networks throughout their lives. They preferred to maintain close ties with their children, grandchildren, and extended families. For some elders, the definition of family expanded to include friends, neighbors, and personal caregivers because these elders lacked blood relatives for emotional, social or financial support. For example, one war bride elder who had no family in the U.S. described her Filipino professional caregiver as her closest family. Even though many elders expressed desire to spend more time with their family members, they often did not try to contact them out of fear of being a burden. One Nisei elder explained, “I want to go out with my family but they have their own plans. So I go by myself. I can do most of things by myself.”

Beside connections with family members, many Nikkei elders expressed need for friendships. They often found social networks through spiritual organizations such as churches and Buddhist temples. Many elders were part of formal or informal social groups, such as a walking group, singles’ group, and lunch club. They also found social networks by participating in classes offered at local community organizations such as Ukulele and line dancing classes. Nikkei elders’ friendship appeared to be strongly influenced by their cultural values and life experiences. For example, due to cultural value of orei (returning favors) they demonstrated effort to keep their interpersonal relationships mutual and interdependent. A family member of made the following observation about her Nisei grandmother:

I think what makes it possible [to live happy] is that she has a lot of friends, and they’re willing to drive from the suburbs to visit her or to take her places. It’s because she’s a very generous person. Part of Japanese culture is that you don’t just keep accepting favors. My grandmother is always aware of the things that people do for her, and she makes sure that she does something in return, maybe cook for them or knit a scarf. (Female)

Our interviews indicated that Shin Issei and war brides appeared to have a stronger tendency to interact with fellow Nikkei elders than individuals from other racial or cultural backgrounds. Many of them felt more comfortable communicating in Japanese than in English. Many Nisei also valued their interactions with other Nisei individuals in their community. It appeared that experiencing the same hardships might have created a strong collective identity among Nisei elders. Some of them also expressed desire to share their life stories and war experiences with their children and grandchildren. One Nisei elder stated, “It gives me a great deal of satisfaction to talk about my internment experiences because I feel that it is the story that has to be told.”

Different life events, such as the loss of a spouse or friend and a change in living situation, along with the timing of these events appeared to impact Nikkei elders’ social networks. For example, those who lost their spouse during their middle age tended to have developed a new supportive social network. One Nisei elder said:

When I lost my husband 20 years ago I didn’t have many good, close friends because I used to be very quiet. I had to start getting out and meet more people and join the women’s fellowship. They knew what I was going through. I really changed after he passed away. (Female)

On the other hand, Nikkei elders who lost their spouse or close friends in their later years appeared to have more difficulty building new social networks. One Nisei elder who lost her spouse a few years ago said, “My husband was the only one in Chicago who knew about me almost 100%. It’s like saying there is no longer one person who knew as much about me as he did.” A family member expressed concern about her elderly father who became socially isolated after losing his wife, saying, “He doesn’t take any initiative to meet new people.” Older elders reported difficulty maintaining active social life because of health problems. One Nisei elder stated:

My social life is kept down to almost nothing, because so many of my friends are gone. My one last friend whom I met here 16 years ago is bedridden to 24 h care. If I have time, I drop in and say hello, but that’s about it. (Female)

Feeling useful

Many Nikkei elders expressed the need to be useful to others and contribute to the community. Some tried to meet this need by volunteering in charitable or spiritual organizations or taking leadership roles in community events. Helping others and being involved might be their strategy to maintain quality of life. One Nisei elder reported:

Because I don’t celebrate the holidays, I go to the local service organization and help feed people who are homeless. That makes me feel thankful for what I have. I think doing things for others is important to bring you out of the aloneness. (Female)

Similarly, a Shin Issei elder made the following statement:

After I quit my job, I thought about what I would like to do. Then I realized that I like cooking for others. It is quite satisfying when they said, “It was really good.” I always want to do something for others, as long as I live. (Female)

Nikkei elders’ need to feel useful to others might be related to their cultural value in which devotion to the group’s well-being was encouraged and focusing on one’s own need was considered selfish.

Nikkei elders often focused on the success and well-being of their family and they tried to help their family members. Those elders who had children or grandchildren living in close proximity tended to support them by providing financial assistance, doing chores, or babysitting their children. In extreme cases, Nikkei elders sacrificed their own health and neglected their own needs. One provider spoke about her elderly Nisei clients who gave away their money to their children, even when they themselves did not have adequate financial resources.

Maintaining pride and dignity

Family members of Nikkei elders and professional providers reported that it was extremely important for Nikkei elders to maintain their pride by not showing weakness or talking about their problems. One professional provider said that Nisei were both “good and bad” patients: While they might be “loyal, punctual, and compliant,” many were “unwilling to express their problems and needs.” The unwillingness to talk about health problems might be how Nisei often coped with their hardships, perhaps something that they learned during their experience in internment camp. A family member of Nisei parents said:

Both of my parents had, not only been in the camps, but lost their parents when they were young. When they were in the camps, they tried to make due and not complain. They’ve never talked at all about it with us. I think that’s what they’ve learned—to keep everything in and pretend it’s all okay. (Female)

Several providers reported that Nisei elders were unwilling to talk about their feelings or psychological problems out of fear of “losing their face.” One professional provider stated, “They’ll tell you horrible facts with no emotional description. No recall of feeling.” Another provider said, “Nisei patents are less comfortable talking about depression and mood issues.”

Nikkei elders’ need to maintain their dignity also affected their service-seeking behaviors. While many Nikkei elders had a number of acute and chronic medical problems that required medical attention and management, some professional providers reported that Nikkei elders, especially Niesei, did not seek treatment until their symptoms became serious. For example, one social worker stated:

The older Nisei in their late 80’s and 90’s have the same attitudes from their parents. If you hurt a little bit, you ’d say come on. You didn’t go to the doctor unless it was serious. (Female)

One dentist reported that her Nisei patients did not complain about their pain or problems because they valued gaman—to endure pain and discomfort with perseverance and dignity:

When they come here [dentist’s office] saying, “I have mild pain,” they often actually have sever pain to the degree that they were unable to sleep or eat well. They do not talk about their toothache, so I imagine they also do not talk about other pains in their life. (Female)

Similarly, a Nisei elder emphasized the importance of gaman saying “no pain no gain.” Nisei individuals believed that enduring pain with gaman would make one a better and stronger person.

Discussion

This qualitative assessment explores the psychological needs of Nikkei elders in the Chicago and its suburban areas. We have identified needs in five areas including independence, cultural connection, social connection, feeling useful, and maintaining pride and dignity. From a life course perspective, we have found that Nikkei elders have different psychological needs based on their acculturation, historical, and life experiences. Based on these findings we suggest the following strategies that may help effectively support Nikkei elders and appropriately meet their health and service needs.

It is important for professionals and caregivers who work with this population to recognize that Nikkei elders need a sense of independence but this need often comes from enryo and fear of being a burden to others. Therefore, not asking for or not accepting help does not mean that they do not want or do not benefit from the assistance. Providers should assist Nikkei elders in a way that enables them to maintain their pride and dignity by treating them with deference and respecting their preferred lifestyle. One potential strategy to encourage their use of services is to explain how their own participation may encourage other Nikkei elders to join. For example, to persuade a Nikkei elder to come to an adult day program, it may be effective to say, “Since you are so good at craft, it would be helpful if you can participate in the program and show that to other elders.”

Given their reluctance to seek help, Nikkei elders may not use beneficial or necessary services despite their availability. Social service agencies should find innovative ways to recruit Nikkei elders, especially those who are culturally, socially, or geographically isolated. These agencies should collaborate with local spiritual or community organizations which Nikkei elders frequently attend (e.g., Buddhist temples, cultural centers) because they tend to trust information and referrals from individuals in their community. Because Nikkei elders are geographically dispersed in Chicago suburbs and some do not drive or have access to public transportation, adequate transportation services also may be important to reduce barriers to service utilization.

Professional providers can better serve Nikkei elders by being aware of the group’s heterogeneity. Nikkei elders appear to differ significantly depending on their life experiences, acculturation level, generation, gender, socioeconomic status, and the presence of family members in proximity. These factors could influence their psychological needs and coping strategies that underlie their treatment seeking behaviors and preferences. In addition, even among the Nisei population, Kibei and non-Kibei could be significantly different in regards to their cultural values and degree of acculturation/assimilation. It is important for professionals to understand each elder’s unique historical, cultural, and individual experiences to provide culturally sensitive service that is tailored to the individual’s need. To increase providers’ competency serving Nikkei elders, skill-based cultural competence training focusing on this ethnic group may be necessary.

Building a trusting relationship is also an important component to effective service delivery for Nikkei elders. As mentioned in the study, Nikkei elders initially tend to be distrustful of professionals, but once the rapport is established they usually become loyal and compliant. It is important to keep in mind that they tend to minimize their ailments because of the gaman mentality. Furthermore, even when they are uncomfortable with the treatment or the professional service providers, they may not verbally express their complaints or disagreements. Professional providers should pay attention to Nikkei elders’ nonverbal behaviors such as tone of voice, facial expressions, eye contact, and gestures. Providers also may need to communicate with elders’ social networks including family members and personal caregivers to fully assess elders’ psychological needs and health concerns. In addition, because of Nikkei elders’ strong ties with their family, it may be effective to involve family members in the treatment process if the elder gives permission to do so. Elders and their family may benefit from information regarding available ethnic-specific services and resources in the community (e.g., professionals who can speak Japanese).

Because many family members of Nikkei elders are concerned about psychological problems such as depression and dementia, they are likely to benefit from psychoeducational programs regarding these illnesses and associated treatments. Groups facilitated by professionals for “at-risk” elders—such as those socially isolated, those with caregiving responsibilities for other family members, or those with recent lost of the loved ones—are potential interventions for prevention and treatment of depression and burnout. Given the stigma associated with psychological services in Nikkei culture, the names for these groups should be creative and euphemistic (e.g., “Genki (lively) Group” instead of “Stress Management Group”). In addition, because Nikkei elders are often reluctant to talk about their feelings, it may be effective to use nontraditional approaches such as activity-based interventions (e.g., dance, craft, or art) or mindfulness-based techniques (McBee 2008) with meditation, gentle yoga, massage, and aromatherapy.

More interventions are needed to meet Nikkei elders’ strong need for social and cultural connections and helping others. Potential interventions include intergenerational programs for Nikkei families that provide opportunities for Nikkei elders to connect with younger generations by sharing their life stories, mentoring them, or engaging in cultural activities together. Assistance with finding volunteering or part-time employment opportunities that match the elder’s needs and interests also may help Nikkei elders to feel useful and stay socially active.

One of the limitations of this study is that all the participants are from Chicago or its suburban neighborhoods. According to the life course perspective, individuals’ geographic location impact their life events and psychosocial development by shaping opportunities and available resources (Elder 1998). Therefore, Nikkei elders in other regions, such as rural areas where Nikkei population is very small or Hawaii and west coast where Nikkei communities are well established, may have different psychological needs. Furthermore, the majority of the sample in this study is Nisei, the generation that experienced the internment camp; however, ten years from now the majority of Nikkei elders will be Sansei. Because Sansei may have different life and historical experiences from Nisei, their psychological needs and cultural values may be different from those of Nisei. Future research on the Sansei will be needed to help social service organizations to prepare and develop programs for this soon-to-be elder Nikkei population.

To develop and deliver culturally competent interventions for Nikkei elders, it is important to understand their unique psychological needs, as well as their cultural, historical, and life experiences. Because Nikkei elders tend to be reluctant in seeking care even if they have physical or psychological problems, they will likely underutilize necessary health and social services. Therefore, it is critical to reach out to these generally hard-to-access populations by implementing innovative and culturally sensitive approaches at the community level.