Recommendations for the Treatment of Asian-American/Pacific Islander Populations

Psychological Treatment of Ethnic Minority Populations produced by the Council of National Psychological Associations for the Advancement of Ethnic Minority Issues

By Gayle Y. Iwamasa, PhD
Asian American Psychological Association

Introduction

According to the 2000 U.S. Census, "single race" Asian-Americans and Pacific Islanders comprised 4.2 percent of the U.S. population. Of the individuals who reported being multiracial, almost 13 percent reported being partially of Asian heritage. Asian-Americans/Pacific Islanders is one of the fastest growing visible racial/ethnic groups, with a projected increase in population to 6.2 percent by 2025, and 8.9 percent by 2050. Although the three largest Asian ethnic groups are Japanese, Chinese and Filipino, the terms "Asian-American" and "Pacific Islander" encompass more than 50 distinct racial/ethnic groups, in which more than 30 different languages are spoken. Indeed, Asian- Americans/Pacific Islanders is the most diverse racial/ethnic group in terms of country of origin, religious/spiritual affiliation, cultural background and traditions, and generational and immigration experiences.

Prevalence rates of mental illness among Asian-Americans/Pacific Islanders are believed to be no different from those of other Americans. However, the type of psychopathology, ethnicity and generational status, acculturation and cultural background all appear to influence the manifestation of psychological distress among Asian-Americans/Pacific Islanders. For example, rates of depression appear to be similar among Asian-Americans/Pacific Islanders and White Americans, while the prevalence of substance abuse appears to be significantly lower among Asian-Americans/Pacific Islanders. In contrast to domestically born Asian-Americans, Southeast Asian and other Asian-American/Pacific Islander immigrants who experienced violence, war, or economic oppression prior to their arrival in the United States appear to suffer psychological distress more frequently.

Understanding the mental health issues of Asian-Americans/Pacific Islanders is important because of the vast heterogeneity of the group, the various Asian cultures' beliefs about mental health, and the emphasis on the connection between the mind and body. Among many Asian-Americans/Pacific Islanders, interpersonal harmony and the focus on family influence the experience, interpretation and expression of psychological distress. For example, in some Asian cultural groups, the experience of psychological distress is not only a reflection on the individual in distress, but also reflects on the entire family. Thus, shame, embarrassment and loss of face contribute to whether or not an individual will admit to experiencing psychological problems. These cultural values affect the willingness of Asian-Americans/Pacific Islanders to seek professional psychological treatment; Asian-Americans/Pacific Islanders have been found to underutilize traditional mental health services. In addition to cultural values such as stigma and loss of face, limited English proficiency, differing conceptualizations of distress, and limited access to culturally competent services also contribute to low treatment utilization rates. Psychological researchers have documented that those Asian-Americans/Pacific Islanders who do seek professional mental health treatment are more likely to terminate treatment prematurely.

Implications for Culturally Competent Care

• There is an increased need for culturally competent mental health services and providers with expertise in working with this population.

• Mental health providers must be aware of the great interethnic variations among Asian-Americans/Pacific Islanders.

• Because the manifestation of mental disorders is affected by cultural, generational and acculturation levels, treatment providers must assess these specific cultural factors when working with Asian-American/Pacific Islander clients.

• Treatment providers need to understand the role of cultural values such as interpersonal harmony, loss of face, and filial piety on their Asian-American/Pacific Islander client's beliefs about psychological distress and the implications for mental health services.

Myths and Misinformation

The promulgation of the "model minority" myth, that Asian-Americans and Pacific Islanders are the most similar to European Americans, and, thus, are viewed as "models" for and/or "better than" other ethnic minority groups, has created many problems for Asian-Americans/Pacific Islanders. The result has been (a) a lack of attention to Asian-American/Pacific Islander issues in mental health research and clinical practice, (b) the creation of antagonisms with other minority groups who may view Asian Americans/Pacific Islanders as co-conspirators with European Americans, and (c) interference with the development of collaborative efforts and coalition building among racial/ethnic minority groups.

Another erroneous belief about Asian-Americans/Pacific Islanders is that they all achieve academic success. Although it is true that education is highly valued in many traditional Asian cultures, the within-group differences in academic achievement among various Asian-Americans/Pacific Islanders are large. Academic achievement among Asian-Americans/Pacific Islanders has been found to vary by ethnicity, generational status, gender and socioeconomic status.

Regarding socioeconomic status, although some Asian-Americans and Pacific Islanders are somewhat better off financially as compared to other ethnic minority groups, they are still more than 1-1/2 times more likely than White Americans to live in poverty. Also, in many Asian-American/Pacific Islander households, all individuals of working age (including adolescents and extended family members) are employed in one or more jobs outside the home, resulting in a higher medium family income. These figures are often used to support the success myth when in actuality they are a statistical artifact.

Type of employment is also quite diverse among Asian-Americans and Pacific Islanders. Many Asian-American/Pacific Islander immigrants, although often trained in specific vocations such as medicine, engineering and business, can only find menial low-paying jobs, which is why they often supplement their income with additional employment. Even among highly educated and acculturated Asian-Americans/Pacific Islanders, research has documented a glass-ceiling effect, whereby many Asian-Americans and Pacific Islanders are unable to be promoted beyond a certain position because of discrimination and institutionalized racism and/or sexism.

Finally, the stereotype of Asian-American/Pacific Islander individuals all looking the same is grossly inaccurate if one simply examines the range of phenotype between various Asian-American/Pacific Islander groups. For example, Filipinos, Korean Americans, Native Hawaiians and Cambodian immigrants are quite different phenotypically. Skin color, hair color and texture, facial features, height, weight, etc., vary dramatically among many of the Asian-American/Pacific Islander ethnic groups, and biracial and multiracial Asian Americans and Pacific Islanders have even more phenotypic differences.

Implications for Culturally Competent Care

• Treatment providers should be aware of inaccurate historical stereotypes and myths about Asian-Americans/Pacific Islanders and how they have affected the mental health of Asian-Americans/Pacific Islanders.

• Treatment providers should assess their own stereotypes and myths about Asian-Americans/Pacific Islanders and work to abolish them.

• Treatment providers should be knowledgeable of the diversity in educational and occupational achievement among Asian-Americans/Pacific Islanders.

• Treatment providers should be knowledgeable about the socioeconomic status of Asian-Americans/Pacific Islanders and the frequent need for family members to have multiple employment in order to make ends meet.

• Treatment providers should understand that Asian-Americans and Pacific Islanders are immensely diverse in many ways and not make assumptions about a client's experiences and adherence to traditional cultural values and practices.

Inadequacies of Traditional Mental Health Care

The number of Asian-American/Pacific Islander mental health providers is very low, as are mental health services accessible to various Asian-American/Pacific Islander communities. The paucity of bilingual and culturally competent therapists compounds the problem of inadequate mental health care. Even the U.S. Surgeon General documented inadequate mental health treatment for Asian-Americans and Pacific Islanders because of inappropriate and biased treatment models that reflect a White American, middle-class orientation.

Historically, Asian-Americans and Pacific Islanders have had good reason to mistrust mental health service providers. Misdiagnosis and underdiagnosis of mental illness among Asian-Americans and Pacific Islanders who have serious mental health and health implications continue to be a problem. Lack of knowledge regarding ethnopharmacology and Asian-Americans/Pacific Islanders continues to put Asian-Americans/Pacific Islanders at risk. Culture-bound nosological systems, such as the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition-TR (American Psychiatric Association, 1999), also do not adequately address the mental health conceptualization of many Asian-Americans and Pacific Islanders. Researchers have documented that treatment adherence is influenced by the match between the client's and the treatment provider's explanatory model of the symptoms and illness. If the treatment orientation matches that of client, the client will be more likely to agree with the provider's explanation and suggested treatment. If the treatment orientation is different from that of the client, the client will not likely benefit from the treatment. Indeed, many mental health treatment providers lack knowledge and training regarding the existence, prevalence, manifestation, and treatment of Asian culture-bound syndromes. For example, "hwa-byung" (Korean syndrome similar to, yet different from DSM-IV major depression),"taijin kyofyusho" (Japanese disorder similar to, yet different from DSM-IV social phobia), and "koro" (Southeast Asian syndrome now referred to as genital retraction syndrome in the global mental health literature) are all psychological disorders that have been documented in Asian-Americans/Pacific Islanders. Clinicians unaware of such disorders are at higher risk for misdiagnosing such problems and, thus, implementing culturally inappropriate interventions. Interestingly, the researchers are now documenting the existence of these disorders among non- Asian-American/Pacific Islander individuals.

Implications for Culturally Competent Care

• More Asian-American/Pacific Islander and bilingual treatment providers are needed.

• Mental health treatment providers should be trained and educated in culturally competent treatment models.

• Culturally appropriate mental health treatment for Asian-Americans/Pacific Islanders should be cost-effective, accessible (located within Asian-American/Pacific Islander communities), and provided at convenient times (e.g., after work and weekends).

• Current mainstream diagnostic systems should include specific considerations for the experience and expression of various symptoms and disorders among Asian-Americans and Pacific Islanders.

• Mental health treatment providers should be knowledgeable about the prevalence, manifestation, and treatment of Asian culture-bound syndromes.

Culture-Specific Views of Mental Health and Healing

For many Asian-Americans and Pacific Islanders, mental health is strongly related to physical health. In many Asian-American/Pacific Islander ethnic groups, the belief is that if one is physically healthy, then one is more likely to be emotionally healthy. Emotional or psychological health is also believed to be strongly influenced by willpower or cognitive control. For example, when one is feeling sad, not dwelling on negative thoughts or avoiding negative thoughts is viewed as an appropriate coping method. In addition, focusing on one's family or community and behaving in a way that maintains interpersonal harmony in the face of psychological distress is demonstrative of strong will and emotional health. As such, many Asian-Americans and Pacific Islanders associate stigma and loss of face with admitting to psychological problems. As a result, in many Asian-American/Pacific Islander cultures, individuals may often report somatic or physical manifestations of stress, as they are viewed as more acceptable than psychological symptoms. Whether these Asian-Americans and Pacific Islanders experience the distress as somatic and/or psychological when having problems remains to be examined.

Indigenous healing has long been a practice of many Asian-Americans and Pacific Islanders. Traditional healers are often religious leaders, community leaders or older family members. Religion/spirituality, community, and family may also be seen as protective factors for the development of psychological distress among Asian-Americans and Pacific Islanders. For example, low divorce rates and extended family households demonstrate the emphasis on family and unity. They also indicate strengths in interpersonal relationships and loyalty. In addition, this results in a strong built-in social support system for many Asian-Americans and Pacific Islanders. Some traditional Asian-American/Pacific Islander indigenous healing practices are controversial. For example, in some Asian cultures,"coining" and "cupping," the practice of vigorous rubbing of coins or cups on the skin of ill children to cure them, often results in bruising. This has resulted in these parents being reported for child abuse.

Implications for Culturally Competent Care

• Treatment providers should be aware of their Asian-Americans and Pacific Islander clients' cultural beliefs related to psychological distress and how they may influence their symptoms of distress.

• Treatment providers should assess if their Asian-Americans and Pacific Islander clients are experiencing both somatic and psychological symptoms of distress.

• Treatment providers should develop treatment plans that match the explanatory models of their Asian-American/Pacific Islander clients and explain the treatment model to the clients and how the suggested treatment will be of benefit to the clients.

• Treatment providers should be aware of the environmental context in which their Asian-American/Pacific Islander clients live and be cognizant of the implications of their suggested treatment on the clients' family members, as it will likely influence treatment adherence.

• Treatment providers should be knowledgeable and respectful of Asian-American/Pacific Islander indigenous healing practices.

Oppression and Racism as Mental Health Issues

Historically, racism and sexism toward Asian-Americans and Pacific Islanders in the United States has been prevalent. Whether mandated by the U.S. government (e.g., Gentleman's Agreement of 1860, antimiscegenation laws, unconstitutional internment of Japanese-Americans during World War II) or acted upon by individuals via hate crimes, Asian-Americans and Pacific Islanders continue to face oppression and racism in the United States. For many Asian-Americans and Pacific Islanders, the sense of collectivism and group identity results in a shared experience of discrimination, even when such events are experienced by other Asian-Americans and Pacific Islanders. Psychological researchers have documented the effects of transgenerational psychological trauma among Asian-Americans and Pacific Islanders. For example, children of Japanese-Americans interned during WWII experienced negative psychological sequelae from the internment. The concept of transgenerational trauma also is particularly important given the large number of Asian-Americans and Pacific Islanders who have emigrated to the United States from countries ravaged by war, famine, and economic and political upheaval. Although their progeny may not have personally been tortured, raped or beaten, their parents who did experience those atrocities may pass down the psychological trauma to them.

Many Asian-Americans and Pacific Islanders are regularly bombarded with messages to assimilate and that their culture and heritage are not valued. A specific example is the English-only initiative. Rather than valuing multilingual individuals as an important resource, several states have had English-only initiatives that could be interpreted as intolerance and non-acceptance for individuals who speak languages other than English. These initiatives are typically generated by European-Americans who lack the ability to speak other languages as well as knowledge of the future potential economic growth and resources of the population they purport to represent. An interesting irony is that a century ago, European-Americans prevented non-English speaking ethnic minorities from learning English for fear that they would become educated and, thus, compete economically. Although the most frequently spoken languages in the world are Asian, the U.S. education system places more value on European-based languages over Asian languages, creating yet another barrier. This is most readily observed by examining the foreign language offerings in most middle schools, high schools, colleges, and universities. This results in fewer individuals having the capability to communicate with Asian-American/Pacific Islander immigrants whose first language is Asian, which, in turn, affects the number of treatment providers who can provide services in clients' first language.

When employed, Asian-Americans and Pacific Islanders continue to experience the glass-ceiling effect. Although trained and competent, in many companies, Asian-Americans and Pacific Islanders find it difficult to move beyond mid- level positions. Stereotypes of Asian-American/Pacific Islander employees of being smart, hardworking and reliable, yet passive and quiet, result in many individuals being passed over for much-deserved promotions and recognition. Implications for negative effects on self-worth are clear. Negative stereotypes of Asian-American/Pacific Islander men being undesirable, while stereotypes of Asian-American/Pacific Islander women as exotic and sexualized are also psychologically damaging.

A damaging result of the model minority myth is that many Asian-Americans/Pacific Islanders are invisible minorities. This is particularly the case when discussions of diversity focus only on "Black/White" issues. Related to mental health, the consequence of being an invisible minority is particularly problematic. As a result of the lack of attention to the mental health needs and experiences of Asian-Americans and Pacific Islanders, combined with the lack of recruiting of Asian-American treatment providers and researchers, little research exists on the mental health status of many Asian-American/Pacific Islander groups. Those familiar with this literature tend only to be Asian-American/Pacific Islander practitioners and not those unfamiliar with Asian-American/Pacific Islander mental health issues.This may result in potentially harmful problems such as underdiagnosis or misdiagnosis.

Providers who lack cultural sensitivity and knowledge have been shown to provide different diagnoses, typically more severe, to ethnic minority individuals with the same symptoms as European-Americans. Furthermore, given the current emphasis on psychopharmacology, there is real concern regarding whether or not Asian-Americans and Pacific Islanders are being over-medicated or prescribed medications that actually exacerbate their psychological distress. What little research that exists which includes Asian-Americans/Pacific Islanders in drug trials indicates that many Asian-Americans and Pacific Islanders metabolize and tolerate medications at different levels as compared to other ethnic groups.

Implications for Culturally Competent Care

• In addition to assessing personal experiences of racism and oppression of their Asian-American/Pacific Islander clients, treatment providers should be aware of the effects of collectivism on the experience of racism and oppression of Asian-Americans and Pacific Islanders.

• Treatment providers should be knowledgeable about the effects of transgenerational trauma and how it may be manifested in Asian-Americans and Pacific Islanders, particularly among immigrants from war-torn countries.

• Treatment providers should assess their Asian-American/Pacific Islander clients' employment history and status, inquire about glass-ceiling effects, and assess the individual's responses to the discrimination.

• Treatment providers should be aware of the negative impact of the model minority myth on their Asian-American/Pacific Islander clients.

• Treatment providers should remain up to date on the developing literature on the mental health issues of Asian-Americans and Pacific Islanders and incorporate such knowledge into their practice with Asian-Americans and Pacific Islanders.

• Treatment providers should be aware of the potential harm of underdiagnosis, misdiagnosis and over medication of Asian-American/Pacific Islander individuals.

The Delivery of Culturally Competent Care for Asian-Americans and Pacific Islanders

In sum, culturally competent treatment of Asian-American/Pacific Islander individuals should not be the responsibility solely of Asian-American/Pacific Islander treatment providers. Little effort has been made to recruit and train Asian-Americans and Pacific Islanders for careers in mental health, resulting in limited numbers of Asian-American/Pacific Islander clinicians. Rather, the mental health field must be accountable for providing accessible, well- trained and knowledgeable treatment providers who can offer culturally competent interventions and services to an increasingly diverse population.

As the population of Asian-Americans and Pacific Islanders continues to grow and become more diverse, the demand for appropriate services will continue to grow as well. Not providing these services will result in negative effects, not just for the Asian-American/Pacific Islander population, but also for the U.S. population as a whole.

Addressing this growing need is not simple, but needs to be addressed from a systemic and multilevel perspective.

• Multilingual Asian-Americans/Pacific Islanders should be valued for their skills and recruited and trained to be mental health professionals.

• Treatment providers must continually examine their own personal stereotypes and biases and how it may be affecting their work with Asian American and Pacific Islander clients.

• Treatment providers must seek knowledge, training and skills so that they may provide culturally competent services to diverse Asian-American/Pacific Islander clients.

• Training programs must be accountable for training their students to be culturally competent treatment providers. This should not be the responsibility solely of ethnic minority faculty, but all faculty in training programs must be accountable.

• Supervisors should be knowledgeable about and prepared to address issues of cultural competence in supervision.

References

• American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th Ed., text revision).Washington, D.C.: Author.

• U.S. Census Bureau. (2001). The Asian and Pacific Islander population in the United States (PDF, 177.5KB): March 2000 (Update) (PPL-146). Retrieved June 28, 2001.

• U.S. Department of Health and Human Services. (2001). Mental health: Culture, race, and ethnicity—A supplement to Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General.

Recommended Readings for Practitioners

• Lee, E. (1997). Working with Asian Americans: A guide for clinicians. New York, NY: Guilford Press.

• Lee, L. C., and Zane, N.W. S. (1998). Handbook of Asian American psychology.Thousand Oaks, CA: Sage Publications.

• Okazaki, S. (2000).Assessing and treating Asian Americans: Recent advances. In I. Cuellar & F.A. Paniagua (Eds.), Handbook of multicultural mental health (pp. 171-193). San Diego, CA:Academic Press.

• Uba, L. (1994). Asian Americans: Personality patterns, identity, and mental health. New York, NY: Guilford Press.

• Uba, L. (2002). A postmodern psychology of Asian Americans: Creating knowledge of a racial minority. Albany, NY: State University of New York Press.