How to promote mental health among Asian American teens

Asian American teens face a range of psychological challenges related to cultural and societal influences, including experiencing a sense of invisibility, feeling pressured to fulfill the stereotype of the “model minority,” and navigating microaggressions and racist encounters. While best practices for treating this group are still evolving, there are many ways psychological practitioners can help them and their families navigate these issues by learning more about racial-ethnic socialization by Asian and Asian American parents, practicing cultural competence, and working with the teen to develop immediate tangible goals from the therapeutic process.

That said, mental health issues among Asian Americans and Pacific Islanders (AAPI), including teens, have received relatively little scrutiny until recently. Psychologists attribute a mix of factors to this lack of attention, including language barriers, cultural mores about mental health care, and pressures to be perceived as members of a “model minority.” In addition, the myth that all Asian Americans are successful strivers renders invisible those in this very heterogeneous population who fall lower on the economic spectrum or cope with physical and mental health issues (Yip, T., et al., American Psychologist, Vol. 76, No. 4, 2021opens in new window).

The model minority stereotype is “a huge disservice” to getting sufficient attention to the struggles of Asian American families, said Tiffany Yip, PhD, a psychology professor at Fordham University. “That stereotype has been so pervasive that people don’t see the vulnerabilities, or the struggle, or really even the need, to focus on this population.”

Asian Americans make up 6% of the U.S. population according to recent census data, and their population increased by 81% from 2000 to 2019, reaching 18.9 million and surpassing the growth rate of other racial and ethnic groups, according to a Pew Research Center analysis published in 2021opens in new window. During the same stretch, the Native Hawaiian and Pacific Islander population increased by 61%, reaching 596,000.

Even so, research attention has been scant. According to one analysis, just 0.2% of National Institutes of Health research funding from 1992 to 2018 was awarded to studies involving Asian American, Native Hawaiian, or Pacific Islander participants (Doan, L. N., et al., JAMA Network Open, Vol. 2, No. 7, 2019opens in new window). Other research indicates that while Asian Americans are less likely to receive health services than other racial and ethnic groups, they also report the lowest perceived unmet need for these services (see Datapoint, Monitor on Psychology, April 2021). One study, which looked at mental health symptoms and treatment among more than 43,000 college and graduate students, found that Asian students had the lowest likelihood of getting mental health care of all racial and ethnic groups, with roughly 80% of cases going untreated (Lipson, S. K., et al., Journal of Adolescent Health, Vol. 63, No. 3, 2018opens in new window).

Since Asian Americans are less likely to pursue mental health services than those in other ethnic and cultural groups, they can be incorrectly perceived as not needing therapeutic support, said Gordon Nagayama Hall, PhD, professor emeritus of psychology at the University of Oregon, who studies Asian American physical and mental health. “It’s this invisible, undocumented suffering.”

But discrimination and racism, including physical attacks on Asian Americans during the Covid-19 pandemic, may have finally illuminated the mental health stressors that this diverse population faces, psychologists say. The emergence of Covid-19, first identified in China, resulted in a surge in harassment, bullying, and other racist encounters, including among teens. From March 19, 2020, until March 31, 2022, the Stop AAPI Hate center collected nearly 11,500 reports of such racist incidents against Asian Americans and Pacific Islandersopens in new window.

Another recent analysis, involving 64,041 undergraduate students in the United States from a mix of ethnic and racial groups, found that nearly 33% of Asian students experienced a direct racial encounter related to Covid-19, the highest rate of any ethnic or racial group. In addition, 68.4% of Asian students reported a vicarious encounter related to the pandemic, either in person or online (Macaranas, A. R., et al., Journal of Affective Disorders, Vol. 325, 2023opens in new window).

Yet, given that so few psychologists identify as Asian—just 3% according to APA data—few teens can count on finding a therapist who looks like them.

“After the summer of 2020, I was slammed with AAPI folks wanting therapy,” said Christine Catipon, PsyD, a staff psychologist at Stanford University and president-elect of the Asian American Psychological Association. Given language, cultural, and other potential barriers that Asian American teens and their families may have to surmount, therapists should be aware that the teen’s mental health symptoms might be more acute by the time they reach out for help, added Yip, who studies how racism and discrimination impact adolescent and young adult development.

“For people working with Asian American families, recognizing that even getting someone into your clinic or getting someone into your office, that’s a huge step,” Yip said. “Most people don’t even make it to that step. So, the fact that you have someone sitting down talking to you, therapists shouldn’t take that for granted.”

Therapists working with Asian American teens will often need to gain a better sense of the unique background of each teen and their extended family to better provide culturally competent therapy. “Asian American” encompasses a widely heterogeneous population of individuals based on their country of origin, language, and cultural and religious traditions. There also is a wide degree of income disparity, surpassing other groups in recent years. By 2016, Asian Americans in the top 10% of income distribution earned 10.7 times those in the bottom 10%, according to a Pew Research Center analysis published in 2018opens in new window.

As noted, some Asian Americans feel considerable pressure to fulfill the model minority stereotype, often starting from an early age, said Annabelle Atkin, PhD, an assistant professor in the department of human development and family science at Purdue University who studies race-related developmental processes in Asian American and multiracial youth. That stereotype emerged during the civil rights movement as a way for White supremacists to argue that discrimination was not a problem and that other racial and ethnic minority groups simply were not working hard enough. “They upheld ‘Asian American’ as a model minority to make that argument,” she said. One potential danger is that if teens internalize this myth, it can lead to unrealistic stress and expectations, which may be associated with psychological distress (Lee, S. J., Unraveling the “Model Minority” Stereotype: Listening to Asian American Youth, Teachers College Press, 2009opens in new window).

Growing up in a culture that often places a strong emphasis on family and collectivism, Asian teens also may feel a responsibility to do well, enabling them to help the family financially and otherwise moving forward, said Catipon, who is Filipina American. In the Filipino language, the expression utang na loob broadly translates to a debt of reciprocity to others, she said. “Many times, the students I work with [in therapy] worry about being able to reciprocate to their families for the sacrifices their families have made,” Catipon said. An example is feeling anxiety over being able to find a job that pays enough to help the extended family. “Even if that isn’t overtly stated, it’s somewhat implied and understood,” she said.

Moreover, Asian American teens may cope with differing expectations and stereotypes that break down along gender lines, psychologists say. Teen girls may face biased perceptions that they are passive or submissive, or the victims of restrictive gender roles within their families or communities, said Vaishali V. Raval, PhD, a psychology professor at Miami University in Oxford, Ohio, who studies the psychological functioning of historically excluded or marginalized groups. For their part, teen boys may deal with the stereotypes that they are studious or not athletic, she said.

At the same time, the cultural messaging in Asian American families can discourage teens and their parents from trying therapy, Yip said. “Sitting down and talking about your feelings is not culturally normative,” she said. Although that situation may change as Asian families become more acculturated to U.S. norms, “there’s still sort of that resistance or maybe just a lack of awareness” about what therapy entails or the benefits it may provide, she noted.

Since parents often play a role in getting their teens into therapy, it is important to understand how they may perceive mental health issues, added clinical psychologist Cindy Liu, PhD, an assistant professor of pediatrics at Harvard Medical School.

In one pilot study she headed, 18 Chinese American immigrant parents with children between the ages of 13 and 21 were presented vignettes involving mental health symptoms. The parents recognized that the more severe symptoms, such as psychosis, warranted treatment. But they responded differently to a vignette describing social anxiety, often labeling such behavior as “shyness” or having a “weak personality” or in other personality or cultural terms ( Asian Journal of Psychiatry , Vol. 47, 2020 opens in new window). In other research, Liu and colleagues found that Asian students were less likely to report mental health diagnoses, including depression and anxiety, than White students, perhaps attributable to the lower likelihood of Asians to seek help or the higher likelihood of encountering challenges when accessing care compared with students of other racial and ethnic backgrounds. Yet they also reported significantly higher rates of suicidal ideation and suicide attempts than White students ( Depression and Anxiety , Vol. 36, No. 1, 2019 opens in new window).

In therapy, psychologists can foster Asian American teens’ mental health by working with parents and teens to understand the realities and effects of discrimination on mental health while supporting their cultural pride and strength. These parents are not generally versed in how to talk about racism: A literature review found that Asian American parents were more likely to discuss ethnic socialization with their kids than to discuss challenges related to racism (Choi, Y., & Hahm, H. C., Asian American Parenting: Family Process and Intervention, Springer, 2017opens in new window).

Various factors may influence this gap, including that parents may not have experienced discrimination as a child in their home country. They also may feel too overwhelmed by the logistics of building lives in a new country to prioritize these conversations. When kids are confronted with bias and discrimination, “they have a smaller toolbox for dealing with it,” Yip explained.

Self-reported measures can help therapists better understand how Asian parents socialize their children about racism and discrimination along with their cultural heritage (Juang, L. P., et al., Cultural Diversity and Ethnic Minority Psychology, Vol. 22, No. 3, 2016opens in new window). The Asian American Parental Racial–Ethnic Socialization Scale was designed to capture some experiences specific to Asian American families, such as efforts to assimilate to a new country and maintain ties to family in Asia. The multidimensional scale includes seven subscales: maintenance of heritage culture, becoming American, awareness of discrimination, avoidance of other groups, minimization of race, promotion of equality, and cultural pluralism.

Atkin and a research colleague at Arizona State University used the scale to assess racial-ethnic socialization approaches with 228 Asian American college students and found that parenting approaches fell into three socialization profiles ( Journal of Counseling Psychology , Vol. 68, No. 1, 2021 opens in new window). They included the guarded separation group, the passive integration group, and the active integration group.

The students in the active integration socialization group felt the most pride in their racial and ethnic identity and had social connections with others. They learned about their cultural heritage and got positive messages about assimilating into American society. Those parents “were not telling their kids to avoid people from other racial groups. They were not minimizing racism. They were moderate on awareness of discrimination. And they were very high on promoting equality or cultural pluralism,” Atkin said.

When working with Asian American families, therapists can encourage parents to foster conversations about discrimination and bias with their children. Parents can share their own experiences to model to children that it is OK to talk about racism, said Richard Lee, PhD, a psychology professor who directs the Asian American Studies Program at the University of Minnesota. They also can ask about any instances of microaggressions and other racial encounters, starting well before their children are teens. At school, for instance, a kid may have commented on the shape of a child’s eyes or on the smell of the lunch they brought from home. In fact, research shows that kids understand concepts of race and unfairness starting early on (Brown, C. S., & Bigler, R. S., Child Development, Vol. 76, No. 3, 2005opens in new window).

Even so, children and adolescents do not always make a direct link to discrimination, Lee added. To open the discussion, a therapist can ask if they have ever been bullied or treated unfairly. Once they begin to discuss a specific encounter, the therapist can start to explore some of the reasons it may have happened. “By helping to facilitate the exploration, they begin to share more and more details and may begin to make the connection [to racism] themselves,” Lee said.

Parents also should be discouraged from minimizing their teen’s description of a troubling encounter or advising them to ignore it and instead to focus on working hard, Lee said. Therapists can work with parents to be more proactive: An example is encouraging parents to stay involved with the child’s school so that if a teen is being bullied or excluded, parents can alert teachers or school leaders.

To prepare Asian American teens for future encounters with bias and discrimination, therapists can help them develop and test-drive responses, Raval said. For instance, the question “Where are you from?” often arises when a teen starts school or another new situation. If the teen shares where they live, the question may be followed by the sometimes response “Where are you really from?”—a microaggression implying that the teen cannot be from the United States given their skin color and communicating the message that “you don’t belong here,” she said.

Depending on preference, Raval said, teens could respond with their family’s country of origin or lob back, “Where are you from?” Or they might prefer to educate the other person a bit, describing why the question itself is offensive. There is no correct response, Raval added, and teens might take a different tack depending upon their personality or their relationship with the person involved. But it is important for them to practice, “to try out what feels more comfortable,” she said.

Therapists who practice cultural competence will find it easier to build trust with Asian teens and their families. Given the paucity of Asian American psychologists, teens, and their families will often work with someone who does not look like them. It is important to address that reality early on, Catipon said, because there is already a power differential between therapists and patients. “But then there’s a heightened one when it comes to the power differential between majority culture and minority culture,” she said.

Raise that differential directly with the teen, Catipon suggests, perhaps by saying, “I’m aware that there is a cultural difference in the room. I want to make sure that this feels like a safe space to explore things that you want to talk about.” Then, make sure the teen has the space to respond.

Therapists also should not expect teens to teach about their culture, added Catipon, who advises asking open-ended questions to gain broader therapeutic insights. Take the example, she said, of a teen who complains that her mother criticizes her body image, saying that it brings shame on the family. “I might ask something like, ‘I’m curious about whether this is something that’s common in your culture, or is it unique to your family?’” Therapists thus gain that broader context, she added. Plus, some Asian teens may have sought mental health support for challenges unrelated to their race or ethnicity.

Other therapeutic strategies can help foster good outcomes and prevent early dropout, a common phenomenon among all therapy patients, but especially among Asian Americans, who are 6.5% less likely to complete treatment than their White counterparts (Smith, T. B., & Trimble, J. E., Foundations of Multicultural Psychology: Research to Inform Effective Practice, APA, 2016).

While some teens may prefer to be treated by someone who looks like them, in the end, displaying cultural competence and creating a bond of trust is more important than ethnicity. Asian teens and their families will benefit from therapy and see its effects relatively immediately, Hall added. In a classic article in the American Psychologist (Vol. 42, No. 1, 1987) opens in new window, for example, Stanley Sue, PhD, and Nolan Zane, PhD, highlight the importance of giving Asian American patients the sense that they are receiving something tangible from therapy relatively early on, ideally in the first few sessions—akin to the Asian cultural practice of gift giving. This approach does not imply that the treatment will be short-term; rather, patients will perceive some type of meaningful gain—a reduction in anxiety, reassurance of some type, or the building of a new goal or coping perspective—that will prevent them from dropping out.

In working with teens, therefore, it is helpful to develop specific therapeutic goals, such as giving them strategies to ease anxiety before taking tests, Hall said. Or, if the therapeutic situation involves a teen who has recently immigrated, the psychologist can both encourage outside tutoring and work with the teen to better recognize that their degree of fluency does not correlate to their intelligence or value as a person, he said.

This approach of moving quickly to tackle an external goal can also help counter the potential that teens who acknowledge mental health symptoms will “lose face,” the perception which is most prominent in East Asian cultures that an individual shortfall can cause shame for the larger group, Hall said. For instance, when Asian teens get in trouble with the law or struggle in school, it may reflect on not just themselves but also the entire family.

“A pragmatic approach for Asian Americans can take the focus away from some kind of individual mental illness to an external problem that can actually be solved,” Hall said. By steering the focus away from that sense of shame, teens might be more engaged in therapy, he said. Therapists can work with those teens to develop problem-solving skills related to that external challenge, which then “could be an avenue into more traditional approaches in which there is a focus on thoughts and feelings,” he said.

With a strong commitment to cultural competence, psychologists can make headway in assisting struggling teens and their families who are reaching out, Catipon said. “Be willing and be curious to step into their shoes and their experience,” she said. “Really hone that empathy. And if you can demonstrate your empathy and really check in with how they’re actually doing, you can go a long way.”