Asian Americans are Americans of Asian descent. Based on the U.S. Census report, there are approximately 14.0 million U.S. residents who identified themselves as Asians. Heterogeneity is particularly important to address when it comes to a group such as Asian Americans, given that this population comprises approximately 43 different ethnic groups with more than 100 languages and dialects represented. According to the recent Census, 2.3 million individuals speak Chinese at home, the second most widely used non-English language in the United States. Immigration history and status are also diverse within this group: 8.7 million U.S. residents are born in Asia, and 25% of the nation’s total foreign-born population and 52% of foreign-born Asians are naturalized U.S. citizens. The median household income for Asians in 2004 was $57,518, the highest among all race groups. Diversity of income within the Asian population was also evident. For example, median household income for Asian Indians was $68,771 and $45,980 for Vietnamese. The poverty rate for Asians was 9.8%. Asians have the highest proportion of college graduates of any race or ethnic group in the United States, with 49% of individuals ages 25 and older holding a bachelor’s degree or higher level of education, 87% of individuals with high school diplomas, and 20% with an advanced degree (e.g., master’s, Ph.D., M.D., or J.D.). Sixty percent of Asian households consist of a married-couple family. The projected number of U.S. residents who will identify themselves as Asian in 2050 is 33.4 million, 8% of the total projected U.S. population.
Counseling psychologists must consider the cultural context of the individuals and the cultural lens from which they view themselves and the world. Understanding the worldviews of Asian Americans from the cultural perspective is critical for an accurate understanding and assessment of how Asian Americans may respond to counseling and psychotherapy. Without accounting for the differences that exist within Asian American ethnic subgroups, it is inevitable that there will be errors of omission, that is, failures to account for culture, ethnicity, or cultural differences, as well as making false generalizations of individuals within a given culture. In this entry, key aspects of the Asian cultural perspective are highlighted. Systematic and practical barriers that impede service utilization and compromise service effectiveness as well as ways of overcoming those barriers through culturally responsive services are outlined. Recommendations for counseling Asian Americans are presented throughout this entry.
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Client Variables within the Asian Cultural Context
Cultural Values and Worldview
Asian American worldview emphasizes humility, modesty, treating oneself strictly while treating others more leniently, obligation to family, conformity, obedience, and subordination to authority. This cultural context also values familial relations, interpersonal harmony versus honesty emphasis, role hierarchy versus egalitarianism, and self-restraint versus self-disclosure.
Awareness of these values sheds light on why research and clinical findings have shown Asian Americans to exhibit greater respect for counselors, preference for a counselor who is an authority but is not authoritarian, tendency to exhibit lower levels of verbal and emotional expressiveness, preference for directive counseling styles, and crisis-oriented, brief, and solution-oriented approaches rather than insight and growth-oriented approaches. Asian Americans are likely to find difficulty with the Western model of counseling and psychotherapy, which is filled with ambiguity by design and typically conducted as an unstructured process. For Asian Americans who tend to be less tolerant of ambiguity, the mismatch with insight-oriented psychotherapy may account for the early termination and the underutilization rates that exist. Similarly, Asian cultural values of reserve, restraint of strong feelings, and subtleness in approaching problems may come into conflict with the Western model of counseling and psychotherapy, which expects clients to exhibit openness, psychological mindedness, and assertiveness.
An example of error of omission leading to false generalizations and conclusions about Asian Americans can be found in career counseling. Asian Americans report significantly high parental expectations and involvement when making career decisions and are likely to be influenced by their families. From a Western cultural worldview the inclusion of parental expectations and wishes may be interpreted as being immature and maladaptive, whereas from an Asian cultural perspective it would be aligned with the cultural norms and values. It is important to know the person being helped, understand his or her cultural context, and use his or her cultural worldview rather than other worldviews to prevent misunderstandings and inappropriate services.
Family plays a central role in the mental health of Asian Americans. Families not only have the potential of facilitating mental health, but they can also serve as potential mental health stressors. Immigrant families may face difficulties with social isolation, adjustment difficulties, and cultural and language barriers, and cultural and language barriers may contribute to parent-child conflicts. Characteristics of immigrant families include a husband-wife dyad, families with dependent children, families with adult children, aging parents, split households, and reunifications, all of which render unique adjustment and relational concerns. Parenting styles also impact the life experiences of Asian Americans. Studies have found that authoritative parenting styles and the number of years lived in the United States are predictive of higher academic competence. Authoritarian and permissive parenting styles are predictive of lower self-reliance, whereas number of years lived in the United States is related to higher self-reliance. Family constancy and equilibrium, duty, obligation, and appearance of harmonious relations are important. Whereas Asian families emphasize connectedness of the family, the Western worldview prioritizes separateness and clear boundaries in relationships, individuality, and autonomy. Therefore, counselors should note that the preferred direction of change may be toward a process of integration rather than differentiation.
Acculturation involves a minority individual’s behavioral, cultural, and social adaptations that take place as a result of contact between the individual’s ethnic society and the host dominant society. Experiences of culture conflicts are inevitable during this process, resulting in mental health issues and interpersonal conflicts. Asian Americans are often caught between the Western worldviews and the traditional cultural values as they attempt to negotiate between the two. As Asian Americans became exposed to Western influence via the schools, mass media, and their peers, intergenerational conflicts often result within family units. Studies have found that Asian American women tend to acculturate faster than their male counterparts. One way that Asian Americans attempt to resolve the cultural conflicts generated by the acculturation process is by developing a sense of ethnic identity to their heritage culture.
Sue and Sue have developed a conceptual scheme for understanding how Asian Americans adjust to these conflicts. They observed that Asian Americans exhibited three distinct ways of resolving the culture conflicts experienced. First of all, there is the traditionalist who remains loyal to his or her own ethnic group by retaining traditional Asian values and living up to expectations of the family. Second, there is the marginal person who becomes over-Westernized by rejecting traditional Asian values and whose pride and self-worth are defined by the ability to acculturate into White society. The third way of resolving cultural conflict is the Asian American, who is also rebelling against parental authority but at the same time is attempting to integrate his or her bicultural elements into a new identity by reconciling viable aspects of his or her heritage with the present situation.
It has been suggested that an Asian American’s level of acculturation may influence his or her response to both therapy process and outcome. It also is important for clinicians to be cognizant that acculturation also plays an important role in the career development of Asian Americans. For example, a high level of acculturation had been found to be positively related to job satisfaction and negatively related to occupational stress and strain. There is a wide research and clinical consensus that there is a significant relationship between levels of acculturation and attitudes toward seeking professional psychological help. More specifically, the more acculturated Asian Americans are, the more likely it is they will seek professional psychologist help. The less acculturated they are, the more likely it is they will seek help from community elders, religious leaders and communities, and student organizations. Individuals who are most acculturated are most likely to recognize the need for professional psychological help because they are most tolerant of the stigmas often associated with seeking psychological assistance.
Asian Americans have shown patterns of underutilization of health services. Those that do make use of mental health services have shown significant dropout rate. As mentioned earlier, acculturation is found to account for ethnic differences in help-seeking behaviors of Asian American students. Those with a high acculturation level are more willing to seek help than those who are less acculturated. Levels of acculturation can also impact the attitudes held by Asian Americans toward mental health services. For example, most acculturated individuals are likely to recognize need for professional psychological help, more tolerant of stigmas, and more open to discuss problems with a psychologist than individuals who are not acculturated.
Underutilization can also be explained by the stigmas that are often attached to seeking professional psychological services by the Asian community. There are correlations found between Asian Americans’ levels of acculturation and stigma tolerance and their confidence in mental health practitioners. In some cultures, there is not a cultural analogy to psychological therapy; therefore, utilization of mental health services may not be viewed as a treatment option. Stigmas and lack of understanding also account for the lower frequencies of self-referrals. In response, efforts have been placed on how to minimize premature termination among Asian American clients by accounting for cultural values, ethnocentrism and the cultural uniformity myth, cultural attitudes and beliefs, styles of interpersonal communication, and cultural determinants of the nature of interpersonal relations.
Psychological Distress and Coping Mechanisms
The prevalence of mental health problems among Asian Americans is noteworthy despite the stereotype of being the “model minority.” Much literature and research attention has been paid to the unique needs and experiences of Asian Americans. The cultural context helps practitioners to understand the experiences and the expression of symptoms of distress. For Asian Americans, there may be a tendency to replace psychological symptoms with somatic ones. This tendency to somaticize may extend beyond the diagnosis stage to influence the actual therapy process itself. Failure to recognize this client characteristic among Asian Americans may result in both diagnostic and therapeutic errors. Cultural experience of Asian Americans is further contextualized by understanding their ethnic identity. Asian Americans’ experience with racism and discrimination should also be taken into consideration in the therapy process. Immigration experiences and acculturative stress have been found to have predictive effects on mental health. Examining within-group differences of immigration status (e.g., international, permanent residents, and naturalized citizens) while taking into account clients’ immigration history will further contextualize the life experiences of the individual Asian American client.
Asian Americans tend to endorse coping sources and practices that emphasize talking with familial and social relations rather than professionals such as counselors and doctors. In one study, among the ethnic groups examined (Chinese, Korean, Filipino, and Indian), Korean Americans were found to be more likely to cope with problems by engaging in religious activities. Indigenous coping resources such as traditional folk healers, spiritual identifications, and religious practices such as Buddhism are support resources that Asian Americans utilize. Social support is also an instrumental tool for coping among Asian Americans. Social support, including friends, family, and even international student offices, has been found to provide buffering effects on the mental health issues faced by Asian Americans. Social support variables have also shown to be predictive of academic persistence.
Barriers to Asian Americans Using Counseling Services
Cultural differences in mental health concepts, idioms of distress, stigmatization of the mentally ill and mental health service use, and preference for alternate coping strategies may contribute to the underutilization of psychological services by diverse Asian American groups. Cultural values of self-reliance and emotional self-restraint explain why Asian Americans prefer to work out issues independently. Strong stigmatization of the mentally ill and mental health service use accounts for why Asian Americans are more likely to seek support from family and friends than reaching out to professional service providers. Mainstream mental health services being inaccessible or culturally irresponsive to the needs of Asian communities continue to be barriers to Asian Americans seeking services. Structural barriers include lack of knowledge of service availability, time constraints, distance, cost of treatment and lack of financial resources, access to transportation, and English-language proficiency. Practical barriers such as cost, time, and language accessibility have been shown to pose more of a problem for less-acculturated individuals, who must learn to navigate an entirely new health care system while also adjusting to life in a new culture.
Counselor’s lack of culture-specific knowledge about Asian Americans may act as a barrier to effective counseling, resulting in Asian American clients not receiving appropriate care. Misdiagnosis frequently occurs, and the existence of culture-bound syndromes points to a lack of precise correspondence between indigenous labels and established diagnostic categories. Counselors should view clients on both macro and micro levels while maintaining cultural sensitivity. Assuming homogeneity among Asian Americans and falling prey to stereotypes would compromise the therapeutic process. It is theorized that counselors’ bias toward Asian Americans and other minorities comes from at least two sources: their own cultural and personal backgrounds and their professional training. When counselors’ cultural background and personal characteristics are in contrast to those of Asian Americans, there is potential for cultural misunderstandings. In addition, the cultural bias of counselors toward minority groups in general can operate against Asian Americans in particular.
The professional training received by counselors can be another source of bias in working with Asian Americans. Training bias tends to operate in the form of using traditional psychotherapeutic procedures acquired from training with culturally different clients, such as Asian Americans, without first evaluating if those procedures would be culturally appropriate. Given that social and cultural variables affect Asian Americans’ help-seeking behaviors, experiences of distress, manifestation of symptoms, and therapeutic process and outcome, it is important that training curriculum place emphasis on these variables as clinicians learn to implement their learning into care of Asian American clients.
Most counselors trained with Western models of psychotherapy possess certain characteristics and assumptions inherent in these models that may conflict with the cultural background of Asian Americans and thus serve as barriers to effective therapy or counseling. The major characteristics of Western models include (a) language variables, such as the use of standard English; (b) class-bound values, such as strict adherence to time schedule and an unstructured approach to problems; and (c) culture-bound values, such as emphasis on the individual (as opposed to the group or family) and verbal and emotional expressiveness. In light of some of the characteristics of Asian Americans already reviewed (e.g., intolerance of ambiguity), counselors using a Western approach with Asian American clients may run into a considerable amount of resistance. The universal applicability of Western approaches to psychotherapy and mental health services has been challenged by several investigators, and some investigators have begun developing training models that are intended to be sensitive to the Asian American cultural background and experiences.
Overcoming Barriers through Culturally Responsive Services
Sue proposed a number of solutions to account for the barriers to receiving effective psychological services. His recommendations include (a) augmenting existing services, (b) establishing parallel or ethnic-specific services programs, and (c) creating nonparallel programs that are culturally tailored to a particular group. Many changes have taken place, including the implementation of these suggestions in ethnically dense communities.
One implementation is to provide racial/ethnic client and therapist matching within the existing public mental health system. Providing clients with a therapist of his or her same racial/ethnic background has increased some service utilization by Asian American clients. Ethnic match, language match, or both, are particularly important for Asians who did not speak English as a primary language. Ethnic and language matches are found to be associated with lower rates of premature termination and greater number of sessions. Clinical and research data show that ethnic/racial matching may have important effects in increasing the utilization of mental health services by Asian Americans. Some research shows that Asian Americans who were receiving mainstream services but were ethnically matched with their therapist returned more often than their unmatched counterparts. This approach has proven to be an effective way to augment existing services.
Ethnic-specific mental health services (ESS) is another response to Sue’s call for action. The emergence of ESS involves modifications on the systemic level. Rather than just augmenting existing services, ESS is designed to improve the cultural fit of service offerings and the clients served. ESS programs are designed to address cultural barriers faced by the specific ethnic groups they treat. For example, ESS programs are frequently located within ethnic enclaves with extended service hours to accommodate transportation or work hour conflicts. ESS programs also work cooperatively with family members, indigenous healers, and community elders, which is rare within the existing public mental health system. Extensive case management services are also provided to address unique social service needs of immigrants. Mental health services may also be integrated with primary care to capitalize on the preference for integrating health and mental health treatments. Recent studies provide preliminary evidence that ESS programs are more effective than mainstream programs. Asian Americans attending ESS programs had a higher rate of return after the first session and attended a greater number of treatment sessions, even if there was no ethnic matching. Studies have found that when psychiatric inpatient units incorporate the systemic-level change of ESS, longer treatment stays and improved referral to follow-up treatment after discharge result. Inpatients are more willing to accept outpatient or residential treatment referrals. Organizational improvements to afford cultural match and/or fit are aimed to enhance service effectiveness, increase service utilization, and result in therapeutic gain to those in need.
Nonparallel programs that are culturally tailored to a particular group are also important. Such programs address the specific cultural concerns and social contexts of a particular ethnic group. Indigenous healing practices are key components to such nonparallel programs. One example of a nonparallel community program is one designed for native Hawaiians, Hale Ola Ho’opakolea. This program incorporates indigenous Native Hawaiian therapies to assist clients in overcoming their concerns. The program has reportedly led to increased mental health service use and has received high client satisfaction ratings. Although it might be difficult to obtain funding support for such innovative programs and reimbursement from insurance companies, there is some preliminary evidence that such programs play an increasingly important role in meeting the service needs of specific populations.
Overall Recommendations for Counseling Asian Americans
When working with any racial/ethnic minority individuals, it is important to consider the cultural context of that individual and the cultural lens from which the individual views himself or herself and the world. Furthermore, service providers must also acknowledge their own cultural biases and learn about the cultures, histories, and values of their Asian clients to determine the appropriateness of their therapeutic approaches and goals. To understand the cultural context and worldview of their clients, service providers should also assess the levels of adherence to Asian cultural values of their Asian American clients. Adherence to Asian cultural values would shed light on the relevance of specific cultural factors impacting therapeutic process and outcome. Service providers who are willing and able to discuss culturally specific and relevant aspects of one’s life experiences would certainly highlight the counselors’ levels of multicultural competency. Cultural competency on the part of the service provider would result in perceived credibility and positive impact on the therapeutic relationship. Having counselors with similar cultural backgrounds, values, and experiences may also help to foster stronger therapeutic relationships. In essence, counselors should view cultural values held by clients as an avenue for connection, mutual learning, and a window toward a more complete understanding of their clients.
Understanding the cultural context of Asian Americans would also highlight ways to work effectively with Asian American clients. Structured therapeutic interventions and directive approaches, such as cognitive-behavior therapy and problem-focused approaches, are effective, particularly for more traditional Asian American clients. Working collaboratively with clients’ families, support networks, and other treatment providers is also important. Similarly, it is important for researchers and practitioners alike to note that although seeking professional help is one resource option for people of Asian descent, not choosing to utilize it does not necessarily mean there are no other, more appropriate coping methods available. Effectiveness of integrating alternative belief systems and healing approaches into service provisions certainly deems continued clinical and research attention.
Finally, it is critical that service providers be aware of the heterogeneity within Asian American groups. Within-group differences include, but are not limited to, ethnic identity, cultural background, degree of acculturation, experiences within the majority culture, circumstances of immigration, family structure, values, social class, and religious affiliation. These aspects of an individual’s background and life experiences are essential to the understanding of that individual client. In essence, efforts should be made to prevent the impact of error of omission by honoring the differences that exist within Asian American ethnic subgroups and the influence of cultural context and the worldview of Asian Americans.
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