 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on improving cultural competence, working with Asian people. Now, throughout this week, we've focused on different cultures each day. Today, we talked about, what did we do? Oh, Native Americans and Alaskan natives. The second day, we talked about working with Hispanics. And today, we're going to talk about working with people of Asian descent. We're going to learn about Asian cultures, traditions and values as they relate to mental health. There's just so much out there, obviously, in an hour. I can't do any of it, complete justice. But I'm going to give you a good overview. We're going to talk about communication styles to help the counselor more effectively communicate with culturally different clients, explore some health disparities and explore appropriate approaches to counseling when working with this population. So again, we're just going to start with some general information. You're not going to be tested on specific statistics necessarily. Your main concepts is what I really want you to get. Asian Americans have a 17.3% overall lifetime rate of any psychiatric disorder and a 9.9% 12 month rate. Yet Asian Americans are three times less likely to seek mental health services than whites. So they have worse mental health problems or more mental health problems and they're three times less likely to seek help. Cultural factors such as language, age, gender and others can influence the mental health of Asians, particularly immigrants. Asians place a great value on the family as a unit and each individual has a clearly defined role and position in the family hierarchy. And it's expected to function within that role submitting to the larger needs of the family. Social stigma, shame and saving face often prevent Asians from seeking behavioral health care. And we're going to talk a little bit more about why that is when we really get past this demographic thing. Asian patients are likely to express psychological distress as physical complaints. So for one, they may go see a medical doctor first. And for two, when we're talking to them, we really want to listen to their somatic symptoms to understand a little bit more about what might be going on. Knowledge of English is one of the most important factors influencing access to care. A lot of people who have immigrated from one of the from our Asian and have immigrated here are not necessarily proficient or fluent in English. The level of acculturation. Typically it takes three generations for immigrants to fully adopt the lifestyle of the dominant culture. So if you're working with somebody who's a first generation immigrant or a second generation immigrant, there are potentially things from their culture of origin that are going to still be quite dominant. And you know, they may end up developing a bicultural identity as well. So we want to see and assess with them, you know, what exactly is your level of acculturation. In general, younger people, the younger people are when they migrate, the more readily they adapt. So if you're working with somebody, you know, a child or an adolescent who came to the United States with their parents, it's likely that they're going to acculturate more easily than their parents. Historically, men have acculturated more rapidly than women. One thing that does come up in among others in the United States is sometimes women earn more than men, which can really disrupt family expectations and traditional values and cause a lot of stress in the family. So it's important to recognize what, even though the woman may be, you know, bringing home a nice paycheck, it may be considered disruptive and it may be very harmful to the self-esteem and self-concept of the male in the family. Religion is spirituality, kind of in order. One of the biggest religious groups among Asians is Christianity. Followed by Muslim and then Buddhism, Confucianism, Taoism and animism. So you don't want to just assume when somebody walks in your office that they're going to have a particular religion. You want to talk to them, see what religion that they ascribe to. Buddhism promotes spiritual understanding of disease causation. So if they do have a Buddhist look on life, even if they're not Buddhist by religion, they may still have some Buddhist philosophies. So we want to look at that. Confucianism supports an ethical belief that stresses respect for authority, filial piety, justice, benevolence, fidelity, scholarship and self-development. So this really supports the Asian cultural ways of thinking, especially the filial piety and the respect for authority. So understanding if they ascribe to Confucianism where they may be coming from. Taoism is the basis for Yin and Yang theory. We're going to talk a lot more about that in a little while, but basically that there's always opposing forces. And animism is the belief that human beings, animals and inanimate objects possess souls and spirits. Traditional beliefs about mental health among Asian peoples. Mental illness can be caused by lack of harmony of emotions or by evil spirits. That's their belief system. We want to make sure that we don't pathologize their belief system. Mental wellness occurs when psychological and physiologic functions are integrated, so that mind, body, spirit thing. The Buddhist belief that problems in this life are most likely related to transgressions committed in the past life. And our previous life and our future life are as much a part of the life cycle as our present life. So if you're working with someone who ascribes to certain Buddhist philosophies, even if like I said, even if they're Christian, but they have some Buddhist principles, you want to talk to them about what's causing their illness. Is this a punishment because of transgressions? Kind of what's going on here? And, you know, how is this impacting your future life? Because obviously if they believe that what they do in this life is going to have an impact on their future life, that's something that they're going to want to look at. So just breaking it down because the different cultures are very different. Chinese, Japanese, Korean, Vietnamese. And we're going to talk about even just some of the customs and traditions among those different cultures. Can't cover all of them in this hour, but hitting the highlights here. For Chinese people, mental illness may be caused by lack of harmony of emotions or evil spirits. They often try traditional herbs and acupuncture first, and healers may be used concurrently to get rid of evil spirits. So obviously counseling is not like right up there. Counseling is actually not looked upon super favorably because mental illness is seen as shameful for the family. Japanese people, mental illness is caused by evil spirits and is often disregarded as a real illness. So they're more with the spirit world. They often delay or avoid seeking professional help and many will use traditional sources of care. Okay. Among Koreans, mental illness is viewed as being caused by a disruption of harmony within the individual or ancestral spirit coming back to haunt the patient because of past bad behavior, the result of bad luck or misfortune, payback for something done wrong in the past and is considered shameful. They may deny problems and are not likely to reveal any issues unless specifically asked. Although they may show signs of distress through their nonverbals or they may show some acknowledgement of a problem through their nonverbals, even if they don't say, yeah, I've been having problems with that. They may use shamanism as a way to start feeling better and deal with some of their problems. In Vietnamese culture, they view depression as sadness. It's not readily acknowledged because of stigma again. They usually try home remedies, spiritual consultations, exorcists or Chinese herbs first. And family members often will try to cheer up or distract the patient to help them get out of their sadness. They don't really view it so much as an illness. They view it as sadness that can be exercised or spiritually uplifted. Health is seen as a state of balance between the physical, social and supernatural environment. So you've got the social in there, which we don't talk about a lot, but you notice psychological is not in there. Health is seen as a balance between how you integrate with the people around you, the spirit world and your physical body. The Eastern approach assumes that the body is whole and each part of it is intimately connected. So each organ has a mental as well as a physical function. For example, the heart, lungs, spleen, liver and kidney are yin organs. And yin tends to be receptive, slower, damp, dark. Those are kind of the words that we're going to talk about. The large intestine, gallbladder, bladder and stomach are yang organs. So thinking about the symptoms of Western diagnoses like depression. When somebody is depressed, what symptoms do you see? A lot of times you see they may have a slower heart rate. They may be slower going through things. They may have constipation and everything just kind of slows down partly because they're not moving. But when they're anxious, they may tend to have more stomach disruption and intestinal problems. So you can kind of see how the yin and yang can parallel the Western diagnoses a little bit. Traditional Korean medicine or TKM emphasizes the specific characteristics of the individual who suffers from the disease rather than a single symptom, which is the focus of TCM or traditional Chinese medicine. So a couple articles on the differences between Korean medicine and Chinese medicine and another one on traditional Asian health beliefs and healing practices. If you're interested in that, if you work with a lot of Asian clients, it gives you an understanding of where they may be coming from. Many Asian people also believe that uncertainty is inherent in life and each day is just taken as it comes. It is what it is. They are excellent with that whole concept of radical acceptance. They may have a fatalistic attitude about sickness. Now remember fatalistic sounds bad, but in reality fatalistic just means there's a belief that all events are predetermined and therefore inevitable. So you need to accept that it is how it is and make the best of the situation. You're not going to fight it. You're kind of resigned to this is the cross I have to bear right now. And then you're going to figure out how to deal with it and live in harmony as much as possible. So because of this attitude, talking in terms of beating a disease is not going to resonate with people who embrace this attitude of acceptance. So if you're talking about beating cancer or beating depression or beating addiction. That's something that they have they've been afflicted with they've been they have for some reason, and they've accepted it. They have to help them figure out how to have the highest quality of life with this current affliction so to speak. And yes we can help them move towards increased harmony, but we want to look at increasing the positives in their life and the harmony and the spiritual, physical and social integration, more than getting rid of the disease so looking towards strengths and additions. Acceptance of what life brings does not indicate an unwillingness to cooperate with doctors and treatment, but rather a belief that fighting the illness is a negative approach to healing. We want to help them examine and regain balance and enhance the quality of life despite the illness. When we talk about Asian families extended families are common among Asian Americans with two or three generations living in the same household. So that's that's a lot of people major decision making is the purview of the father, followed by the oldest son who receives preferential treatment. Sounds a little bit similar to the Hispanic culture we talked about yesterday. The mother's job is to nurture and care for her husband and children and female children have a lower status than male children. Women usually believe their husbands have a legitimate right to make final decisions and will withdraw from spousal conflict to maintain harmony within the family. So there's definitely a hierarchical role in in these family structures. Value placed on males manifests in sex specific infanticide and a disproportionate number of females in orphanages. So let's just think for a second about the stress that must pose on families. If, you know, a mother gives birth and because it's a female child, it has to go to she has to go to a orphanage or worse yet is is killed. So there's a lot of stress and strife around that NFA wife is unable to bear bear a male child and continues to bear female children. What does that communicate about the wife's usefulness and utility and how is the father's name going to carry on Asian families may value group consensus on health care matters. So, you know, dad may make the major major decisions, but they want to look at how is this going to affect the entire group and they may get everybody's input. Children are highly valued in Asian American families, though they're taught to be polite, quiet, shy, humble and deferential deferring to adults and other people. Conformity to expectations is emphasized and emotional outbursts are discouraged. Emotional outbursts are seen to bring shame to the family because you're losing control and control is prized. Failure to meet the family's expectations can bring shame and loss of faith face to both the children and the parents. So the children, when they do things, not only are they getting, you know, losing face for whatever they do, but they're also bringing shame to their families. So they have to think about it in terms of the big picture whenever they do anything. Parents are seldom forthcoming with affection and praise because of fear that such demonstrations will encourage laziness. You know, we teach in the majority culture a lot of praise. We teach that children should be praised. We should focus on strengths and, you know, winning is in everything. And there's a lot of concepts that we teach that run pretty contradictory to Asian culture. We should look at that if we're working with an adolescent or if we're working with a parent or a family in which there is a child that's struggling. What do they see as appropriate to appropriate ways to parent? We want to understand more about their parenting styles and their cultural approach. Education is important and children who do not do well in school bring shame to their families. Okay, so we want to look at if the child is starting to fail in school. That could be a significant stressor for that family, more so than in the majority culture. So we may need to look at what's causing that child to fail and provide some early interventions. Positive reinforcement and discussion of personal achievements are very uncommon. So from a clinician's perspective, you know, we tend to elicit strengths people have, we tend to elicit accomplishments, give them a lot of praise for making progress, you know, set those reinforcers up. This is not common in the Asian culture and it may feel very uncomfortable to a lot of Asian people to talk about accomplishments because they feel like they're boasting and they're being rude. Adolescence has limited meaning in most Asian cultures because seeking a definition of self outside the family is discouraged. So where we see people going to high school and individuating and developing their personal identity and separating from the family, Asian culture really discourages that and they want the person to stay within the family unit and avoid individuation. Parents expect children to acquire the language and skills they will need to enable them to be successful in their new country, but are reluctant to have them fully embrace most aspects of American culture for fear that they will abandon their native culture. For example, parents may encourage their children to learn but may refuse to allow them to speak English at home. So they speak English just fine when they're at school, but when they're home, they have to speak their language of origin. These confusing messages can often lead to not only transgenerational conflict but transcultural conflict because the youth is trying to figure out what their identity is. Elderly Asians look forward to having their grown children care for them. Elders tend to have full control over family and financial decisions whether or not they live with their children. So if big decisions are going to be made about somebody going to treatment or whatever the case may be, the elders are going to be consulted. And if you've got multiple generations living in a household and there's an elder male, then that person is probably going to be the one that makes more of the decisions. Most elderly Chinese immigrants are not inclined to value independence. When they live separately, it's only to avoid conflict over family roles. So they're not wanting to get out. They're wanting to be part of the family and they value that interdependence. Elders are highly respected and honored by all Asian cultures. In Chinese families, grandparents are often responsible for the care of the grandchildren. Other family stressors that we look at when we're working with Asian families, young adulthood for a lot of people means achieving for the family. Again, you're not individuating, you're not developing your identity, but you are figuring out how you are going to achieve and thrive and bring pride to the family when you grow up and become a full-fledged adult. Young Asian American adults often begin to question their family values, though. Well, that makes sense because when they're in the United States, they're trying to figure out which culture do I identify with. So this process of acculturation or biculturation is common. And in Asian Americans, a lot of times it doesn't start taking place until high school and young adulthood, if you will. Interpersonal relationships can also become more of a challenge. Interracial relationships can cause serious conflicts because of parental fears that biracial children will diffuse the family lineage and culture. So this can cause huge issues. When you look at just about any school that I can think of, the proportion of Asian students in comparison to other races in the school is significantly smaller. So the chances of a young adolescent or a young adult finding someone that they have feelings for who is of another race is pretty darn high, which causes conflict within the family. Many Asian adults also misunderstand the meaning of the transient relationships that are common in urban settings in the West. And so in the West meaning the United States, not the East, where they came from. So our transient relationships, you know, six-month relationships, boyfriends, girlfriends, that's confusing to a lot of people that come over from Asia. So we want to help families understand if they're trying to acculturate and trying to accept the changes that are going on in their family, especially if you've got, let's see, great-grandpa and then you've got great-grandchild who is fully acculturated. And great-grandpa is, you know, not. There may be some significant stress and conflicts. And since great-grandpa is probably still living in the household, that can create a lot of family stress and disharmony. Young adults also face the dilemma of dual identity because they have one for home and one for in public, just like they may speak English when they're in public and speak Chinese or Japanese when they're at home. They need to figure out how to navigate this. And obviously there are other people who have dual identities, and it is a stressor, figuring out what face you give to the public and what face you have in private. The obligation to parents takes precedence over the individual's choice of career. And a choice of career that's different from that chosen by his or her parents can result in laws of emotional and financial support. So even going into college when they're choosing their career and getting their training to become whatever they're going to be, their choices are dictated by that of the family and what will bring pride to the family. They're not able to go off and say, you know what, I think I'm going to be happier if I do this. They are expected to follow in line with whatever the expectations are of the family. Westerners may have a hard time figuring out all the customs and formalities in China, especially because they're so different from the customs and formalities of other Asian countries. So China is significantly different, and that's important to pay attention to if you have a large Chinese immigrant population. It's a mistake to assume that Chinese customs are like Japanese ones. The two countries are very, very different and the Chinese will be quite insulted if you assume their culture is like that of the Japanese. So know your traditions, know your values, know all of this stuff. And you know, if you've got Chinese and Japanese people that you work with, make sure you're aware of which culture fits with which person because it can be seen as quite offensive. So we're going to talk about Chinese and the Japanese and the Korean real quick. When a Chinese person asks someone their age, they often do this so they know how to address the person because age is a huge symbol of power or whatever you want to say. They defer to their elders quite a bit. They revere their elders. So they're not trying to be nosy. They're not trying to be rude. They're just trying to figure out how to appropriately address you. In China, it's rude to call someone by their first name unless you've known them since childhood. And in work-related situations, people address each other by their title. So in a counseling situation, you're likely not going to address your client by his or her first name. You are probably going to address him or her by her last name, obviously asking what they want to be called. And they are probably going to address you as Mr. Miss Doctor so and so because it's not appropriate, especially since you haven't known each other and you have a position of power as a clinician. They're not going to feel comfortable addressing you by your first name. The Chinese sometimes don't smile or exchange greetings with strangers because smiling or being friendly to someone you don't know well is considered rude and too familiar. Again, if the client comes in and seems to have a flat expression, may seem kind of depressed, they're not smiling, they're not making good eye contact, that doesn't necessarily mean anything. You want to make sure that your interpretations of their nonverbals are on point. They may just be being polite by not smiling and breaching that boundary of etiquette. When saying goodbye, it's generally considered appropriate to give a quick bow or nod to everyone present and go. They don't linger, they don't sit around and you know how when you leave a dinner party or something or even when you're leaving your therapist's office or whatever, you may talk for a second and make chit-chat as you're walking out. That's not how the Chinese culture does it. So it doesn't mean necessarily that you had a bad session. They may just say okay, thank you and be gone and that's fine. Understanding what that means because a lot of the nonverbals can be quite confusing. A limp handshake is regarded as a gesture of humility and respect and in the West we are taught that firm handshake, you know, no wet fish here. So when a Western man meets a Chinese person, especially a woman, he should wait for the other person to offer his or her hand first before offering to shake hands. And there's a lot of other rules around shaking hands. But if you do shake hands with your client, don't, you know, try to break their fingers or something. Give a gentle handshake as a gesture of respect for that person. Both thumbs up or tugging on the earlobe is also a sign of excellence. So if clients do something good, you can give them a both thumbs up and they know what that means. I didn't realize this was a cultural, I mean, I remember Fonzie, but I didn't realize it was an Asian cultural symbol and my children's grandmaster does that a lot. And so now I understand kind of where that was coming from. And yes, one of you points out that when you are starting a meeting or when you're greeting someone, you also may bow and in China, interestingly, they're required to have business cards. So when they have a business card or when you have a business meeting, you exchange business cards and the person may put that business card on the table. And it's considered really rude to jam the business card into your wallet or into your pocket or something. They put the business card on the table sometimes to remember your name. An outward pointing pinky and a raised pinky means you are nothing, poor quality or not very good at something. So you want to kind of avoid that. The Chinese consider it rude to look someone directly in the eye, cross your arms and legs or have your hands in your pockets when you're speaking to them. So generally we're sitting when we're doing counseling, but it is totally not uncommon for me in the way I sit, especially when I'm wearing a skirt, to cross my legs. And sometimes I'll sit back and I'll kind of cross my arms pensively. And that is considered quite rude. So if you're working with this culture, be aware of your nonverbals and stay open, both feet on the floor. Chinese usually focus their eyes on the lower neck of the person they're talking to, stand very close to them and try to avoid staring. So if they seem to be standing closer than what we do typically in the West, that's culturally normal. Chinese also don't like it when Westerners point at people, don't show proper respect, boast and offer their opinions readily, want immediate answers and show a lack of patience. They consider it rude to say no directly and instead they may often say something like maybe or even yes when they mean no. So we want to make sure that we understand we're all on the same page about it's okay to say no in dealing with things. Punctuality is also very important to Chinese people and we're going to learn as we get down. That's not so much the case with the Korean culture, but if you're working with a Chinese person, be on time. Japanese culture, saving face is a crucial and it's crucial and harmony is a key value and that's true among most of the cultures, but saving face is big in the Japanese culture. Another thing that I point out because a lot of times I'll ask clients to give me three examples of something or write down five things. I don't, I can't remember ever using the number four, but just kind of as a point of reference, the number four should be avoided because it's extremely unlucky and it sounds like the word for death in Japanese. So you want to avoid having appointments at four o'clock and things like that. When you meet with them, always try to wear conservative color clothing, nothing that's too right out there. There's a general stigma associated with mental illness and the concept of shame is also associated with it. So we do want to realize that somatic talk is a culturally coded idiom of distress to avoid being labeled with a psychiatric disorder. So instead of saying I'm depressed, they may say, you know, I'm constipated and, you know, I'm exhausted all the time and, you know, all those physiological complaints that somebody may have when they're feeling depressed. Somatization in Japan then can be understood as an inherently ethical event that has more to do with morals than medicine. And why is it ethical? Because it's avoiding bringing shame on the whole family. We want to respect that as much as possible. Japanese people are typically quiet and polite and tend not to disagree or ask questions. So we want to be cognizant of that. Again, that they tend to be more submissive in their interactions, especially with authority figures. So we want to make sure that we're on the same page and what we're asking them to do or what we're asking is hitting on point. And again, punctuality is important. They may have little direct eye contact like Chinese, they don't prize direct eye contact. And remember that nodding doesn't necessarily mean understanding or agreement. It's a minimal encourager, but it may not mean they agree with you. So just because your client, you're saying, do you understand what I'm saying? And they're sitting there nodding. Don't assume that that means yes. So you may need to have them paraphrase back or give some sort of explanation of understanding another way. The Japanese view of the self is one in which the individual is seen as socially embedded and dependence on and compliance to others wishes is crucial for harmonious social order. So kind of letting that set in and thinking about how that's different than traditional Western United States culture goals. Symptoms can be seen in terms of how the person is in disharmony with their social environment, among other things. So, you know, if they're having these symptoms, how is it causing disharmony with your social environment and what in your social environment is a miss that also might be causing this disharmony. A Western diagnosis of a mental illness implies that there is something wrong with the purity or the morality of oneself. So if you're seeing a Japanese client and, you know, they have insurance and you have to diagnose, there probably is a need to have a good discussion about what this means and why you've got to put a label on this. For the Japanese, a person's true beliefs or own are not necessarily the same as their public pronouncements. So they may tell you, yeah, that works for me. Yeah, I'm doing a lot better. And then they go home and they're like, oh, I'm still struggling. So we want to understand what's going on what their true beliefs are and make a safe space for them to feel like they can communicate that. So the therapy room needs to become less about being in public and with, you know, a stranger with a doctor and more about sort of a home away from home. And it takes a while to develop the rapport. Any emotional outburst can be perceived as a sign of character weakness and is often avoided because such behavior threatens social harmony. Again, thinking about clients, if you do counseling with people, it is not uncommon to touch a nerve where they get angry, where they get upset, where they cry, where they raise their voice. And this can be seen as very threatening to a lot of people who are Japanese if they suddenly have these strong emotions. So going gently in the counseling process, and if you are going to get into an area that potentially could prompt an emotional reaction, talking about that with them ahead of time, letting them know it's okay and getting their feelings on how do you want to handle this sort of situation can help kind of smooth that transition. Gibbon, which loosely means once current emotional state or temperament also can mean your feelings, your dignity and pride. Gibbon can be hurt, for example, when someone's not shown the proper respect by a subordinate. Now, I failed to mention we switched over to Korean culture here, Korean cultural concepts, the first one being Gibbon or personal dignity. Nunchi is much like empathy, and it's essential to assessing another's Gibbon and acting accordingly and tactfully. So Nunchi is something you do or don't have. If you don't, you're liable to unwittingly hurt others' feelings or make a faux pas. So if you are not sensitive, if you are not empathetic to others, then you don't have Nunchi. Nunchi can also relate to assessing how others view you. Many people, especially Koreans, care about what other people think about them, including you. So if you're busy at looking at others' Nunchis, it means you're spending a lot of time caring about what others are thinking about you. And that can cause a lot of distress for people. So thinking about what that might mean. My son, sometimes when he goes to class, he will have a not-so-good day sparring or doing whatever he's doing, and he will just mull it over in his head for ever in a day, all the way home, all night, the next day. And Grandmaster told him, he's like, when you come, you give your full effort, you do your best, and when you go home, you laugh all the way. And that was it. So basically that was his way of saying, you leave what you did at the studio, at the studio, and not worry about what he, Grandmaster, is thinking about him and all those other things. So hopefully eventually he'll digest that. He's still kind of working on it. Han is a deep feeling, difficult to precisely capture with words, but it's a combination of sorrow, anger, helplessness, due to greater forces of oppression. But conversely, so Han's one of these confusing terms, it can also represent hope of overcoming the injustices in one's life and hope of a better tomorrow. Even though you may feel angry and sorrowful and feel oppressed at the moment, if you have Han, you can also have hope that you can overcome these injustices. The concept of Jiang is the feeling of affection, concern, understanding loyalty, warmth, and emotional connection to someone or something. You can feel Jiang for your family, friends, lovers, teachers, coworkers, strangers, and even for places or objects such as your hometown or first car. Why are we going over these terms? Because when you're working with a client that is from Korea or Japan or China, knowing some of their terms for their cultural concepts can help you communicate in a way that's meaningful to them. I told you that time is a little bit different when we talk about the Korean culture. Korean time describes the widespread tardiness or more specifically the relaxed attitude with which Koreans approach appointment times. Koreans were originally an agrarian society, so they got up whenever and went to work whenever the sun came up and they came home whenever the sun went down. It wasn't get to work at nine, leave at five. So everything kind of goes more with the rhythms of life than with the ticking of the clock. Being a few minutes late to an appointment without giving prior notice is almost the norm among friends and even being late by an hour or more is not uncommon. But when a Korean is the one having to wait, previously acceptable delays, even as little as five minutes, can be a big deal. So when you're scheduling, if you're scheduling a client who is Korean and you want to be respectful, hopefully everybody, but people who are Korean are going to take great offense if you run late. Common stressors among Koreans, parental pressures to succeed in academics. Discussing mental health concerns is considered taboo, causing many Asian Americans to dismiss, deny or neglect their symptoms. Pressure to live up to the model minority stereotype, which means that a lot of Americans believe Asians successfully integrate into mainstream culture and overcome the challenges of racial bias way easier than everybody else. We believe it's like a no-brainer for them to come over here. And that's not the case. So there's a lot of pressure to show that you're integrating well and to prove that you've got the stuff, so to speak. We have to help people figure out how to deal with that pressure, especially if they're not dealing with it well. They may feel like they're failing and we know that failure brings shame to the whole family. Family obligations are based on strong traditional cultural values. Discrimination due to racial or cultural background is another stressor. And difficulty in balancing two different cultures and developing a bicultural sense of self is another stressor that you may commonly talk about in counseling, especially if you're working with a Korean youth who is second generation or third generation. His or her parents have started to acculturate or have acculturated partially and they're trying to figure out where they fit in everything. The mental health stuff is probably still taboo even in the second and third generations. So opening up that door to how to discuss it, where they can get help, where they can get confidential help and providing early intervention tips and strategies. One of the things we want to do when we work with this population is not necessarily focus on preventing depression, but how to enhance your life, how to enhance your harmony with others through communication skills. And these different skills we're teaching, we can put them out there as strength-based tools to improve harmony instead of relief pathology. Traditional Asian expectations of women conflict with white American ideals that emphasize independent thinking, achievement and self-sufficiency, even at the expense of others' feelings and needs. So a lot of traditional Asian women may appear to be what we might term codependent and we don't want to pathologize that. These conflicting views can play out in several ways. Stress and conflict leading to isolation and withdrawal or acting out behaviors, which in turn can lead to depression. Spousal conflict can occur as women work in and interact with a culture in which their status is compared to that of their husband. So that dynamic in our culture tends to be more on equal footing and that can be very stressful in the traditional Asian household. Resistance or refusal of psychiatric treatment resulting from chronic low self-esteem can lead to a sense of fatalism. It is what it is. I'm destined to this. And among persons 15 to 24, you're not going to be tested on these numbers, but I think it's really important to know. Among 15 to 24 and older than 65, Asian females are at the greatest risk of suicide compared with women of all other racial groups. So if you're seeing an Asian woman who is in this age group, you know, be especially cognizant of that. Fear of help singing among the community believing if anyone finds out they will be ostracized is another stressor. So how can we make services available? Telemental health is one of those ways so they don't have to be seen going into a therapist's office. But, you know, telemental health, you have to make sure that they clear their caches and everything if they're worried about anybody and their family finding out. So there are a lot of issues that may come up, including safety and what's going to happen in your family if they find out that you're seeking counseling. Now, you know, a lot of times it's not a big deal, but if you have a client who's especially resistant to coming into the office, that might be an option. Distorted stereotypic images of Asian communities as evil, mysterious, exotic places filled with gangsters, warlords and prostitutes, which Hollywood movies and television networks often portray also creates another stressor because you're not necessarily seeing what the true Asian culture is like. So there's a lot of bad feelings and animosity towards Hollywood for the way that they perceive they're being interpreted or being what's the word I'm looking for shown in the media. Successful assessment of mental health persons in the Asian American patient is based on practitioner awareness of individual patient demography. Where do they come from? What are their normal symptoms? What are their culture-bound symptoms? The patient's belief about health and mental health, you know, so are they going to present more somatically or more with the psychiatric symptoms that we're more likely to see? Eliciting an explanatory model from the patient, what do you think is causing this problem? Negotiating around acceptable diagnoses and treatment, and some clients may, you know, really need that physiological diagnosis as opposed to the psychological to avoid bringing shame on their family. And the use of family support systems to increase adherence to treatment regimens and to reduce barriers. So complementary approaches. Traditional Chinese medicine. TCM practitioners don't see mental disorders as any one syndrome. They see it as a dysfunction in the system. TCM does treat specific symptoms. The goal is to rebalance the body's inner function. Some things that they may use include Tai Chi, acupuncture, Reiki, herbal medicine, nutrition, and feng shui. Now, we're going to talk a little bit about some of these, but don't be surprised if your clients want to integrate some of this into their treatment. There has been a ton of research done on Tai Chi and acupuncture specifically in its healing properties for physical and psychological issues as they come up. You can look that up on Google should you want to. Now, I said Yin and Yang theory is prevalent in Asian cultures. Yin typically represents night, dark, cold, negative, passive, female, solid, you know, those sorts of things. Damp is another one that will come up. Yang tends to represent day, light, warm, positive, active. So when you have these things, it's important to understand the way the image is drawn. When one starts to become bigger, the other one's chasing it. So you can have somebody who's depressed, for example, may have too much Yin. They may have too much negativity and depressing stuff, just holding them down and not enough Yang to compensate. So we might want to help them build up their Yang and reduce the Yin. By the same token, they may not have that much negative stuff going on in their life, but they don't have enough Yang. They don't have enough happiness in their life and they're just kind of blah. So we want to help them build that up and that is very oversimplified. But understanding that it's not just like neurotransmitters, it's not necessarily that you have too much of something. You may have not enough of whatever it is to balance it out. So it's always a balance and a harmony. Li Jima classified human beings into four main types based on the emotion that dominated their personality and developed treatments for each type. So people with too much Yang, not enough Yang, too much Yin or not enough Yin. Just knowing that so if you start to look at Chinese medicine and the way they perceive mental health, you kind of understand what they're talking about when they say greater Yang or lesser Yang. Moxibustion is a technique in which heat is applied to the body with a stick. The tool is placed over the affected area without burning the skin and the cone or stick can be placed over a pressure point to stimulate and strengthen the blood. So a brief introduction into Chi, Chakras and Meridians. Just again so you understand a little bit about where they're coming from. Chakras are spiritual energy centers and they tend to have, there are seven of them. Meridians are the energy paths in the body which the Chi flows through. One must have balanced Chakras and Meridians in order to be physically, emotionally, mentally and spiritually healthy. So if you want to think about Chakras as major metropolitan areas and Meridians as the streets that get you in and out of there, you know, maybe a poor metaphor but that's the best one I can come up with. The seven main Chakras are located at various points along the spine and correlate with the various Meridian points flowing along the spine. There are 12 main Meridians, six are Yin and six are Yang. So six are calming, six are energizing. Traditional acupuncture unblocks Meridians and is vital to allowing the free flow of Chi or life energy throughout the body. The article that I cited here and you can find many others acupuncture has been found to be as effective as cognitive behavioral therapy and comparable to the use of SSRIs in its effectiveness. If you combine acupuncture with CBT, then both of them have a boost. I mean it's like exponential acupuncture has also been identified as a prominent promising practice for use in addiction treatment to reduce cravings. So I do want to point out where I used to work, we did have acupuncturists come in and for those clients who were IV drug users, they had the option of using magnets on the around the ears in order to get a similar effect. So they weren't being exposed to the needles which were triggering for my IV drug users. Feng Shui, still working with Chi here. Chi is the life's breath or energy that binds life together. The practice of Feng Shui teaches us how to influence the Chi and its effect on our daily lives. According to Feng Shui, there are three main forces of Chi, the cosmic Chi, which is the force of nature, the human Chi, which is inside each person. That's what we were just talking about with acupressure or acupuncture meridians and chakras, and the earth Chi, which is the way the earth affects you, the forces of your physical environment. So when you walk outside, how do you feel when if you see roads and power lines versus mountains and streams? That's how it's affecting your Chi and impacting and influencing you. A couple of primer articles on Feng Shui. You do want to view the house as a whole being in which one part is intricately connected to another. So you've got people, clients who are living in their houses, hopefully, and this is an environment they spend a lot of time in. So clearing out the clutter and adjusting the energies within the house can be a helpful activity for people who, you know, think that Feng Shui would be an effective intervention for them. And there are Feng Shui practitioners that can guide them and give them consultations. The environment can be thought of as a reflection of your internal self. So if you've got a chaotic, messy, dark environment, that's probably a reflection of what's going on inside you. And I found this to be true 99% of the time. You know, if when my environment is chaotic, it usually means I've got 15 projects I'm trying to juggle and my life is chaotic. And I'm feeling kind of pulled six different directions. When my environment is calm and clutter free, tend to represent that's kind of how my mind is to your environment has an effect on your energy on a constant basis. So to create Feng Shui in your home, first identify the areas that need the most attention and define the steps necessary to improve these areas. I personally really loved the Feng Shui for Dummies book. And because it gives you that quick and dirty outline where you can start feeling empowered to make your environment a healthier place, but it's not overwhelming with theory. Many people completely ignore the areas that feel like too much work such as the attached garage, laundry groomer closets. Well, you know, think about it. When we do counseling, what do people often ignore or avoid those skeletons they've got in the back of the closet. They want to feel better right now, but they don't want to talk about this stuff over here because that's overwhelming to think about. Well, when I think about cleaning out my one car garage, that's overwhelming too. So it kind of parallels what's going on with clients. So they may avoid the things that they that feel like too much work that may help them find more harmony. The Bagua is used to identify different areas in the home and different colors to help create or help free up the flow of Qi and we don't have time to go into all that right now. But the Bagua is really interesting if you put it on your home and you can figure out how you might be able to use colors to enhance the energy and the flow in your house. Tai Chi is a gentle exercise program that is part of traditional Chinese medicine. It's composed of slow deliberate movements, meditation and deep breathing, which enhance physical health and emotional well being. So those slow deliberate movements, you know, think about it, if you're doing those or if you do yoga, you're probably quite familiar. You're making movements and you're holding them, which is helping kind of realign those muscles as you're making these movements. Those muscles are loosening up and some of that pain is going away and you're theoretically bringing in more oxygen, getting the blood flowing more, which helps the Qi move around in your body. Tai Chi is based on spiritual and philosophical ideas that advocate a need for balance in the body, mind and spirit. Central to Tai Chi is the idea that Qi flows throughout the body and must be able to move freely for good health. The principle of Yin and Yang is important too. They are opposite and complementary forces in the universe in the same way that light and dark are. And Tai Chi is meant to harmonize these pairs of opposites. So whenever there's a push motion, there's a corresponding pull motion when the front and the back are also balanced with one another. Finally, Tai Chi imitates motion found in nature, such as movements of animals, thereby uniting human beings with the natural world. So you can go online and you can look at videos on YouTube on the basic Tai Chi movements and get an understanding of the push and the pull and the Yin and the Yang and look at how it might improve health, well-being, etc. But they found even with people who are wheelchair bound or who have significant problems because of arthritis that Tai Chi provides significant pain relief and improvement in mood and outlook. Tai Chi's three main components, movement. All of the major muscle groups and joints are needed for the slow, gentle movements. It improves balance, agility, strength, flexibility, stamina, muscle tone and coordination, which is important, especially for older people and even adolescents who are trying to, their bodies just growing at these weird rates. Tai Chi can help them develop some skills so they feel less self-conscious and they feel more independent and empowered. Meditation soothes the mind, enhances concentration, reduces anxiety and lowers blood pressure and heart rate. And deep breathing increases the lung capacity, stretches the muscles involved in breathing, releases tension, slows the heart rate, enhances blood circulation to the brain, boosts mental alertness, partly because of the increased oxygen and blood flow, and supplies the entire body with fresh oxygen and nutrients, which helps energize people. A lot of times in American culture, we breathe really shallowly and, you know, it's not that, you know, there's anything wrong with us. We just don't breathe deeply, which keeps us from getting as much oxygenated blood. One of the main reasons that we yawn is not because we're tired, but because we're not getting enough oxygen into our system. So our body goes, well, you need to take a big old breath now. Tips for providers. Checking for understanding is critical when working with Asian clients. It's all too easy to misinterpret a common gesture as agreement or understanding when the patient is actually confused or even resistant to a diagnosis or treatment. There was an incident that came up at the Dojang a few weeks back, and there was a... One of the people had their gi tied in a certain way, and it was backwards. And there was differences in interpretation about exactly what that meant. And when they asked Grandmaster, you know, does this mean this? He just kind of nodded his head and shook and said, sure. And I don't think he really understood what it said because upon closer looking at what that actually meant, the two concepts were not equal. So it's important to not just assume that the other person understands what's going on or understands the language that you're using. Asian patients and families will often be reluctant to complain or ask for clarification. So we need to ask them to tell us what's going on. If we ask, do you understand, they're going to say yes. So we need to ask more specifically. So what is it that you're going to be working on over the next week? Avoid using the use of yes or no questions because we need to elicit more from them than that because they're most likely going to agree with whatever they think that we want them to agree with. Establish the professionals role and assume authority. So this is a little bit different, not the collegial thing, but we do need to assume authority and command respect. Check for understanding. Be patient and consider periods of silence opportunities for reflection on what has been said. Don't cut those silences short. It's really important to allow them to think about what's going on and for you to take what they've said and cherish that for a few minutes and sit with it in order to get the full meaning. Provide clear and full information such as what's expected from each participant in the discussion. So when you're talking about treatment issues or when you're talking about goals for next week, be clear about what needs to be done. Even write it down. Be attentive to nonverbal cues because most Asian cultures have high context communication styles. So if they're nonverbals indicate that they're closing off, we want to stop and address that. Address immediate needs and give concrete advice. Avoid direct conflict and reach consensus by compromise. It's most effective to educate the entire family while treating the patient because it is a family unit and we're looking how everything that we ask the patient to do, we need to consider how that impacts the family unit. When seeing Asian American patients, the family often accompanies the patient into the interview room. So don't be surprised if that happens. If you go to bring Mr. Jim back and the entire family starts coming with him, okay. As long as he's okay with that, then that's perfectly acceptable and that's actually more culturally sanctioned than him going into the room by himself. All right. We covered a whole lot of territory in an hour. Are there any questions? And yes, remember that what we've talked about are generalizations. There are starting points to figure out, you know, what might be present when working with someone from a different culture, but you've got to figure out from them and you've got to talk to them and see what level of a culturation they're at. All right, everybody have happy holidays. Merry Christmas and I will see you next week. Thank you.