Advanced Psychopathology

Thursday, April 13, 2006

 

Ethnic Russian Immigrants in New York: Cultural and Historical Factors that Contribute to their Psychology

Any idiot can face a crisis – it’s day to day living that wears you out.”
-Anton Chekhov

By, James Ellis

It has often been said that America is a melting pot of different cultures and ethnicities. This metaphor is problematic because it implies an integration of unique components that have melted together into one. In this metaphor individual identity is lost. Many view New York City as the epicenter of this infamous pot. In a broad historical spectrum this may be the case. However, with its rich cultural landscape and ethnically diverse neighborhoods, New York is also a place where immigrants settle and retain a great deal of their cultural and ethnic identities.
As a mental health care provider, it is essential to recognize and understand the unique cultural and ethnic factors that are an integral aspect of a patient’s psychology. Due to the heavy concentration of Russians in neighborhoods like Brighton Beach in Brooklyn and Forest Hills in Queens, it is likely that this population will be in need not only of mental health services, but a clinician who understand their unique cultural and ethnic identities.

It is estimated that up to 36% of New York City residents are foreign born. Of these immigrants, roughly 3% are of Russian descent (http://nyc.gov, April 2, 2006 ). Many of these Russians are Jews who fled their country seeking political asylum from religious persecution. However, many are ethnic Russians who share some common characteristics with their Jewish countrymen, but also exhibit unique concerns of their own.

The first wave of Russian emigration began in 1917 when the Revolution sent hundreds of thousands into exile in America and Western Europe (Althausen, pg. 680). Russia was also devastated by the atrocities of World War II and many Russians who sought refuge in the West chose not to return for fear of being persecuted as “betrayers of the motherland” by Stalin. More recently, the fall of the Soviet Union in 1991 lifted the ban on emigration which thousands of Russians have taken advantage of, seeking a better life from the economic and social upheavals of the post-Soviet era (Althausen, pg. 681).

Despite the dire circumstances that Russian immigrants might be leaving behind, abandoning their homeland is often quite difficult emotionally. Russians are well known for their attachment to their country of birth, which they call rodina (motherland) or, even more affectionately, Rossiya-matushka which translates to ‘little mother Russia’ (Althausen, pg. 680). This concept of Russia in a “parental” role extends much further than a nickname for the homeland. The nature of Soviet communism instilled a collectivistic mentality in which the government was in a paternal (provider) role with the citizens as its children, an extended network of brothers and sisters. In Soviet times citizens appropriately regarded one another as camarades, and they often still do.

In the Soviet communistic system, equality was paramount. While many think that this simply involved shared labor, it extended to gender roles, social systems, and family arenas as well (Levant, et al., 2003). Together, these ideals were intended to create a cohesive and independent society that was far more progressive than the rest of the civilized world. The impact this had on the psychology of Russians was in some cases beneficial and in other cases quite detrimental.

Children in the Soviet Union were seen as the vehicles that would carry the communist tradition into the future. Their upbringing was viewed as a delicate matter, and it was considered important to shape their nationalistic mentality from an early age. As a result, the government taught parenting to its citizens. This traditional Soviet pedagogy promoted child-rearing methods that were designed to foster values supportive of citizenship in a totalitarian socialist society. These values included conformity, loyalty, group-mindedness, and unquestioning acceptance of authority (Hart, et al., 1998). The government pedagogy did not assign the family primary responsibility for the upbringing of the child. Instead, “a collective-centered system of child rearing was developed in which families were considered to be an organic part of Soviet society…and persons outside the family were viewed as having primary roles in the collective upbringing of children”(Hart, et al., 1998). This system often involved relatives, neighbors, and, most importantly, teachers in school.

Soviet schooling was quite different than in the West. The start of school each year, the first day of September, was a national holiday. On this eventful day children and their parents attended traditional soviet ceremonies which were designed to instill a sense of nationalism and camaraderie between generations as well as an induction rite for the youngest members of the society (Goldenberg & Saxe, 1996). Once the school year was underway, subjects studied were largely vocational and historical in order to provide practical skills for jobs while still promoting nationalism. Teachers had permission to discipline students with whatever means necessary. Nevertheless, in Soviet times punishment usually involved group sanctions which were designed to threaten exclusion of group membership (Hart, et al., 1998). By the early 1990s, however, after the fall of the Soviet Union, philosophical shifts on school curriculum were evident. Both parents and teachers “appeared to favor democratic nuturant, child rearing strategies to promote more independent thinking and autonomous behavior in children”(Hart, et al., 1998).
Gender roles were also greatly influenced by the Soviet system. Although Russia has always been a predominately patriarchal society, women traditionally maintained much more responsibility than in the West. In forming their new society, early Bolshevik leaders attempted to establish equal opportunities for women in political, social, economic, and family arenas (Levant, et al., 2003). While it may seem progressive, these ideals were never fully realized as men continued to have better jobs. Women were still required to work, but were additionally relegated most child care duties as they were deemed more suited to taking care of children and the home (Kukhterin, 2000). Furthermore, men were often physically or mentally unable to help women domestically because they were “absent or disabled, due to the combined effect of three devastating wars (1914-1918; 1918-1920; 1941-1945), Stalin’s terror (1936-1953), and continued widespread alcoholism” (Althausen, pg. 682).

Russian masculinity ideology has also experienced drastic shifts depending on the historical context. In the 1970s Russia experienced a low birthrate crisis. Inadequate gender roles were blamed for this phenomenon. The government criticized men for becoming feminized while over-worked Soviet women were criticized for being neglectful of their families (Levant, et al., 2003). Bolshevik leaders insisted that men and women return to more traditional gender roles. Likewise, the fall of the Soviet Union and a move towards a market economy in 1991 was seen as a reason to reassume traditional male responsibilities. It was thought that capitalism was a system in which traditional male roles were highly valued and beneficial (Levant, et al., 2003). Yet, Russian boys during this time were at a disadvantage. Due to the frequency of absent or incapacitated fathers, they lacked opportunities to have masculine behaviors modeled and reinforced (Levant, et al., 2003).

Perhaps most startling is data which suggest that although men’s life expectancy has generally decreased since 1965, the rate of decrease rapidly accelerated in the 1990s (Cockerham, 2000). From 1991 to 1999, men’s life expectancy dropped from 63.5 years to 59.9 years respectively (Cockerham, 2000). This data also notes that women’s life expectancies also declined in the 1990s. However, they did not decline nearly as much as men’s, decreasing only from 74.3 years to 72.4 years during that decade (Cockerham, 2000). It is thought that possible factors for the decline of life expectancy in men involve unhealthy behaviors such as heavy drinking, smoking, not sleeping enough, avoiding doctors, overworking, and rarely taking vacations which are all part of the traditional notion of the “real man” in Russia (Levant, et al., 2003).

While many of these Soviet-influenced values are still inherent, today’s Russian-American family values and loyalties have formed largely in response to the prevailing conditions of economic deprivation and political oppression (Althausen, pg. 681). After the collapse of the Soviet Union, Russia essentially abandoned its insular system and joined the world economy. Unfortunately, the country lacked an adequate economic infrastructure that could handle this change (Jose, et al., 1998). The value of the ruble plummeted and citizens who were relying on government subsidies became very poor. Often parents had to take second or third jobs just to meet basic necessities for living (Jose, et al., 1998). Drawing on their collectivistic mentality, Russians often relied on the extended family’s combined resources, both financially and socially. Grandparents often lived in the house and provide care for the young as well as financial support. Following suit, adult children were expected to assume responsibility and care for their aging parents (Althausen, pg.682). This domicile structure continues even today in Russian immigrant families.

As far as mental health is concerned, Russians tend to assume the Buddhist position that life is suffering. Based on their quality of life circumstances, it is not difficult to understand why this position has been adopted. In an essay on Russian families, Leonid Althausen describes the meaning of a Russian word that is relevant to this notion, toska:
"For Russians, suffering is not only a natural part of life, but it also has a certain redemptive value. In the Russian lexicon of psychological pain, arguably the most important word is toska, which connotes melancholy, depression, yearning, anguish, pangs of love, ennui, weariness, tedium, boredom, and nostalgia all rolled into one. However, the word does not have negative connotations; almost any thinking individual was expected to have this malaise to some degree" (pg. 682).

Althausen contrasts this with the very American values of constantly maintaining a positive attitude and having the belief that a solution to life’s problems can always be found. In working with Russian patients it is important to realize that what might be conceptualized as a depressive mood might simply be a normal case of toska (Althausen, pg. 682).

Despite the social acceptance of melancholic moods, Russians are generally reluctant to discuss psychological suffering with others (Althausen, pg. 683). This is in part due to the socially valued custom of keeping “strong” and not buckling in the face of Soviet life’s adversities. Even within the family system, suffering is seldom expressed. Keeping personal information private serves an adaptive function since it is common for a multigenerational extended family to share one small apartment (Althausen, pg. 683). As a result, it is not common for Russians to engage in help-seeking behavior.

Pervasive alcoholism is perhaps the stereotype most frequently associated with Russians. Its prevalence is estimated at anywhere from 66% to 80% in ethnic Russian men (Goodman, et al., 2005). This statistic is difficult to estimate more precisely due to the fact that Russian men often avoid healthcare in general. As Leonid Althausen states, “in a nation that keeps its suffering to itself, and where neither antidepressant medication nor psychotherapy has yet taken root, vodka is widely regarded as the remedy for a range of physical and emotional problems” (pg. 683). Consequently, alcohol abuse is cited as one of the major contributing factors to the high death rates of men in the 1990s (Levant, et al., 2003). In addition to alcoholic poisoning, it is believed that pervasive drinking is a major contributing factor in the high rates of suicide and homicide among Russian men (Levant, et al., 2003). In the family system, alcohol abuse is often condoned if it makes the drinker more socially engaged and convivial. There is much denial surrounding the dangers with drinking and popular belief has it that one only has a drinking problem when one drinks in solitude (Althausen, pg. 683). It is noted that in contemporary Russia, drinking and its negative consequences are much less common among the intelligentsia than among the working class (Althausen, pg. 683).

As with many other immigrant groups, ethnic Russian immigrants’ well-being will be contingent on the dual tasks of mastering the new culture and resolving the grief surrounding the loss of their motherland (Althausen, pg. 685). While emigration is no longer prohibited, psychologically it may still elicit feelings of shame for leaving rodina and the extended family (Althausen, pg. 684). Unlike Jewish Russians who are automatically given refugee status and allowed to immigrate with their elderly parents and children, ethnic Russians can not do so until they have been awarded their U.S. citizenship (Althausen, pg. 684). This exhausting process can take many years and often times family members in Russia are rejected during the screening process due to annual quotas maintained by the federal government.

Once in New York, many Russians are lucky enough to join other expatriates in Russian neighborhoods such as Brighton Beach and Forest Hills. Still, Americans tend to perceive all immigrants from the former Soviet Union as “Russian” and, since the majority are Jewish, ethnic Russians may become “lost in the shuffle” (Althausen, pg. 684). Furthermore, ethnic Russians may not “receive the attention and resettlement resources given to their Jewish countrymen by the local Jewish community” (Althausen, pg. 684).

While Russian immigrants may underutilize mental health services this does not mean that they need fewer services. If we can better understand their cultural complexities, we may be able to ease the discomfort associated with help-seeking behavior. For starters, Russians often have shameful feelings about “resorting” to psychotherapy. In the interest of establishing a rapport with a Russian patient, “it may sometimes be necessary to de-emphasize the ‘mental health’ aspect of work by using appropriate euphemisms that are more acceptable culturally”(Althausen, pg. 684). In Leonid Althausen’s essay, he provides a case example of a young boy who was referred to therapy because he refused to continue speaking Russian with his parents. His Russian parents were reluctant to put their child into psychotherapy. However, when it was suggested that they make an appointment with Dr. Althausen, a “tutor” who can help their child emotionally reconnect with his native tongue, the parents had no objections (pg. 685).

Once in session with a Russian patient it will be important to begin by clarifying the role of the therapist. In Russian, the word “therapist” (terapevt) means “physician”, so the patient might expect a therapist to write a prescription. Also, it will be important to begin by acknowledging the Russian patient’s courage and achievement in transplanting themselves to the New World (Althausen, pg. 685). This will help convey confidence from the therapist in their ability to resolve their problems, and ultimately have a more meaningful experience in their new life.

Wednesday, April 12, 2006

 

Life Across the Border: Family Composition and Mental Health Behavior of Mexican Americans

Desiree Castillo
Psyc 755-Psychopathology II
Ethnicity Paper
4/10/06

Mexican Americans


Results of the U.S. Census Bureau (2001; as cited in Sharma & Kerl, 2002) found that there are an estimated 32.8 million people of Latino origin living in the United States. It is predicted that this number will increase from about 10% of the U.S. population in 1990 to 14% or 15% by the year 2020, making this group one of the four largest ethnic groups in the country (Garcia & Marotta, 1997; as cited in Sharma & Kerl, 2002). Falicov (1998) wrote that Mexican Americans account for 64% of the total Latino population, comprising the largest Latino group in the United States. California and Texas encompass nearly half of the total Latino population, with nearly 25% of the population in each of these two states being of Mexican American descent (Garcia & Marotta, 1997; as cited in Sharma & Kerl, 2002). Estimates indicate, based on combined percentages with 2000 population statistics, that there are about 20 million people of Mexican American descent living in the United States today. Mexican Americans constitute a significant component of the overall Latino population in that they have many shared experiences and cultural beliefs representative of the Latino culture as a whole. In addition, however, they have different migration patterns and influences upon the American economic infrastructure that are distinctive of Mexicans.
Typical Family Constellations and Family Roles & Attitudes Towards Independence and Dependence:
From a family systems perspective, Mexican American families can be characterized as encompassing a preference for traditional family arrangements where lifelong, parent-child cohesion and high levels of respect for parental authority are revered and expected. Strong religious beliefs (Roman Catholicism) and a need to garner support from a variety of economic resources further encourages the tendency to have large families consisting of four or more children and with extended family members playing an active role in the activities of daily family life. The need for a sense of strong familial interconnectedness, or sense of “familismo” is especially keen among Mexican American immigrant families who have often times experienced great hardship and sacrifice due to the need for certain family members, namely women, to stay behind in Mexico while her husband or sons(s) migrate to the United States in search of better employment opportunities (Falicov, 1998). Although many Mexicans choose to migrate to the United States, many do so only out of significant economic need and if given a choice, many would choose to maintain their sense of culture and family unity by staying in their villages and homes in their native land (Falicov, 1998).
The path to better economic opportunities in the United States is often fraught with extreme physical and mental hardship, the constant threat of being detected by American immigration authorities, and the possibility of being physically harmed, robbed, or abandoned by their “coyotes,” the people who are hired to help them cross the American border (Falicov, 1998). Despite these ever-present dangers, every year millions of undocumented Mexican immigrants successfully cross the border and enter into the United States only to be met with problems related to harsh, unsafe working conditions, language barriers, the constant threat of deportation and experiences with ethnic discrimination and stereotyping (Sharma & Kerl, 2002). All of these possible negative experiences reinforce the need for strong, supportive interconnected family ties and a sense of unity with immediate and extended family members.
The importance of cohesion and sense of interdependence is the hallmark of the concept of familismo. Mexican American culture and the emphasis placed on family relations supports the notion that the family unit is more valued and more greatly revered than the individual (Sharma & Kerl, 2002). The construct of familismo is highlighted by the importance placed upon cyclic rituals by Mexicans. One example of a cyclic ritual is the la comida semanal (the weekly meal) in which all members of the extended family unit partake in the ritualized celebration of sharing stories and time together over a large meal (Falicov, 1998). In addition to household duties, the benefits of working in a collective family group extend to achieving greater financial responsibility, emotional support, help with child-rearing duties, and a more collectivistic approach to problem solving.
In terms of the roles of children in Mexican culture, it is dictated by unspoken rules within their culture that children of all ages must respect and obey their parents at all times. This is an especially difficult struggle for children, particularly adolescents, who must tow the line carefully between assimilating to the cultural norms of their adopted American culture and the traditional beliefs strongly adhered to by their parents, which tend to lie in direct contrast with mainstream American beliefs. Many Mexican American children who are first generation are expected by parents to do well in school and to adopt the English language. In contrast, they are expected to strictly adhere to the more traditional Mexican beliefs of speaking Spanish at home, participating fully in all family functions, and listening to the guidance of parents and other respected elders (Falicov, 1998).
Strong familial bonds between siblings are also a crucial component to the Mexican American family structure. Older siblings are usually called upon to take care of and protect younger siblings, in turn serving as a surrogate mother/father for when parents have become too old or have passed away and are unable to care for younger children. In addition, Mexican American siblings tend to act as a confidante and supporter to each other, reinforcing family bonds that extend to each other’s children and future generations of family members. Siblings tend to reflect the roles of their parents in that sisters tend to act nurturing and emotionally supportive towards siblings, whereas brothers tend to act protective and provide financial support and mentoring to other siblings (Falicov, 1998).
Attitudes Towards Different Gender Roles:
A major component of the family unit in Mexican American families relates to the notion of family member roles, in particular the roles of women and their position within the family system. The concept of marriage and the stratified gender roles ever-present in traditional Mexican families have come under increased scrutiny and pressure in the past three decades due to factors related to assimilation with the mainstream American culture that lie in direct contrast with more traditional notions of gender in the Mexican culture. Often the focus of marriage in Mexican society is on the concept of parenthood instead of partnerhood. Spouses often focus on their role as “mothers” and “fathers” instead of their roles as husbands and wives (Falicov, 1998). The sanctity of marriage is often held together because of obligations as parents and to firmly held religious beliefs that oppose divorce or separation, although as more Mexican Americans become increasingly integrated into American society, the divorce rate among Mexican Americans has risen significantly (Falicov, 1998).
When focusing on Latino culture and in particular Mexican culture, significant emphasis must be paid to the concepts of machismo and marianismo. Machismo relates to the idea of the concept of manliness among Latino men. This construct dictates that a Latino man should be strong in character and physicality, be virile and able to provide for and protect his family (Falicov, 1998). Initially, the concept of machismo had overwhelmingly positive connotations, but as the concept grew to be more closely associated with domination towards women and infidelity within marriage, the notion of machismo has come to embody negative aspects in more recent decades. In terms of stereotyped gender roles for women, the female Latina often times must struggle with her female identity being fused into her identity as a wife and mother. Traditional notions of womanhood categorize women into two distinctive groups “the good ones” and “the bad ones” (Falicov, 1998). The good ones are likened to the image of the Virgin Mary and maintain the image of the sacred mother and submissive and devoted wife who must only be sexual for the purposes of procreation. She maintains the concept of “Marianismo” (like the Virgin Mary) by adhering to self-sacrificing practices and a strong sense of fidelity to her husband and children, causing almost complete negation of her needs as a woman for sexual satisfaction or for her own wants, desires, drives or ambitions in life to be acknowledged. In contrast, “bad women” are categorized as those whom Latin men would engage in sexual relations with outside of the family unit, but who would remain hidden and kept on a lower status than wives. In addition, it is not seen as uncommon for many Mexican men to have separate families (“la casa chica”-the little house) with a mistress whom he provides for, but who does not garner the same level of status or privileges as the legitimate children and wife (Falicov, 1998).
Culturally Defined Symptoms & Attitudes Towards Psychological Problems and Help:
Many mental illnesses that have been categorically defined in the DSM-IV by a list of definitive symptoms that serve to characterize the illness have significantly similar manifestations in Mexican culture but are defined differently. Many culturally-bound syndromes are explained as “folk illnesses” and are treated with folk medicine cures. Harwood (1981; as cited in Falicov, 1998) conducted a study in which he found that for Mexican American traditional folk concepts the majority of ailments fall under the category of males naturales (natural illnesses) and the remaining fall under the category of mal puesto (witchcraft). In terms of conceptualizing these illnesses, the most common ailments are mal de ojo (the evil eye), susto or espanto (fright), empacho (indigestion), nervios and ataque de nervios (Falicov, 1998). Susto can be characterized by bouts of restlessness, listlessness, diarrhea, vomiting, weight loss or lack of motivation after experiencing a traumatic event such as a car accident or after watching a violent act occur. In mainstream American society, susto would most likely resemble the effects of Post Traumatic Stress Disorder (PTSD) in which flashbacks and feeling of anxiety and helplessness occur after experiencing trauma. Mal de ojo is a common ailment in many Mediterranean cultures and is usually linked with witchcraft, or the ability for a person with strong supernatural powers to exert negative influences over the health of another. A person with mal de ojo typically experiences uncontrollable weeping, fretfulness, insomnia and many other symptoms that are on par with depression-like or anxiety type symptoms. Empacho describes an ailment of the stomach where an individual experiences bloating, intestinal blockage or issues related to stomach disturbances which seems to characterize an ailment akin to indigestion, irritable bowel syndrome, or acid reflux disease. Nervios or ataque de nervios relates to experiences of crying or shouting spells, nervousness, fainting, hyperventilation and perhaps even amnesia (Falicov, 1998). This disorder tends to be more prevalent among women from lower socioeconomic status and is usually interpreted as an acceptable reaction to a highly stressful or shocking event, such as a sudden death in the family or acute trauma. Highly dramatized reactions among Mexicans, in particular women, appears to be a socially acceptable and psychologically sound way of coping with the stresses of traumatic experiences.
In terms of more severe psychological disturbances such as schizophrenia, many of these chronic and treatment-resistant illness are characterized as being the result of brujeria (withcraft). It is typically believed among Mexicans (especially those from a low socioeconomic status) that when ailments cannot be explained by natural folk illnesses, that mal puesto (bewitchment) must be at play in which those with severe and chronic symptoms are believed to have had a hex placed on them by a witch or sorcerer (Falicov, 1998). In order to cope with such ailments, it is typical in Mexican culture to seek the help of a curandero (folk healer) who are called upon to ward off evil spirits and to cure the body of all ailments through the use of rituals, candles and herbs. Many of the curandero’s ritualized treatments are related to the notion of espiritismo, or the belief that good and evil exist in an invisible world where it can attach itself to humans through spirits that in turn influence the behavior of the individual to whom they are attached (Falicov, 1998). In addition, religious beliefs, particularly those of the Roman Catholic religion, play an important role in how mental and physical disorders are conceptualized and responded to. Many Mexicans believe that if one is struck with a physical or mental ailment, it is the will of God and that one must pray to God and saints in order to receive help with the difficulties that living with these disorders presents for the afflicted individual as well as their family. It is typical for Mexicans to believe that God will protect them and forgive them for their sins as long as they perform rituals and behave in line with what the Bible dictates as acceptable behavior.
Snyder, Lopez, Polo, Karno, Hipke, Jenkins and Vaughn (2004) conducted a study that followed up on two previously performed analyses of Mexican American and Anglo American patients and families and their expressed emotion and attributions towards a family member with schizophrenia. The results of the study found that patients with schizophrenia who were discharged to a family environment with high levels of criticism, hostility, or emotional overinvolvement were more likely to relapse than patients who returned to families with low levels of the same negative emotional and/or attitudinal attributes (Butzlaff & Hooley, 1998; as cited in Snyder, Lopez, Polo, Karno, Hipke, Jenkins and Vaughn, 2004). In addition, this study found that for Mexican Americans, family warmth was a significant protective factor against the patient’s tendency to relapse whereas for the Anglo Americans, family criticism was found to be a significant risk factor for the chance of relapse for the patient (Snyder et al., 2004). The results of this study were significant in that it provided further evidence to support the notion that social factors are related to the course and treatment of schizophrenia and identified the need for family treatments that incorporate psycheducation, communication, and problem-solving skills training in order to create more positive emotional and/or attitudinal attributes in the family’s social environment. In addition, this study found that for Mexican Americans, family warmth was a significant protective factor against the patient’s tendency to relapse whereas for the Anglo Americans, family criticism was found to be a significant risk factor for the chance of relapse for the patient (Snyder et al., 2004).
Attitudes towards seeking psychological help among Mexican Americans is one of initial caution and mistrust. Mexican Americans tend to seek advice and counsel from those whom they trust, namely family members and elders within their community. Underutilization of mental health services among Mexican Americans is common due to many obstacles such as a language barrier and the lack of sufficient health insurance due to their undocumented status (Falicov, 1998). A sense of personalismo (personalism) between the therapist and client is one of the keys to allowing the client to feel more comfortable in the therapeutic setting and to allow for more disclosure on the part of the patient (Falicov, 1998).
Implications for Psychological Treatment:
When working with Mexican Americans, it is important for therapists to address cultural differences that may exist between therapist and client as well as for the therapist to outline the expectations and procedures typical of therapy in addition to addressing any concerns the patient/s may have regarding the therapeutic process (Falicov, 1998). A sense of confianza (trust) between patient/s and therapist is one of the crucial components to engaging and retaining Mexican American clients in therapy. Pamela Hays (2001) devised a model with the acronym ADDRESSING for conceptualizing cross-cultural work. The main ideas of this model are to create a foundation for the therapist to be culturally responsive to the needs of minority clients, and thus this would be a beneficial model for working with Mexican Americans. The components of the ADDRESSING model are:
• Age and generational influences (e.g., children, adolescents, elders)
• Disability (e.g., people who have developmental or acquired physical, cognitive, psychological disabilities)
• Religion and spiritual orientation (e.g., people of Muslim, Jewish, Christian, Hindu, other minority religions and faiths)
• Ethnicity (e.g., people of Asian, South Asian, Latino, African American, Middle Eastern heritage)
• Socioeconomic status (e.g., people of lower status by occupation, education, income, rural or urban habitat, family name)
• Sexual orientation (e.g., people who are gay, lesbian, bisexual)
Indigenous heritage (e.g., in North America—American Indians, Alaska Natives, Samoans)
• National Origin (e.g., immigrants, refugees, international students)
• Gender (e.g., women, transgender people)
The utilization of Hay’s ADDRESSING model with Mexican American patients would possibly provide several benefits such as an ongoing involvement in one’s own cultural self-assessment and learning about other cultures, recognition of the possible significance of diverse cultural identities and influences in a client’s life and consideration of the interaction between the therapist’s and the client’s identities as well as the establishment of meaningful connections with clients (Hays 2001).
In another study, Constantine and Baron (1997) found that educational attainment for Mexican Americans (Chicanos(as) had discouraging results. Although Mexican Americans constitute the largest percentage of the Latino population, they are also one of the least educated. In terms of successful completion rates for four years or more of college, Mexican Americans fall behind other Latino groups (20.2% Cubans, 9.7% for Puerto Ricans, and 5.4% for Mexican Americans) and also in comparison to Asians (39.9%), Whites (28.5%), African Americans (11.4%) (Aguirre & Martinez, 1993: U.S. Bureau of the Census, 1991). Constantine and Baron (1997) conducted a study in which they found that three constructs in particular are of concern when addressing the mental health needs of chicano(a) college students: acculturation, ethnic identity development, and gender role socialization. Acculturation variables refer to the notion of how assimilated or acculturated a Chicano(a) college student may be to mainstream American society. If the student is not fluent in English, it would be necessary to provide a bilingual therapist for this student in the student psychological services clinic. Ethnic Identity Development refers to how the Chicano(a) student may have internalized racial stereotypes about Mexicans and how they identify themselves culturally and ethnically. Gender role socialization concerns the degree to which the Chicano(a) student adheres to traditional gender role behaviors and how they view male/female relationships (Constantine & Baron, 1997). Assessing these three major constructs enables the therapist to take a more proactive and empathic stance towards addressing the needs of these Mexican American students more efficiently and appropriately.
Mexican Americans are a group that has a strong presence and influence in the Unites States. They are a culture characterized by deep interpersonal relationships and interdependence on family members. Many Mexican Americans encounter hardship and adversity during the transmigration process to the United States, yet many succeed in establishing a successful life and gain better employment opportunities and living conditions for their families as a result. Mexican Americans continue to be a driving force within the American economy and have shown to display better therapeutic outcomes when specific cultural needs have been sufficiently addressed by mental health workers. As the population of Mexican Americans continues to increase within the United States, so too will the need for creating better and more productive means of addressing their mental health concerns.












Annotated Bibliography

Aguirre, A., Jr., & Martinez, R. (1993). Chicanos in higher education: Issues and
dilemmas for the 21st century (ASHE-ERIC Higher Education Report No.3). Washington, DC: George Washington University, School of Education and Human Development.
Aguirre and Martinez outline issues and dilemmas that Chicano college aged students face in higher education. A framework is provided for addressing these issues and suggestions for implementing possible solutions for these problems are addressed. An interesting source for clinicians of any level to understanding obstacles Chicanos face surrounding entering into and completing higher education.


Constantine, M. G., & Baron, A. (1997). Assessing and Counseling Chicano(a) College
Students: A Conceptual and Practical Framework. American Counseling Association, Alexandria, VA.
Constantine and Baron give detailed statistics regarding the discouraging percentage of Mexican Americans (Chicanos(as) that complete four or more years of college in comparison with other Latino and other cultural groups. Factors are identified regarding key issues clinicians should address when working with Mexican American college students and a framework is provided for implementing effective measures for addressing these issues in practice. A useful chapter for identifying specific concerns of the Mexican American college aged population.


Falicov, C.J. (1998). Latino Families in Therapy. The Guilford Press, New York, NY.
Falicov identifies typical issues related to working with Latino clients (mainly Mexicans, Puerto Ricans, Cubans, and Dominicans) in the therapeutic setting. She defines these issues through a comprehensive and detailed analysis of many components of the lifestyles and cultural specificities of these particular Latino groups. This book is a valuable tool for clinicians at any level, for it provides a comprehensive and structured model for working effectively with Latino clients and their families.


Hays, P. (2001). Addressing cultural complexities in
practice: a framework for clinicians and counselors.
Washington, DC: American Psychological Association.
Hays describes her ADDRESSING model for conceptualizing cross-cultural work. She outlines a cohesive framework for conducting an ethno-cultural assessment for working with clients who come from various multicultural backgrounds. This book is a valuable resource for mental health clinicians at any level of experience for it addresses ways for becoming a more culturally responsive therapist.


Sharma, P., & Kerl, S.B. (2002). Suggestions for Psychologists Working With Mexican
American Individuals and Families in Health Care Settings. Rehabilitation Psychology, 47, 230-239.
Sharma and Kerl discuss key cultural factors related to the therapeutic treatment of Mexican Americans. They give a thorough background analysis of typical Mexican American cultural values, attitudes, and behaviors and address these factors in explaining how to appropriately address cultural issues in therapy with Mexican American clients. A valuable study for clinicians of any level, due to specific suggestions for working with Mexican American patients being offered.


Snyder, K.S., Lopez, S.R, Polo, A.J., Karno, M., Hipke, K.N., Jenkins, J.H., Vaugh, C.
(2004). Ethnicity, Expressed Emotion, Attributions, and Course of Schizophrenia: Family Warmth Matters. Journal of Abnormal Psychology, 113, 428-439.
The authors examined the role of family factors and the course of schizophrenia by conducting additional assessments based on two previous studies of Mexican American and Anglo American patients and families. The authors found that for Mexican American families, family warmth is a significant protective factor against relapse and for Anglo American families, family criticism is a significant risk factor for the family member with schizophrenia regarding potential for relapse. Interesting study for understanding that social factors are related to the course of schizophrenia and that several changes can be made in creating family treatments which encompass components to combat negative emotional/attitudinal attributes.


U.S. Bureau of the Census. (1991). The Hispanic population in the United States, March
1990. Washington, DC: U.S. Government Printing Office.
Population statistics are outlined regarding the Hispanic population in the United States. A valuable technical resource for understanding information regarding the population statistics of Hispanics in the United States and for utilizing these statistics for research purposes.

Tuesday, April 11, 2006

 

Chinese Americans – Family Structure, Interdependence, Culturally Defined Symptoms, and Help-Seeking Behavior

Chinese Americans –

Family Structure, Interdependence, Culturally Defined Symptoms,

and Help-Seeking Behavior


Jennifer Lo

Psychopathology II

Final Paper

April 10, 2006


Data obtained by the United States Census 2000 found that the Asian American population (including people who categorized themselves as “Asian and 1 or more other races”) increased by 72.2% since 1990 (http://www.awib.org/content_frames/census2000.html). The largest ethnic subgroup was Chinese Americans whose population increased 48% totaling 2.4 million people. If immigration rates maintain, as they did from 1990 to 2000, the Chinese (and Asian American population overall) will continue expanding exponentially. As their numbers increase it is expected that Asian Americans will exert more economic, social and political influence than ever before. As clinicians and social scientists, it is imperative that psychologists understand the contributing influence and acculturative processes of the various ethnic groups living within the U.S. This paper focuses upon the Chinese people, describing (1) characteristic family constellations, (2) perspectives on gender roles, (3) attitudes toward independence and interdependence, (4) typical or culturally defined symptoms, and (5) attitudes toward psychological problems and mental health services.

Chinese Americans frequently maintain a collectivist orientation toward relationships with others (Ho, 1990; Shon & Ja, 1982; Sue & Chin, 1983). Their identities are deeply embedded in the groups to which they belong, including family, company, school, or nation (Chung, 1992). Group interests and requirements often take priority over an individual’s needs. This perspective is in direct opposition to the Euro-American focus on the individual and the supplanting of one’s desires over those of the group. One significant result of the latter orientation is the preservation of the individual’s identity in spite of the groups with which he/she associates.

Because of the collectivist mindset Chinese Americans define families differently than Euro-Americans. In both cultures, the family is a central unit. However, European American parents tend to define family in “nuclear terms” (i.e. as a unit consisting of parents and their dependent children) (Shon and Ja, 1982). In contrast, the Chinese family concept typically includes the nuclear family and extended relatives (e.g. grandparents, aunts, and uncles). In fact, the Chinese family perception extends backward to all preceding generations of the family lineage as well as forward to future generations (Ho, 1990; Shon & Ja, 1982; Sue & Chin, 1983). Given this family model and collective point of reference, an individual’s actions reflect not only on him/her but also upon the entire past, present, and future lineage (Shon & Ja, 1982).

Traditional Chinese families also have specific roles and hierarchical positions for each member (Ho, 1990; Uba, 1994). The use of rank and hierarchy operates to further maintain family harmony. Ordinarily, elders hold a higher status than younger individuals and women are subordinate to men (Ho, 1990; Uba, 1994). Additionally, as a male, the father is generally recognized as the family leader and authority figure. He provides the family’s financial needs, executes decisions, and imparts discipline (Shon & Ja, 1982; Uba, 1994). The mother traditionally occupies the position of family nurturer. She is the children’s principle caregiver and typically completes the majority of household tasks (Shon & Ja, 1982; Uba, 1994). The mother is the most important route of communication between the children and the father, and she often mediates on her children’s behalf. Nonetheless, as a female, she is generally placed lower in the family hierarchy in comparison to her husband, her father, her in-laws, and even occasionally, her son (Lee, 1996).

A child’s role within the family is also highly structured. Literature on Asian American families commonly depicts children as expected to respect their parent’s interests and desires without question, even at times sacrificing their own needs and wants for the benefit of the family (Hong & Hong, 1991; Uba, 1994). Typically, the oldest son is the most cherished child (Shon & Ja, 1982). He is the younger sibling’s role model and (other than the father) their authority. In fact, when the father is absent, the oldest son is regarded as the head of the family. If he is unable to fulfill these responsibilities, the next oldest son takes up the position of family leader (Shon & Ja, 1982). Daughters typically lack authority within the family. In fact, in traditional Chinese families, daughters are brought up by their parents to marry and ultimately become part of their husband’s family (Shon & Ja, 1982; Uba, 1994). Daughters are also required to be passive (Sue & Sue, 1999). The importance placed on close family ties and commitments is based on the idea of filial piety, which refers to obedient respect for parents, grandparents, and other elders (Ho, 1990). Great significance is attached to filial piety and it is usually expected from all family members.

Unfortunately, more acculturated Chinese children are often faced with deciding between family loyalty and the expectations placed upon them by their western peers and elders. Intergenerational conflict commonly occurs when offspring born and raised in the United States defy their parent’s cultural values and opt for western ideals of independence and self-determination (Tan & Dong, 1999). In these cases, guilt and shame are often used as a means of controlling the aberrant adolescent’s behavior (Sue, 1997) with severe consequences for those who do not conform; including, emotional abandonment, exclusion from the family or community, and/or removal of societal faith and support. Rejection of a child who attempts to individuate is founded in the Confucian belief that children who act independently or disagree with their parents are disrespectful, self-centered, and thoughtless (Sue & Sue, 1993; Tan & Dong, 1999).

Gay or lesbian adolescents are at an even greater disadvantage than their heterosexual peers. They are subject to the same guilt and shame as their heterosexual peers for attempting to individuate/separate from their parents. However, their sexual preference intensifies the shame and guilt since they are stepping outside of their expected roles. As previously stated, maintaining external roles and conforming to one’s environment are highly valued traits within Chinese culture. Homosexual males who disclose their sexual preference are rejected by their family for failing to continue the family line and name by marrying and having children (Chan, 1989). Females are rejected for shaming the family line as well as failing to fulfill their positions as dutiful daughter and, eventually, wife and mother (Chan, C.S., 1992; Pamela, 1989).

A literature review of studies aimed at measuring Asian American mental health service usage revealed that Chinese American’s attend mental health services less often, have higher dropout rates, and shorter stays than whites and other ethnic minorities (Bui & Takeuchi, 1992; Cheung & Snowden, 1990; Lee, Lei, & Sue, 2001; Loo, 1982; Sue & McKinney, 1975; Sue & Sue, 1974; Sue, Fujino, Hu, Takeuchi, & Zane, 1991). The Chinese American Psychiatric Epidemiological Study (CAPES), for instance, queried participants with and without mental disorders on whether or not they had sought assistance for difficulties with emotions, anxiety, drugs, alcohol, or mental health in the preceding six months. The results showed that 17% of participants experienced problems but less than 6% of this group pursued care with a mental health professional; 4% visited a medical doctor; and 8% spoke with a minister or priest (Young, 1998). The finding that Asian Americans who use mental health services are more acutely ill than white Americans using the same services has been demonstrated in community health centers (Brown, Huang, Harris, & Stein, 1973; Sue, 1977), county mental health systems for adults (Durvasula & Sue, 1996); for adolescents (Bui & Takeuchi, 1992), and student psychiatric clinics (Sue & Sue, 1974).

One hypothesis for these findings is that Asian Americans are hesitant to seek mental health care due to their collectivist mindset. Legal infractions, unemployment, mental illness, and demonstration of intense feelings are all considered marks of weakness among traditional Asian Americans since these actions draw attention to the individual and cause disruption within the community (Ho, 1976). As collectivist cultures exist upon the understanding that every person works to maintain harmony, shamed individuals who do not exert self-control are cast off. Thus, the lack of support and empathy from their community as well as the requirement to remain inconspicuous may prevent many Chinese Americans from openly expressing distress.

A second hypothesis for the underutilization of mental health services by Chinese Americans is that families persuade disturbed members not to seek assistance until the ill individual becomes unmanageable. As mentioned previously, the collectivist view towards family structure can lead to a belief that if one person is (mentally) ill, the entire unit has a problem. Chinese Americans may avoid revealing their disorder because they believe it will bring shame not only to themselves but also family members (Uba, 1994). Additionally, since mental illness is seen as an indication of weakness, some individuals may choose to suffer silently rather than instigate family discord or abandonment.

In fact, open discussion of marital strife, academic or employment difficulties and psychological problems is generally avoided between family members so that harmony can be maintained. Members of traditional Chinese households may allow one individual to suffer in order to maintain the entire family’s cohesion, peace, and stability (Ho, 1990). This enduring and deep-rooted emphasis on submission of self to the family derives from Asian / Confucian ethics, which focuses on appropriate and harmonious social construction (Tan & Dong, 1999). Taoist influences of living peacefully with nature and with other people also stress harmony and unity within the family and outer community over the individual (Hopfe, 1983; Matsui, 1996).

In addition to fear of family shame, other specific cultural beliefs towards mental illness may prevent Chinese Americans from seeking professional treatment. For example, people may not attribute their emotional problems to mental difficulties. Many traditional Asian cultures believe that mental illness is a punishment for past wrongs of the family and lack of direction and restraint from the family leader (Chan & Leong, 1994; Tan & Dong, 1999). Belief in the existence of a spirit world and multiple gods that govern the universe may also cause Chinese to interpret their emotional difficulties as the result of demonic forces or spiritual warfare (Tan & Dong, 1999). Furthermore, in conventional Chinese culture, personal and emotional problems are attributed to bad thoughts, deficiency in willpower, and immaturity. Instead of asking for help from a friend or stranger, conservative Chinese parents may encourage their children to develop self-restraint and solve their own problems (Leong, 1986; Sue & Morishima, 1982). Chang (2000) found among high school students in Taiwan, the principal barriers for seeking mental health services included: “reluctance of self-disclosure, perceiving problems as not serious enough…unfamiliarity with the counseling process, and self-reliance.”

Self-restraint/reliance is so culturally engrained that somatization of psychological stress is a common occurrence among Chinese people (Cheung, 1982; Lee, Lei, & Sue, 2001; Tabora & Flaskerud, 1994). Somatization disorders as defined by the DSM-IV are complaints of physical pain or discomfort that cause distress and impair a person’s functioning but have no medical explanation (DSM-IV TR, American Psychiatric Association). The Chinese cultural etiology of these complaints has several key factors. First, the Chinese language lacks vocabulary to describe the affective states; therefore they must resort to physical expressions of emotion. Second, even with a more diverse vocabulary, Chinese people do not easily differentiate between affective states. Third, the Chinese holistic view towards health intimately links the mind and body as one (Cheung, 1982; Sue & Sue, 1995). Consequently, there is often no distinction made between physiological and psychological problems. Thus, some Chinese Americans may avoid mental health treatment because they genuinely experience their distress as physical, not mental pain.

Buddhist perspectives on fate and suffering may further inhibit some Chinese Americans from seeking mental health services. Ho (1976) defines fatalism as adjusting to a situation without attempting to control one’s environment. Suffering without protest is seen as testament to an individual’s strong character (Ho, 1990). Many Chinese Americans who are fatalistic may also give credence to the Chinese yin-yang philosophy. Here, there are constant opposing forces; every positive state within an individual’s life has a counteracting negative – e.g. health and sickness, wealth and poverty, power and submission. At any one time, either state has temporary dominance over the other. Because no one principle dominates eternally, all conditions are subject to change into their opposites (http://www.wsu.edu:8080/~dee/CHPHIL/YINYANG.HTM). Hence, fatalistic individuals endure pain knowing that if they remain strong, eventually their suffering will subside and become the opposite state (happiness).

With regards to parenting, some Chinese do not seek help for their emotionally distressed children out of reluctance to admit (self-perceived) failure to cope with problems (Chan, S., 1992). The avoidance is related to the values of self-reliance and shame associated with seeking help. Traditional Chinese parents would rather tolerate deviant or troubling behavior in their children than admit their own parental inadequacy. This is particularly true if their school-age children demonstrate continual learning disability and/or psychosocial difficulties at school. In these instances, the child’s behavior is viewed as lazy or oppositional and the result of their parents inability to provide proper training. Instead of seeking professional assistance for ongoing learning or emotional problems, some Chinese parents may resolve themselves to provide better instruction to their children and hope they outgrow their issues.

There are also pragmatic barriers preventing Asian Americans from seeking mental health services. One of the most basic obstacles is finding clinicians who are able to effectively communicate with clients in their native languages (Ho, 1990; Lee & Mokuau, 2002; Root, 1985; U.S. Surgeon General, 1999). Of the mental health care professionals practicing during the late 1990’s, about 70 Asian American clinicians were available for every 100,000 Americans in the United States; this is approximately half the ratio for whites (Manderscheid & Henderson, 1998). Ma (1999) found that many elderly Chinese feel frustrated and embarrassed that they cannot fully convey their difficulties with their physicians. Instead of bearing this shame and attempting to overcome the communication barrier, Chinese elders may opt to stop seeking health care altogether. While having a family member translate for a relative may appear plausible, it can be problematic when the translator is unfamiliar with medical terminology.

Lack of familiarity with the U.S. health system and limited financial resources may also contribute to Asian Americans underutilization of mental health treatment (Ho, 1990; Lee & Mokuau, 2002; Rao, DiClemente, & Ponton, 1992). Recent immigrant’s job opportunities are often limited due to: low level of acculturation and employment experience; American racial prejudice; and sexist practices. Without employment, many newly arrived Asians are unable to pay for professional health services (Ho, 1990). Even if they do acquire a job, many immigrants are working class and therefore lack health insurance or other benefits that may allow them to seek professional treatment (Lee & Mokuau, 2002). In 1999, the U.S. Surgeon General reported that 21.1% of Asian and Pacific Islanders (API’s) are uninsured, compared with 11.9% of non-Hispanic Whites. Furthermore, the rate of Medicaid coverage for most Asian Americans and Pacific Islander subgroups is significantly below that of whites. For instance, only 13 percent of Chinese American families with children and incomes below 200 percent of the Federal poverty level have Medicaid coverage. This is compared to 24 percent of whites in the equivalent income bracket. One hypothesis for this occurrence is that many Asian immigrants mistakenly believe if they register themselves or their children for Medicaid, their citizenship applications will be put at risk (Brown, Ojeda, Wyn, & Levan, 2000).

Finally, racist experiences may prevent some Chinese Americans from seeking professional mental health services (Ho, 1990). Multicultural individuals in the United States are subject to racial attack and discrimination in any public arena, because their skin, hair color, and facial features are different from European Americans. Seemingly minor negative experiences with the U.S. Health system can pressure some people of color into staying invisible in order to avoid violence and bigotry (Kitano & Kikumura, 1976). In avoiding mental health services, Chinese Americans may be afraid that clinicians will misunderstand their culture and reject, negate, and denigrate it.

Psychologists and therapists in the U.S. can help increase Chinese American mental health service usage by becoming more culturally sensitive (Lee & Mokuau, 2002). For example, clinicians should recognize the importance of cultural and ethnic matches between client and provider. Asian American clients tend to prefer therapists who are also Asian American (Tan & Dong, 1999). In fact, research has documented that Asian American clients who are matched with therapists of their same race are less likely to prematurely leave treatment than Asian American clients who do not work with a person of their same background (Sue, Fujino, Hu, Takeuchi, & Zane, 1991). However, while ethnic similarity is one of the most significant aspects of therapist match for APA’s, it is not the only one. Matching religious beliefs between clinicians and Christian Asian American clients is also vital and may be even more important than race or ethnicity. When Christian APA’s seek assistance from professionals, they are partial towards Christian professionals over non-Christian professionals (Misumi, 1993). Gender also plays an important role in therapist-client match for female Asian American clients; having the same gender and ethnicity as their therapist has shown to be crucial towards their staying in therapy (Fujino, Okazaki, & Young, 1994).

When treating Asian clients, it is also important that mental health clinicians identify a method to overcome stigma and engage parents and family members. Due to the emphasis on cohesion and harmony, family involvement has been shown to be extremely valuable towards the psychological treatment of Asian Americans (Lin, Miller, Poland, Nuccia, & Yamaguchi, 1991; Tan & Dong, 1999). Clinicians must acknowledge and respect a family’s power structure; treatment will not be successful without the family leader’s permission (Lee & Mokuau, 2002). By understanding how decisions are made and which relatives hold influence, therapists may avoid competition. There are generally two categories of authority in an APA family system: “role prescribed power” (typically given to the grandfather, father, or eldest son) and “psychological power” (often upheld by the grandmother or mother). By sharing goals or treatment plans with a client’s family members, clinicians not only avoid power conflicts but also gain inside knowledge into a client’s family life. Furthermore, by collaborating with family members, clinicians give clients an in home resource for guidance and support. Finally, partnership with a client’s relatives reclassifies a clinician’s role from expert to partner (Wu, 1999).

The Chinese American community is one of the fastest growing ethnic groups within the

United States. A dynamic acculturative process is taking place as thousands of Chinese immigrants move beyond Chinatown enclaves, establishing themselves in areas that were predominantly Euro-American. Western and Eastern traditions are commingling in a way that psychologists, as social scientists and scholars of the human condition, cannot ignore. As the definition of “American culture” continues to change simultaneously with growing ethnic communities, psychologists must learn and appreciate the needs, expectations, traditions, and attitudes of their future and potential clients.
References and Annotated Bibliographies

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental

Disorders. 4th Edition. Revised (DSM-IV TR). Washington, D.C.: American Psychiatric Association.

Brown, E.R., Ojeda, V.D., Wyn, R., & Levan, R. (2000). Racial and ethnic disparities in access

to health insurance and health care. Los Angeles, CA: UCLA Center for Health Policy and Research and The Henry J. Kaiser Family Foundation.

This policy report gives an overview of health care access for Latinos, African Americans, Asian American and Pacific Islanders, American Indians, and Alaskan Natives. The entire report is 105 pages; two page fact sheets with tables, charts, and essential data are available for all four ethnic groups. All this information may be located at: http://www.kff.org/uninsured/1525-index.cfm/

Brown, T.R., Huang, K., Harris, D.E., & Stein, K.M. (1973). Mental illness and the role of

mental health facilities in Chinatown. In S. Sue & N. Wagner (Eds.), Asian-Americans: Psychological perspectives (pp. 212-231). Palo Also, CA: Science and Behavior Books.

Editor, Stanley Sue, is an eminent and distinguished researcher in Asian American mental health. Unfortunately, this book is relatively old and the information it contains is somewhat outdated. The book from Laura Uba (1994) [see citation below] is a better choice.

Bui, K.T., & Takeuchi, D.T. (1992). Ethnic minority adolescents and the use of community

mental health care services. American Journal of Community Psychology, 20, 403-417.

The authors examined utilization rates, treatment dropout rates, and length of treatment for minority adolescents (African American, Asian American, and Hispanic) in the Los Angeles County mental health care system. The information obtained (spanning the years 1983-1988) is somewhat outdated and may only apply to the particular California county used by researchers.

Chan, C.S. (1989). Issues of identity development among Asian American lesbians and gay men.

Journal of Counseling and Development, 68, 16-20.

This is a survey study completed by nineteen Asian American lesbians and sixteen Asian American gay men. The authors pose an interesting question regarding self-definition and choice of identity – racial/ethnic vs. sexual orientation. One drawback is the inability to understand the perspective of individuals who chose not to answer the author’s questionnaires. Another limitation is the relatively small sample size.

Chan, C.S. (1992). Cultural considerations in counseling Asian American lesbians and gay men.

In S.H. Dworkin & F.J. Gutierrez (Eds.), Counseling gay men and lesbians: Journey to the end of the rainbow (pp. 115-124). Alexandria, VA: American Association for Counseling and Development.

Using case studies, gay psychotherapists offer their perspectives on anti-gay violence, career counseling, counseling the elderly, and counseling HIV-positive patients. The book contains chapters on gay Blacks, Latinos, and Asians.

Chan, S. (1992). Families with Asian roots. In E.W. Lynch & M.J. Hanson (Eds.), Developing

cross-cultural competence: A guide for working with young children and their families (pp. 181-250). Baltimore, MD: Paul H. Brooks Publishing Co.

This book’s primary audience is professionals in the educational, health care and social services industries that work with families with children who have, or are at risk for, disabilities. Case examples are offered for working with Anglo-European, Native American, African-American, Latino, Asian, Filipino, Native Hawaiian and Samoan, and Middle Eastern families.

Chan, S., & Leong, C.W. (1994). Chinese families in transition: Cultural conflicts and

adjustment problems. Journal of Social Distress and the Homeless, 3, 263-281.

See Ho (1990) for a better review of Chinese culture and intergenerational stress/conflict.

Chang, H.W. (2000). The help seeking for psychological problems and barriers to counseling

among Chinese high school students in Taiwan. Dissertation Abstracts International Section A: Humanities & Social Sciences, US: Univ Microfilms International, 60, 3915.

A highly specific study on help seeking – see the Uba (1994) for a more comprehensive review of Asian American mental health service usage.

Cheung, F. (1982). Somatization among Chinese: A critique. Bulletin of the Hong Kong

Psychological Society, 8, 27-35.

This is a summary of cultural explanations for somatization among Chinese people. Although this was published over twenty years ago, it offers valuable insights from the perspective of someone who speaks the Chinese language.

Cheung, F.K., & Snowden, L.R. (1990). Community mental health and ethnic minority

populations. Community Mental Health Journal, 26, 277-291.

This article draws upon data from 1950 to 1980 and describes mental health treatment obtained by African Americans, Asian American / Pacific Islanders, Hispanics, and Native American / Alaska Islanders. While somewhat outdated, this research covers the entire U.S. and includes data on admissions to mental institutions.

Chung, D.K. (1992). Asian cultural commonalities: A comparison with mainstream American

culture. In S.M. Furuto, R. Biswas, D.K. Chung, K. Murase, & F. Ross-Sheriff (Eds.), Social Work Practice with Asian Americans (pp. 27-44). Newbury Park, CA: Sage.

The Ho (1990) book offers a better comparison of Asian vs. Western culture.

Durvasula, R.S., & Sue, S. (1996). Severity of disturbance among Asian American outpatients.

Cultural Diversity and Mental Health, 2, 43-52.

This article compares help-seeking among Asian and White clients seeking services from a large mental health system over a 5-year period. Subjects were compared on three measures of severity of disturbance: severity of diagnosis, ratings of functioning, and presence of psychotic features. Although the study does not cover mental health facilities across the U.S., it’s population size is large, ensuring validity of the researchers findings.

Fujino, D.C., Okazaki, S., & Young, K. (1994). Asian-American women in the mental health

system: An examination of ethnic and gender match between therapist and client. Journal of Community Psychology, 22, 164-176.

The Uba (1994) provides a better summary of the mental health needs of Asian American women.

Ho, C.K. (1990). An analysis of domestic violence in Asian American communities:

Multicultural approach to counseling. Women and Therapy, 9, 129-150.

The author discusses domestic violence in Asian American communities, and presents results from a focus group study with Southeast Asians (Laotians, Khmer, Vietnamese, and Chinese). Helpful information is offered in understanding the impact of traditional Asian values (close family ties, harmony, and order, fatalism, perseverance, and self-restraint) on acculturation.

Ho, M.K. (1976). Social work with Asian Americans. Social Casework, 57, 195-201.

This article is relatively old and outdated. More up to date information on Asian American mental health needs can be found in the Uba (1994) book.

Hong, G.K., & Hong, L.K. (1991). Comparative perspectives on child abuse and neglect: Chinese versus Hispanics and Whites. Child Welfare, 70, 463-475.

This study examined the incidence of child abuse among a sample of Chinese, Hispanic, and White participants. Cultural explanations (fatalism and filial piety) are given in accounting for the greater tolerance for abuse within the Chinese group.

Hopfe, L.M. (1983). Religions of the world. New York: Macmillan.

This is an excellent reference for individuals involved in religion and the study of religion. The book focuses on the lives of particular religious founders, their fundamental teachings, and their current status in the world. Information is offered on Native American and African religions as well as Jainism, Sikhism, Zoroastrianism, and Baha'I. For more specific information about religious beliefs and psychotherapy, see the Handbook of psychotherapy and religious diversity Tan and Dong (1999).

Kitano, H., & Kikumura, A. (1976). The Japanese American family. In C.H. Mindel and R.W.

Havenstein (Eds.), Ethnic families in America. New York: Elsevier.

This book is outdated; more current information can be found in the Uba (1994) book.

Lee, E. (1996). Asian American families: An overview. In M. McGoldrick, J. Giordano, & J.K.

Pearce (Eds.), Ethnicity and family therapy (2nd ed, pp. 227-248). New York: The

Guilford Press.

This is considered to be an essential textbook for acquiring and enhancing cultural competence in clinical practice. A third edition of this book was published in 2005.

Lee, J., Lei, A., & Sue, S. (2001). The current state of mental health research on Asian

Americans. Journal of Human Behavior in the Social Environment, 3, 159-178.

This information can be found in greater detail in the Uba (1994) book.

Lee, E., & Mokuau, N. (2002). Cultural Diversity Series: Meeting the mental health needs of

Asian and Pacific Islander Americans. National Technical Assistance Center for State Mental Health Planning, February, 2002.

This is an excellent and current summary of research on mental health concerns within the Asian American population. The entire publication can be downloaded from: http://www.nasmhpd.org/general_files/publications/ntac_pubs/reports/ASIAN.PDF

Leong, F. (1986). Counseling and Psychotherapy with Asian-Americans: Review of the

Literature. Journal of Counseling Psychology, 33, 196-206.

This literature review is relatively short and outdated – see Uba (1994) for a better summary.

Lin, K.M., Miller, M.H., Poland, R.E., Nuccia, I., & Yamaguchi, M. (1991). Ethnicity and family

involvement in the treatment of schizophrenic patients. Journal of Nervous and Mental Diseases, 179, 631-633.

This is a relatively specific study comparing family involvement of 26 Asian and 26 Caucasian patients. The Uba (1994) offers more information on mental health, cultural practices, and the Asian emphasis on family.

Loo, C. (1982). Chinatown’s wellness: An enclave of problems. Asian American Psychological

Association Journal, 7, 13-18.

This study is relatively old, did not include Chinese-American men, and its findings may be location specific. More up to date information can be found in Uba (1994).

Ma, G.X. (1999). The Culture of Health: Asian Communities in the United States. Westport, CT:

Bergin & Garvey.

This readable book summarizes existing research on health care issues affecting Asian Americans. The topics addressed include: sociocultural approaches to health, illness, and health care; clients' experiences in acquiring health care services; and the critical role of alternative practices in primary health care.

Manderscheid, R.W., & Henderson, M.J. (Eds.). (1998). Mental health, United States: 1998.

Rockville, MD: Center for Mental Health Services.

A summary of the state of mental health within the U.S, updated and published every two years. This book is an excellent complement to the Surgeon General’s report on Mental Health: Culture, Race, and Ethnicity.

Matsui, W.T. (1996). Japanese families. In M. McGoldrick, J. Giordano, & J. Pearce (Eds.),

Ethnicity and family therapy (2nd Ed, pp. 268-280). New York: Guilford Press.

This is considered to be an essential textbook for acquiring and enhancing cultural competence in clinical practice. A third edition of this book was published in 2005.

Misumi, D. (1993). Asian-American Christian attitudes towards counseling. Journal of

Psychology and Christianity, 12, 214-224.

This article addresses the topic of help-seeking behavior and ethnic/cultural match. It is, however, relatively specific. A more general summary on this topic may be found in the Uba (1994) book.

Pamela, H. (1989). Asian American lesbians: An emerging voice in the Asian American

community. In Asian Women United of California (Ed.), Making waves: An anthology of writings by and about Asian American women (pp. 282-290). Boston: Beacon.

This is a collection of historical and sociological stories, poems and essays by 53 Asian-American women. The topics covered include stereotypes of female docility and subservience. This anthology does not specifically address the issue of psychotherapy and Asian Americans. However, the personal perspectives and histories may provide a background for better understanding clients.

Rao, K., DiClemente, R.J., & Ponton, L.E. (1992). Child sexual abuse of Asians compared with

other populations. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 880-886.

The authors reviewed clinic charts of children with substantiated cases of sexual abuse. Asian victims were compared with random samples of black, white, and Hispanic victims. Asian children were found to have a distinct demographic profile along with unique survivor issues. The problem with this review is it was done with charts from one clinic in California, thus the results may not apply across the U.S.

Root, M.P. (1985). Guidelines for facilitating therapy with Asian American clients.

Psychotherapy, 22, 349-356.

More up to date and detailed information can be found in Ethnicity and family therapy or Uba, 1994.

Shon, S.P., & Ja, D.Y. (1982). Asian families. In M. McGoldrick, J.Pearce, & J. Giordano (Eds.),

Ethnicity and family therapy (pp. 208-229). New York: Guilford.

This is considered to be an essential textbook for acquiring and enhancing cultural competence in clinical practice. A third edition of this book was published in 2005

Sue, D. (1997). The interplay of sociocultural factors on the psychological development of

Asians in America. In D.R. Atkinson, G. Morten, & D.W. Sue, (Eds.), Counseling Americ an minorities: A cross-cultural perspective (5th ed., pp. 205-213). Boston: McGraw-Hill.

A more recent version (2003) of this book is now available and may contain more pertinent, up to date information.

Sue, D.W., & Sue, D. (1999). Counseling the culturally different: Theory and practice (3rd ed.,

pp. 255-271). New York: John Wiley.

This is the revised edition of a best-selling, classic reference on cross-cultural counseling. The book addresses general issues in cross-cultural psychotherapy as well as approaches toward counseling particular ethnic populations. A special section with case examples is included.

Sue, D., & Sue, D.M. (1995). Experiencing and counseling multicultural and diverse populations

(3rd ed.)., Philadelphia, PA, US: Accelerated Development, Inc; 63-89.

Using research and clinical material, this textbook discusses the needs, experiences, and characteristics of 13 ethnic-American subgroups encountered by psychotherapists. The more recent book Counseling the culturally different: Theory and practice is probably a better reference since it provides more case examples and useful information.

Sue, D., & Sue, D.W. (1993). Ethnic identity: Cultural factors in the psychological development

of Asians in America. In D. Atkinson, G. Morten, & D.W. Sue (Eds.), Counseling American Minorities: A cross-cultural perspective (pp. 199-210). Dubuque, IA: Brown & Benchmark.
A more recent version (2003) of this book is now available and may contain more pertinent, up to date information.

Sue, S., & Chin, R. (1983). The mental health of Chinese-American children: Stressors and

resources. In G.J. Powell, J. Yamamoto, A. Romero, & A. Morales (Eds.), The psychosocial development of minority group children (pp. 385-397). New York: Bruner-Mazel.

The information offered by this chapter is relatively outdated – the Ethnicity and Family Therapy textbook is a better reference.

Sue, S., Fujino, D.C., Hu, L, Takeuchi, D.T., & Zane, N.W.S. (1991). Community mental health

services for ethnic minority groups: A test of the cultural responsiveness hypothesis. Journal of Consulting & Clinical Psychology, 59, 533-540.

This article is relatively old – more up to date information on help seeking behaviors within the Asian American community can be found in Uba (1994).

Sue, S., & McKinney, H. (1975). Asian Americans in the community mental health care system.

American Journal of Orthopsychiatry, 45, 111-118.

The information offered by this article is relatively outdated – the Uba (1994) reference is more useful.

Sue, S., & Morishima, J.K. (1982). The Mental Health of Asian Americans. San Francisco:

Jossey-Bass.

The information offered by this article is relatively outdated – the Uba (1994) reference is more useful.

Sue, S., & Sue, D.W. (1974). MMPI comparisons between Asian Americans and non-Asian

students utilizing a student health psychiatric clinic. Journal of Counseling Psychology, 21, 423-427.

The information offered by this article is relatively outdated – the Uba (1994) reference is more useful.

Tabora, B., & Flaskerud, J.H. (1994). Depression among Chinese Americans: Review of the

literature. Issues in Mental Health Nursing, 15, 569-584.

More up to date information on Depression among Chinese Americans can be found in the Lee, E., & Mokuau, N. (2002) reference.

Tan, S.Y., & Dong, N.J. (1999). Psychotherapy with members of Asian American churches and

spiritual traditions. In P.S. Richards & A.E. Bergin (Eds.), Handbook of psychotherapy and religious diversity (pp. 421-444). Washington, D.C.: American Psychological Association.

This book summarizes the beliefs, traditions, customs and organization of religious communities and their impact on the therapeutic process. Among the topics discussed are: the therapeutic process, establishing relationships with clients, assessment and diagnosis, customary clinical issues, and interventions that correspond with client’s beliefs.

Uba, L (1994). Asian Americans: Personality Patterns, Identity, and Mental Health. New York:

Guilford.

This book is an excellent summary of existing research on Asian American psychology. Topics covered include: cultural values, family characteristics, personality patterns, ethnic identity, mental health needs, psychotherapy, and service utilization. Information is given on a variety of ethnic groups, including: Chinese, Japanese, Filipino, Korean, Samoan, and Southeast Asian Americans. A more recent edition (2003) is also available.

U.S. Department of Health and Human Services (1999). Mental Health: Culture, Race and

Ethnicity – A Supplement to Mental Health: a Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.

The U.S. Surgeon General presents an excellent and readable summary of Mental Health amongst several ethnic groups. A more up to date report (2001) is also available.

Wu, S.J. (1999). Counseling Asian families from a systems perspective. In K.S. Ng (Ed.),

Counseling Chinese families: A postmodern approach (pp. 41-54). Alexandria, VA: U.S. American Counseling Association.

This book describes several ethnic groups comprising Asian cultures and emphasizes their diverse educational, political, socioeconomic, and religious backgrounds. Information is offered on culturally relevant treatment strategies.

Young, K. (1998). Help seeking for emotional/psychological problems among Chinese

Americans in the Los Angeles area: An examination of the effects of acculturation. Unpublished doctoral dissertation, University of California, Los Angeles.

This study concentrates on Chinese Americans in the Los Angeles area; the Uba (1994) book offers more information regarding Asian American help-seeking.


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