In many Asian countries, there is a general cultural assumption that the family exists as the basic unit of society. Individual family members can be called on to make personal sacrifices for the sake of the family. In contrast, in the United States, there is a general assumption that the family exists for the development and protection of individual family members. Unlike the extended family in Eastern cultures, the nuclear family in the West stresses independence and autonomy among family members. A Western family life cycle begins when two individuals meet, fall in love, marry, and have children. They raise their children to be self-sufficient, ultimately to leave and repeat the process.
Internal Family Structure
In Eastern cultures, a well-defined hierarchy of authority exists depending on age, role, sex, and birth order. The head of household (usually the father) makes important family decisions. However, in the West, equality tends to exist among family members and each individual's opinion is valued. Decision making is more democratic.
Traditional Asian cultures avoid open conflict. Family conflict is frequently managed by role segregation, indirect communication, and polite inattention. The strong hierarchy within the family defines who may voice an opinion and who must suppress it. In the West, open conflict is relatively common and normal and is part of family communication and dynamics.
Attitude toward the Elderly
A striking contrast exists in the East-versus-West attitude toward the elderly. For example, a 1988 National Family Survey in Japan found that more than 70% of adult respondents desired to live with a parent when he or she became old or ill. Recent family surveys in the United States indicated that fewer than 5% of Americans have such desires (Cho & Yada, 1994).
Note that the East-West cultural differences in Table 1.2 do not apply to all individuals in each culture, because most people fall somewhere within this continuum. An acculturated person from the Eastern culture may possibly identify more with Western culture, or vice versa. Within one particular family, the likelihood is that various family members (depending on age and acculturation rate) may identify with different elements within the continuum.
Changes in Contemporary Asian Countries
In the past two decades, Asian countries have changed rapidly in many aspects as a result of the forces of modernization, urbanization, and industrialization. The socioeconomic revolution and consequent rapid widespread migration from villages to cities and towns began to have a major impact on the form, structure, and functions of the family. The most notable change was the transformation of the family's function from production to consumption, as people began to work away from home. In addition, the transition from high to low fertility led to the decrease of traditional extended families and the emergence of nuclear families as a predominant form.
These changes are more obvious in modern industrialized Asian countries such as Taiwan, Japan, Hong Kong, Singapore, and Korea. For example, in Taiwan, the per capita gross national product rose from US$250 in 1967 to more than US$6,000 by 1986 (Sun & Liu, 1994). The proportion of couples living with the husband's parents decreased from 60% in 1967 to 41% in 1986. In Japan, the average number of household members has decreased from 4.89 in 1920 to 2.99 in 1990 (Kuroda, 1994).
It is important for clinicians to remember that an Asian country, as it evolves from these recent socioeconomic forces, may take on dramatically different characteristics which affect their people and family systems. For instance, a family from the mountaintop in Laos is very different in family values, Westernization, education, and outlook from an urban family in Hong Kong or Singapore.
ASIAN AMERICAN FAMILIES IN TRANSITION
The different Asian American groups came to the United States at different times and exhibit varying degrees of acculturation. They represent a wide range of cultural values, from very traditional to very "Americanized." Within this continuum, there are numerous variations. Generally speaking, five types of Asian American families are described in the succeeding paragraphs. These five family types are hypothetical constructs for the purposes of discussing and understanding the complexity of Asian American families.
Type 1: The Traditional Family
Such families usually consist of all family members who are born and raised in Asian countries. These include families from agricultural back-grounds, families recently arrived with limited exposure to Western culture, unacculturated immigrants who are older at time of immigration, and families living in ethnic Asian communities (e.g., Chinatown or Koreatown) with limited contact with mainstream U.S. society. Family members hold strong beliefs in traditional values as described previously and speak in their native languages and dialects. They practice traditional customs and belong to family associations and other social clubs consisting of people with a similar heritage.
Type 2: The "Cultural Conflict" Family
In these families, members usually hold different cultural values. A typical family consists of parents and grandparents with strong traditional beliefs who live with a more acculturated and Westernized younger generation. This type of family experiences a great deal of family stress caused by intergenerational conflicts. These conflicts are usually caused by the disparity between the children's and the parents' values and expectations. Traditional parents expect the children to be obedient, hardworking, and respectful to authority. Such value orientation is not only different but opposite to American values, which place a strong emphasis on independence, self-reliance, autonomy, assertiveness, open communication, and competition. The family members frequently argue over dating, marriage, educational goals, and career choice. Role reversal occurs because the children speak better English and the monolingual parents/grandparents depend on them as the "cultural brokers" to deal with the outside world. Such dependence can evoke anger and resentment in both parties and may lead to prolonged family stress.
Another type of "cultural conflict" occurs one when one spouse is more acculturated than the other. For example, a husband may have lived in the United States for many years and then gone home and brought back a wife who is not familiar with American culture. Cultural conflicts may be caused not only by different degrees of acculturation rate of family members but also by religious, philosophical, or political differences.
Type 3: The Bicultural Family
A majority of these families consist of well-acculturated parents who came to the United States many years ago and are quite familiar with American culture. Many of them grew up in major Asian cities and were exposed to urbanization, industrialization, and Western influences. Some are American-born who were raised in traditional families. These parents often hold professional jobs and come from middle- or upper-class family backgrounds. They are bilingual and bicultural and are familiar with both Eastern and Western cultures. In such families, the power structure has moved from a patriarchal to an egalitarian relationship between parents. Decision making is not solely the father's responsibility; family discussions are allowed between parents and children. Such families typically do not live in the Chinatowns, Japantowns, Koreatowns, or Little Saigons but in the suburbs. The nuclear family members usually visit their extended family members (e.g., the grandparents) on weekends and holidays.
Type 4: The "Americanized" Family
Most of these families consist of parents and children who are both born and raised in the United States. As generations pass, the roots of the traditional Asian cultures begin to disappear and individual members tend not to maintain their ethnic identities. Family members communicate in English only and adopt a more individualistic and egalitarian orientation.
Type 5: The Interracial Family
Interracial marriages for Asian Americans are increasing rapidly, with an estimated 10% to 15% of all marriages. Japanese Americans lead in this trend, with more than half marrying outside their group, followed by Filipino, Chinese, Vietnamese, and Korean Americans (Karnow & Yoshihara, 1992). Some interracial families are able to integrate both cultures with a high degree of success. However, others, for example, often experience conflicts in values, religious beliefs, communication style, and childrearing issues and in-law problems.
MANIFESTATIONS OF PSYCHOPATHOLOGY
No large-scale prevalence studies on psychopathology have been conducted on Asian Americans. Available research strongly implies that major mental health problems exist among various Asian American groups, contrary to the widespread belief that Asian Americans are well adjusted. Research also suggests that Asian Americans have a rate of psychopathology equal to or higher than that of European-Americans. If, indeed, Asian Americans do have higher rates of psychopathology than other Americans, it is reasonable to attribute such differences to additional psychosocial stressors resulting from their minority status and migration experiences (Uba, 1994).
The most common mental health problems among Asian Americans are depression, somatization, anxiety disorder, adjustment disorder, and suicide. Chinese Americans and Japanese Americans have reported more somatic complaints than European-Americans on the Minnesota Multiphasic Personality Inventory (Sue & Sue, 1974). Kuo and Tsai (1986) found that Asian Americans have higher average scores on the Epidemiological Studies Depression Scale measure than do whites. In a study of anxiety levels, Chinese American males and females expressed significantly more discomfort than their control counterparts. This study also revealed that recent immigrants were more likely to experience anxiety than those immigrants who have been in the United States longer (Sue & Zane, 1987). The rate of suicide among Japanese Americans and Chinese Americans is generally lower than among European-Americans. However, the suicide rate is higher than that of European Americans for Chinese Americans after the age of 64, and for Japanese Americans after the age of 74. The foreign-born Chinese Americans and Japanese Americans have higher suicide rates than do their American-born counterparts (Yu, Chang, Liu, & Fernandez, 1989).
The mental health problems of Southeast Asian refugees require special attention. Researchers have found that this group has a very high rate of psychiatric disorder (Berry & Blondel, 1982; Gong-Guy, 1987; Kinzie, 1989; Lin, 1986). They have displayed a variety of disorders, including posttraumatic stress disorder, dissociative disorders, organic brain syndromes, schizophrenia, conversion disorders, and paranoia (Uba, 1994).
Another area of special interest is culture-bound syndromes. Certain illnesses, known by their indigenous names, have been reported in many countries in Asia, such as amok, koro, and qi-gong psychotic reaction. With the increase in the Asian immigrant and refugee population, some of these rather dramatic and rarer forms of mental disorder are increasingly found in the United States (Caw, 1993).
In comparing the severity of psychopathology of Asian Americans with other ethnic groups, research studies also revealed some interesting interracial differences. For example, studies have found that Asian Americans who use mental health services are more severely disturbed than their non-Asian American counterparts (Sue & McKinney, 1975; Sue & Sue, 1974). An extensive study in Los Angeles found that the proportion of Asian Americans diagnosed as psychotic was larger than that of European-American clients. Asian Americans were found to have major affective disorders at a proportionally higher rate than African Americans or Latino Americans (Flaskerud & Hu, 1992). There is also some evidence of interethnic differences among Asian American groups. Southeast Asians refugees, given the traumas and hardships many of them have experienced, apparently have the most severe problems, whereas Japanese American have the least severe problems (Gim, Atkinson, & Whitely, 1990).
Most Asian Americans attempt to deal with their psychological problems without seeking professional services. Many tend to rely on the family in dealing with their problems. Traditional families often treat mental disorders by urging the disturbed family members to change their behavior. They believe that self-control, will power, avoidance of unpleasant thoughts, keeping busy, and trying not to think too much about problems can help individuals to deal with their troubles. Each family member, including the extended family members, may offer his or her recommended treatment. When the troubled person and his or her family are not able to resolve the problem, they often turn to resources available in their community, such as elders, spiritual healers, ministers, monks, herbalists, fortune tellers, or physicians. Many come to mental health professionals as the last resort, while others are forced to receive counseling by the courts, hospitals, schools, and other social services agencies.
Acculturated Asian Americans have a more positive attitude toward receiving professional counseling. Unlike newly arrived immigrants and refugees, who come to agencies with specific, concrete problems that require assistance, their presenting problems are commonly associated with intrapsychic difficulties or relationship-related issues. They may even opt for long-term psychotherapy. A survey of Asian American therapists revealed that depression, low self-concept, and relationship conflicts affected at least 50% of Asian American clients. Between 40% and 50% of the clients were affected by problems with parent-child relationships, acculturation, somatic complaints, and isolation (Matsushima & Tashima, 1982).
MAJOR FAMILY THERAPY APPROACHES AND RELEVANCE TO TREATMENT
In working with Asian groups, the clinician must be flexible and able to draw from the work of many schools of family therapy. Whereas some acculturated Asian Americans can benefit from Western psychotherapy, such therapy may not be effective in working with the majority of immigrant and refugee Asians. Some traditional Western psychotherapeutic approaches are designed based on the assumptions of individuation, independence, self-disclosure, and verbal expression of feelings. These may be contrary to Asian values, which focus on interdependence, self-control, and repression of feelings. However, some therapeutic approaches in the field of family therapy have been found to be useful.
- The structural family therapy model provides a method for assessing the structure of a family, identifying the areas of difficulties, and restructuring the family system to produce change. The roles of the grandparents and the parental child in the three-generation family are quite applicable to Asian American families (Minuchin, 1974).
- The problem-solving approach is particularly helpful in engaging many immigrant, multiproblem families. It is focused, concise, and directive. This approach provides a sense of empowerment and accomplishment as each problem is resolved (Haley, 1976).
- The Bowenian approach provides strategies for exploring extended family dynamics. The use of a family tree to help families map their genealogy is helpful (Bowen, 1976). However, given the resistance of Asian families in initial therapy sessions, this history-based approach may raise suspicion and tends to be more helpful in the midphase of therapy-after trust is established.
In the past two decades, several family therapy books have been published with special focus on ethnic minorities (McGoldrick, Pearce, & Giordano, 1982; Hansen & Falicov, 1983; Ho, 1987; Comas-Diaz & Griffith, 1988; Paniagua, 1994). In addition, some authors focused on specific groups (Sue & Zane, 1987; Kim, 1985; Boyd-Franklin, 1989). In addition to contributions from authors in the field, national organizations of mental health professionals have also developed cultural competence criteria or cultural formulation guidelines. In 1991, The American Psychological Association published Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations. In 1994, the Diagnostic and Statistical Manual of Mental Disorders provided an outline for cultural formulation designed to assist the clinician in systematic evaluation and reporting of the impact of an individual's cultural context. A glossary of culture-bound syndromes is also included. All these contributions have created a new impetus and immense excitement in the field.
The family is a complex institution which can be investigated and understood from various dimensions. The proposed assessment guidelines emphasize two perspectives:
- Assessment of the family dynamics based on system theory. The family is examined and understood within the network of each system inwardly and outwardly in ecological and dynamic ways (Tseng & Hsu, 1991). The clinician needs to assess (a) the internal family system, which includes understanding individual members, family subsystems, family life cycle, family hierarchy, leadership, communication, behavioral styles and norms, and role patterns; and (2) the external factors, which include the impact of war, migration, racism, housing, and other environmental stressors. Clinicians must also recognize available support systems.
- Assessment of mental health problems based on a holistic concept of health and illness. In addition to Western psychological and biological understanding of emotional difficulties, we need to appreciate the Eastern holistic way of thinking and incorporate it into clinical practice.
Based on these two perspectives, I recommend a model that takes into account the psychological, social, biological, spiritual, cultural, and political influences on the lives of families. The evaluation and assessment of Asian American families should include additional information beyond traditional intake data, as discussed next (Lee, 1989, 1996).
Assessment of the Family's Ethnocultural Heritage
The clinician should obtain information on the family's past background, including culture of origin for both maternal and paternal lines of the client's family and delineation of ethnic heritage. A simple statement of parental geographical origin is not sufficient for a complete under-standing of a client's often complex multicultural-multiethnic back-ground. Unfortunately, it is far too common for a single, readily identifiable attitude of an individual or family (e.g., name or native language spoken) to be simply accepted as implying a vast assortment of stereotyped cultural characteristics (Jacobsen, 1988). For example, a Cantonese-speaking young woman who was raised by her grandparents in Mexico experiences very different cultural influences in comparison with a Chinese woman who grew up in China during the Cultural Revolution.
Assessment of Migration Stress
Sluzki (1979) provides an excellent framework in his article on migration and family conflict. He describes a five-stage model: (1) preparatory stage, (2) migration, (3) period of overcompensation, (4) period of crisis decompensation, and (5) transgeneration phenomena. Each state requires assessment and interventions geared for the specific phase the family is experiencing. In family assessment, the clinician should be aware of which stage of development the family is in and its impact on the family dynamic.
For many Asian American families, especially immigrants and refugees, the stress of migration can result in psychological strain, which in turn jeopardizes mental health. With few exceptions, a majority of Asian countries have suffered years of war and political turmoil. Many immigrants and refugees experienced unwilling separations and exposure to trauma, both in their home country and in their search for sanctuary. Caught in varying degrees of unpreparedness, many suffered personal losses in many aspects of their lives. A systematic and longitudinal understanding of the refugee experiences is crucial and should be included as part of the assessment of all Asian refugee families. When taking a thorough migration history, the clinician can apply the following chronological approach focusing on two major aspects of the family migration history: premigration history and immigration history.
Family premigration history. History includes the following: country of origin, cities or villages where the family previously lived, relocation experiences, family composition, educational level of each member, employment status, level of support from other extended family members and community, religious beliefs, social and economic status of the family, major political changes, and experiences of war and traumatic events.
Family immigration history. History includes the reasons for leaving, who decided, who left first and who was left behind, and who was the sponsor, as well as hardships endured during the trip. Working with refugee families, it is very important to explore the family's experiences of trauma, such as starvation, rape, torture, and imprisonment. Clinicians also need to explore the extent of loss.
Five types of losses are associated with refugee status: (1) material losses, such as properties, business, career, and investment; (2) physical losses, such as disfigurement, physical injuries, hunger, and malnutrition; (3) spiritual losses, such as freedom to practice religion and support from religious community; (4) loss of community support and cultural milieu; and (5) loss of family members, other relatives, and friends. Such losses are particularly traumatic for the Southeast Asian refugees, to whom the family, community, and religion are exceedingly important (Lee, 1990).
Clinicians sometimes fall into two extremes in the exploration of premigration and migration history. Some fail to ask for the information with the belief that the former life data is not relevant to current problems. Others may not be ready to deal with the trauma stories. The reasons the victimized refugee clients often do not report these events spontaneously are numerous: guilt, shame, wanting to deny and forget, fear of reprisal, emotional distress in recalling and discussing the events, and lack of the "psychological mindedness" that these events may be related to the current clinical problems (Westermeyer, 1989). At the other extreme, some clinicians are too eager to explore the past traumatic events and force the family members to deal with their psychological trauma prematurely. Skillful assessment of the family members' readiness to share their migration history is very important. Before the establishment of trust, the clinician should try to avoid questions or commentaries dealing with traumatic events. Also, clients should not be pressured to say more than what they want to (Paniagua, 1994).
Assessment of Postmigration Experience and Cultural Shock
In discussing the family's postmigration experiences, it is essential to assess the degree of cultural shock and its impact on the family. Many new Asian immigrants are placed in a strange and unpredictable environment. In addition to language barriers and homesickness, they have to adjust to physical changes (new city to live, different type of housing arrangement, increased population density, etc.), economic changes (new forms of employment, downward social mobility, etc.), cultural changes (religious, educational, and value orientation of the host country), political changes, and social relationship changes. For many immigrant and refugee families, there is a sudden lack of extended family support when it is most needed. The new isolated family unit is, for the first time, responsible for making and maintaining its own set of rules and adjusting to a new environment with its strange demands. When the stresses are extreme and the support system is insufficient, the family may become isolated, enmeshed, and disengaged (Landau, 1982).
Assessment of the Impact of Migration on Individual and Family Life Cycle
The adjustment to a new culture is a prolonged developmental process that will affect family members differently, depending on the individual and family life cycle phase they are in at the time of transition (McGoldrick, 1982). For example, a Chinese teenager who migrates during adolescent years is confronted by not only migration and acculturation stresses but also the special developmental tasks such as identity and sexual role formation, separation, and individuation (Lee, 1988). An elderly Korean who lost his family members and business has to deal with the physical and psychological impact of growing old, particularly in a youth-oriented society.
The impact of the migration experience on the family life cycle may be different at every stage. For example, families that migrate with young children are perhaps strengthened by having each other, but they are vulnerable to the parental reversal of hierarchies. Families migrating when their children are adolescents may have more difficulty because they will have less time together as a unit before the children move out on their own. Thus, the family must struggle with multiple transitions and generational conflicts at once (McGoldrick, 1982). When families migrate in the launching phase, it is very difficult for the parents to break into new jobs, find new friends, and deal with "empty nest" syndrome.
Assessment of Acculturation Level of Each Family Member
Several researchers have made significant contributions in the area of acculturation. Lin, Matsuda, and Tazuma (1982) proposed five adjustment patterns: (1) neurotic marginality (develops high levels of anxiety while trying to comply with expectations of both cultures), (2) deviant marginality (becomes isolated due to ignoring norms of both cultures after being unable to satisfy both simultaneously), (3) traditionalism (withdraws into the old culture to escape loss and confusion), (4) overacculturation (abandons former culture, loses traditional supports), and (5) biculturation (integrates both cultures with the best possible compromises). Berry (1990) suggested that the greater the cultural dissimilarity across two cultures, the greater the acculturation stress.
The acculturation rate of each individual depends on the following factors: (1) age at the time of migration-the younger, the easier; (2) language; (3) past and present exposure to Western culture; (4) ethnic and cultural pride; (5) ethnic density of the neighborhood; (6) socioeconomic status and profession; and (7) immigration status-temporary or permanent. Each family member may have a different acculturation within the same family. Intergenerational conflict may be caused by the disparity between grandparents, parents, and children, who have different acculturation rates.
According to my experiences, traditional views of acculturation need to be adapted to our contemporary multicultural society:
- Acculturation is not totally a linear process. An individual does not necessarily have to give up his or her own culture to become Americanized. For example, a highly acculturated Chinese American can still hold on to some traditional Chinese values with minimum conflict.
- Acculturation to the mainstream culture may not be all positive. For many immigrant and refugee youths, giving up their own cultures and identifying with the new culture (e.g., drugs, alcoholism, and gangs) may have negative effects.
- In a multicultural society, one can become acculturated not only to the mainstream American culture but also to other cultures of ethnic groups, such as Latino and African American.
- A higher acculturation rate does not necessarily imply better mental health. Maintaining a positive identification with one's ethnic group as well as the mainstream culture provides a more solid base for positive self-esteem.
Assessment of Work and Financial Stresses
Research studies have found that clinical depression was significantly associated with unemployment (Yamamoto, Lam, Fung, Tan, & Iga, 1977). For Asian Americans, two common types of stress related to employment exist. Among immigrants, many experience unemployment and underemployment. "Downward mobility" leads to low self-esteem, insecurity, and role reversal in families. For acculturated and professional Asian Americans, a "glass ceiling" (a term that refers to a barrier to promotions and success because of one's ethnicity or gender) and subtle discrimination at work sites often lead to frustrations and job dissatisfaction.
The parents' type of work and work hours often influence the family dynamics. At one extreme, a typical Asian American small business owner (e.g., laundry or grocery store) requires the whole family to spend long hours together, sometimes resulting in relationships that are intense and too close. At the other extreme, parents may work extremely long hours away from home (e.g., restaurant or engineering/research office). Family members seldom have sufficient time together to communicate. One recent phenomenon is the so-called astronaut family, where the family resides in the United States and one parent still maintains a business in the home country. Such families maintain their relationships by telephone, fax, and "frequent flyer" trips.
Assessment of the Family's Place of Residence and Community Influence
Whether or not the family lives in an ethnic neighborhood will influence the impact of the family cultural heritage on their lives (McGoldrick, 1982). For those Asians who live in their ethnic communities, such as Chinatowns and Japantowns, the community support systems provide a cushion against the stresses of migration. Unfortunately, due to housing shortages, many recent immigrants and refugees have to live in poor neighborhoods, where they feel isolated from their ethnic communities and encounter problems of crime, violence, drugs, racism, and inadequate housing. Those who live in areas with relatively small Asian populations, such as small towns and rural areas, generally have more trouble adjusting and are pressured to assimilate more rapidly.
Assessment of Family Stresses Caused by Role Reversal
In many Asian American families, conflict may be caused by role reversal among grandparents, parents, and children. Many monolingual adults depend on the English-speaking children as cultural brokers and interpreters. Such dependence can cause anger and resentment. Role reversal may also occur between husband and wife. Husbands who are accustomed to male-dominated Asian cultures find it difficult to accept wives who may find work more easily and become more independent and assertive.
The issue of family loyalty is another source of stress. Such stress may be caused by the fact that many immigrants and refugees are raised by someone other than their biological parents, because of the extended family system and separation from family members. Family reunions in the United States after years of separation may trigger many unresolved family conflicts and resentment.
Assessment of Stress Caused by Legal Problems and Sponsor Relationship
Because of language difficulties and unfamiliarity with immigration law, many immigrants depend on their sponsors for legal, financial, and emotional support, especially when they first arrive in this country. The legal sponsor is often given a great deal of power in many family decisions, including where to live, which school to attend, and even which family members back home will be sponsored. Sometimes the sponsor may object to the family's receiving assistance from a social services or mental health agency because he or she fears that doing so may jeopardize future sponsorships and bring shame to the family name. The family may simultaneously feel gratitude as well as resentment toward a sponsor's exercise of power. A hostile-dependent relationship may result.
Assessment of Family's Experiences with Racism, Prejudice, and Discrimination
As a visible minority with distinctive physical characteristics and accents, Asian Americans find it impossible to hide their ethnic heritage to achieve total acceptance. Historically, Asians have been subjected to many forms of racism and discrimination in the United States. For example, from the 1880s through World War II, Chinese men who immigrated to this country to work in the gold mines and railroads were prohibited from bringing their wives with them. Many Japanese families suffered immensely due to their internment experience during the war. Despite significant improvement in the life of minority groups in this country as a result of the civil rights movement, racism and discrimination still persist against Asian Americans. Many clients encounter racial discrimination in their workplaces, schools, and communities. Not only recent immigrants but also well-educated and highly trained professionals face such discrimination. Clinicians should be sensitive to the impact of immigration policies on the Asian family system and should encourage the family members to share their frustration and anger caused by their minority status in this society.
Assessment of Family's Religious and Spiritual Beliefs
Asian Americans come from a variety of religious backgrounds (e.g., Christian, Buddhist, Shintoism, or Muslim). Family behavior is governed to a great extent by religious beliefs. In many Asian countries, religious organizations are highly respected. The priest, minister, or Buddhist monk is a key figure in the process of understanding and solving family problems. The clinician should assess whether the family is a member of a particular church or temple and the availability of emotional support or counseling from the particular organization. In many Asian American households, beliefs shared by the grandparents or parents may be in conflict with and challenged by the beliefs of the younger generation, who are typically exposed to Western religions. The clinician should encourage family members to share their religious beliefs in relation to the presenting problem and problem-solving strategies.
Assessment of Family's Physical Health and Medication History
The exploration of physical health is important for three major reasons. First, Asian clients tend to express their emotional problems in somatic terms. They usually come to treatment with many physical complaints. Second, many Asians, especially refugees, are in need of medical attention as a result of physical injuries, malnutrition, and lack of adequate medical treatment during war. It is important to request information on the client's physical condition and family medical history. Third, many Asians who are not familiar with Western medicine may become confused by drug names, dosages, and effects. Furthermore, for many Asian Americans, concurrent use of Western and traditional medicine is quite common. A clinician's concern over these health and medication matters is often appreciated.
Assessment of Culturally Specific Responses to Mental Health Problems
When trying to understand the causes of emotional problems or mental illness, many traditional Asians do not accept Western biopsychological explanations. A mental health problem may be conceptualized as a manifestation of organic disorders, hereditary weakness, imbalance between yin and yang disturbance of qi energy, supernatural intervention, or emotional exhaustion caused by external environmental factors (Lee, 1982). In the assessment process, it is essential for the clinician to encourage the client and his or her family members to openly discuss their cultural and religious viewpoints on the cause of the problem, their past coping style, their health-seeking behavior, and their treatment expectation. The discussion can be based on the following questions (Lee, 1990):
- What are the symptoms and problems as perceived by each family member?
- What would be the diagnostic label given in the client's home country? What are the family's cultural explanations of the causes of the problem?
- What kind of treatment would the family get if they were back in their home country?
- Where did the family go for help before they came to see the clinician? What is the family's experience with herbal medicine and indigenous healers?
- What was the family's previous experience with Western health and mental health care systems?
- What are the family's treatment expectations?
Assessment of Cultural Strengths and Community Support Network
In addition to the assessment of family stress and pathologies, an assessment is necessary with respect to individual and family strengths in past adaptation, coping, and problem solving. The Asian family usually arrives in the United States with many problems. At the same time, the family also brings along highly developed cultures, religions, and philosophies. For instance, these strengths may include the Confucian teaching of the "middle way," the Buddhist teaching of karma and compassion, the strong focus on the importance of family harmony and interpersonal relationships, and the high value of education and hard work. Asian cultures emphasize family, friends, and ethnic community. During a crisis, Asian families can usually count on support from extended family members, friends, and ethnic community network and organizations. The clinician should explore and recognize such support systems.
Special Issues in Family Assessment
The previous assessment guidelines provide a comprehensive and holistic view of Asian American families. However, in the evaluation process, the clinician may encounter several potential difficulties.
First, Asian American families may be very discreet about family secrets and problems. Family members feel loyal and protective of each other and will not readily offer information before trust is established.
Second, many Asian Americans do not comprehend the significance and sometimes lengthy procedures of evaluation. Either they are not used to detailed history taking or they do not understand the relationship between the questions and the presenting problems. Some may even suspect that such information will be put to political use, thus jeopardizing their immigration status.
Third, there is a lack of bilingual and culturally competent assessment tools. Many psychological testing and mental status examination questions are irrelevant to the Asians' world views and may lead to over- or underdiagnosis.
Fourth, Asian families may not be accustomed to verbal expressions of emotion to outsiders. Therefore, data collection on Asian American families may require more than the usual question-and-answer mode of interaction. Effective techniques include the use of family genograms (McGoldrick, 1985), photographs and albums, sharing of trauma stories, paintings, songs, and philosophical discussions.
TREATMENT RECOMMENDATIONS: STRUCTURE AND STRATEGIES
Structural Aspects of Family Therapy Assessing Readiness for Family Therapy
Even though family therapy can be highly effectively as a treatment modality in working with Asian American families – due to the strong family orientation – Asian American clients generally are quite reluctant to seek family treatment. The following reasons highlight some of the possible difficulties:
- Asian American clients are mostly unfamiliar with the concept of family therapy or the role of the family therapist. Traditionally, family members consult family elders, village chiefs, a trusted member of the clan, monks or ministers, or indigenous healers in case of family crises.
- Asian family members usually do not see individual problems as family related. They are unfamiliar with "family system" or "family communication" theories and usually do not understand the need for family therapy as a way to improve the individual's pathological symptoms. They rarely agree to the suggestion that the problem is the group's instead of the identified client's.
- Because of the traditional hierarchical and vertical structure of Asian American families, which prohibits free verbal expression of emotions, especially true thoughts and negative feelings, family members may not be equipped with the communication skills to discuss problems and to express themselves openly in a family group setting. For example, for parents to discuss their "adult" problems or to express their sadness in front of the children is considered culturally inappropriate and is viewed as losing control.
- In view of the long years of separation among the family members of immigrant and refugees families, there are many family secrets and unresolved grief that members are not ready to share openly with each other. Family therapy may bring out the "ghosts" in the past and can be very overwhelming and at times damaging to family relationships.
- Traditional Asian husbands or fathers are quite resistant to attending family sessions or allowing the therapist to enter into the family system. Many traditional Asian men may interpret the admission of emotional problems and receiving help from outside the family network as a sign of weakness and losing face. In the event that their children are in trouble and the parents are forced to receive treatment, they usually send their wives to be the family representative to deal with service agencies. It is very difficult to conduct family therapy without the cooperation and participation of the male adult figures.
- Many immigrant and refugee Asian families do not have all the family members living in the same country or city. Sometimes, family members do not reside in the United States or in the same city.
- The great discrepancy in the degree or level of acculturation among family members may discourage individual members to accept family therapy as the means to resolve family problems. In those families with severe intergenerational conflicts and very different value orientations and communication styles, family sessions can be overwhelming not only to the family members but to the therapist as well.
Prior to determining family therapy as the treatment of choice, the clinician needs to assess the previously mentioned factors and the readiness of family members to work together as a group. For some families, family therapy sometimes is neither the feasible nor the desired treatment modality. However, if the clinician believes in his or her best clinical judgment that family therapy is the most effective treatment strategy, the family members (especially the decision makers) should be educated on the benefits and rationales of such decision. This can be done by making the initial appointment with the head of the family (e.g., the father) and soliciting his (or her) assistance.
Involving Family Members in Therapy
The definition of "family" in traditional Asian cultures may include a wide network of kinship. For example, a Vietnamese teenager who left his homeland with his aunt when he was an infant may have many more emotional ties with his aunt and her family than with his own biological parents. In many Filipino families, trusted friends and allies serve as godparents to children and play an important role in their growth and development. If appropriate, the clinician can ask the identified client to define his or her own concept of family members and discuss who should be included in therapy. In many cases, it is advisable to encourage all family members to come to the first session so that the family dynamic can be observed. However, in many instances, family members are either emotionally not ready or physically unavailable to participate in treatment.
Family therapy for Asian families does not always require all-encompassing family involvement. A flexible family subsystem approach in the establishment of therapeutic relationships with family members at the beginning phase can be very helpful. For example, an effective method is for a clinician to interview the parents first, then the identified client, and then the sibling group. The parents can discuss their adult concerns or express their emotions freely when the children are absent. The children, usually more acculturated and more fluent in English, can negotiate issues they might not bring up with their parents present. When all parties feel safe and have more control over what may be discussed in the family group, they will be more willing and ready to accept family therapy. This "staging" process requires skills in establishing trust and credibility with each family member at the initial phase of treatment.
Setting Client-Centered Goals
Many Asian Americans find it difficult to admit having family problems or psychological difficulties. They usually present themselves as victims of some unfortunate environmental events or physical discomfort. The clinician should take their presenting problem seriously and respond immediately to the concrete needs of the clients. A problem focused, goal-oriented, and symptom-relieving approach is highly recommended in the beginning phases of treatment. Rather than defining goals in abstract, emotional terms, goals may be best stated in terms of external resolution or symptom reduction. Many clients find loosely targeted and emotionally oriented goals as incomprehensible, unreachable, and impractical (Ho, 1987). Long-term goals may best be broken down into a series of easy-to-understand, achievable, measurable short-term goals. Once the family is engaged in the therapeutic relationship and gains a sense of success, the therapist can introduce other more insight-oriented goals and renegotiate with the family members.
Deciding on Language Used in Therapy
There is a lack of common language spoken in many Asian American households, especially families with "Westernized" adolescents who do not speak their parents' and grandparents' native dialects. It is quite difficult to conduct therapy in two or three different dialects and different communication styles. Ideally, the clinician is fluent in the languages spoken by the family members and has a good understanding of the variability in linguistic expressions. When family members are bilingual in both English and their native dialect, the therapist can discuss with them which language they prefer to use in therapy. English-speaking clinicians should avoid the use of bilingual children as interpreters, particularly when the presenting problem involves parent-child issues. The bilingualism of a child could reinforce the problem of role reversal and the monolingual parents' sense of helplessness. Also, clinicians should avoid the use of relatives and friends as interpreters. They are often not objective and tend to minimize or maximize family pathology, depending on their own issues with the family. 1f interpreters are used, clinicians should try to use interpreters who match the Asian dialects and cultural background (see Lee, Chapter 32, this volume, for more details).
Determining Duration of Therapy and Number of Sessions
It is not uncommon for Asian American families to ask for mental health assistance only in times of crisis. The first session is usually the most crucial one and may determine whether the family will stay in treatment. The clinician should take advantage of the family energy mobilized by the presenting family crisis to conduct an extensive evaluation and offer immediate help if possible. An extended amount of time for the first session is often necessary. In the beginning phases of therapy, the traditional 1-hour, once-a-week session may not be sufficient. Appointments should be made at the convenience of the family. Most Asian families expect a short-term treatment period, no more than 2 to 3 months. Asians who seek help for chronic psychiatric disorders should be informed that an immediate recovery may be unrealistic and that treatment may require a longer period.
Conducting Office Interviews versus Home Visits
For family members who are motivated to engage in treatment, office interviews can be very therapeutic and cost-effective. Although travel to the home increases the expense of therapy, use of the home offers many unique benefits. Family members are more relaxed. Therapy can be "delivered" to resistant members who are less motivated to join the family sessions. Family members can reenact family disputes and rehearse more effective communication and problem solving. The clinician also has the opportunity to observe the community and neighborhood in which the family resides. Furthermore, the home visits may enhance the therapeutic alliance. Family members may see such visits as symbols of the clinician's caring and commitment to help.
The following guidelines summarize treatment strategies I have found to be effective in working with Asian American families.
Forming a Social and Cultural Connection with the Family during the First Session
The most important process in working with Asian American families is "joining," that is, initiating therapeutic intervention by building a relationship with the family. Many Asian American families are often new to therapy, and they need to be prepared and "coached." During the first session, the clinician should address the family in a polite and formal manner. Giving the Asian cultures' emphasis on interpersonal relationships, the family may expect the clinician to disclose a certain amount of personal information or her family, country of origin, regarding his academic, and professional background. Appropriate self-disclosure may facilitate positive cultural alliance and a level of trust and confidence.
Asking nonthreatening personal questions can put the family at ease. It is also important to avoid direct confrontation, to demand greater emotional disclosure, or to discuss such culturally taboo subjects as sex or death. There is a need for caution in the use of paradoxical approaches. This technique is particularly problematic in the initial stage of treatment.
Acknowledging the Family's Sense of Shame
For many Asians, public admission of mental health problems can bring intense shame and humiliation. The clinician may counter those emotions by empathizing with them and encouraging them to verbalize this feeling. It is important to reassure family members about confidentiality and anonymity. One helpful technique is to reframe their courage in seeking help as love and concern for family members. If appropriate, the mobilization of the family's sense of obligation to receive help to achieve family harmony or for the sake of the children can be very effective.
Establishing Expertise, Power, Credibility, and Authority
Many Asian clients come to their first session believing that the clinician is an authority who can tell them what is wrong and how to solve their problems. It is helpful for the clinician to establish credibility right away, to ensure that the client will return. An air of confidence, empathic understanding, maturity, and professional mannerism are all important ingredients. Other ways to establish credibility and authority include (I) using professional titles when making introductions; (2) displaying diplomas, awards, and licenses in the office; (3) obtaining sufficient information about clients and their families before seeing them for the first time; (4) offering some possible explanation for the cause of the problem; (5) showing familiarity with the family's cultural background; (6) providing a set of cues that will help the family to judge the clinician's expertise (e.g., "according to my experience working with Asian families during the past 20 years ... "); and (7) utilizing the crisis intervention approach to offer some immediate solutions to the problems. It is important for family members to feel that they are in good hands and there is a sense of hope before they leave the first session.
Defining the Problem
A problem focused family therapy approach with Asian American families appears to be very effective. The clinician should focus on the immediate crisis or problem that brought the family to the agency. In most instances, family members ask for professional help because of the difficulties they encounter with one particular family member (the identified patient). Family members are either unaware of their roles in contributing to the problem or are unwilling to discuss it openly in front of others, particularly the children. For many families, working on the parent-child issue at the beginning is safer than working on marital problems that may exist.
To engage the family in therapy, it is important for the clinician to (1) acknowledge the family's feeling that the identified patient has problems, (2) verbalize the family pain caused by the difficulties, (3) assist the family to shift from a person-focused orientation to a problem-focused orientation to minimize scapegoating, (4) focus on the effect of the problem on each family member, and (5) reinforce the sense of family obligation and the significance of solving the problem together. At times, it may be helpful to encourage family members to elaborate on previous attempts in dealing with the problem. Acknowledging their failure to cope and the unpleasant consequences if the problem remains uncorrected may motivate the family to continue in treatment. 1n some instances, the clinician may use the family's sense of guilt to induce them to participate in treatment for the sake of the family name (Lee, 1990).
Applying a Family Psychoeducational Approach
Asian cultures value education highly. The psychoeducational approach based on social learning principles may be compatible with Asian values and beliefs. Such intervention focuses on four major areas: (1) education about the illness (or problem)-printed educational materials in the patient's primary language are helpful; (2) communication training; (3) problem-solving training; and (4) behavioral management strategies (McGill & Lee, 1986). Family education about the U.S. legal system (child-abuse laws, patients' rights, etc.) may be necessary. In addition to providing education on individual and family levels, psychoeducational programs dedicated to multiple families in the Asian community can be very effective.
Building Alliance with Members with Power
An accurate assessment of the power structure of the family is essential. Generally speaking, there are two types of power in the family system: "role-prescribed power" (usually given to the grandfather, father, eldest son, or sponsor) and "psychological power" (usually maintained by the grandmother or the mother). Treatment will not be effective without permission of the leader(s). Clinicians should acknowledge and respect their power in decision making, avoid competition, and use all possible means to build a therapeutic alliance.
Employing Reframing Techniques
The technique of reframing can be helpful to build rapport with family members with power. For example, the clinician can reframe the mother's overprotectiveness as "loving too much" and the father's overly excessive working hours as "sacrificing for the economic well-being of the family."
Assuming Multiple Helping Roles
Flexibility and willingness to assume multiple helping roles enhance the therapeutic relationship, especially when working with multiproblem families. In addition to being the counselor, the clinician should be comfort-able with playing the role of teacher, advocate, interpreter, and the like. Acting as a "cultural mediator" or using a family intermediary can be an effective tool in dealing with family conflicts. Show caring by doing and being there when the family needs help.
Restructuring Social Support System
Asian American families usually consist of strong and close-knit extended families and support systems. However, many families isolate themselves when they encounter problems. As soon as possible, the clinician should assist the family to establish a social support network whereby the family or the individual can form friendships, ventilate frustrations, and learn social and problem-solving skills.
Integrating Eastern-Western Health Approaches
Clinicians should take advantage of the holistic model of health in Eastern cultures and integrate its elements with the best Western medical and psychological practices. For example, in the treatment of a depressive Chinese patient, it can be helpful to educate the patient on the Western biological and psychological perspectives of the illness. It is also important to explore the Eastern approaches of treatment (e.g., Chinese herbal medicine, acupuncture, and qi gong). It is my belief that such treatments will benefit not only Asian patients but also mainstream American society.
Mobilizing the Family's Cultural Strength
One of the functions of therapy is to mobilize the family's cultural strength. Strengths include support from the extended family, the strong sense of obligation and family loyalty, parental sacrifice for the children's future, filial piety, strong focus on educational achievement, the work ethic, and the support from their ethnic communities. In many circumstances, especially when family members are coping with death, losses, and unpredictable changes, discussions of religious stories or philosophical teachings in the Asian culture can be very therapeutic.
Employing the Concept of Empowerment as a Treatment Goal
Empowerment is the process whereby the clinician mobilizes the family's ability to interact successfully with external systems. It is particularly important in working with immigrant women who have victimized by years of sexism, loss of power due to language barriers, role reversal, and racism in the new country.
Understanding the Family's Communication Style
In addition to determining the preferred language and dialect used in therapy, the clinician must understand a family's communication style. Shon and Ja (1982) discussed the communication process with Asian American families in three areas: the revelation of information, the expression of feelings, and the process of disagreement in therapy. Traditionally, Asian Americans have been taught to employ indirect styles of communicating and to avoid direct confrontations. The clinician is expected to read between the lines to grasp the major issue. On the other hand, the family may perceive the clinician to be too blunt, pushy, and insensitive.
If Asian clients discuss emotional difficulties, they are often expressed in an oblique, understated way with little obvious emotion, implying that the problem is less serious than it really is (Hong, 1989). Negative emotions such as anger, grief, and depression may be expressed in an indirect way. A culturally naive clinician may mistake this style for denial, lack of affect, lack of awareness of the client's own feelings, deceptiveness, or resistance on the part of the client (Sue, 1990). Even positive feelings (e.g., love) are frequently not expressed in an open manner. Asian parents may be misunderstood as unloving and uncaring. To overcome this communication barrier, it is quite helpful to introduce the structural family therapy model (Minuchin, 1974) because of its emphasis on actively restructuring the interaction in the family to create change rather than relying on direct, open expression of feelings (Shon & Ja, 1982).
Acknowledging Countertransference and Racial Stereotypes
Clinicians should explore their own stereotypes, both positive and negative, about Asian American families. Many non-Asian clinicians who have been exposed to the "model minority" myth may tend to minimize a family's pathology. On the other hand, a clinician who has worked with poor, traumatized refugee families may adopt a missionary zeal and may not recognize the many family strengths. In addition, a clinician with a superficial or stereotypical understanding of Asian American cultural values might overemphasize cultural similarities in all people of a particular ethnic group. Such a clinician might unconsciously assume that the cultural values and behavioral patterns of a client's ethnic group coincide with the values and behaviors of a particular Asian American client (Sue & Zane, 1987). Such stereotyping can have a negative impact on clinician client relationship.
For Asian American clinicians, special issues include overidentification with the family and guilt for "having made it" in mainstream America. For those who still have their own identity issues (denial or rejection of one's racial identity), working with Asian American families may evoke unresolved pain and emotions. An Asian American clinician who works in mainstream settings as a token expert may feel undue pressure to succeed. He or she should receive supervision or consultation on countertransference issues that may exist.
Most Western family therapy approaches have been limited in their application to families with an Eastern value orientation. This chapter offers an alternative assessment and treatment model that takes into account the physical, psychological, social, spiritual, and cultural back ground of Asian American families. The proposed framework is intended to be a stimulus for the future development of a systematic approach more compatible with Asian Americans' world view and family characteristics. Asian Americans are a heterogeneous group reflecting a diversity of educational, political, socioeconomic, and religious backgrounds, as well as different migration histories. The scope of this chapter does not allow for an in-depth discussion of each group, and readers are encouraged to examine the following chapters for more in-depth discussions.
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