The following chapter appeared in Evelyn Lee's book Working with Asian Americans: A Guide for Clinicians (1997). Reprinted with the permission of Guilford Press.
In the past three decades, there has been a tremendous influx of Chinese immigrants and refugees in the United States. As the largest Asian Pacific American ethnic group, Chinese Americans share many of the same characteristics and values of other Asian Americans, but they also possess their own unique migration history, political background, linguistic styles, and cultural and religious beliefs. This chapter attempts to sensitize clinicians to the complexities and diversity of major Chinese American subcultures, reviews relevant clinical considerations in the treatment of psychological problems, and recommends effective assessment and treatment strategies.
The Chinese characters for China mean the Middle Kingdom. It has a land mass about 9.6 million square kilometers, which is more than 300,000 square miles larger than the United States. In 1994, the Chinese population in China was 1.192 billion, with a projection of 1.504 billion by the year 2025. The Chinese constitute about one-fifth of all the people on earth. More than 95% of the population live on approximately 40% of the land (Bunge & Shinn, 1981).
China has the world's oldest continuous history and culture. (Although there have been earlier civilizations elsewhere, they have flourished and then become extinct.) China's traditional value system is a complex amalgam of ideas that evolved over centuries from the philosophical teachings and religious beliefs of Confucianism, Taoism, Buddhism, and other influences. Social values emphasize the importance of family solidarity, friendship, morality, and conformity of prescribed roles. when the Chinese Communists came to power in 1949, the political revolution also brought along social revolution. Many aspects of traditional social life – social relations, family organization, women's roles, personal values, and so forth – experienced fundamental changes. The industrialization of China in recent years has created another wave of economic and social changes.
The Chinese migration history to the United States tells a complex yet fascinating story of change, adaptation, and survival. Their experience also reveals how the Chinese family system has been affected by the immense power of political, legal, social and economic forces in the United States and in China (see Table 3.1). The Chinese have been residing in this country in significant numbers for more than 150 years. Major national immigration policies and economic upheavals in the U.S. and in Asian countries have resulted in different waves of immigration and different types of family systems.
Although there were Chinese residing in the United States as early as 1785, the impetus for large-scale immigration to this country did not take place until the discovery of gold in California in 1848 and the need for manual labor for the construction of railroads. Many Chinese migrants, mostly peasant farmers, left their village in China to pursue their dreams in Gam Saan, the "Gold Mountain." In addition to employment opportunities, many sought sanctuary from intense conflicts in China caused by the British Opium War and the harsh economic conditions. From their arrival in the 1850s until the 1920s, the overwhelming majority of the early Chinese immigrants were men. More than half of the arriving men were single, and those who were not often were separated from their wives and condemned to live as bachelors in Chinese communities. Racial and ethnic antagonism, coupled with xenophobia against early Chinese immigrants, succeeded in the passage of the Chinese Exclusion Act of 1882. This act barred Chinese laborers and their relatives (including their wives) from entering the United States.
The early Chinese pioneers lived in a virtually womanless world without family life. In 1900, of the 89,863 Chinese on the U.S. mainland,
| Year | Events in the United States | Events in China | |
|---|---|---|---|---|
| 1850-1860 | California "Gold Rush." Male sojourner immigration from southern China to California. | Chinese immigrants came to the United States seeking sanctuary from internal conflicts in China caused by the Opium War with Great Britain; peasant uprisings; Western imperialism; economic and political turmoil; heavy peasant taxation; flooding and starvation. | |
| 1864 | Central Pacific Railroad recruited Chinese laborers from Canton. | |
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| 1866 | every Civil Rights Act: Gave persons of race and color, citizenship and all privileges, to hold property and to testifying Court. The law did not apply to the Chinese. | |
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| 1869 | Burlingame Treaty: Unrestricted Chinese immigration was allowed primarily to supply cheap labor to build the railroad. | |
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| 1871 | Anti-Chinese riots in Los Angeles. | |
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| 1877 | Anti-Chinese riots in San Francisco. | |
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| 1879 | California Constitution adopted with anti-Chinese provisions. | |
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| 1882 | Chinese Exclusion Act Suspended immigration of Chinese laborers for 10 years. Barred Chinese naturalization. Provided for deportation of Chinese illegally in the United States. | |
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| 1882-1920 | Declining immigration; decline of agriculture, mining, and railroad occupations; rise of urban service occupations; immigration of "paper sons" and "treaty merchants." | |
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| 1891 | Immigration Act First comprehensive law for national control of immigration. Established Bureau of Immigration under U.S. Treasury Department. Directed deportation of aliens unlawfully in country. | |
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| 1892 | Geary Act: Extended exclusion for 10more years. | |
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| 1898 | U.S. Supreme Court recognized children born in the United States with Chinese parents as citizens. | |
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| 1900-1930 | Rise of "family associations" and "tongs" (secret societies). | |
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| 1911 | Birth of Republic of China. End of the Chin Dynasty. Sun Yat-Sen became the president. | |
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| 1924 | Immigration and Naturalization Act Imposed first permanent numerical limit on immigration. Established the national origins quota system, which resulted in biased admissions favoring northern and western Europeans. | |
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| 1927 | Kuomintang Party unified most of China. | |
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| 1929-1939 | Great Depression. | |
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| 1931 | Japan invaded Manchukuo. | |
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| 1932 | Manchukuo established under Pu Yi. | |
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| 1934-1935 | The Long March: Communists to Yen'an. | |
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| 1937 | Japanese attacked across China; Communist Kuomintang alliance. | |
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| 1940-1946 | 16,000 Chinese Americans served in Armed Forces in World War II. | |
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| 1943 | Repeal of all 15 Chinese Exclusion Acts: Quota set at 105 per year. | |
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| 1945 | War Brides Act: Facilitated the entry of wives of men in the U.S. armed forces. | Japan surrendered. | |
| 1948 | Displaced Person Act: 3,465 Chinese students, visitors, and seamen were granted permanent resident status. | Kuomintang-Communist Civil War (to 1949). | |
| 1949 | People's Republic proclaimed. Chiang Kai-shek and Kuomintang to Taiwan. Many Chinese moved to Hong Kong, Taiwan, and overseas. | |
Although immigration law excluded the majority of Chinese from entering this country, it did allow entry of relatives of U.S. citizens of Chinese ancestry. When the 1906 San Francisco earthquake and fire destroyed most of the municipal records, this provided a loophole by which the Chinese could immigrate to the United States. American-born Chinese would visit China, report the birth of a son, and thereby create an entry slot which could be sold years later to someone wanting to immigrate. The purchaser, a "paper son," simply assumed the name and identity of the alleged son (Wong, 1988). The "paper family names" passed on from generation to generation.
The discriminatory Immigration Act of 1924 made it impossible for American citizens of Chinese ancestry to send for their wives and families. This law was changed in 1930 to allow wives of Chinese merchants and Chinese wives who were married to American citizens before 1924 to immigrate to the United States (Chinn, Lai, & Choy, 1969). As a result, sizable family units with second-generation American-born Chinese population were emerging in Chinatowns. At the same time, many first-wave laborers began to leave mining and railroads and used their savings to start their own small businesses, such as laundry shops or fishing, either alone or with partners. The small-producer families emerged during this period. This family type consisted of the immigrant and first-generation American-born family functioning as a productive unit (Wong, 1988). Although all family members participated in the family enterprise, there was a division of labor according to age and gender. There was also an emphasis on collectivity over the individual.
The liberalization and reforms of immigration policies during and after World War II were instrumental in partially rectifying past discrimination against the Chinese and slowly led to the development and normalization of family life among the Chinese in the United States. In 1943, the Chinese Exclusion Act of 1882 was repealed, making Chinese immigrants eligible for citizenship. In 1945, the War Brides Act was passed, allowing Chinese women to enter to this country as brides of men in the U.S. military. The Displaced Persons Act of 1948 gave permanent resident status to Chinese visitors, seamen, and students who were stranded here because of the Chinese civil war. The Refugee Relief Act of 1953 allowed a group of highly educated Chinese into the United States as refugees. During the period from 1943 to the repeal of the quota law in 1965, Chinese immigrants were largely female. After years or sometimes decades of separation from their husbands, many wives were reunited with their husbands for the first time. By the time they arrived in the United States, these women and their children had already established very powerful bonds which were far more intense than the marital tie. Reform in immigration policies also encouraged Chinese men to return to Hong Kong to find wives. These trans-Pacific marriages, with wives who were 10 to 20 years younger than their husbands, were usually arranged by matchmakers or relatives (Wong, 1988).
Unlike the pre-1965 immigrants who came over as individuals, most of the Chinese immigrants who arrived under the Immigration Act of 1965 came as families. Many of them initially settled in or near Chinatowns in the major metropolitan areas. Approximately half of them were working class, employed as service workers or laborers. Most of husbands and wives sought employment in the labor-intensive, low-capital services such as garment sweatshops and restaurants. Unlike the small-business families, they tended to completely segregate work and family life, and family members had very little time to spend together. Economic survival was the primary goal for many families, especially the new immigrant families.
In the past two decades, there has been a tremendous influx of Chinese immigrants from China, Hong Kong, Taiwan, and Vietnam. Since 1979, after three decades of a closed-door policy, the United States started to admit immigrants from mainland China to join their relatives. The reestablishment of diplomatic relations between the United States and the People's Republic of China in 1978 also provided an opportunity for students and professionals from China to study in this country, and many elected to stay. The massacre at Tiananmen Square in June 1989 and its political aftermath increased the desire of many students to seek permanent residency in the United States. Another group of immigrants who came from Hong Kong worried about the 1997 transfer of British sovereignty to China. The recent political climate in Taiwan and the desire to seek higher education for their children also created an impetus for many Chinese to come to this country.
Many of the refugees from Vietnam, Laos, and Cambodia were ethnic Chinese. They constituted the second wave of Southeast Asian refugees. A significant number of them were survivors of hunger, rape, incarceration, forced migration, and torture. Although most of the original South-east Asian refugees came under the sponsorship of churches and social services agencies, the new arrivals were often reunited families who were petitioned by family members.
Another recent phenomenon is the so-called astronaut families. These are the "frequent fliers" who set up two households, one for the children in the United States and one for the adults who work in their home country after they have received their green cards. The increased number of such families is a result of the economic boom of the Pacific Rim and the difficulty of finding suitable employment in the United States. In recent years, this phenomenon has applied not only to new immigrants but also to many Chinese American families who have lived in the United States for many years.
In summary, the influx of immigrants and refugees from many different parts of Asia and from many different socioeconomic and political backgrounds has contributed to the complexity of existing Chinese American communities.
According to the 1990 figures (U.S. Bureau of the Census, 1990), Chinese Americans, numbering more than 1.6 million, were the largest Asian Pacific American group, making up 22.6% of the Asian Pacific American population. Between 1980 and 1990, the Chinese American population doubled due to the new influx of immigrants. Currently, more than 63% of Chinese Americans are foreign-born, 23% do not speak English well, and 53% live in the Western parts of the United States. There are 542,121 Chinese Americans who reside in California, 147,250 in New York, and 55,916 in Hawaii. It is estimated that 13.3% of Chinese Americans live below the poverty level, 69.4% are high school graduates, and 72.5% speak a language other than English at home (Asian American Health Forum, 1990).
There is no single Chinese language. It is very important for clinicians to assess the primary dialect used by the client and to ask for an interpreter who is fluent in that dialect if he or she is not bilingual. There are many different dialects spoken by the different groups of Chinese Americans. Mandarin is the national dialect of China. However, many earlier immigrants who came from villages in the southern part of China still maintain their village dialects, such as Toishanese, Chiuchow, or Hakka. Chinese from cities such as Canton or Hong Kong use Cantonese as their primary dialect. Chinese who were born and raised in Shanghai speak the Shanghainese dialect, which is very different from the Mandarin Beijing dialect. Chinese from Taiwan mostly use Mandarin as their primary dialect, but some Taiwanese prefer the Taiwanese dialect. The Vietnamese Chinese are perhaps the most talented group of Chinese in regard to languages. Many can speak English, French, Vietnamese, and several Chinese dialects (e.g., Cantonese, Mandarin, Chiuchow, Fukien, and Hakka). Some American-born Chinese Americans who grew up with their monolingual parents and grandparents are capable of communicating with their elders in Chinese, but English is still their primary language. Acculturated immigrants are mostly bilingual and use both English and their native dialect, depending on the situation. It is important for the clinician to determine what dialect the family prefers to use in counseling sessions.
The written Chinese characters are less complicated than the variety of Chinese dialects. Generally speaking, there are two major styles: the "traditional" style practiced by the majority of Chinese from Hong Kong, Taiwan, and Southeast Asian countries and the "simplified" style of writing developed by the People's Republic of China.
Eastern communication styles are very different from Western ones. In counseling sessions, Asian American clients often appear quiet, passive, polite, and formal and make a great deal of effort to avoid direct confrontation and offending others. Silence and lack of eye contact are also common forms of indirect communication. Among Asians, silence is a sign of respect and a desire to continue speaking after making a point during a conversation (Sue & Sue, 1990). Direct eye contact is considered a sign of lack of respect and attention, particularly to authority and older people.
Traditional family in China had many unique characteristics. These characteristics were heavily influenced by Confucianism, with its emphasis on harmonious interpersonal relationships and interdependence. Family interactions were governed by prescribed roles defined by family hierarchy, obligation, and duties. Independent behavior or expressions of emotions that might disrupt familial harmony were discouraged. The family was patriarchal. Males, particularly the father and eldest son, had dominant roles. Marriages were commonly arranged, and it was socially acceptable for influential men to have mistresses. Husbands deal with the outside world and provide for the family. The spousal relationship was secondary to the parent-child relationship. Filial piety was highly cherished, and parents used respect and shame as a means of control. The father usually played the role of a stern disciplinarian whereas the mother was affectionate and caring. The eldest son was expected to carry on the family name and enjoyed special privileges; the eldest daughter was taught to assist the mother with household chores and to attend to younger siblings. The most elevated family dyad was the father-son dyad.
Throughout history, Chinese mothers have been portrayed as self-sacrificing, suffering, guilt inducing, and overinvolved with their children. Traditionally, in accordance with the custom of "thrice obeying," women were expected to comply with their fathers or elder brothers in youth, their husbands in marriage, and their sons after their husband's death. As wives, their value was judged by their ability to produce male heirs and to serve their in-laws. In many middle- and upper-class families, children were raised by wet nurses, who breast-fed the babies and took over the mothering roles. Grandparents and other extended family members also significantly influenced family life. Because of the strong bond and the intense sense of obligation, many sons never left their parents in their adult lives. Parents expected to be taken care of in their old age and never experienced the so-called empty nest period in their family life cycle.
The patterns of family systems tend to be molded by economic, political, and sociocultural factors outside the family system rather than determined merely by emotional and psychological factors within the family (Tseng & Hsu, 1991). In the past generation, the traditional Chinese family has undergone tremendous transformation as a result of economic and political forces in the United States and Asia. As indicated previously, the structure and composition of Chinese American families are heavily influenced by U.S. immigration policy changes.
With the large number of Chinese immigrants from China, Hong Kong, and Taiwan, clinicians should recognize that economic and political changes in those countries have a dramatic impact on Chinese family system and values. Since the communist takeover of China in 1949, Confucian thought and religions were largely banned. A one-child family system has replaced the traditional extended family system. During the 10 years of the Cultural Revolution, many families suffered forced separation. Red Guard youths openly challenged their parents and teachers; filial piety and respect for the elderly no longer dominate life in China. In recent years, the economic boom in China has brought another wave of Western influences and urbanization.
After World War II, both Hong Kong and Taiwan underwent rapid growth in light industries and exports. The forces of industrialization, Westernization, urbanization, and economic affluence have brought a change in Chinese social and family structure. Although the older and middle-generational Chinese still embody some traditional beliefs, the younger generation has shown some evidence of their rejection of conservatism and traditionalism. Political history has also influenced traditional Chinese family values. In the case of Hong Kong, a British colonial past had a profound effect on the education, legal, and social systems. In Taiwan, a long period of Japanese occupation until the end of World War II has had a large impact on the society, especially among the older generation.
In summary, there are several distinct shifts in the contemporary Chinese American family: (1) The traditional Chinese extended family has gradually yielded to a more nuclear family, where functional relations apply instead of actual household structure; (2) the traditional patriarchal family has transformed in many cases to a biarchal system, where a mother shares decision making with the father; (3) the parent-child dyad has diminished in importance while the husband-wife dyad has increased; (4) favoritism of sons has slowly decreased because daughters now attain comparable education and careers and can be counted on to take care of aged parents; (5) the family life cycle has changed from arranged marriages and no empty nest period to one in which romantic love occurs before marriage and adult children leave the home; (6) successful childrearing is now measured mostly by the children's academic and career achievements; and (7) earning power is no longer solely the father's but is shared with other adult family members.
These observations are general ones. There is no one typical Chinese American family. There are many individual differences, and they represent a wide range of cultural values from very traditional (such as newly arrived family from a rural area in China or Vietnam) to very "Americanized" (such as a third-generation American-born professional family). The five types of Asian American families identified in Chapter 1 serve as a general guideline for understanding these differences.
Given the fact that no large-scale prevalence studies have been conducted on Chinese Americans, it is difficult to specify the rates of mental disorders within this population or to compare these rates with those for other ethnic minority groups. However, findings from the available research on prevalence and needs strongly imply that major mental health problems do exist among Chinese Americans, which is contrary to the widespread belief that Chinese Americans are a well-adjusted "model minority."
Several research findings have reported the prevalence of somatization symptoms among the Chinese (Kleinman, 1982; Tseng, 1975; Marsella, Kinzie, & Gordon, 1973). Many Chinese Americans who are treated for mental health problems complain of headaches, and back and chest pains. They have reported more somatic complaints than European Americans on the Minnesota Multiphasic Personality Inventory, even when Asian Americans and European Americans have mental disturbances of equal severity (Sue & Sue, 1974). Chinese American students seem to have a rather definite pattern of depression associated with somatic functioning (Marsella et al., 1973). Chang (1985) also found ethnic differences in the patterns of depressive symptomatology, and the Chinese were the most likely to exhibit somatic complaints.
There are many hypotheses on why Chinese tend to express their emotional problems in somatic symptoms. It may be a reflection of Chinese cultural values that emphasize avoiding shame and protecting the family's name from the negative stigma of mental problems. In addition, expression of physical complaints is more socially acceptable than expression of emotional complaints in Chinese culture. Somatization may be a socially acceptable means of suppressing direct depressive affect while allowing the individual to receive secondary gain. Many Chinese women, for example, may use the sick role to seek attention and emotional support from family members otherwise may not be available. In addition to the psychological and sociological explanations of somatization, clinicians need to understand the Chinese holistic view of health and illness based on traditional Chinese medicine. There is a strong belief in unity between the mind and the body, an organ-oriented conception of pathology that emphasizes close correspondences between human emotions and body organs. Somatic problems frequently are explained by traditional Chinese as resulting from weak kidneys, hot intestines, or qi energy imbalances.
Depression has been widely found among Chinese Americans, especially among the immigrants and refugees. This may, in part, be a result of social isolation, lowered status, grief (Lin, 1986), acculturation stress, war trauma, financial problems, and other social stressors. Many experience symptoms of exhaustion, weakness, dizziness, diffuse bodily complaints, and difficulty with sleep and appetite, as well as a sense of hopelessness. They may meet the official diagnostic criteria for a major depressive disorder. However, from the traditional Chinese patient's perspective, the chief problem is not depression but "neurasthenia," an official diagnosis in China and a diagnosis widely offered by traditional herbalists in Chinatowns.
In an earlier study in San Francisco's Chinatown, Bourne (1973) reported a high suicide rate among the Chinese. From 1952 to 1968, the suicide rate among Chinese was 27.9 per 100,000 population per annum, which was three times higher than the reported rate for the national average. The study also found that the frequency of Chinese men committing suicide was four to five times more than that of Chinese women. Barbiturate ingestion was noted to be the most common method of suicide of Chinese men. Lonely elderly men who came to the United States as sojourners, and who were despondent over physical illness, constituted a very high-risk group. Suicide attempts for Chinese women were usually precipitated by such interpersonal conflicts as chronic family strife, desertion by husband, or parental scolding. Yap (1958) borrowed Lindemann's concept of hypereridism to explain the high frequency of interpersonal stresses as a precipitating factor for female suicide. In traditional Chinese culture, women were denied opportunities for self-expression and assertion. Interpersonal conflicts may produce a hyperidic state, which exerts an impersonal pressure that slowly leads to despair and cannot be alleviated by threats or appeals. Under such circumstances, an acute quarrel or even a minor reprimand can set off an impulsive, poorly planned suicide attempt. For Chinese women, the most frequent method for suicide was hanging. A popular traditional belief held that the ghosts of those who died by hanging could return to torment the living as a means to achieve final and lasting vengeance.
In a more recent study of the percentage of all deaths of 15- to 24-year-olds attributed to suicide, Chinese Americans have a higher rate in comparison with European Americans in that age range. The rate for female Chinese is 20.8% versus 8.8 for European American females. Foreign-born Chinese Americans have higher suicide rates than do American-born Chinese Americans (Yu, Chang, Liu, & Fernandez, 1989).
There is an absence of epidemiological data in the United States on schizophrenia prevalence for Chinese Americans. The prevalence data indicate a band of prevalence rate ranging from roughly 2 to 10 cases per 1,000 population across a range of populations (Sartorius & Jablensky, 1976). The prevalence of schizophrenia in China ranged from 0.77% to 4.80% (Lin & Kleinman, 1981). In Chinese culture, mental illness is stigmatized and a mentally ill member usually brings shame upon the entire family.
Other common manifestations of psychological problems among Chinese Americans include anxiety disorder; dissociative disorder; posttraumatic stress disorder; paranoia; hypersensitivity; identity confusion; low self esteem; conduct disorder; drug, alcoholism, and gambling (a serious problem in the Chinese community which has not been properly studied) addictions; family problems (intergenerational conflicts, marital disharmony, in-law problems, domestic violence, child abuse, and neglect); difficulties at work, in school, and in dating; and impaired interpersonal skills.
Western-trained clinicians have paid a great deal of attention to either the intrapsychic influences or the biological explanation of the cause of mental illness. The views of many traditional Chinese are still highly influenced by their religious and spiritual beliefs and, most important, the concepts of health and disease in traditional Chinese medicine. Generally speaking, several common popular explanations of factors may contribute to the development of mental illness (Lee, 1982).
| Five phases | Direction Season | Organs | Orifices | Emotions | |
|
|---|---|---|---|---|---|---|---|
| 1 | Wood | East Spring | Liver | Eyes | Anger | |
| 2 | Fire | South Late summer | Heart | Ears | Joy | |
| 3 | Earth | Middle Summer | Spleen | Nose | Compassion | |
| 4 | Metal | West Autumn | Lungs | Mouth | Sorrow | |
| 5 | Water | North Winter | Kidney | Genitals | Fear | |
Despite the existence of an advanced, highly institutionalized U.S. medical system and the availability of mental health professionals, it is evident that Chinese clients still utilize many types of traditional healing methods for physical health or emotional problems. Various indigenous healing practices are available in major Chinatowns and refugee communities. The most popular ones are herbal medicine, acupuncture, and therapeutic massage. Religious faith healing is also perceived to be helpful. The sick person believes that there is a supernatural power and sickness can be cured through the very power of his or her faith. Religious faith-healing ritual treatments are usually conducted by Buddhist monks or priests. Many go to temples to chant and receive counseling from their spiritual leaders. Other practices such as geomancy and fortune telling are also being used to prevent or to remove "bad spirit."
Nutrition is another popular means to restore health. According to Chinese traditional medicine, foods are categorized in five groups: hot, cold, allergic, moderate, and nutrient. Chinese are usually very conscious of good nutrition. Therapeutic cuisine that gives "good qi" is very popular in treating health and emotional problems. In addition, many Chinese practice health exercises such as tai chi chuan and qi-gong to bring harmony to their body and mind.
There are a number of similarities between the indigenous healers and Western health practitioners. Both have diagnostic tools that help them identify the nature of the problems; both are able to provide interpretations to their respective patients; and both have treatment methods to treat the problems presented to them. Beyond these similarities, there are important areas of difference. One of the most prominent is found in their methods of categorizing health problems. The primary distinctions that traditional healers are likely to make in the diagnosis and treatment of illnesses are in terms of their basic cause: Illnesses are regarded as either natural or supernatural in origin. Western health professionals are more biopsychologically oriented. Whereas indigenous systems of healing tend to treat illness, modern professional health care workers tend to treat disease. They usually treat a single individual patient, out of the context of his or her family, social network, and community. The holistic nature of Eastern healing systems recognizes that illness is a psychosocial process.
Most Chinese Americans try to deal with their psychological problems without seeking professional mental health counseling. Traditional families usually seek help from family members first because it is considered the collective responsibility of the family to take care of the disturbed member as long as possible. Such problems are kept from outsiders for fear of the shame, guilt, and stigma that this knowledge might bring upon the family. The family often tries to deal with the problem by denying the seriousness of the illness, or by extorting or reasoning with the patient to "correct" his or her behaviors (Lin & Lin, 1981). Each family member may contribute his or her own proposal for treatment. When the family and the troubled person are not able to resolve the problem, they often turn to certain trusted outsiders and helpers within the ethnic community, such as community elders, spiritual leaders, indigenous healers, and physicians (Sue & Morishima, 1982). When these efforts fail, assistance from other agencies and providers, including psychiatrists and other mental health professionals, is sought while the troubled family member is still kept at home. Family members usually resist hospitalization until all other efforts have failed. The introduction of the label of mental illness seems to hasten the transition from intrafamilial coping to hospitalization of the troubled member, who ultimately is rejected, scapegoated, and blamed for things that went wrong within the family (Lin & Lin, 1981; Gaw, 1993). Providers thus need to be keenly aware of the help-seeking behavior and the family dynamic involved in coping with mental illness in Chinese families.
For many clinicians, the success of a case is measured by the emotional growth of the client or the psychological understanding of the problem.
Although some of the acculturated Chinese may expect "insight" therapy, the majority of Chinese immigrants and refugees expect more concrete help to produce physical and behavioral changes and the immediate alleviation of such symptoms as the inability to work, eat, sleep, and assume allocated family roles. Many come in with physical complaints, expecting medication from the doctor.
A traditional Western treatment model usually goes through a rather complicated and lengthy sequence of steps with each client: initial assessment, psychosocial evaluation, formulation of diagnosis, development of treatment goals, actions to achieve these goals, and, finally, termination. The major activity in the treatment process is verbal communication, or "talk therapy," between the clinician and the client. Chinese clients will probably have difficulty understanding such a therapeutic process. They seek help from mental health agencies only as the last resort after they have exhausted all other resources, and they usually come in for help in a state of crisis with expectation of an immediate "cure." They are used to traditional Chinese healing practices, which usually include a brief physical observation, diagnosis, and prescription writing-all in one session. They expect a rapid diagnosis and do not understand the purpose of lengthy evaluation and the apparent lack of treatment in the initial process. They may also get upset with initial interviews that probe into their family and personal backgrounds, which they perceive as having nothing to do with the presenting problem. For immigrants and refugees who have suffered many losses and separations, this process can be extremely stressful. To reveal family secrets to an outsider also evokes a sense of guilt. Consequently, many Chinese clients drop out of treatment (Lee, 1982).
Many mental health disciplines (e.g., psychiatry, psychology, social work, marriage counseling, and family therapy are not widely recognized in some Asian countries. Many Chinese do not have the sophistication to understand the roles of the clinicians or their special professional orientations. Because the role of a physician is more clearly understood and respected, Chinese patients may expect clinicians to conduct themselves in the traditional role of physicians who prescribe medication. Therefore, especially in the initial stage of the therapeutic relationship, it is very important for clinicians to explore their clients' exposure to mental health professionals in the past and their experiences. Mental health disciplines function quite differently in different Asian countries. It is also very helpful for the clinician to explain his or her role to the client and at the same time to explore the client's expectations with regard to the clinician's role.
For many Chinese immigrants and refugees with language limitations and cultural differences, family and community networks often provide the sole means of support, validation, and stabilization. To treat Chinese American families effectively in therapy, the clinician must be able to both conceptualize and intervene at multiple levels and in multiple systems. This approach is built on the structural family systems model (Minuchin, 1974), an ecostructural approach (Aponte, 1976), and the multisystems model (Boyd-Franklin, 1989). In addition, the clinician also needs to incorporate the Eastern holistic way of thinking into clinical practice. Based on these perspectives, a model that takes into the account not only the psychological and biological influences but also the cultural, social, political, and spiritual forces and their impact on the individual, the family, and the community (Lee, 1989, 1990). The multisystems model provides an overall framework that allows a clinician to provide treatment successfully at whatever level or levels are relevant to the family situation. This model proposes intervention at the following levels:
The multisystems model allows the clinician to organize complex data and to plan and prioritize intervention. It does not require that the clinician intervene at all levels (Boyd-Franklin, 1989). Different families may require different levels of involvement. For some Chinese families who enter treatment, the clinician may make the decision that one or more family members needs individual work for a variety of reasons. For example, many Chinese young adults struggle with the dilemma of how to be differentiated and individuated within a close extended family and yet not become either too enmeshed or totally cut off. They may need individual counseling to find a balance between cultural and familial expectations and their own needs. Or, when communication has totally broken down between the teenagers and parents, both subsystems may need to be "coached" before they can meet together for family therapy. Some families may enter treatment with an overwhelming number of survival issues instead of problems related to family structure or dynamics. The primary intervention should be at the community resources level. The clinician assumes the role as the system guide or facilitator, helping the family to navigate effectively within the service systems. The flexibility with which the clinician approaches this model is the key to its effectiveness.
To work with Chinese families more effectively, the clinician may need to postpone extensive evaluation until trust is established. The basic components of the therapeutic process consists of the following six steps:
Because of the reluctance with which many Chinese American families come to treatment, the joining process is the most difficult and challenging.
There are two major tasks for the clinician in this phase: (1) to observe the family and to begin the formation of initial hypotheses about the family structure and (2) to assess the presenting problem(s) and family members' readiness for therapy. Questions that the clinician might consider are:
A problem-focused family therapy approach with Chinese American families appears to be very effective. From a multisystems perspective, problem solving is a cyclical process. It does not occur one time but throughout treatment. In the initial stage of treatment, it is important to respect the family's priority for which problem(s) require immediate attention. Many immigrant and refugees families are "multiproblem families" whose members feel overwhelmed by a vast number of problems.
The clinician should spend early sessions helping the family to identify the most urgent problems and then to remain focused on these problems. It is important to start with a problem that can be addressed and solved quickly to establish credibility and to gain the trust. However, it is very important for the clinician not to offer an inappropriate "instant quick fix" just because the family members are pushing for solutions.
Information gathering with Chinese American families often occurs at a point later in the treatment process. Many Chinese will not share important family background information or "family secrets" until they feel that the clinician is no longer an outsider and is part of the family. In working with clients who have suffered from psychological and physical trauma (e.g., the "boat people" from Vietnam and Chinese who were tortured during the Cultural Revolution), it is extremely important not to force the clients to deal with their psychological traumas prematurely. Skillful assessment of the family's readiness to share their trauma stories is very important.
Based on the multisystems/holistic model, the clinician should gather information not only on the internal family system but also on the external factors, which include many environmental stressors. In providing culturally competent services to Chinese families, the clinician needs to understand the social, psychological, physical, cultural, and political impacts on the client, his or her family, and the community in which they live. Effective assessment must take into consideration the Chinese holistic view of health and illness and their culturally specific ways of coping with emotional difficulties. The assessment must include information beyond traditional intake data. Relevant personal, familial, and community information and cultural mapping are extremely helpful in the assessment of Chinese families who have undergone rapid social change and cultural transition (Ho, 1987). Effective techniques include the use of family genograms (McGoldrick, 1985), family albums, stories, and so on.
Information gathered on each family should include (1) demographic information (years in the United States, country of origin, immigration status); (2) personal data (language and dialect spoken, physical health and medical history, educational level, occupation, income, marital status); (3) family data (family composition, birth order, roles, communication style, decision making, extended family network, parent-child relationship); (4) social and cultural data (individual's migration and relocation history, community work and organization membership, religious affiliation, help-seeking pattern); and (5) psychological data (role and process of adaptation and acculturation of family member, member's perceptions of problems and solutions, extent and kind of interruptions to the family life cycle). Based on the assessment model discussed in Chapter 1, Table 3.3 provides a summary of the kind of information needed in each key area.
The treatment approaches I suggested in Chapter 1 are mostly applicable to Chinese American families. Effective strategies include forming a social and cultural connection with the family during the initial stage, acknowledging the family's sense of shame, establishing expertise and credibility, building alliance with members with power; restructuring social support networks, and mobilizing the family's cultural strength, holistic approaches to health, and religious belief. In addition to the need to be flexible in providing services to family members at the individual, family, or community level, clinicians also need to assume flexible roles. In addition to being the therapist, he or she may play the roles of teacher, advocate, interpreter, facilitator, mediator, and so on. As many Chinese families often do not see the connections between talking about their problems and actual changes, the use of educational approaches such as psychoeducation, role play, and assignment of tasks at home can be very effective. The clinician also needs to understand the family's communication style and be skillful in overcoming language barriers, especially when an interpreter is used.
To summarize the key recommendations, the following seven (CHINESE) strategies are found to be effective in working with Chinese American families:
| Area of assessment | Assessment content | |
|
|---|---|---|---|---|
| 1 | Family's ethno cultural heritage | Country of origin: paternal and maternal ancestryProvince/city/village of origin Generations in United States Cultural identity of each family member | |
| 2 | Family migration stress and relocation history | Premigration experience (life before migration)Type of community where the family lived Socioeconomic statusSignificant political events Family compositionEducational, health and mental health systems in the home county Traumatic events encountered Migration experience (the escape/relocation process) Decision to leave: why, when and who Degree and type of hardships during escape Stress induced by legal immigration process: uncertainty of sponsorship, duration of waiting | |
| 3 | Degree of loss and traumatic experience | Post migration (life immediately after the arrival in United States) School adjustment Job and financial worries Changes in living environment and neighborhood Significant changes in family composition and relationship Learning and adjusting to Western values Problems with housing, transportation, childcare, legal issues Racism and minority status | |
| 4 | Post migration experience and cultural shock | Separation and losses of family members, relatives, and friends Financial and material losses Loss of spiritual and cultural communities Physical trauma Psychological trauma | |
| 5 | Acculturation level of each family member | Individual family member acculturation rate depends on: Years in host country Age at time of migration Exposure to Western culture Professional affiliation Contacts with American peers English-speaking ability Work or school environment | |
| 6 | Work and financial stresses | Unemployment Underemployment/downward mobility Long working hours Language difficulty Racism at workplace" Glass ceiling" issue | |
| 7 | Family's place of residence and community support | Type of neighborhood Availability of support system Help available from community-based service agencies Community stigma | |
| 8 | Family dynamic | Family membership/composition Leadership Decision making Role assignments Communication patterns | |
| 9 | Family problems | Intergenerational conflicts In-law conflict Marital difficulty Role reversal Addiction, substance abuse, gambling | |
| 10 | Family strengths | Functional coping strategies Strong family bond Support from the ethnic community and networks | |
| 11 | Physical health and medication history | Medical history of client and family members Exposure to Western and herbal medicines Consultation with physician and indigenous healers | |
| 12 | Family's concept of presenting problem, help-seeking behavior, and treatment expectations | Symptoms and problems as perceived by family Causes of the problems as perceived by family Relationship with traumatic events Family help-seeking behavior Treatment expectations | |
The process of termination should take into consideration the Chinese client's concept of time and space in a relationship. The client and family members may regard the clinician as a family member and may want to maintain contact with the clinician even after they have successfully achieved their treatment goals. For many Chinese clients, especially those who experienced many losses and separations, a good relationship is a permanent one that is to be maintained and treasured. They may like to contact the clinician on special occasions, perhaps bringing food to the office during Chinese New Year or reporting special family events such as the birth of a grandchild or a death in the family. The traditional psychodynamic therapeutic concept of separation anxiety during the termination phase may not apply when working with Chinese clients.
Mrs. L, age 52, was referred to an outpatient mental health clinic in Chinatown from the emergency room of a public hospital. She went to the hospital with complaints of shortness of breath, dizziness, insomnia, and fear of "ghosts." She suffered from acute anxiety attacks and talked in a whisper.
During the first interview, she related one particular precipitating event–the death of an old Chinese man who was a tenant in her attic. He had died and had lain undiscovered for a long time. She found the body and was highly traumatized.
Because of Mrs. L's life experiences as a Chinese immigrant and her unique cultural background, the evaluation and assessment of her case must include information beyond traditional intake data. Based on the suggested assessment guidelines in this chapter, the following vital information on the patient and her family was obtained.
Mrs. L was born in a rural farming village in Kwantung, China, the oldest daughter of three children in a Chinese, Toisanese-speaking family. Her father worked as a farmer while her mother took care of the household responsibilities. She spent most of her childhood helping in the farm and taking care of her younger brother. She experienced many losses, separations, and deaths in her lifetime.
Mrs. L gave birth to a daughter 2 years after she came to the United States. Her husband was very disappointed. Like most traditional Chinese parents, they raised their daughter the "Chinese way," expecting their daughter to be hardworking, obedient, dependent, and polite and to take care of them in their old age and bring honor to the family. However, like many acculturated adolescents, their daughter identified with American values, with their strong emphasis on independence, self-reliance, and assertiveness. As an American-born Chinese American, Mrs. L's daughter spoke very little Chinese and was not able to communicate with her parents. She also resented her monolingual parents' dependency on her as the cultural broker and interpreter in negotiations with the outside world. She spent most of her time dating non-Chinese boyfriends and threatened to leave home as soon as she finished high school.
Mrs. L worked in a sewing factory with low pay and long hours. As a result of her "poor health" (e.g., dizziness and headaches), she was not as productive as other workers and was fired several times. Mr. L worked in a Chinese restaurant located 3 hours from the city and came home once a week on Mondays. Mrs. L felt very lonely as her husband and daughter were gone most of the time.
Other stressors included legal problems (Mrs. L wanted to apply for her son to come from China), health problems (Mrs. L suffered from severe headaches, dizziness, and anxiety attacks and Mr. L had a heart condition and had been recently hospitalized), and stress caused by the living environment (the family lived in a high-crime neighborhood, and Mrs. L had been robbed three times on the streets).
In spite of the trauma of war, relocation, and years of separation, the family members demonstrated a great deal of love and caring with each other and a strong sense of commitment and obligation to take care of each other. Mrs. L's daughter and her husband visited every week and provided Mrs. L a great deal of support. A lovely granddaughter brought much joy to the family.
At the beginning of the evaluation, all family members denied that the somatic complaints were related to mental health problems. They attributed all symptoms to physiological causes. Mrs. L declared that she was not crazy and did not understand why she was referred to a mental health clinic.
The family's belief in the physical cause of the patient's problems was not openly challenged by the therapist. Instead, family members were encouraged to talk about traditional Chinese medicine and cultural beliefs. After several interviews, Mrs. L revealed her belief that her dizziness was caused by too much "wind" in her body because she went back to work in the farm soon after the delivery of her baby. She was convinced that her poor health was highly related to having sexual intercourse during her "period." She also believed that she might be possessed by a male ghost (the old man who died in the attic), who made her lose her ability to speak. She consulted with a local fortune teller in mental health professionals was considered the last resort, and the family entered treatment with extreme anger, resentment, and a sense of hopelessness.
It is beyond the scope of this chapter to discuss the treatment approaches of this case in detail. The patient came in for weekly therapy for 9 months and had a successful treatment outcome. Mrs. L's anxiety attacks disappeared after a few sessions, and her somatic symptoms decreased gradually over the course of treatment. In addition to individual therapy, Mr. L and the two daughters were also involved in family therapy. Several important treatment strategies contributed to success in this case:
This chapter provided a brief overall description of Chinese American families and the demography, migration, language, and unique family characteristics of traditional and contemporary Chinese families. Special clinical considerations in treating Chinese American families were discussed. In providing culturally competent services to this population, clinicians need to understand the cultural meanings of the Chinese concept of mental health problems, health-seeking pattern, the process of healing, ways to deal with psychological problems, and treatment expectations. A practical guideline in assessing and treating Chinese American families based on a multisystems/holistic model is also offered. Clinicians can try to incorporate this model into their clinical intervention, with the goals of establishing trust and credibility, improving communication, overcoming cultural barriers, and obtaining more effective treatment outcomes. The most challenging task in working with Chinese Americans is to integrate the very rich cultural strengths of the East with the best modern Western medicine and psychology can offer. I believe that such an integrated model will not only benefit the treatment of Chinese Americans but can also benefit clients from many different cultures.
Chinese American families are in transition. From the pioneer family to the newly arrived immigrant family, Chinese American families have undergone numerous changes and are continuing to evolve. With the present political and economic trends in the United States and Asia, Chinese American families may undergo more rapid changes. We need to stay in tune with these changes and be flexible in designing culturally competent clinical service for this underserved population.
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