An Asian American woman in her early 20s, her voice barely a whisper, tentatively joins a telehealth therapy session. The marriage and family therapist, perhaps well-intentioned but lacking cultural sensitivity, fails to grasp the gravity of her whispered greeting. Oblivious to the weight of familial burdens she carries, the therapist presses on, asking what’s wrong. As the client recounts her struggles with depression and the dismissiveness of her family, the therapist, well-meaning yet culturally unaware, suggests to the client that she should confront her parents. Unaware of the complexities of Asian familial dynamics and the stigma surrounding mental health, the therapist fails to grasp the depth of the young woman’s apprehension, and as such, the therapist’s words fall flat, shattering the fragile trust between them. Feeling misunderstood and unseen, the young woman retreats further into silence, ultimately choosing to forego future therapy sessions; the gap between her pain and the therapist’s understanding too vast to bridge.
This is just one example of how the lack of cultural attunement and humility on the part of the therapist accentuates the barriers faced by Asian Americans seeking mental health support. This also further underscores the need for culturally sensitive and inclusive therapeutic approaches since cultural blindness affects us all and limits our perspectives.
Research over the last few years has also shown this scenario to be common amongst the Asian American community. Within Asian American culture, there is a large emphasis placed on familial values, such as honoring family hierarchy, maintaining family cohesion, and coping in silence to ensure family privacy. The idea of “saving face” is a significant cultural value that preserves the dignity of others and reduces placing shame upon the family (Yang et al., 2020). The vast majority of the community still views mental health illnesses and the process of attaining treatment as disruptive to the entire social group as a whole, hence leading to a multitude of internalized struggles (Yang et al., 2020).
While a variety of reasons contribute to the gap in mental health service use amongst Asian Americans, research shows the main contributors are the lack of bilingual clinicians and clinicians who demonstrate cultural humility (Augsberger et al., 2015). In addition to the low utilization rate, research shows that retention rates for therapeutic services are shockingly low, with “over 80% of [participants] who did seek services ended up dropping out between four to eight sessions” (Augsberger et al., 2015). The question then remains: how can Asian Americans not only be encouraged to seek mental health services without shame but also effectively be seen on a cultural level by these services?
As Allen (2022) notes in an earlier article on the pervasive effects of systemic racism, how often have you considered the following perspectives regarding Asian American clients?
- “Saving face” is a fundamental cultural value that is not only about saving one’s own face but also that of others.
- The “collectivist view” seeks harmony above all and rejects group conflict.
- It is better to keep silent and let problems resolve within the family rather than seek outside resources.
- Racialized expectations and stereotypes heighten the tensions felt intrapersonally and interpersonally for Asian American families.
- Cultural norms are dynamic, adaptive, and shaped by assimilation.
- Strong fear of judgment and stigma also stem from generational trauma experienced in the home country and/or life in America.
- There are generational differences that cause further mental health use discrepancies when seeking out mental health care services.
- Asian cultures already have unique models of healing that have supported them for centuries (i.e. Chinese herbal medicine, acupuncture, meditation, etc.) that have a more holistic view of the mind-body connection.
Where is the representation?
Representation is important for highlighting different people, cultures, and ideas. Representation is especially important for younger individuals when in the process of forming perceptions about their identity, and this can directly impact one’s self-esteem. Within the mental health field, there is an alarming lack of representation of the Asian American population: both therapy attendees and mental health clinicians.
What is the attributing factor? Stigma.
Stigma plays a role both inside and outside of the therapy room. The lack of Asian American therapists/clinicians in the mental health field is apparent. According to a study done in 2021, “only 11.3 percent of therapists in America were Asian, and 72.6 percent of therapists were white” (Shrestha, 2023). Why are there so few Asian American clinicians in the field? A main contributor is the stigmatized view of mental health in the Asian American community. Traditional values within Asian cultures teach individuals to tolerate difficulties, never complain to others, and consider it to be taboo to pursue a career in the mental health field. There is a lot of shame surrounding mental illness in the Asian American community, so it is often hidden and not discussed.
On the client side, Asian Americans have lower rates of mental-health-related service use compared to the general population (Derr, 2015). According to Dr. Ito at UCLA Health, “Asian Americans are 50% less likely than other racial groups to seek mental health services” (Apodaca Schlossberg, 2023). Similarly to the stigma that exists amongst Asian American mental health clinicians, mental health difficulties are viewed as an individual issue, and talking openly about these issues is discouraged. In addition, a significant barrier that contributes to the low utilization rate for mental health services within the community is when cultural values are not being addressed and acknowledged in the therapy room. This lack of recognition and connection leads to a disconnect between the therapist and the client, making the client less likely to return to therapy services or even utilize services to begin with.
What is the solution?
The existing research is limited when it comes to outlining solutions or culturally attuned and specific therapeutic treatments for Asian American clients. However, there appears to be some success and movement with the use of Solution Focused Brief Therapy (SFBT) with Asian American clients. One of the more recent studies by Cheung and Jan (2017) emphasizes that SFBT “actively draws on the cultural resources and strengths of the client in their clinical work.” Given its collaborative, client-oriented, and strength-based framework, SFBT allows the therapist to follow the client’s needs and see the benefits of how their cultural values play into their experiences more closely. In the example earlier, if the therapist were more open to the cues and strength of the client for showing up to therapy and discussing their depression despite their family’s judgment, perhaps the session would have ended differently. Additionally, SFBT emphasizes measurable goals that appeal to most Asian American clients and their value of pragmatism (Cheung & Jahn, 2017). However, therapists should be careful to extend respect to their Asian American clients and their families even before offering solutions or trying to solve problems since respect is the foundation for the cultural and family values that Asian American clients build upon (Cheung & Jahn, 2017).
Having a working knowledge of acupuncture clinics and Chinese herbal medicine clinics may help the therapist to be more sensitive to the client’s particular needs…
Also, therapy may not be a setting where most Asian American clients feel comfortable engaging. As such, it is important for clinicians to consider blending or bridging the distance between Western and Eastern healthcare practices by both exploring and providing resources to clients for alternative healing and medicinal practices. Having a working knowledge of acupuncture clinics and Chinese herbal medicine clinics may help the therapist to be more sensitive to the client’s particular needs and meet them where they are while attuning to the mind-body connection that Asian American clients and their families may value.
Lastly, as clinicians, we must advocate for our clients and push for more community mental health services and outreach programs that support the Asian American community as a whole. With this advocacy comes education and more self-of-the-therapist work to help our future Asian American clients feel safe and seen in the therapy room.
Despite the setback with the therapist, the young woman decides to take agency over her mental health journey. She seeks out resources and support from within her own community. Through online forums, support groups, and culturally sensitive resources, she finds validation and understanding from others who share similar experiences. With the support of peers who understand the nuances of Asian familial dynamics and the stigma surrounding mental health, she gains confidence and insight into her own journey.
Meanwhile, the marriage and family therapist, reflecting on the failed interaction, seeks further education and training on cultural sensitivity and understanding diverse perspectives. Through workshops, seminars, and self-reflection, the therapist learns to recognize and respect the unique challenges faced by individuals from different cultural backgrounds. Armed with this newfound knowledge and awareness, the therapist becomes better equipped to provide effective support and guidance to clients from diverse communities.
Though their paths may not cross again, both the young woman and the therapist undergo personal growth and transformation. The young woman finds solace and empowerment within her community while the therapist becomes a more culturally competent and empathetic practitioner. In this way, while their initial encounter may have been a stumbling block, it ultimately becomes a catalyst for positive change and understanding for both parties.
Within the mental health field, there is an alarming lack of representation of the Asian American population: both therapy attendees and mental health clinicians.
Julie Payne, DMFT, LMFT, is an AAMFT Professional member holding the Clinical Fellow and Approved Supervisor designations and a Clinical Assistant Professor at Chapman University in the Marriage and Family Therapy Program. She has over 17 years of clinical experience working in community-based mental health and private practice settings. Dr. Payne is currently licensed and practicing in California and Texas specializing in working with families and individuals living with chronic illness/pain, military families, children and adolescents, and trauma.
Katie Sy, is a second-year Marriage and Family Therapy student at Chapman University. Katie aspires to work with the Asian American population, specifically children and adolescents and aims to destigmatize the practice of seeking mental health assistance within the community.
Julie Koh, is a second-year Marriage and Family Therapy student at Chapman University. Julie aspires to be a multiculturally competent therapist and work closely with the Asian American community. One of her biggest goals is to address mental health issues that continue to persist and remain untreated in the Asian American community.
AAMFT. (2022, May 20). Systemic racism and the Asian American community. Family Therapy Magazine – American Association for Marriage and Family Therapy. https://ftm.aamft.org/systemic-racism-and-the-asian-american-community/
Apodaca Schlossberg, J. (2023, May 9). Confronting mental health barriers in the Asian American and Pacific Islander community. UCLA Health. https://www.uclahealth.org/news/article/confronting-mental-health-barriers-asian-american-and-2
Augsberger, A., Yeung, A., Dougher, M., & Hahm, H. C. (2015). Factors influencing the underutilization of mental health services among Asian American women with a history of depression and suicide. BMC Health Services Research, 15(1), 1-11. https://doi.org/10.1186/s12913-015-1191-7
Derr A. S. (2016). Mental health service use among immigrants in the United States: A systematic review. Psychiatric Services, 67(3), 265–274. https://doi.org/10.1176/appi.ps.201500004
Shrestha, S. (2023, April 19). Challenges Asian American and Pacific Islander youth face in accessing mental health services. Public Health Institute; Public Health Institute. https://www.phi.org/press/challenges-asian-american-and-pacific-islander-youth-face-in-accessing-mental-health services/#:~:text=In%202021%2C%20only%2011.3%20percent,the%20majority%20of%20their%20life.
Yang, K. G., Rodgers, C. R. R., Lee, E., & Lê Cook, B. (2020). Disparities in mental healthcare utilization and perceived need among Asian Americans: 2012–2016. Psychiatric Services, 71(1), 21–27. https://doi.org/10.1176/appi.ps.201900126
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