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Improving Cultural Competence
Working with Asian People
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director:, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery

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CEUs available at: 20 Hour Class Covering Multiple Subjects.

– Learn about Asian cultures, traditions and values as they relate to mental health
– Learn about communication styles to help the counselor more effectively communicate with culturally different clients
– Explore health disparities
– Explore appropriate approaches to counseling
General Information
– Asian Americans have a 17.30 percent overall lifetime rate of any psychiatric disorder and a 9.19 percent 12-month rate, yet Asian Americans are three times less likely to seek mental health services than Whites
– Cultural factors, such as language, age, gender, and others, can influence the mental health of Asians, particularly immigrants
– Asians place great value on the family as a unit. Each individual has a clearly defined role and position in the family hierarchy and is expected to function within that role, submitting to the larger needs of the family.
– Social stigma, shame, and saving face often prevent Asians from seeking behavioral health care
– Asian patients are likely to express psychological distress as physical complaints

General cont…
– Language Knowledge of English is one of the most important factors influencing access to care.
– Level of acculturation Typically, it takes three generations for immigrants to fully adopt the lifestyle of the dominant culture.
– Age In general, the younger people are when they migrate, the more readily they adapt
– Gender Historically, men have acculturated more rapidly than women
– Occupational Issues: Sometimes, women earn more than men, thereby disrupting family expectations and traditional values

Religion and Spirituality
– Christianity
– Muslim
– Buddhism which promotes spiritual understanding of disease causation
– Confucianism, an ethical belief system that stresses respect for authority, filial piety, justice, benevolence, fidelity, scholarship, and self-development
– Taoism, which is the basis for yin and yang theory
– Animism, which is the belief that human beings, animals, and inanimate objects possess souls and spirits.-
Beliefs About Mental Health
– Traditional beliefs about mental health:
– Mental illnesses are caused by a lack of harmony of emotions or by evil spirits.
– Mental wellness occurs when psychological and physiologic functions are integrated.
– Buddhist belief that problems in this life are most likely related to transgressions committed in a past life.
– In addition, our previous life and our future life are as much a part of the life cycle as our present life.
Traditional Beliefs
Beliefs About Health
– Health is seen as a state of balance between the physical, social, and super-natural environment
– The Eastern approach assumes that the body is whole, and each part of it is intimately connected. Each organ has a mental as well as a physical function.
– Heart, lungs, spleen, liver, kidney are Yin organs
– Large intestine, gall bladder, bladder and stomach are Yang organs
– Think about how the symptoms of the Western diagnoses of depression and anxiety are physiologically manifested
– TKM emphasizes specific characteristics of the individual who suffered from the disease, rather than single symptom as is common in TCM Historical difference between traditional Korean medicine and traditional Chinese medicine

Traditional Asian Health Beliefs and Healing Practices

Beliefs cont…
– Uncertainty is inherent in life and each day is taken as it comes.
– A fatalistic attitude about sickness (belief that all events are predetermined and therefore inevitable) may make Asian patients/families seem resigned to their situation.
– Talking in terms of beating a disease will not resonate with those who embrace an attitude of acceptance.
– Acceptance of what life brings does not indicate an unwillingness to cooperate with doctors and treatment, but rather a belief that fighting illness is a negative approach to healing.
– Examine and regain balance
– Enhance the quality of life despite the illness
Family Dynamics
– Extended families are common among Asian Americans, with two or three generations in the same household.
– Major decision-making is the purview of the father, followed by the oldest son who receives preferential treatment.
– The mother's job is to nurture and care for her husband and children.
– Female children have a lower status than male children
– Women usually believe their husbands have a legitimate right to make final decisions, and will withdraw from spousal conflict to maintain harmony within the family.
– Value placed on males manifests in sex-specific infanticide and a disproportionate number of females in orphanages
– Asian families may value group consensus on healthcare matters
Family Expectations
– Children are highly valued in Asian American families.
– They are taught to be polite, quiet, shy, humble, and deferential.
– Conformity to expectations is emphasized
– Emotional outbursts are discouraged.
– Failure to meet the family's expectations brings shame and loss of face to both the children and their parents.
– Parents are seldom forthcoming with affection and praise because of fear that such demonstrations will encourage laziness.
– Education is important and children who do not do well in school bring shame to their families.
Family Expectations
– Positive reinforcement and discussion of personal achievements are uncommon.
– Adolescence has limited meaning in most Asian cultures because seeking a definition of self outside the family is not encouraged.
– Parents expect children to acquire the language and skills that will enable them to be successful in their new country, but are reluctant to have them fully embrace most aspects of American culture for fear that they will abandon their native culture.
– For example, parents may encourage their children to learn but may refuse to allow them to speak English at home.
– Such confusing messages lead to transgenerational conflict.
Family Expectations
– Elderly Asians look forward to having their grown children care for them.
– Elders tend to have full control over family and financial decisions whether or not they live with their children.
– Most elderly Chinese immigrants are not inclined to value independence and, when they live separately, it is to avoid conflict over family roles.
– Elders are highly respected and honored by all Asian cultures.
– In extended Chinese families, grandparents often are responsible for the care of grandchildren.

Family-Related Stressors
– Young adulthood means achieving for the family.
– Young Asian American adults begin to question their family values.
– Interpersonal relationships become more of a challenge.
– Interracial relationships cause serious conflicts because of parental fears that biracial children will diffuse the family lineage/culture
– Many Asian adults may misunderstand the meaning of the transient relationships that are common in urban settings in the West.
– Young adults also face a dilemma of dual identity—home and public
– The obligation to parents takes precedence over the individual's choice of career.
– Choice of a career that is different from that chosen by his or her parents can result in loss of emotional and financial support.

Differences Between Cultures
– Westerners have a hard time figuring out all the customs and formalities in China, especially because they are so different from the customs and formalities in other Asian countries.
– It is a mistake to assume that Chinese customs are like Japanese ones. The two countries are very different and Chinese will be quite insulted if you assume their culture is like Japanese culture.
Communication– Chinese
– When a Chinese person asks someone their age they often do this so they know how to address the person.
– In China it is rude to call someone by their first name unless you've known them since childhood. In work-related situations people address each other by their title
– Chinese sometimes don't smile or exchange greeting with strangers. Smiling or being friendly to someone you don't know well is sometimes considered rude and too familiar.
– When saying goodbye it is considered appropriate to give a quick bow or nod to everyone present and go

Communication– Chinese
– A limp handshake is regarded as a gesture of humility and respect. When a Western man meets a Chinese person, especially a woman, he should wait for the other person to offers his or her hand first, before offering to shake hands.
– Both the thumbs up or tugging on the earlobe are signs of excellence.
– An outward pointing and raised pinky means you are nothing, poor quality or not very good at something.
– Chinese consider it rude to look someone directly in the eye, cross your arms or legs, or have your hands in your pocket when you are speaking to someone.

Communication– Chinese
– Chinese usually focus their eyes on the lower neck of the person they are talking to, stand very close to them, and try to avoid staring.
– Chinese also don't like it when Westerners point at people; don't show proper respect; boast and offer their opinions to readily; want immediate answers; and show a lack of patience.
– Chinese consider it rude to say “no” directly. They often say something like “maybe,” or even “yes” when they really mean “no.”
– Punctuality is important
Tips About Japanese Culture
– Saving face is crucial and harmony is a key value
– The number 4 should be avoided because it is extremely unlucky and sounds like the word for death.
– Wear conservative-color clothing
– There is a general stigma associated with mental illnesses. There is the concept of shame or “hazukashii.”
– “somatic talk” becomes a culturally coded idiom of distress to avoid being labeled with a psychiatric disorder.
– Somatization in Japan, then, can be understood as an inherently ethical event that has more to do with morals than medicine.
– Typically quiet and polite, tend not to disagree or ask questions
– Punctuality is important

Tips About Japanese Culture
– May have little direct eye contact
– Nodding doesn’t necessarily mean understanding or agreement.
– The Japanese view of the self is one in which the individual is seen as socially embedded, in which dependence on and compliance to other's wishes is crucial for a harmonious social order
– Symptoms can be seen in terms of how the person is in disharmony with their social environment (among other things)
– A Western diagnosis of a mental illness implies that there is something wrong with the purity or the morality of one's self.
– For the Japanese, a person's true beliefs (Honne) are not necessarily the same as his public pronouncements (Tatemae).
– Any emotional outburst would be perceived as a sign of character weakness and is avoided because such behavior threatens social harmony.

Important Korean Cultural Concepts
– Gibun loosely means one’s current emotional state or temperament.
– Gibun is loosely “feelings, “personal dignity and pride.
– Gibun can also be hurt—for example, when someone is not shown the proper respect by a subordinate
– Nunchi is much like empathy. It is essential to assessing others’ gibun and acting accordingly and tactfully.
– Nunchi is something you do or do not have; If you don’t, you’re liable to unwittingly hurt others’ feelings or make a faux pas
– Nunchi can also relate to assessing how others view you. Many people, especially Koreans, care about what others think of them.
– If you’re busy looking at others’ nunchis it means you’re spending much time caring about what others are thinking of you.
Important Korean Cultural Concepts

– Han is a deep feeling difficult to precisely capture with words, but is a combination of sorrow, anger, helplessness due to greater forces of oppression.
– Han is also hope—hope of overcoming the injustices in one’s life, hope of a better tomorrow.
– Korean concept of Jeong is the feeling of affection, concern, understanding, loyalty, warmth, and emotional connection to someone or something.
– You can feel jeong for your family, friends, lovers, teachers, coworkers, strangers and even for places and objects such as your hometown or first car.
– Source:
Concept of Time–Korea
– “Korean time” describes the widespread tardiness or, more specifically, the relaxed attitude with which Koreans approach appointment times.  (originally agrarian society)
– Being a few minutes late to an appointment without giving prior notice is almost the norm among friends, and even being late by an hour or more is not uncommon.
– When a Korean is the one having to wait, previously acceptable delays suddenly become a “big deal.”
– A wait of as little as 5 minutes, particularly when waiting for food at a restaurant or for a bus, often leaves a Korean flustered and tapping his watch, repeating, “Why is it not coming-”
– Source:

Common Stressors
– Parental pressure to succeed in academics
– Discussing mental health concerns is considered taboo causing many Asian Americans tend to dismiss, deny or neglect their symptoms
– Pressure to live up to the “model minority” stereotype (a view that inaccurately portrays Asian Americans as successfully integrating into mainstream culture and having overcome the challenges of racial bias)
– Family obligations based on strong traditional and cultural values
– Discrimination due to racial or cultural background
– Difficulty in balancing two different cultures and developing a bicultural sense of self

Common Stressors
– Traditional Asian expectations of women conflict with White-American ideals that emphasize independent thinking, achievement, and self-sufficiency, even at the expense of others' feelings and needs.
– These conflicting values can play out in several ways:
– Stress and conflict leading to isolation and withdrawal or acting out behaviors that in turn can lead to depression
– Spousal conflict can occur as women work in and interact with a culture in which their status is compared to that of their husband
– Resistance to or refusal of psychiatric treatment resulting from chronic low self-esteem can lead to a sense of fatalism
– Among persons aged 15 to 24 and older than 65, Asian females are at the greatest risk of suicide compared with women of all other racial groups

Common Stressors
– Fear of help seeking among the community believing if anyone finds out, they will be ostracized
– Distorted, stereotypic images of Asian communities as evil, mysterious, exotic places filled with gangsters, warlords and prostitutes, which Hollywood movies and network television so often portray.

Successful Assessment
– Successful assessment of mental health problems in the Asian American patient is based on:
– Practitioner awareness of individual patient demography
– The patient's beliefs about health and mental health
– Eliciting an explanatory model from the patient
– Negotiation around acceptable diagnosis and treatment
– Use of the family support system to increase adherence to treatment regimens and to reduce barriers

Complimentary Approaches
Traditional Chinese Medicine (TCM)
– TCM practitioners don't see mental disorders as any one syndrome.
– TCM treats specific symptoms. The goal is to re-balance the body's inner functions.
– Tai Chi
– Acupuncture
– Reiki
– Herbal Medicine
– Nutrition
– Feng Shui

Yin and Yang Theory
Korean Traditional Medicine
– Lee Je-ma classified human beings into four main types, based on the emotion that dominated their personality and developed treatments for each type:
– Tae-Yang (–, –) or “greater yang”
– So-Yang (–, –) or “lesser yang”
– Tae-Eum (–, –) or “greater yeum”
– So-Eum (–, –) or “lesser yeum“
– Moxibustion is a technique in which heat is applied to the body with a stick. The tool is placed over the affected area without burning the skin. The cone or stick can also be placed over a pressure point to stimulate and strengthen the blood

QI, Chakras and Meridians
– Chakras are spiritual energy centers
– Meridians are energy paths in the body in which Qi/Ki flows through
– One must have balanced Chakras and Meridians in order to be physically, emotionally, mentally and spirituality healthy.

– Traditional acupuncture unblocks meridians and is vital to allowing the free flow of Qi
– Acupuncture for Anxiety and Depression
– Acupuncture is as effective as cognitive behavioral therapy (CBT) and comparable to use of selective serotonin reuptake inhibitors (SSRIs) in effectiveness.
– When acupuncture is used in combination with CBT,  the overall effectiveness of treatments are given a boost.
– Acupuncture is also a “promising practice” for use in addiction treatment to reduce cravings (magnets can be used in place of needles for IV drug users)

Feng Shui
– Chi is the “life’s breath” or energy that binds life together.
– The practice of Feng Shui teaches us how to influence chi and its affect on our daily lives.There are three main forces of Chi that sustain all of life:
– Cosmic Chi is the force of nature. This energy is similar to the way the earth is pulled by the sun and the way the tides are affected by the moon. The existence of Cosmic Chi helps explain why the weather affects personal moods and feelings.
– Human Chi is inside each person. Each person has his or her own unique chi. Human Chi can be likened to the western concept of bio-energies.
– Earth Chi is the way the earth affects you. The forces of your physical environment: roads, powerlines, mountains, streams, etc. all impact and influence you.
Feng Shui
– Awesome primer article
– In Feng Shui, the house is viewed as a whole being in which one part is intricately connected to the other.
– The environment can be thought of as a reflection of your internal self.
– Your environment has an effect on your energy on a constant basis
– To create good Feng Shui in your home – first identify the areas that need the most attention and define the steps necessary to improve these areas.
– Many people completely ignore the areas that feel like too much work, such as the attached garage, the laundry room or the closets (where skeletons are kept). (depression, exercise, relationships…)

Tai Chi
– Tai chi is a gentle exercise program that is a part of Traditional Chinese Medicine (TCM).
– Tai chi is composed of slow, deliberate movements, meditation, and deep breathing, which enhance physical health and emotional well-being.
– Tai chi is based on spiritual and philosophical ideas that advocate a need for balance in the body, mind, and spirit.
– Central to tai chi is the idea that qi flows throughout the body, and must be able to move freely for good health.
– The principle of yin/yang is important, too. Yin and yang are opposite and complementary forces in the universe, in the same way as light and dark are. Tai chi is meant to harmonize these pairs of opposites.
– Finally, tai chi imitates motion found in nature, such as the movements of animals, thereby uniting human beings with the natural world.

Tai Chi
– Tai chi has three major components
– Movement. All of the major muscle groups and joints are needed for the slow, gentle movements in tai chi. Tai chi improves balance, agility, strength, flexibility, stamina, muscle tone, and coordination.
– Meditation. Research shows that meditation soothes the mind, enhances concentration, reduces anxiety, and lowers blood pressure and heart rate.
– Deep breathing. increases lung capacity, stretches the muscles involved in breathing, and releases tension, slows heart rate, enhances blood circulation to the brain, boosts mental alertness and supplies the entire body with fresh oxygen and nutrients.

Tips for Providers
– Checking for understanding is critical. It is all too easy to misinterpret a common gesture as agreement or understanding when the patient is actually confused or even resistant to a diagnosis/treatment.
– Asian patients/families will often be reluctant to complain or ask for clarification
– Avoiding the use of yes/no questions is very important.
– Establish the professional’s role and assume authority.
– Check for understanding
– Be patient, and consider periods of silence opportunities for reflection on what has been said.

Tips for Providers
– Provide clear and full information, such as what is expected from each participant in the discussion.
– Be attentive to nonverbal cues—Most Asian cultures have high-context communication styles.
– Address immediate needs and give concrete advice.
– Avoid direct conflict and reach consensus by compromising.
– It’s most effective to educate the entire family while treating the patient.
– When seeing Asian-American patients, the family often accompanies the patient to the interview room