Cultural issues to be aware of when working with Asian clients in general

Stigma

The stigma and shame associated with mental health in most Asian communities often results in the 'conspiracy of silence'. Some see mental illness as a form of weakness or laziness, whilst others regard it as an extreme disturbance, bringing shame to the family and community. Discrimination and avoidance of people with mental illness is therefore high, and emotional and behavioural expressions of mental illness often transgress cultural norms. In some Asian countries those with mental health issues are hidden or shunned, and sometimes arrested for crimes. For this reason people often avoid exposing mental health problems for fear of the consequences. Stigma may contribute to the typical help-seeking pattern associated with mental health care (see below). In some cases stigma is self-directed for bringing shame to family.

Te Pou (2010) conducted focus groups on attitudes to mental illness with New Zealand immigrants and found that in Chinese and Korean cultures health is often seen as a personal responsibility. Some Chinese New Zealanders regard mental illness as a result of bad parenting, some see it as an overindulgence of emotional concerns in the face of more pressing needs. Serious conditions such as schizophrenia are highly stigmatised in Indian cultures.

'Saving Face'

Related to stigma, is the importance of 'Saving Face' (the need to preserve the dignity and reputation of a person in the face of an embarrassing or disruptive event) which also discourages clients from disclosing emotions or psychological difficulties for fear of reflecting poorly on families. Mental health issues and other challenging health issues often remain concealed in order to 'save face'.

Absence of Cartesian mind-body dichotomy

From a traditional perspective it is uncommon for Asians to dichotomize the mind and body systems; these are regarded as one integrated system. The distinction made by the Western health systems is in contrast with the yin-yangcosmology and sometimes causes confusion about healthcare services and professional roles. This can contribute to accessibility problems for some clients, and to the issue of 'somatization'.

'Somatization'

Stigma, 'saving face' and the absence of a mind-body dichotomy may all be contributing factors to why Asians are reported to 'somatize' more than their Western counterparts. This issue is covered in some depth in the CALD 9 learning programme, but it is a reminder here that culture is a more predominant influence in Asians nominating somatic symptoms, than the wish to distort or deny integral illness patterns. Chan and Parker (2004) highlight how in the Chinese context bodily symptoms are more salient than psychological ones, and that idioms and metaphors throughout the culture reinforce this. They also note that the workload of doctors and psychiatrists in Chinese regions leave them with little time to discuss psychological concerns, and that this can reinforce the tendency towards somatic presentations. Because of related shared values amongst Asian cultures included in this resource, these suggestions are likely to apply to ethnicities other than Chinese. 

In addition, language dictates the ability to express, so this may also be a contributing factor for people using a second language. The extent to which people somatize may depend on age at migration and levels of acculturation.

Implication for practice 

Whilst there is a tendency to present somatically, this does not mean that clients do not experience psychological and emotional distress. A distinction needs to be made between somatizing distress and how distress is reportedto others.

Health-seeking patterns

Many Asian clients attempt to deal with their health issues in traditional ways before consulting Western clinicians. (See CALD modules 2 and 7 for traditional treatments and approaches). This also applies to mental health where meditation and other traditional approaches are seen to be more acceptable and effective. Initially help may be sought from family members, who will advise self-control, will power, avoidance and keeping busy, in accordance with cultural beliefs. If the problem is not resolved, the client may seek help from community resources like elders, spiritual healers, monks, traditional Chinese medicine (TCM), herbalists and fortune tellers. 

Only after these resources have been exhausted with no benefit, are some clients likely to seek western help through ED or A&M, or their GP or community mental health services. 

The types of interventions sought, and the delays and methods of health-seeking are influenced by treatment norms in countries of origin and therefore differ between the various Asian cultures. Level of acculturation and age group of client will also influence the way they view mental health and seek help (Te Pou, 2010). For these reasons many Asian mental health clients present late with more severe and chronic symptoms.

Language Barrier

Low English proficiency is a barrier to accessing health, understanding a new system, and engaging in treatment. The English language is particularly challenging for Koreans (Lim, 2011). For this reason Koreans may avoid seeking help (especially with mental health issues) because they develop low self-esteem and loss of face if they feel they cannot communicate sufficiently. Not being able to access services often results in withdrawal and isolation, ensuing poor mental health and wellbeing.

Reframing

Indirect questioning and reframing is preferable when eliciting sensitive information and assessing emotional distress. For example, there are a number of Chinese words associated with 'mood', and a relative ease in talking about 'heart', so if mood and heart are combined, there may be less discomfort around the concept of mood. 

Possible re-frames:

• 'You don't look very happy, is there anything bothering you?' (The linguistic negation of 'happy' is more comfortable to Asians than asking 'Do you feel depressed?')
• 'How is your mood?'
• 'Tell me some of the things you are worrying about.'
• 'It seems as though your heart is heavy.'
• Referring to 'tired' or 'stressed', is also more acceptable to most Asians than using the word 'depressed'.

Note however, that more direct questioning of clients is required to elicit information about causes of distress.