Unit 4.1 DB: Racial/Ethnic Backgrounds

As our expert guest, Roberto Almanzan, indicates, a central factor in understanding the psychological situation of most Latino/a clients is their individual experience, as well as the experience of their family units in migrating to the United States.

11-2Family and Cultural Values

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11-3Our Interviewee

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Roberto Almanzan, M.S., is a counselor, teacher, trainer, and consultant on diversity and multicultural issues in the San Francisco Bay Area. He has worked with schools, corporations, mental health agencies, and various nonprofit organizations. He also teaches in the multicultural program at the Wright Institute, Berkeley. He has trained with Stirfry Seminars in Berkeley and was a key participant in the film The Color of Fear—produced in 1994 and probably the most widely used film in training and education on racism—and participated in the production of The Color of Fear 2 and The Color of Fear 3 as well as a number of other documentaries on racism, privilege, and social justice.

11-3aThe Interview

Question:

First, could you begin by talking about your ethnic background and how it has impacted your work?

Almanzan:

My mother’s family came from Sonora, a northern state on the western edge of Mexico and settled in Douglas, Arizona, another border town. I don’t know much about my maternal grandparents. They both died before I was born. I do know that my mother’s father was a successful businessman. My mother’s family was large, like many Mexican families. My maternal grandfather owned a large general store and stables in Douglas. All the children, including my mother, were born in Douglas, so the family was settled there. My grandfather was able to send his eldest son, Jose, to Stanford University in 1915. However, when the United States entered World War I in 1917, my grandfather feared that his son was going to end up in the U.S. military fighting in the war. He did not want his son to go to war in Europe, so he pulled him out of the university and brought him home. He sold everything in Douglas, moved his family back to Mexico, and settled in Mexicali, a city on the border with California.

In the 1920s in Los Angeles, my father was the first of his family to graduate from high school. Some of his classmates from Polytechnic High School went to Stanford University. After hearing about Stanford from his friends, he set his mind on joining them. He was accepted at Stanford, and although he had to drop out for a while due to lack of finances, he graduated from Stanford as a civil engineer in 1933. Racism and the Depression made it very difficult for my father to land an engineering job. He finally ended up working for an American company that was doing some surveying in the agricultural area around Mexicali. My mother was living there with her eldest brother, Jose, and his family. By a miraculous coincidence, the kind that only happens in real life, my father was placed on a survey crew led by my mother’s brother, Jose. It wasn’t long before Jose introduced my father to his eligible sister, Bella. My father met my mother, courted her, and they married. I was their first child, born in Calexico, again on the border in California.

I grew up in a Mexican barrio in East Los Angeles. We started out in Boyle Heights and moved eastward as I grew older. All the teachers, counselors, principals, police officers, anyone in authority in East Los Angeles then was white. Although there was racism present and a white power structure, I felt fairly protected and supported in my identity, as most of the people in my environment were Mexican, and I was enveloped in my extended family. It was a white world, but in some way, I did not really see that until I graduated from Garfield High School and, following my father’s footsteps, went to Stanford University. That was fifty years ago. There was no diversity on the Stanford campus then. The need to include American students of color in universities or the benefits of a racially integrated student environment did not exist and were not known. The only ones I could see who were non-white on campus were the international students from Asia, Africa, and Latin America. I ended up hanging out at the International House because, in a way, I felt more at home there and more included.

Question:

What led you to become a human service provider and involved in the kind of diversity training you do?

Almanzan:

It’s kind of a jagged history. When I graduated from Stanford with a degree in international relations, my first job was working for the State Department of Employment (now EDD) in one of its newly created Youth Opportunity Centers. There were at the time various efforts to locate satellite offices in minority communities in San Francisco and other cities and target youth of color for intensive counseling and support services in finding employment or vocational training. I worked in these programs for several years—at first excited by what seemed to be a shift in attitude and a desire to do more for people in minority communities. In time, however, I grew discouraged with things that were going on around me. Many of the people we had trained were coming back through for another vocational training program. It seemed like the programs were not working, and we were just going through the motions.

In the mid-80s, I was drawn to the men’s movement and attended several men’s groups and conferences. I liked that men were encouraged to talk openly to each other about their inner lives in ways that men don’t usually do. It was referred to as “men’s work,” although almost all of the men who participated were middle class, white, and heterosexual. I thought if we are really doing “men’s work,” where were the black men, the Latinos, the Asians, or the Native Americans? I met other men of color and gay men who wanted more diversity. Together, several of us went to the organizers of a large upcoming conference and challenged them to change it in ways that made it more accessible and attractive to men of color and gay men. After a bit of resistance, they agreed, and we created the most diverse men’s conference I had ever seen.

My interest in these diversity issues led to a career change. I applied to CSU East Bay (Hayward) to enter their master’s program in counseling. Shortly after, I was accepted, and before classes started, I was asked to participate in a documentary film about a racially diverse group of men talking about race and ethnicity. That documentary film was The Color of Fear. After earning my master’s, I worked with immigrants, particularly Latinos, at The Center for New Americans in Contra Costa County. I kept getting requests to facilitate dialogue based on The Color of Fear, and these increased to the point that I had to make a choice between continuing my work with immigrants or to focus on dealing more directly with diversity issues. Although working with Latino immigrants and their families was very satisfying, I decided to focus on the diversity work because it connected me deeply with issues I had been dealing with all my life.

Question:

Who are the Latinos and Latinas, and what characteristics do they share as a group?

Almanzan:

Time also takes on a different flavor than in dominant white culture. Latinos tend to be more flexible about it and tend to experience the precision and narrowness of the white definition of time as overly rigid and often problematic. They don’t think of time in such rigid concepts, and this can be a source of conflict. Latinos may not show up for appointments at the exact time specified. Punctuality does not have the same importance and value for Latinos or often for other people of color as it does for the dominant culture. Time does not take precedence over other matters, such as greeting others or attending to personal relationships.

A final difference has to do with gender roles and the concepts of machismo and marianismo. For men, the concept of machismo has been very much distorted and corrupted in the popular media in United States. In its purest form, it refers to the sense of responsibility the male feels to care for and protect his family and those around him. Especially in the United States, it has come to mean a sense of bravado, being loud, aggressive, and tough. This is really its shadow side. Latin America itself has been influenced by this distorted image through the media and has come to increasingly see machismo in this way. I remember growing up with this image of Mexican men from the movies I saw and was shocked when I asked my mother, and she told me this was not machismo. She said that machismo means that “you must make sure that your wife and children are safe and cared for and that you always show respect to your elders.” Similarly, marianismo, the role of women in Latino culture, has come to be wrongly defined by its extremes. It is the tendency in women toward self-sacrifice and a focusing on the needs of others for the benefit of the family as well as to acquiesce to their husband’s role as the head of the family.

Question:

Could you now talk a bit more about the various names that different Latino and Latina subgroups use to describe and identify themselves?

Almanzan:

Another shared experience, which we will be talking about at greater length later, is the process of migration.

Question:

Let’s switch our focus and begin to look at issues related to providing services to the Latino community. Could you talk about factors that influence how Latinos and Latinas go about seeking help when they have problems?

Almanzan:

First, it is important to keep in mind the great diversity within Latino culture. When I talk about aspects of service delivery—how members of the Latino community go about looking for help, for example—I will be making generalizations that cover many but not all Latinos. What I will be sharing are general guidelines, but these may vary from case to case.

The Latinos most likely to be looking for help or finding themselves with problems are recent immigrants and first-generation born in this country. Latinos will turn to their own extended families for help first. After that, they will usually go to their church for help. The church plays a powerful role in their lives, so when they encounter problems, it is often the first place they turn to outside the family. As much as possible, they will first try to solve their problems within the family. If there is a respected elder available, they might speak to him or her. If the problem revolves around issues of physical or mental health and the family believes in folk healers, they might consult a curandera or curandero. But, in general, they are more likely to first approach their priest or clergyman.

If they are willing to approach an agency, it is usually one that exists in their community and one with which someone they know and trust has had some experience. They have seen the agency and know of its existence in the community. They may know some of the people who work there or people who know people who work there. They may have family members, neighbors, or friends that have received services there. In some way, there needs to be a personal connection and credibility, often through word of mouth. They are less likely to seek services outside their community or speak to people who are strangers and not of their community. Referrals to unfamiliar agencies are most likely to be successful if they are made by someone familiar to the client’s family.

I have sought therapeutic help at various times in my own life. My mother was scandalized when I told her that I had gone to see a therapist when I was at Stanford. She was perplexed and really outraged. “How can you do this? What are you talking to them about? You’re going to talk to somebody outside the family? What do you think I’m here for? What do you think your father’s here for?” It was scandalous and even offensive to conceive that someone outside the family would know about any problems within the family. In her declining years, before her death, my mother was living alone, having a hard time, but refusing to move. She would not leave her house, and we could only visit her every few days. We had a social worker come to see her once every week to listen, converse, and offer help. My mother wanted to believe that she was a friend coming by to talk, which meant she could then talk personally with her. My mother would put out coffee and some food and have a social visit with her. It took her about a year to realize that this was in fact counseling, and she immediately cut it off. Many Latinos—depending on class, education, and acculturation—are just not open to mental health approaches, especially nondirective therapy. If they do find themselves seeing a therapist or counselor, what they expect is good advice, not a free-flowing dialogue or therapeutic reflections. They want to be told what they need to do, what they should do, or where they can access resources.

Question:

What are some of the common problems that Latino clients might bring to you as a counselor?

Almanzan:

Many problems have to do with the process of immigration—coming to this country and not knowing how the system works. How do I do this? I got this letter from immigration—where do I go? Where can I get some legal assistance? What to do about food stamps. Very much related are the difficulties of learning and understanding English and, as a result, being taken advantage of, for example, by landlords. Being ripped off for their deposits or having their rent raised or given short notice to vacate. Not getting plumbing or roofs or other repairs taken care of. Then, there are problems related to dealing with the government and its bureaucracy: driver’s licenses, taxes, Social Security, etc. All of these are issues that have to do with a lack of familiarity with American culture and how to operate within it. Also, employment and the fact that new immigrants can only get menial jobs that don’t pay a lot and don’t have benefits and that they often have to hold two or three jobs at once and require all family members to work in order to survive.

There are also social problems. With migration, children tend to acculturate more quickly than their parents. They are in school, exposed more extensively to an acculturated environment, learn English more rapidly, are attracted to the ways and values of the nonimmigrant children. This inevitably creates separation and conflicts with parents, especially when the values and behaviors that the children are adopting are in conflict with family values. And there are often relationship issues between husbands and wives due to changing gender roles and women having to work outside of the home and children getting involved in delinquent activities, antisocial behavior, maybe even gangs and drugs. All of these social and migration issues are translated into stress, culture shock, self-esteem issues, depression, anxiety, etc.

Question:

How do socioeconomic and class issues affect the psychological lives of Latinos?

Almanzan:

I have already talked about those who are poor and from lower socioeconomic classes. Often, Latinos who were professionals in their country of origin migrate to the United States but cannot work in their professions here. I have met lawyers and medical doctors who have menial jobs in the United States as janitors and warehousemen because they can’t get anything else. For such middle-class people, the experience of such loss—of being reduced in status and income—can be very debilitating. They are more likely to seek help, including mental health treatment, because they tend to be more sophisticated about modern culture, having already acculturated in Latin America. They are also in a better position to assimilate because they tend to be more steeped in modern ways and knowledgeable about bureaucracies. Generally, with each generation here and the more education, economic stability, and acculturation they gain, Latinos tend to avail themselves of mental health services when they are needed.

Question:

Could you talk about issues of identity and belonging in different generations of Latinos in America?

Almanzan:

Question:

Next, let us talk about some of the factors that you see as important in assessing a Latino client. What kind of things would you look for? What kind of information do you need?

Almanzan:

First, I’d notice if they spoke to me in Spanish or English. My Spanish is not completely fluent, but it’s good enough to make myself understood. I would speak Spanish with them if they spoke Spanish. I’d try to find out whether they were born here or immigrated. Each represents a very different type of experience. I would assess their degree of acculturation.

What country did they come from? What is their immigration story? Did they come alone? If they joined family members that are already here, I would know that they are more secure and settled. If they are alone and their family is in Latin America, I would ask how long they have been away. If from Central America, I would try to ascertain if they immigrated because of the conflicts in their country. If they have fled a conflict, I would look for evidence of emotional distress.

Do you feel that there are any therapeutic approaches that are better matched with certain Latino subgroups?

Almanzan:

I think that any approach can work well with someone who is acculturated. With more traditionally oriented people, I would use a more directive style and would take my lead from them. It is very important to be able to understand their problem from their own perspective, not that of the counselor, and communicate that understanding. Also, be very careful to not unintentionally pathologize them or their behavior. Try to get a sense of why it is problematic for them from their cultural perspective and normalize it.

When I first began therapy in my twenties at Stanford, I was still living at home with my parents. The counselor questioned my living situation, and his questioning made me feel that there was something wrong about that. I came to feel very bad about myself and that this reflected my thwarted development. In retrospect, I am aware that there was nothing wrong with the fact that I was living with my family at that time. It is a very normal behavior in my culture, and I had been pathologized because of his cultural ignorance.

Question:

Are there any subgroups within the Latino/Latina community that are at particular risk for mental health problems?

Almanzan:

Research has documented that the closer one is to the immigrant experience, the less mental health issues one has. The longer one has been living in the United States, the more likely that mental health issues will crop up. I find that very interesting. I have already talked about the stress of the immigration experience, but there is also the daily stress of living as a Latino, an immigrant, and a person of color in this country and experiencing the impact of racism and discrimination. Together, they wear on one’s self-esteem and sense of who one is and what one’s values are. But there is more. When people come from Latin America, they have coherent worldviews and coherent cultural values. Living here, these cultural identities and worldviews are taken apart, picked at, and strained. In time, they lose this coherent sense of who they are. They try to assimilate to improve their situation. They are pressured to adopt some of the cultural values and perspectives of the dominant culture, and this sets up a lot of conflicts within them and adds to their stress and internal confusion.

Question:

Last question. You’ve shared a lot of rich information with us. Could you finish by presenting a case that shows how it comes together in work with a client?

Almanzan:

I would like to talk about a Latino woman I saw for depression whose husband eventually joined her in the treatment. I remember seeing this female client for depression, and it soon came out that there were serious relationship issues between her and her husband. At first, she came by herself for two afternoon sessions. She was in her mid-thirties, Mexican. They had been in the United States for less than ten years—probably around eight. They were lower socioeconomic class, with limited education, and had three children: one girl and two boys. The girl was sixteen; the boys twelve and ten. She came in complaining of depression, of hopelessness. Much of it revolved around surviving financially. She was desperately looking for work without success. Then, she found some work, and I didn’t see her for a while.

After several weeks, she called and made an appointment to see me in the early evening because she was working in the day. Her husband came with her but sat in the waiting room as if he was only there to give her a ride in the evening. I was very conscious to attend to him with a sense of respect and to acknowledge that this was his wife that I was working with. There can be a lot of fear and jealousy in such a situation, and I wanted him to know that I respected him and his family.

She complained that her husband often spoke of going back to Mexico—that they were here just temporarily. Even after eight years in the United States, this was an ongoing conversation in the household. The children said they wouldn’t go back. The girl, the oldest, had become rebellious and was staying out late and ignoring their rules. The daughter and what to do about her out-of-control behavior became a central issue in the parents’ escalating conflict. The daughter worked at stimulating the conflict between her parents. The mother, though very worried about where her daughter’s out-of-control behavior was heading, sided with her daughter because the husband was being increasingly violent with the kids.

The process we went through helped them communicate a little better and lessened the tension in the household. But it did not totally change everything. He still had outbursts of violence, and she eventually decided to leave the relationship. I had given her information on an organization helping battered women earlier, and she had contacted them. She left him while he was at work and took the children with her. She spent some time in a battered women’s shelter, then some transitional housing, before going on her own.

I saw him alone for two sessions afterwards, and we talked about what had happened, why she left, and how he was going to carry on. I can’t say this therapy was totally successful. They were able to communicate better; she found the courage to move out and hopefully become helpful to her teenage daughter. I felt particularly proud that he was willing to meet with me and open to understanding why she had left, for it would have been very easy to blame others, me included, and not return. It was his style to externalize his anger, disappointment, and helplessness, all of which were made worse by his lack of work, the increasing loss of control at home, and his related migration experiences. I did feel he was able to relate his wife’s leaving to his own behavior, and that was a big step in understanding what had happened. He left after the last two sessions, and I didn’t hear from him again. I would have liked to see both of them longer, but in this kind of work, clients are often transitory, and it is important to appreciate the small successes and little victories in such difficult situations.

Working with Native American Clients: An Interview with Jack Lawson

12-1Demographics

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12-2Family and Cultural Values

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Sue and Sue (1999) identify five values that typify Native American cultures:

· Sharing and cooperation

· Noninterference

· A cyclical orientation to time

· The importance of extended families

· Harmony with nature

12-2aSharing and Cooperation

Sutton and Broken Nose (1996) quote an Oglala Lakota elder regarding the Native American attitude toward sharing: “When I was little, I learned that what’s yours is mine and what’s mine is everybody’s” (p. 40). Status and honor are earned not by accumulating wealth, but rather by sharing and giving it away. Gifts are profusely given, especially during life cycle events, as a means of thanking others and acknowledging their achievements. Material possessions are freely shared and expected to be shared. Similarly, great importance is placed on hospitality and caring for the needs of strangers. Working for wages is purely instrumental. A native person, for example, may stop working once enough money has been earned to meet immediate needs. Of course, such a selfless attitude toward material wealth and possessions may prove counterproductive in the mainstream economy. Sutton and Broken Nose (1996) describe the traditional owners of a restaurant on a Navajo reservation who were hard put financially because they felt obliged to serve free food to relatives, and most people on the reservation were relatives. Related to sharing is cooperation.

As in the Latino/a culture, competition and egotism are anathema to Native ways. The family and tribe take precedence over the individual, and it is expected that one will set aside personal activities and striving in order to help others. Interpersonal harmony is always sought and discord avoided.

12-2bNoninterference

12-2cTime Orientation

· Third, for generations, the government systematically destroyed Native culture and alienated individuals from their traditions and customs. Our guest expert, Jack Lawson, describes this loss of identity and disconnection from tradition as the source of all contemporary Native woes.

12-3Our Interviewee

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Jack Lawson has worked in the field of alcohol and drug treatment, primarily with Native peoples, for over twenty-two years. Currently, he is the Native American Coordinator for the State of Oregon Youth Authority. In this position, he is responsible for establishing relations with the nine federally recognized tribes in Oregon, developing and implementing culturally relevant treatment services, and helping to oversee the Oregon Youth Authority’s mission of implementing cultural competency and community development in juvenile crime prevention plans. He has also provided treatment services to Native inmates in the Oregon State Prison System, was lead trainer for the Oregon State Alcohol and Drug Office’s cultural diversity training program, and worked as a counselor in a wilderness treatment program for the Siletz tribe in central Oregon. Ethnically, he is a member of the Creek Nation.

12-3aThe Interview

Question:

Could you first talk about your own ethnic background and how it has led to your work in alcohol and drug treatment?

Lawson:

Both my mother and stepfather were alcohol-dependent. After their separation, my stepfather died in a fire. My mother remarried when I was about sixteen and had quit drinking. During high school, I developed an alcohol addiction. I took to alcohol like birds to flight. In retrospect, I realized what I was struggling with was issues of internalized racism and, as a result of it, a variety of self-destructive behaviors.

I received my first message about recovery from a couple of Native Americans who were active in Alcoholics Anonymous (AA) while serving in a military jail. After a couple of false attempts at sobriety, I was able to catch onto the program. My first two years of recovery were made possible by strict attendance at AA meetings. Several years later, I had the opportunity to attend my first sweat lodge ceremony. Experiencing it seemed to make all the difference in the world for me. It directed my recovery in a way that would not have been possible without access to my culture and identity as a Native person. It was through exposure to the traditions of my People that allowed me for the first time to develop long-term relationships with others and good connections with my community. As a result of this experience, I began to understand the influence of culture and identity in the recovery process and the influence of people who can teach these cultural ways and traditions to us. My own recovery experience taught me what has to happen for other Native People. It has been a real blessing to be exposed to people knowledgeable in the ways of our culture and traditions, who could and did teach me about myself, about who I am, and where I came from.

Having those mentors in my life, with their understanding of Native ways and identity issues, has allowed me to access areas of my life that otherwise would have remained invisible to me. I would have been left with a substantial void inside. Learning how I, as well as my People, reacted to being oppressed by oppressing others and losing ourselves in destructive behavior and thinking has made it possible for me to bring that understanding to the treatment process and to others who are still suffering from mental health and addiction problems so that they too can transcend those barriers for themselves.

Question:

How would you define Native Americans or Native People as a group, and what characteristics do they share?

Lawson:

Differences among Native Peoples are small in comparison to those things that set us apart from members of the dominant culture. I think we stand apart because of a value system that is qualitatively different and a set of historic experiences that cannot really be understood by dominant culture. When I take a look at the behavior of Native People, the first thing that strikes me is that we keep to ourselves—[we] are very insular and private, especially in comparison to members of the dominant culture. Some of this is certainly dictated by culture. But for Native Peoples, it is also a matter of self-protection. This is because of a shared sense of historical oppression and victimhood. The historical experiences of genocide and culturicide have left a deep mark upon our thinking and feelings, which is all the more tragic because our only “crime” was being on this land first. Everyone else that is in America today has come from somewhere else, but as Native People, this is the land from which we originated. We believe that we were created here. This is where our People have come from. It is an intricate part of who we are—how we define our communities and our mental health. When we view many of the problems that have arisen in our communities, we know they arise because of the loss of our land and our way of life that is so tied to the land. And of all the peoples in America today, we have been the least welcome.

Culturally, Native People tend to be nonintrusive and nondirective. They let people make up their own minds. If people come and seek advice, it will be given but not offered. Life is experienced as an interconnected entity. Nature, the People, the community all intertwine and depend upon each other for meaning and existence. We also tend to be very spiritual in our orientation, and the underlying force of our spiritual beliefs comes from the geology of the area from which we come. That spirituality infuses the community and becomes its base. It is central to the identity of each person and gets expressed through various religious and cultural practices. The creation stories of each People, for example, are set in the geographic area from which they came. The Navajo and the Hopi believe that they came up through the center of the world, and that center is located in their sacred places. For the Modoc people of central Oregon, their creation story is built around the lava beds of northern California, and they believe that humanity enters the world through the creation center, which is located there. All things come from our ties to the land, and all Native People are joined in their commonality with the Turtle Island, as we refer to the continent.

Question:

Could you describe some of the names that have been used historically to describe and identify Native Peoples and the general process of naming within the culture?

Lawson:

In regard to names, there are the names that we call ourselves and then there are the names that other people have given us. Most familiar to dominant culture is the term Indian. It is actually a misnomer. It comes from the time that Europeans first landed on this continent. Christopher Columbus mistakenly believed he had landed on the coast of India, and, hence, we got tagged with the name Indian, which has over time taken on a pejorative meaning for us. In spite of the fact that the term has been prevalent in describing us, it carries no significance in our world. At some point, we as a People decided to take control of how we identify ourselves.

The process began with the term Native American, which signifies that we come from this continent. But, then, because we predate the naming of this continent and the Americas, we have begun to look at ourselves as the Indigenous People or First People of this land.

When first making contact with a Native client, it is perfectly appropriate to ask where they are from, what their tribal affiliation is, and how they prefer to identify themselves. I think we get into trouble when we don’t do that and start making assumptions or just randomly use a term without being respectful enough to ask.

Asking about this information is probably a good way to begin contact. In mainstream America, people are identified primarily by what kind of work they do. We don’t ask people what they do for a living. Instead, we ask each other: “Where are you from?” or “Who are your people?” This is because we come from a relationship-based culture, and our relationships are defined by our communities, our relatives, and our tribal affiliations. We socially locate ourselves by our human connections, not by our activities or jobs. Two last points. Spiritual names are sacred and private and used only during ceremonies. It is considered inappropriate to inquire about these names unless they are spontaneously offered. In addition to Christian names, nicknames are very commonly used in Native communities. One might go an entire lifetime calling someone by a nickname and never know their given name.

Question:

We have already talked some about history. Could you give us a nutshell version of historical events of which a provider should be aware?

Lawson:

Historically speaking, Native People have suffered greatly at the hands of governmental policies and the actions of various religious groups. The experience of colonization is not just historical but is still happening in our communities today. Loss of our culture, loss of religion, loss of community, and loss of family cohesion are contemporary realities. And these patterns, which are the consequences of oppression, continue to play themselves out emotionally and psychologically in the lives of our people. They are major issues that concern us deeply because they involve nothing less than the loss of our identities and integrity.

Perhaps most insidious about this practice was its effect on the Native family and its cohesion. When the children were taken out of their families, they were separated from their grandparents, parents, extended family, aunts, uncles, community, and so on. For generations, many Native American children were robbed of the nurturing of their families—deprived of the opportunity to learn parenting skills and other cultural lessons that would have enabled them to raise healthy families of their own. These children were forced to reside in institutions that were harsh and brutal. Some of our elders believe that our many social problems stem from the boarding school experience. Many of the children, as adults, remained isolated from families, no longer able to communicate because their language had been beaten out of them. They felt no comfort returning to their communities and were generally left alone to deal with the many internal issues that had been created as a result of growing up in the schools: low self-esteem, negative feelings about being Native, and a deep self-hatred. We can now see very clearly how generations of such experiences have impacted our communities and made them into what they are today.

Question:

Let us switch focus and begin to look at issues related to help giving and treatment. What factors influence how Native People go about seeking help?

Lawson:

When Native People become involved in treatment programs, it’s usually because of some external motivating force. That is, they are mandated either because of trouble with the law, family problems, child protective services, or the like. Generally speaking, that’s how most people will come to be involved with outside agencies. Sometimes, the tremendous anger and mistrust that Native People feel prevent them from seeking help outside of their community. Sometimes, it is discrimination against them that serves as a barrier to accessing treatment. When you do find Native People coming into your agencies by themselves seeking help or assistance, they often are assimilated or bicultural—those who are more familiar and comfortable with white institutions and practices.

As a result of these patterns, there is a movement among various tribes to develop mental health and addiction services within our own communities so that people no longer have to choose between white services or no services at all. The hallmark of this trend is the creation of culturally relevant services. “Culturally relevant” means that the treatment process is infused with Native cultural values, that treatment goals make sense to Native sensibilities, that the need and value of developing positive ethnic identity are acknowledged, and that services are relevant to the lives and daily existence of the people being served. It also means that services are provided in a manner that is culturally comfortable to Native People. This trend is extremely important because the fact is that Native People usually experience less success in programs designed for mainstream white clients. Cultural barriers are a major obstacle to successful treatment in any program.

Question:

Are there any other things you would like to say about the nature of family, community, and culture among Native People that have relevance for human service providers?

Lawson:

Family structure in Native communities is very different from the nuclear family that predominates in dominant culture. Among Native Peoples, extended families are more typical, where an aunt may also act in the role of the mother or the grandparents raise the children or an uncle is the primary teacher for a youth or cousins are treated as brothers and sisters. Traditionally, responsibility for child care is communal. Also included in the family structure are clans, which are determined by kinship, and bands, which are people living in the same locale.

Other disruptions for the family come from state children services agencies that routinely adopt our Native children out to non-Native homes. Often, in conjunction with religious organizations or acting on stereotypical beliefs about Native American families, these agencies disregard the critical importance of Native culture for these children. There are many horror stories from the past of white people coming into Native American communities and removing children. Fortunately, this is a practice that has been stopped by implementation of the Indian Child Welfare Act of 1978, which re-established tribal authority over the adoption of Native children. Even though our rights have been reinforced, we are constantly struggling with agencies who are working to undermine the law. By these few examples, it is obvious how there has been a basis for the development of mistrust of social service agencies—a feeling that continues today.

Question:

What are the kinds of problems with which a Native client might present?

Lawson:

One hundred percent of Native People are affected either directly or indirectly by alcoholism. Underlying this are a host of complex problems related to the loss of culture, identity, and disruption of the family unit, all symptomatic of a long history of genocide and oppression. There are also a lot of anger and anger-related issues, depression and hopelessness, health problems, and unusually high rates of suicide and homicide, especially among the young. There has also been a serious increase in the diagnosis of HIV in our community, mostly related to IV drug use. Among Native People who are incarcerated, alcohol and drugs are a major contributor to their incarceration.

Question:

Do class or other socioeconomic issues play any role in these various problems?

Lawson:

Definitely. Unemployment rates can be astronomical on a reservation, and the same is true for Native Peoples living in urban areas. The Relocation Act of the 1940s was one in a series of efforts by the government to encourage Native Peoples to leave the reservation, move to cities where jobs are more plentiful, and become part of the American mainstream. That was the ultimate goal. However, the reality was not quite as simple as that. Although some did relocate successfully, many found the experience traumatic. In the move from reservation to city, many traditional ties were lost. Kinship ties weakened with distance, and some people became disassociated from their relatives and community. Many ended up living marginal existences in the skid row areas of cities, and those who followed them from the reservations would tend to migrate toward these same enclaves. What the logic of the Relocation Act did not envision was the reality that most of these people, familiar with a very different kind of existence, did not have the dominant cultural tools to survive successfully, let alone prosper in such a foreign environment where they were met with substantial discrimination and rejection.

There is an important cultural point here as well. In mainstream culture, success is measured in economic terms, and socioeconomic success implies a certain lifestyle that depends on having sufficient monetary resources, accumulating wealth, regular employment, living according to a certain style, and so forth. Our traditional cultural values are very different from this. Our wealth is located in the richness of our culture, tradition, ceremonies, and in the richness of our lifestyle. Difficulties arise when a person tries to live by a cultural value system that is not based on material economic gain within a broader culture that is so absolutely dedicated to it. These are not value systems that are easily integrated. Such clashes set the stage for Native Peoples losing our lands and having our language and culture outlawed in the first place. Today, we struggle with a similar conflict around remaining attached to our traditional way of life that cares little about accumulating economic wealth. It comes down to the question of divergent value systems. Those who are bicultural know what they would need to do to be successful—and that would be to eliminate their culture and perform accordingly—but that would go against their beliefs, which are based in indigenous culture and tradition. The integration of two such diverse value systems is difficult, to say the least.

Question:

In making an initial assessment, what kinds of information do you feel it is important to collect from a Native client?

Lawson:

Assessments must be carried out within the framework of the client’s own culture. It is important, however, to not let the client be your only source of information about their culture. This information needs to be balanced with information from their community as well. It’s necessary that you reach out to our communities and listen to the people. It has been my experience that the more you learn about another’s culture, the more open they are to you. Learn as much as you can. You get that information from the community through developing relationships. Go to the communities and events and develop relationships. This doesn’t mean that you have to give up your own cultural values or beliefs. It does mean that you should be able to understand and respect beliefs of others and evaluate their behavior from within their cultural context.

Perhaps the most important piece of information to gain about Native clients is where they fall on a continuum from assimilated to traditional. People that are assimilated will often feel uncomfortable around their own People, not knowing the behaviors and what is expected of them. They appear to be Native and possess all the physical features of being Native, but internally, they’re different. They may feel uneasy because of their lack of knowledge of traditional ways and may feel unaccepted because of it. Assimilated individuals tend to act differently than those who live by traditional values and possess a traditional belief system. The assimilated person may appear more talkative and open, even though there might be distrust. They will be the ones who know the rules of the program and of society in general. In short, they will have learned what one needs to do within dominant culture to survive. Traditional Native People present themselves as more reserved and quiet. But rather than being indicative of withdrawal, it comes from a cultural value of respect, non-intrusiveness, and honor.

What kind of information should you seek from a client? There is all the standard assessment material. Who was a person raised by? Family structure? Religion? But with Native People, what is important is to interpret this information through the filter of how they see themselves culturally.

Question:

Are there subgroups within the Native community that are particularly at risk?

Lawson:

I believe that all Native People, especially children, are at risk for developing alcoholism or some other form of dependency. There are physiological issues—social, economic, and emotional ones as well. They have been passed down from generation to generation and together create a “lump sum” of a risk for us as Native People. At one time, it was prevalent in our communities to accept alcoholism as a way of life. That is how we tended to cope with oppression and the discrimination in our lives. It became part of our continual grieving process. Although in many places this is still the norm, there are many of us who are beginning to take more control over our lives and find recovery.

Question:

What suggestions can you give regarding developing rapport with Native clients?

Lawson:

I believe we have to be aware of our own prejudices and biases and the way we regard people who are culturally and racially different from us. It is not a matter of learning to say or do the right things. Instead, we have to be aware of ourselves and the underlying issues that affect our clients. It’s not about having to learn all the ins and outs. We are dealing with a very diverse population. It’s impossible for me to say, “Well, this is the one thing you will need to say or this is the one thing that you do in order to develop rapport.” I would be merely creating a new stereotype.

We are all going to make mistakes, and mistakes are a common thing in working with diverse cultures. But if one really comes from a place of acceptance and respect as a care provider, then that is going to translate into developing rapport with clients. As helpers, we all have a goal in mind: helping to develop a therapeutic relationship so that clients can heal themselves. But there is more than one road we can travel to get to the same place.

Question:

What else is important to know about working therapeutically with Native clients?

Lawson:

I have provided services to both white and Native clients, and there are clearly some important differences. In the white groups, traditional counseling methods are effective. I am more direct and confrontational here, and the clients tend to respond positively. I use a very different approach with Native clients. We sit in a talking circle, but it is the issues we talk about that are important. The issues have to do with Native culture, identity, how they see themselves as Native People, the effects of stereotyping, justified anger, positive identity development, and ceremony. And we use ritual objects and ceremonies as part of the process: eagle feathers and pipes, smudging, sweat lodges, and so on, introducing our culture into the treatment process and acknowledging what they are going through ritually and with ceremonies. Such a process fits naturally with our cultural understanding of health and sickness. We also discuss the effects of oppression while at the same time addressing the issues around denial, relapse prevention planning, and recovery maintenance.

As far as therapeutic styles with Native People, you will most likely be working with those who either know nothing of their culture or are bicultural. In both cases, I find that traditional counseling methods generally prove effective but with the incorporation of cultural material. My approach with Native Americans is to use culture as an avenue to recovery because loss of culture and identity is the most basic problem that Native People face. In this regard, I assist clients in identifying their culture, how it has influenced them, how they came to lose touch with it, and how they may become reconnected to their culture. I also have them identify where they stand along the continuum between traditional and assimilated. At times, I come across clients who hide their issues behind culture or try to use it to get something for themselves. They use it as a “front”—as a means of not dealing with treatment issues. The value of culture and community is not about what it can get you but who you can become because of it. The challenge for non-Native service providers is to know the difference between clients using culture as a defense and when the Native culture is genuine.

Similar dynamics can occur in treatment in general, and that’s why it’s important for non-Native providers to have connections and resources in the Native community. It is clearly not productive for providers to exclusively learn about Native culture from their clients. Contact with the community will also give you a certain credibility. In working with our People on a regular basis, you just have to get out of your office and make contacts. We are a relationship-based culture.

Question:

Finally, could you present a case that brings together the different issues and dynamics about which you have been talking?

Lawson:

Through continuing positive contact with Native culture, in the form of ceremonies and positive role models, he was able to begin to distinguish between what was truly cultural and what was internalized from negative stereotypes of Native People and culture. This, in turn, enabled him to develop a more positive cultural self-image, something which was totally lacking before coming to the program. He increasingly took pleasure in attending sweat lodge ceremonies, learned to drum and sing, learned more about Native values, and in time began to work at incorporating these values in his treatment plan. He became more open to attending Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings and eventually involved himself more and more in the Native community. As part of treatment, he received a lot of very direct feedback from other Native clients and staff. He found it very helpful to hear others who had gone down a similar path of alcoholism and dysfunction “call him” on his self-destructive behavior, attitudes, thinking patterns, and lifestyle.

The eventual result was better feelings about himself, an emerging ethnic identity, and a positive sense of belonging to the Native community. During group therapy, he was able to make the connection between his own self-destructive ways and the lack of culture and traditions in his life. In short, participation in the program forced him to experience a powerful identity crisis and reformation, and it gave him an outlet and place to experience feelings that he thought were unique to him. After completion of the program, Joe continued to seek out sweat lodges and remained actively involved in community events. He has begun to take on some communal leadership roles and actively strives to encourage others to find recovery through their culture and traditions.

Working with African American Clients: An Interview with Veronique Thompson

13-1Demographics

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According to researchers who have worked to adapt family therapy practices to the cultural realities of African American families, three strategies are critical:

· Understand the cultural context of the family.

· View differences in family dynamics as adaptive mechanisms and strengths.

· Develop practices that take into account the needs, cultural dynamics, and style of African American culture.

Furthermore, these researchers favor interventions that mobilize existing family structures, and they are opposed to creating new forms similar to those found in white families. Hill (1972, 2003) identifies the following three factors as positive strengths to be built upon.

13-2aKinship Bonds

· Greater empathy for the husband’s frustration in a racist society

· Awareness of the extent to which they outnumber black males

· Strong religious orientation that teaches tolerance for suffering

Economic demands and oppressive forces have, in addition, created unique roles in the African American family. Included are the parental child—which involves parental responsibilities allocated to an older child when there are many younger children to attend to or when both parents are absent from the home for considerable amounts of time—and the extended generational system of parenting, in which the parent role is shared and distributed across several generations living in the home. It is important to emphasize that such adaptive strategies within the African American family, while clearly a potential positive force, can in themselves become sources of problems that require intervention. This occurs when their intended function becomes distorted, overused, or rigidified. According to Pinderhughes (1982), “if the mother’s role is overemphasized … it can become the pathway for all interactions within the family. This requires children to relate primarily to her moods and wishes rather than to their own needs. The result is emotional fusion of the children with the mother …” (p. 113). Or parental children can be forced to take on responsibilities well beyond those of which they are capable and at the expense of necessary peer group interactions (Minuchin, 1974). Shared parenting in the multigenerational family can become highly chaotic or a source of open conflict and dispute. In each of these cases, the goal of therapy should not be to eliminate or “repair” the adaptive pattern (i.e., to move the family closer to white middle-class norms). Such patterns may, in fact, be necessary for family survival. Rather, the goal should be to set it back on its purposeful course so that it can once again function as intended.

13-2cReligion

The trauma of slavery and a long history of racism have shaped and defined the African American experience in the United States. It is impossible to understand the African American psyche without keeping these two events clearly in mind. Kivel (1996) states the facts of slavery quite succinctly: “From 1619 until slavery ended officially in 1865, 10–15 million Africans were brought here, and another 30–35 million died in transport” (p. 121). The magnitude is staggering and even difficult to conceive. But that is not even the full story; there was also the systematic destruction of African culture and identity by the slavers and slave masters, the tearing apart of families, the creation of myths of inferiority and subhuman status to justify what was being done, and an entire nation that benefited greatly—economically and socially—from this cruel institution.

13-3Our Interviewee

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Veronique Thompson, Ph.D., received her training at Spelman College and the University of California, Berkeley, where she held several distinguished minority fellowships. She is a licensed clinical psychologist and a tenured faculty member at the Wright Institute in Berkeley. She is the director of clinical training at the Center for Family Counseling in East Oakland, where she conducts training for the counseling staff that provides family therapy and community-based prevention programs in the Oakland Public Schools. She also maintains a small private practice. Dr. Thompson has special expertise in narrative theory and social justice therapy and has received training at the Dulwich Center, Australia, and the Family Center, New Zealand.

13-3aThe Interview

Question:

Can you begin by talking about your own ethnic background and how it has impacted your work?

Thompson:

I identify as African American, although I use the words black and African American interchangeably. My racial identity impacts and shapes my life—who I am—and has a heavy, heavy influence in my work. Racism, in fact, makes it impossible for me to forget about the color of my skin. In some ways, sexism does the same thing. Both are at the forefront of my thinking and so cannot help but affect me as a professional. African American culture focuses my attention on certain aspects of experience. It teaches me about what’s important, like spirituality and respect, education, family relationships, political unity, and fighting for the oppressed, freedom fighting. My culture has me paying attention to these things, and it shows up in my practice. It forms the metaphors and language I use and shapes and defines the way I think about psychological problems. Take respect, for instance. Because I come from a group that’s been very disrespected, respect is a real important thing to me and other African Americans. There’s a slang term that the young people use called “dis”—to “dis” somebody—and it means to disrespect them. My style of therapy is very connected, intimate. The humor that I use is very cultural. My language, the intonations that I use, how I speak, all come from being African American.

The thing that really got me interested in psychology was a book called I Never Promised You a Rose Garden that I read as a teenager. It was about mental illness, and I was fascinated by the realization that everybody had different minds, different inner worlds, different personalities. I have a sibling who struggles with depression, and it made me curious about such differences. As African Americans, we also occupy a certain reality that is different than other peoples’ reality. Things like sexism and racism are really up close and personal. They’re not merely interesting intellectual constructs. As a result of the denigration and oppression, there is often rage and anger, and you have to do something with that. I use it to inform my work, turn it into something constructive. It fuels my commitment for working with my own people.

Lastly, I have a lot of passion and try to be creative with it in my work. That part of me feels very African American. My mother always mentions a paradox she sees in our culture—that there is so much joy among us in spite of all the hardship. There’s really a lot of exuberance, joy, and zest for life that shows up in things like the arts and all the many ways that African American people contribute to American culture. It comes from a deep place of both spirituality and joy.

Question:

How would you define African Americans as a comprehensive group? What characteristics do they share?

Thompson:

The term African American refers to people of black, African descent, who can be distinguished from people of white African descent, as well as from black Africans who are currently immigrants to this country. There are Caribbean blacks who have a very similar history to African Americans but who reside or have resided in the Caribbean Islands, and black people from South America and other places in the larger African diaspora. African Americans have a particular common history of being the descendants of those people who survived the Middle Passage and went through post–Civil War Reconstruction, the period of Jim Crow law, the period of cultural revolution, really from the ’30s up into the 1950s and ’60s.

Time. Every group has their own time frame. We refer to ours as CP time—that is, Colored People time. African Americans tend to be more informal around social time. For example, when I have a party and am inviting both my African American and white friends, I often tell them … speaking well and having good verbal communication and persuasive skills are highly prized among African Americans. Look at rap music, the high value placed on people being ministers and preachers. In my generation, it was called “capping,” a contest to see who could verbally outdo the other person. Spirituality, even if it’s not religious, there’s great respect there. You almost never see African American people, if they win some kind of award on TV, I don’t care what it is, you know, the Academy Awards, the Tony Awards, the music awards, they thank God. That reverence is always there.

As African Americans, we also have a shared history here in America that has been organized around oppression and its consequences. Included are the experiences of economic disenfranchisement, second-class citizenship, racial discrimination, healthy paranoia, social vigilance. Not every African American person reacts to these factors in the same way, and some may be well off right now or second- or third-generation middle class, but at some point, economic disenfranchisement was a shared and common experience, even if it is not currently in a person’s life. It remains a generation or two away from you. A last thing related to all of this is a shared concern for the importance of respect. Parents being respected by their children; men being respected in a certain way. Self-respect is shown in how we dress, grooming, the very fancy clothes. Dressing down—not wearing shoes or going barefoot—are not valued because such activities are associated with being poor and economically disenfranchised. I remember being at an agency picnic and noticing that all of my white colleagues were sitting on the ground to eat and my African American colleagues were all standing. They all agreed that if you have on your professional clothes, you just never sit on the ground.

Question:

What names or terms do individuals within the African American community use to describe and identify themselves?

Thompson:

The term African American is my preference. First, it focuses on culture—both our connection to Africa, where we came from, and America, where we reside now. It also distinguishes us from other peoples with black skin. East Indians can be very dark in their complexion. The aboriginals in Australia have very dark skin. But what makes us African American is having a cultural connection to Africa and to others who have come from there. It is also the only term that we’ve truly chosen for ourselves. It puts us on the same status as other groups in America. It describes the kind of American you are. Like, a person is an Italian American or Jewish American or African American. It both gives us status and places culture in a very salient position in defining who we are. Finally, it tends to be more inclusive. I have not found it useful to distinguish people who are recently mixed racially from African Americans, who have always been a mixed people. From the time we came to this country, there was extensive mixing with Whites and Native peoples. By “recently mixed,” I mean a person who has a parent from another race and an African American parent. I see these children as part of the African American group. They are welcome within our community, and the term African American is more inclusive and makes room for them. Jane Lazar wrote a book entitled Beyond the Whiteness of White: White Mother Raising Black Sons. In it, she argues for the importance of giving her mixed-race sons a powerful and accurate identity as part of the African American community.

Question:

What historical experiences should providers be aware of in relation to the African American community and African American clients?

Thompson:

I would divide our history into four segments: pre-enslavement, the Middle Passage, enslavement, and post-enslavement. You’ll notice I’m using the term enslavement. I do that because it is more socially responsible and accurate as far as providing a context for understanding. It focuses on what has been done to our people, as opposed to labeling them as just slaves, as if that is a part of their character and who they are.

Question:

Can you next discuss some of the factors that influence the ways African Americans seek mental health services?

Thompson:

Trust, as I said before, is a very big influence. African Americans tend not to seek help from professionals. We have learned not to trust them, and our reasons are legitimate and sound, not a reflection of some sort of pathology. Really bad things have happened to us in the name of professional treatment, like the Tuskegee Syphilis Study. African American men participated in research without their knowledge and consent; they had treatment withheld so that the researchers could watch the course of development of syphilis. Psychological testing has been used against us, and many in our community just don’t feel that psychology has much to offer us as a system of care. Cost and access are also factors. Many of the fees are just too high, and it is difficult to get to where therapists are located. There aren’t tons of people with private practices located in East Oakland. Cultural competence is also a big issue. Will my life experience be understood and valued by the counselor? I would say that most practitioners are not culturally competent. I’ve also talked about respect. I think many African Americans expect that if they go to a practitioner, they will be blamed, misunderstood, and pathologized. We feel we’re going to be seen as somebody who has a problem with anger, as opposed to somebody who’s outraged at unjust treatment.

Question:

What do providers of service need to know about family and community issues among African Americans?

Thompson:

As I have been saying all along, practitioners need to know the present-day ramifications of our history: to really understand what it is like for an African American client to live life in their community today, to focus on and appreciate the strengths and creativity that it takes to survive and live a full life, and to understand and acknowledge the privileges they hold in the world because they are white and how their African American client might feel about those privileges.

Let’s begin with privilege. It is important to know that African Americans see white privilege as problematic for them as is racism. And I want to acknowledge that this is hard stuff for white providers to sit with. So, I appreciate that. But unless you understand this and bring it into the room with you, you are not going to be accepted and trusted. The fact is that not only are there the acts of direct discrimination and racial injustice that African Americans experience on a daily basis, but also, we see that white people are by and large still benefiting from a system that gives them advantage and at the same time treats us unfairly. We just want a fair and equitable system, and the privilege whites hold is a constant reminder of what we as African Americans don’t have. When white practitioners are able to cop to the fact that white privilege exists—to acknowledge it and the effects of racism—they’re more likely to be trusted and thus helpful.

So, here comes the psychologist: well-meaning, a professional, who’s part of a social institution, a school, or maybe the client is court-mandated. You’re not going to be necessarily trusted. Practitioners need to know that. It has nothing to do with you as an individual; you’re connected to a larger social institution that does not have a track record of building trust. Our families feel disrespected by contact with the system, intruded upon by institutions that are largely staffed by white people that don’t understand or care for us. That’s how many people in the community think. Here’s an agency whose staff is all white, and all the kids getting treatment in the program are black. And then they’re calling CPS (Children’s Protective Services). If an African American client is testing you or untrusting, you might see that as a natural and healthy thing because these folks come from a group that has not been cared for. Providers of service also need to know that there’s a real lack of safety in our communities, and that lack of safety is stressful for those of us who live there. You may feel some fear coming to that community. Imagine what it’s like to live in a community where you’re continually afraid. But it’s more complex than that because you also have really good relationships with many of the people there (your neighbors), and there are times when the fear is not present. You have to be strong, creative, and adaptive to survive here.

Question:

What kinds of problems are most commonly brought by African Americans into treatment?

Thompson:

Question:

What factors do you see as important in assessing African American clients?

Thompson:

And then there is the gay/lesbian/bisexual/transgendered community. First, you’re outcast in the wider culture and then you’re outcast in your own African American culture. I get so angry about that and even tearful—that the GLBT community would be doubly rejected from within their own group, which should be more sensitive to such issues of exclusion. There needs to be more attention paid to what it is like being black and gay.

Finally, there are the children, who are the most voiceless. A significant number of African American children are born below the poverty line and for generations have remained impoverished—born into poverty and most likely to stay in poverty. There is this overgeneralization that all African American people are poor, and as a result, both the very poor and those who are economically higher up remain invisible. Another issue that impacts African American children greatly, as it does white children, is addiction to drugs among their parents. Addicted parents are unable to properly raise children because drugs rob you of your mind, your sense of social connection, and your ability to be responsible. Families with rampant addiction tend to be chaotic environments, difficult places to grow up, and addicted parents are incapable of passing on cultural knowledge and identity, a very significant loss for African American children.

Question:

What suggestions do you have for developing rapport with African American clients, and is there a therapeutic style with which African American clients are most comfortable?

Thompson:

So, directness, authenticity, and honesty are vital because people who have been lied to have special antennae in relation to: “This doesn’t sound right. Why are you being so nice to me when you don’t even know me?” We have feelers. Nancy Boyd-Franklin talked about it as a vibe. African American people get your vibe, and it’s really hard to hide. Being passionate and interactive are also important because our cultural style is to be both. We’re a very passionate, exuberant, excitable people. So, if your style as a practitioner is flat in its affect or distant, passive, or minimally reactive with frequent silences, it is likely to be interpreted as something negative. And it is critical to be respectful of people’s spiritual beliefs. Not all African Americans are religious. In fact, awful things have happened to many of us in the name of religion. But African Americans are still spiritual, and that is a powerful issue around which to connect.

I have found that the use of (what I have termed) “socially conscious self-disclosure” is very effective with African American people. Nondisclosure can be problematic with people who are from oppressed groups. If you don’t disclose personal information, there is no way to place you in a context and, therefore, to know if you can be trusted. The therapist must be sure that the self-disclosure is done in the service of the client—that is, it is an attempt to create safety, connection, empathy—not because the therapist is insecure, needs to vent, or needs to be heard. If the therapist shares personal information in that spirit—to do so in a socially conscious way—it will be helpful with African American clients.

I would encourage other African American practitioners to consider some of these approaches. Now, if you’re not African American, you obviously can’t use deep cultural knowledge, and that’s a limit. I don’t think that means you can’t work with African American clients, but I think it’s important to acknowledge the limits of what your experience is. And don’t try to join with African American clients by acting black. When white people try to do the “slap me five, brotha” thing, it’s a turn-off. It’s likely to be experienced as inauthentic and phony. I’ve met a few white people who grew up in African American culture, and for them, such behavior is natural, so that’s fine. But for most whites, such appropriation of our culture is considered an insult.

Finally, it’s not a good idea to ask too many questions initially. Such questioning without sufficient trust and rapport will be viewed as interrogation. Too many questions too soon. We’re talking about people with a history where trust and giving out information about oneself has been repeatedly violated. When I was a teenager, the Census person came to the house. My mother said, “Don’t tell them anything,” and my mother is a very warm, welcoming person. She’s not particularly suspicious or paranoid. We, as African Americans, are raised not to tell strangers, especially white ones, anything about ourselves. The Census, for example, was just seen as white people coming in and trying to find out about us. But as therapists, we’re taught to ask questions. So, how do you do that? The timing and pace of when you ask questions is critical. I would suggest that one wait before asking too many direct questions. Give the client time for them to tell you their story, time to check you out, and time to develop rapport. That’s a style I think works better with African Americans.

Question:

By way of ending and putting together some of the ideas you’ve shared, could you present a case?

Thompson:

I was working with a second woman who had a lot of social anxiety and came into therapy quite well versed in the language of social phobia. She said she knew they had medicine for it and asked if she could she get some of that. I don’t prescribe medication but told her she could pursue that if she liked. In her work with me, I was particularly interested in how she came to think of herself as a social phobic. Using narrative therapy, I helped her deconstruct the messages she had gotten in life about who she was and how she had gotten to think of herself. So, we developed a metaphor for how she was feeling, using the language of escape, liberation, and freedom. We externalized her fear as imprisoning her. She had become a prisoner of it. Though it is normal for most people to feel a little awkward in new social situations, she was terrified of meeting people, especially about going back to school.

She wanted to go back to school but felt quite strongly that she didn’t belong. Part of it was the fact she would be going to a largely white institution where she was going to be an ethnic minority. This scared her and stimulated a sense of not belonging. As we sorted out what this was about, we found hidden messages about poor black girls not going on for higher education, about her not having important things to contribute, and that no one would listen to her. This is another subtle way that racism shows itself in people’s lives, and therapists can ask questions that can help uncover racism in this way.

And I asked, “What did they say?” sitting on the edge of my seat. She said that the answer came to her in the form of a poem. She shared the poem, and it was eloquent. It was about breaking free, cutting the shackles of fear, liberating her from social anxiety and fear. The poem connected her culturally and gave her both pride and courage.

Here’s a young woman who came in talking about social phobia and medication, disconnected from the social context of her fears. She was able to connect the fear to a cultural background and through that connection deepen her own connection with who she was culturally.

Working with Asian American Clients: An Interview with Dan Hocoy

14-1Demographics

14-1

Asian Americans were the fastest-growing racial group in the United States from 1980 to 2000, with their population nearly doubling (179 percent) during that period. The 2010 Census (which divides the larger group into two subgroups) reported an Asian population of 14.6 million, or 4.8 percent of the general population, and a Native Hawaiian and other Pacific Islander population of 540,000, or 0.2 percent. This represents an increase of 43.3 percent and 35.0 percent, respectively, for the ten-year period. Projections into the future estimate a population increase from 5 percent of the United States total in 2010 to 9 percent by the year 2050.

Recent Asian and Pacific Islander immigration has followed two streams. One came from countries such as China and Korea, which already have large populations in the United States. The majority of these were college-educated and entered under special employment provisions. The second stream came from Southeast Asia—Vietnam, Laos, and Cambodia—arriving after the Vietnam War to escape persecution in their home countries. Most were poor and uneducated.

As a group, Asian Americans and Pacific Islanders, 49 percent of the U.S. population, are concentrated in the western United States, with the largest urban populations located in Los Angeles and New York City. Sixty percent of the Chinese population reside in California and New York; two-thirds of the Filipinos and Japanese live in California and Hawaii. Koreans and Asian Indians tend to be more dispersed, with the largest concentrations in California, New York, Illinois, New Jersey, and Texas. Southeast Asians, on the other hand, can be found in unexpected pockets of population as a result of governmental resettlement policies. For example, in 1990, 40 percent of the Hmong population resided in Minnesota and Wisconsin (Pollard and O’Hare, 1999).

Unlike African Americans, Latinos/as, and Native Americans, Asian Americans have been quite successful economically and educationally, even in comparison with the white population. In 2002, the median income in an Asian household was $65,469, when it was $54,461 for white households and $38,039 for African American households. Asian Americans, in addition, account for 30 percent of minority businesses, although they account for only 13 percent of the non-white population. They also score high on business ownership rates (BORs) (businesses per 1,000 population), with Koreans and Asian Indians surpassing white BORs. Asians graduate from high school at the same rate as do whites—approximately 90 percent—but the former are more likely to complete two or more years of college. In 1990, 13 percent of the Asian and Pacific Islander population earned graduate and professional degrees in comparison to 9 percent of whites and three to four times the rate of other minorities.

· “Traditional” families are largely untouched by assimilation and acculturation, retain cultural ways, limit their contact with the white world, and tend to live in ethnic enclaves.

· “Culture conflict” families are typified by traditional parents and acculturated, Americanized children who experience intergenerational conflict over appropriate behavior and values, exhibit major role confusion, and lack agreed-upon family structures.

· “Bicultural” families tend to include acculturated parents, born either in the United States or in Asia and exposed to Western ways. They are professional, middle-class, bilingual, and bicultural. Family structures tend to be a blending of family styles but with regular contact with traditional family members.

· “Americanized” families have taken on the ways of the majority culture, with ties to traditional Asian culture fading and little interest in connection to ethnic identity.

· “Interracial” families represent marriage with a non-Asian partner where family styles from the two cultures have been successfully integrated or there is significant value and style conflict.

Sue and Sue (1999) similarly identify five potential value conflicts that may arise between Asian American clients and Western trained counselors:

· Asian clients value a collective and group focus that emphasizes interdependence, and Western counselors adopt a focus on individualism and independent action.

· Asians tend to be most comfortable with hierarchical relationships in comparison with a Western emphasis on equality in relationships.

· Asian cultures see the restraint of emotion as a sign of human maturity, and the Western counselor is likely to see emotional expressiveness as healthy.

· Traditional Asian clients will expect the counselor to provide solutions, but the Western counselor will encourage finding one’s own solutions through introspection.

· Mental illness and emotional problems are seen within the Asian context as shameful and indicative of family failure in contrast with Western counseling, which views mental and physical illness similarly.

14-3Our Interviewee

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Dan Hocoy, Ph.D., received his degree in clinical psychology from Queen’s University, Kingston, Ontario, Canada. His dissertation focused on the effects of apartheid and racism on black mental health in South Africa. He has also carried out research on racial identity and other cross-cultural topics throughout the world, including Chinese racial identity and the psychological impact of racism on Chinese in Canada. He is a member of the core faculty of the psychology department of the Pacific Graduate Institute, Carpinteria, California, and previously served as assistant professor in the PsyD (Doctor of Psychology) program at John F. Kennedy University, Orinda, California.

14-3aThe Interview

Question:

One of your areas of expertise is racial identity. Could you talk about some of your own experiences growing up Chinese?

Hocoy:

Being Chinese has always been very central to my life, although I haven’t always been conscious of it. That is to say, I didn’t always recognize its influence. I went through various phases of racial identity development. At first, I felt embarrassed about being Chinese. My family was the only Chinese family on the block, and because we were struggling immigrants, I always associated being Chinese with being poor. There was a lot of ethnic self-hate in me at that time. There was also external discrimination. For instance, I was always picked on in school for being Chinese; kids would tease me about the way my eyes, hair, and nose looked. I got into a few fights in the schoolyard as a result. During this stage of my racial identity development, I always wanted to be white. This continued into high school. I wanted wavy, more combable hair. I wanted to be taller. I wanted a sharper nose. I always felt inferior. Chinese people were always ugly to me. At the time, I wasn’t aware of the influences of having internalized Euro-American standards of beauty. I didn’t think I was very attractive. At the height of my racial self-hate, my looks actually disgusted me. Not accepting my ethnicity pushed me toward greater degrees of conformity and assimilation. Yet, I never felt I fit into the dominant culture either. Not feeling comfortable in either culture, I found myself marginalized and caught in the middle.

My training in psychology helped me process what was going on inside me, both in realizing the effects of my experiences as a person of color and in coming to terms with the self-hate. Today, I regard my Chinese identity as an asset both personally and professionally. As I became clearer about my own ethnic heritage, I also became aware of the cultural bias in psychology and the need to redress the systematic neglect of minorities in both research and therapy. That, in turn, spawned an interest in multicultural counseling. But the process of racial self-acceptance is an ongoing one, and I have yet to completely free myself from what Bob Marley called “the chains of mental slavery.”

Question:

Let’s begin with some definitions. Who are the Asian Americans, and what characteristics do they share as a group?

Hocoy:

First, I think it is important to understand that there is a large degree of diversity among Asian Americans and that they do not conveniently fit into one categorization or description. There are many shades of yellow, so to speak, and it is difficult to make global generalizations. Having said that, individual and subgroup differences are significant, and there do exist commonalities that Asian cultures share. When I talk about Asian Americans, I am referring to people with Mongolian and early Chinese ancestry. This includes the mainland Chinese, Japanese, Koreans, the Vietnamese, people from Hong Kong, Taiwan, Singapore, Malaysia, the Philippines, Laos, Thailand, and others from that region. I know this is not inclusive of all Asians, as it omits East Indians and others, for instance, but these are the groups with which I am most familiar.

I think the lack of acceptance of Asians in U.S. culture at least partially stems from the fact that Asians possess such a different worldview. For instance, “East vs. West” is a common dimension of comparison and dichotomy. Individuals who have been socialized into traditional Asian cultures are likely to possess completely different worldviews with philosophies, values, and beliefs that are very disparate from Western ones. This major difference, I think, engenders much of the fear and misunderstanding about Asians. Another important factor is that much of Asian culture and society is based on the value of collectivism, which in recent years has been associated with Communism. Such ideas go against the familiar values and traditions of individualism and capitalism that are so basic to American culture and thus threaten many Americans.

The history and treatment of Asians in the United States have caused them to be very closed in terms of their interactions with other Americans. Asians have generally kept to themselves in very small enclaves. For instance, to this day, there are Chinatowns in most large urban areas, which from early times served as ghettos that ensured survival in the economic and political structure of the United States. Another trait Asians generally possess is a tendency to be less overtly militant and politically active than other racial groups. As a result, they have been an easy and frequent target for abuse and discrimination. Although, it should be acknowledged that Asians have historically made significant challenges to the status quo through equity legislation; this has primarily been through the judicial system. Generally, Asians have been less likely than other ethnic groups to engage in activism toward redress of public policy. Characteristically, this is very reflective of the Asian attitude of not wanting to disturb things. There’s a saying among the Chinese: “If you don’t know what to do, at least don’t do anything.” This is very different from the American maxim: “If you don’t know what to do, at least do something.” This tendency is probably also related to the cultural norm of not showing certain emotions in public. It is very important in many Asian cultures that certain social protocols are followed and that one conforms to the cultural script of not displaying emotions in public.

Question:

Could you next talk about the various names that Asian-American subgroups use to describe and identify themselves as well as protocols in addressing various individuals within Asian culture?

Hocoy:

Again, I can speak most confidently about the Chinese. In terms of racial self-labeling, I think most Chinese regard themselves as Chinese, Chinese American, or just American. The name or self-reference that one uses is a useful source of information. Clinically, by asking clients what they consider themselves or what they would like to be called, you can get a sense of where they fall in terms of acculturation; namely, assimilation, integration, marginalization, or separation. If they identify themselves as Chinese, this says something very different about their cultural attachment, as opposed to referring to themselves as American. An integrationist would be more likely to say, “I’m Chinese American,” whereas a separationist is more likely to self-label as Chinese. An assimilationist would typically use the term American, while someone marginalized would probably have difficulty identifying with any of these labels. It is thus quite useful for a provider to ask this question early on and to use it as an entree into these issues.

There are other aspects of naming that are important to know. Within Asian cultures, great honor is given to authority and age, and this is manifest in a general respect for people who are older than you. So, if there is someone in the room of similar age or older than the therapist, it is important to address them formally and with deference, as Mr. or Ms. or whatever is appropriate. If there were several people present, the therapist should address the older person first. Conversely, an Asian client may feel uncomfortable calling a therapist, especially an older one, anything other than “Doctor,” even if invited to do so. I, for instance, didn’t call my supervisor by his first name until the sixth year of graduate school, when I was about to defend my dissertation. I didn’t feel comfortable referring to him in such a familiar manner until I was of similar academic status. It is also important to be aware that older Asian clients, as a result of their traditional Asian worldview, expect to be treated with a great deal of tolerance and patience by the therapist. Asian culture dictates that elders be treated with an obvious tone of respect and deference, and such an attitude is a necessity for facilitating rapport with older clients.

Question:

These sound like some very useful and important suggestions. Let’s go back to a topic you alluded to earlier—the history of Asians in the United States. Could you give a nutshell version of this history?

Hocoy:

There is a long history of racial discrimination against Asians in both legislation and public policy. In 1882, Congress passed the Chinese Exclusion Act, which prohibited Chinese immigration for ten years. It was renewed in 1892 and became permanent law in 1902. This resulted in great difficulties for the Chinese men already here. They were forbidden to bring their wives over, but what they could do was go back and father children, and these offspring were allowed to enter. The result was a very lonely existence: a culture of lonely, hardworking men, isolated from the dominant culture, who kept largely to themselves and lived lives of great hardship and misery. By 1943, immigration restrictions were loosened, and women were allowed to enter. They worked as dressmakers and in sweatshops in the growing Chinatowns, while men opened laundries and restaurants and, as had become typical, took jobs that were of interest to no one else.

And then there are the more recent reminders of discrimination against Asian Americans in the United States: the internment of Japanese during World War II; reactions to the influx of Southeast Asian refugees; reactions to Asian economic success in the United States; reactions to the emergence of Japan and the other “four tigers” as global economic forces; and in the 1990s, talk of quotas limiting the enrollment of Asian-American students in U.S. colleges, universities, and specialized professional programs.

Question:

Let’s change our focus somewhat and begin to look at issues related to help-seeking and treatment. First, could you talk about issues that influence the ways in which Asian Americans go about seeking help?

Hocoy:

In general, we are talking about very closed and tightly knit communities. They are very insular and cohesive and distrustful of outsiders. Their survival has depended on it being this way. These enclaves or ghettos—the Koreatowns, Chinatowns, Japantowns—have learned to live on the fringes and construct for themselves self-sufficient alternative social and economic systems outside the dominant culture. As a result of this mentality, Asians can be very distrustful of white people. The Chinese call whites “ghost people” and consider their ways of life to be strange and sometimes inferior. There is clearly a sense of arrogance here. Both Japanese and Chinese mythologies contain beliefs that view themselves as highly advanced in terms of human evolution. My grandmother described it to me as there being a racial hierarchy according to color. White people reside below the Chinese because they are “pasty and ill looking” in appearance, whereas the Chinese have a touch of gold in their skin. Another example comes from the name China itself, which literally means Middle Kingdom; the early Chinese were pompous enough to believe that the world revolved around them. The Chinese do bring with them a rich cultural tradition outside of the United States and a long history of inventing everything from gunpowder to eyeglasses, from ice cream to the printing press. When these events were playing themselves out in the East, Europeans were still barbarians. This history engenders much pride among Chinese as well as arrogance and serves to support and justify their isolation.

Another thing to be aware of regarding help-seeking is the fact that there may be a great degree of shame and stigma associated with someone leaving the community and seeking professional help. The airing and telling of private affairs to strangers are virtually unheard of; it is a concept foreign to the Asian worldview. Part of this has to do with a fear of not being understood culturally by Western counselors. So, building rapport is an important first step to therapy. It is important for therapists to convey—both explicitly and implicitly—a knowledge of Asian culture or at least a respect for it and an openness to learning more. It is also helpful to understand that given this general taboo, those who do seek out therapy are either very acculturated or desperate and have probably exhausted what resources they had within the culture and feel compelled to go outside.

Question:

The discussion of help-seeking has led naturally to aspects of the Asian family and community. Could you talk more about family and community and how these shape what happens in therapy with an Asian American client?

Hocoy:

To understand Asian culture, it’s important to grasp the philosophical traditions and religious influences on the culture. One needs, for instance, to understand the role of Confucian ethics and the Buddhist “middle path” of moderation in life. Asians, in general, come from strong, interdependent family and community bonds; both are very self-contained and self-sufficient. Chinatown, for example, is a microcosm of the greater society in that it contains everything that is needed for life and sustenance. In terms of the family, an important value is the obedience of children. The flip side is respect for elders and their wisdom. These are Confucian values. In the home, there are many token gestures manifesting these attitudes. For instance, in my own family, my grandmother would always sit at the head of the table, even though she was demented in her later years. If there was a big decision to be made, her opinion would always be sought. It was obviously a token gesture, but what was more important was that it was a sign of respect. It’s considered taboo to send relatives off to old-age homes once they get old, as is common among Anglo Americans. Doing so is almost unheard of and looked upon with disdain in Asian cultures.

Much communication in the Asian family is indirect, wherein messages are not directly stated but instead must be inferred. There’s a reticence to talk about personal issues openly. I think the fear is that someone may be embarrassed by what is said. In my own family, certain things are understood. For example, my mother says something without referring directly to it, but everyone knows what she’s referring to. The therapist may see some of this reticence in therapy, especially in regard to subjects that are taboo or that the client finds sensitive. Sex might be such a topic.

The therapist may not initially get a very explicit account of the problem. Much may be implied, and clinicians must be attuned to subtle meanings and innuendoes. This is especially true with clients who are less acculturated. Again, this indirectness has to do with avoiding embarrassment. Clinicians need to be tactful and equally subtle in identifying the client’s problems, being careful to validate the client’s experiences, avoiding judgment or confrontation, and gradually honing in on the problem. In treatment, it may initially come down to talking in metaphors and indirectly about a topic in order to make the client feel comfortable enough to name and address it directly. This cultural tendency to imply meaning rather than to speak of it explicitly is very foreign to most Western therapists and counselors, whose training has focused on the spoken word and direct verbal communication. The therapist needs to recognize this difference as a cultural artifact rather than be frustrated by it.

Another Asian value that may result in different therapeutic goals for clients is tolerance for ambiguity and inconsistency in life. In Western psychotherapy, psychological integration is promoted through the achievement of clarity about one’s life, consistency in various aspects of one’s life, and the resulting decrease of cognitive dissonance. Among Asians, however, the ability to tolerate the ambiguities and contradictions in one’s life is considered an aspect of maturity. Thus, striving for complete consistency in or understanding of one’s life may not be considered as important nor a goal of therapy. In general, it is essential for Western counselors to realize that the paradigms and models upon which Western psychology is based are infused with Euro-American middle-class values and may have little application to other cultural groups.

Another aspect of therapy with Asians relates to the tendency of Asian cultures to de-emphasize the self and a prescription against self-promotion. For instance, one is not supposed to accept a compliment without resistance. If I compliment my mother on her cooking and the preparation of a certain dish, she would never acknowledge that it was deserved. She would probably say instead: “Oh, no. There’s not enough salt, and this is actually the worst I’ve ever made.” The implication of this for the clinical setting is that affirmation of the client’s self, which goes against cultural norms, may be difficult for him or her to model. A corollary to the lack of emphasis on the self is the avoidance of personal embarrassment. Consequently, direct confrontations and demands on the client to accept personal responsibility for personal difficulties or specific behavior may be problematic for the therapeutic relationship.

Question:

What are some of the common problems that might bring Asian Americans into treatment?

Hocoy:

A related problem has to do with identity confusion resulting from minority status and the impact of discrimination on personality development. Some young people have a hard time identifying with their Asian heritage because this identity is often disparaged in their non-Asian peer group. Strong pressures to assimilate to Western ways are also likely to be communicated, either explicitly or implicitly. A client might experience “a tyranny of shoulds,” pulling in opposite directions. They should be doing this according to the peer group; they should be doing that according to their family. In addition, people may not possess a strong sense of themselves, of who they are, or of what they really want to do. Instead, they may feel caught between two worlds: one side saying, “You should be studying or practicing violin; you shouldn’t be going out drinking”; and the other countering, “No, no, man. Come on out; you should be getting stoned and having lots of sex in college.” It’s a very difficult thing to bridge these different worlds. Feelings of being different because of one’s ethnicity and not completely fitting in are often accompanied by feelings of alienation and loneliness as well as those of being misunderstood. It is a short psychological step from feeling different to feeling inferior—that there’s something wrong with me; that I’m not worthy of love. And there’s the depression that comes from wanting to be someone I’m not and will never be.

Many of these characteristics are subsumed in the literature under the title “mismatch syndrome,” which speaks to the disparity in values between one’s culture of origin and the dominant culture. Common symptoms of this mismatch are self-rejection and low self-esteem, depression, an emphasis on negativity, rigidity in thinking and problem solving, and even attempts to escape reality via addiction and suicide. Also inherent in the mismatch syndrome is active value conflict: traditional vs. modern gender role definition, an emphasis on family and community vs. self-interest, age status vs. youth emphasis, obedience and conformity vs. questioning authority and individualism. Self-restraint and formality may lead to a lack of social experience. People brought up in a culture that suppresses the open sharing of emotions may find themselves alienated and unable to make contact with their non-Asian peers, who depend on sharing emotions in order to move toward intimacy. Lack of emotional expression can also lead to the somatization of various ills. Insomnia is a particularly common way in which such problems are manifest.

Other typical problems for which Asian Americans may seek help include compulsive gambling, cross-cultural dating and marriage, overbearing parents, caring for aged parents and other family members, immigrant poverty, extreme work ethics, racial identity issues, and post-traumatic stress in those escaping war-torn countries of origin.

In carrying out an assessment of a new Asian American client, what factors do you think are most important to attend to?

Hocoy:

As alluded to earlier, it may help to remember that the concept of counseling is foreign to traditional Asians. It’s the counselor’s responsibility to introduce them to the roles of the counselor and client and explain the process of therapy before any kind of rapport can be established. Counselors have to be perceived as knowledgeable about that client’s cultural group right off. That’s particularly important for Asians because they may be apprehensive about therapy. Fear of shame and distrust of non-Asians act as potential obstacles to building rapport. Thus, it is critical that the therapist demonstrates clearly that he or she respects and understands the cultural differences that exist and that these differences are not obstacles. At the same time, therapists must be very careful of stereotyping and of recognizing the kind of expectations they hold about Asian clients.

When treating Asian clients, it may be important for Western therapists to be more directive than they normally are with non-Asian clients and to be prepared when an Asian client exhibits what might be considered more than normal dependency in the therapeutic relationship. Western conceptions of psychological health emphasize client responsibility, openness, and personal exploration as well as self-reliance and self-determination in the therapeutic process. Clinical research, however, has found Asians to prefer a more directed and authoritative therapeutic style and to expect a certain degree of caretaking and direction. It is also important for the therapist to be nurturing and to have the therapeutic interaction reflect a familiar family atmosphere: directive regarding instructions, deferential to authority, but also nurturing.

For Asian Americans, few emotions are allowed and there is generally difficulty with public displays of feelings. Emotionally laden content may not be easily discussed or easily identified by the therapist. The therapist must realize that there may be substantial difficulty with trusting and establishing rapport, given the taboos related to going to non-Asians for help and expressing emotions in public. Similarly, interventions should reflect or be consistent with Asian norms. The alternatives offered should be equally subtle, indirect, and nonconfrontational. There’s a risk of Asian clients dropping out early, so it’s especially important to build rapport and trust and to intuit any problems and check them out early on. As the client can be rather nonverbal, the therapist may have to ask if there are problems or identify them rather than waiting for them to be reported.

With Asian Americans, the therapist may notice very subtle body gesturing and facial expressions. Large displays of emotion will rarely be seen, even if much is being felt and experienced. In many cultures, emotional states are rather transparent, easily read in the faces and body language of clients. With Asians (traditionally socialized), non-verbal communication is much more subtle. Sometimes, all one can discern is a very slight head nod as a sign of affirmation if a question is asked. There may also be a general reticence. Asians are brought up to be indirect and to avoid emotional expressiveness. You probably won’t see much gregariousness or strong displays of emotion. Also, as suggested above, non-verbal cues may have different meanings than for non-Asians. For instance, giggling often means embarrassment rather than a sign of humor. This is particularly true for the Japanese. Irrespective of the particular message, it is vital not to assume a commonality between Asian and Western “non-verbals.”

The therapist should not challenge or confront avoidance or resistance immediately or in any way single out the client for what might be experienced as criticism. One may eventually be able to address relevant issues through more indirect communication. It is, however, important to lead with regard to the direction of therapy and spell out expectations the clinician has of the client. This is different than being confrontational, which is likely to induce shame and guilt. Again, it’s related to “saving face.” The therapist can subtly bring up deficits and shortcomings in the person—but not directly. Asians do tend to be familiar with very direct advice giving—but as to how or where they might go or what they might do as opposed to direct commentary on their personality, faults, or shortcomings.

Finally, it is important to remember that Asian Americans often experience a sense of guilt or selfishness in pursuing their own interests in therapy as opposed to thinking of the family first. The whole act or exercise of going to therapy is an individualistic pursuit. A client may feel some guilt around it. There is also a sense of collective embarrassment to have to go outside the community. It is a capitulation saying, “My community cannot serve me.” It may, in addition, be considered a sign of weakness to go outside the community. These are all issues Asian clients might bring with them to therapy.

Question:

Finally, could you share with us a case that shows how these various themes that you have defined all come together?

Hocoy:

When I worked as a university counselor, I’d very often work with Asian students feeling a lot of pressure to excel in school and having difficulty living in two cultures. Terrence is a good example. He was an engineering student who came to counseling because he was getting Bs, and there was a strong demand both from his family and from himself to get better—and even perfect—grades. Terrence revealed other difficulties as well. Because he focused almost exclusively on academics, he had developed few social skills and didn’t have many friends. During his second year of university, these various factors came together to cause a depression. He found it difficult to concentrate in school and was increasingly losing interest because he was coming to the realization that there was more to life than just school. When his marks deteriorated, pressures from home increased. At the same time, he had difficulty forming the friendships he desired with non-Asians (his primary peer group).

It became clear very early that much of his conflict was cultural in nature. He was caught between two worlds: unable to negotiate socially and establish relationships with non-Asians and, at the same time, unable to motivate himself to focus on his schoolwork. He also questioned the expectation that he had to date another Asian. Ultimately, what was at conflict were Asian values regarding the paramount importance of study and maintaining Asian cultural separation vs. the value of making friendships with non-Asian peers and spending more time in nonacademic pursuits. He did not feel a part of his non-Asian peers and was increasingly feeling unaccepted by his family because of his “failing” grades. In short, he was increasingly becoming marginalized.

We spent the initial sessions helping him discern his emotions; often, I had to make suggestions as to what he might be feeling. With time and effort, a bit more clarity emerged in what he was feeling. He had great difficulty separating his feelings from those of other people, whether it be his peers or his parents. His emotional boundaries were very blurred—not uncommon in individuals from collectivist cultures. He was eventually able to report feeling pressured by his family to pursue good grades at the expense of social activities and to date and marry someone Asian. These were accompanied by simultaneous feelings of guilt and resentment. He was eventually able to understand that he had internalized the pressure his family had placed on him vis-à-vis academic performance and began to sense that there could be a difference between the demands his family placed on him and what he wanted for himself. It became clearer to him why his studying had become difficult and why he was internally caught between the values of two cultures. He also came to recognize the disparity between the Asian values of academic success and cultural isolation and his desire for relationships with those in the dominant culture and activities outside of school.

I encouraged him to pursue an integrationist path—one that allowed him to maintain his cultural traditions and, at the same time, establish relations outside the Asian community. By this point, he had developed clarity that this is what he wanted to do but felt uncertain as to how to proceed.

I assured him that he could participate in the non-Asian world without compromising his heritage and that, in fact, he could have the best of both worlds. The issue with his parents actually worked itself out as his marks improved because he was able for the first time to pursue the things he wanted to do, including spending more time enjoying himself and establishing friendships with non-Asians.

Working with Arab and Muslim American Clients: An Interview with Marwan Dwairy

15-1Demographics

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The 2010 U.S. Census data estimates 3.5 million Arab Americans: 80 percent are U.S. citizens while 37 percent are foreign-born. This population is about equally distributed between Christians and Muslims and emigrated primarily from the Middle East. As a collective, they share the Arabic language and descend from nomadic tribes from the Arabian Peninsula. Muslim Americans number 8.5 million, come from over 75 countries, and vary widely as to language, ethnicity, and national origin. In general, the combined Arab and/or Muslim American populations are younger (30 percent below 18 years old), more highly educated (40 percent have earned bachelor degrees), and earn more (over $50,000 yearly) than the average American. The vast majority resides in major cities (such as New York, Detroit, and Los Angeles) and is concentrated in 11 U.S. states.

Abu-Baker (2006) enumerates a number of difficulties and demands that Arab and/or Muslims regularly face in their adaptation to life in the United States. These include:

· Expectations that already settled immigrants will help bring over and settle relatives and friends

· Difficulties related to failing to develop language proficiency in English

· Problems of living in a non-Islamic country where religious requirements often clash with “the rhythm of American daily life”

· Work difficulties where individuals cannot find jobs in their professions, a resulting lessening of social status, and difficulties related to having to work in family businesses

· Differences in social interaction patterns between the collective and interdependent nature of Arab societies and families and the more individualistic values and interactive styles of mainstream America

· Increased tensions between spouses, tensions created by inhibitions on interfaith and intercultural relationships and marriages, and conflicts between parents and children over changing behaviors, values, and parenting practices

15-2Family and Cultural Values

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As stated earlier, Arab Americans identify and practice in about equal numbers as Muslims and Christians. Abudabbeh (1996) offers the following overview of Islam:

In turning to Arab and/or Muslim American families, we must first acknowledge what will be the central theme in Dwairy’s interview: the collective nature of the Arab and/or Muslim family and psyche. Elsewhere, Dwairy (2006) has written the following about the collective aspect of Arab Muslim society:

Individuals in a collective society are dependent for their survival on their families; and families’ cohesion, economy, status, and reputation are in turn dependent on individuals’ behavior and achievements. Individual choices in life are collective matters, and therefore almost all major decisions in life are determined by the collective … In the collective, social norms and values determine the course of people’s life rather than personal decisions, and therefore diversity within such a collective is very limited. People think, feel, and behave according to prior determined standards. Within the family, it is unusual to find diverse attitudes in social, religious, or political issues. All family members adopt and voice similar attitudes. (p. 24)

The Arab family has been described as patriarchal and authoritarian, hierarchical and extended. Although families have more recently tended—especially in the West—toward the establishment of individual households, allegiance to kin still remains strong. Men, women, and children are each given duties to perform in relation to each other and specific instructions on how to carry out these responsibilities. Men and women are expected to follow specific codes of family and honor, maintain the family, and rear the children. Communication within the family tends to be vertical rather than horizontal—top-down. Parents tend to “use anger and punishment and the children respond by crying, self-censorship, covering up, or deception” (Abudabbeh, 1996). Child-rearing techniques range from mild rebukes to threats, balanced by unconditional love and appreciation. This is especially true for sons. Boys and girls are treated differently, with an eye to instilling traditional sex role expectations in both. They are expected to maintain close family ties and discouraged from individualism and separation from parents and the family. They are expected to obey the authority of the father and family, as opposed to having and acting upon their own ideas. They spend more time with and are more emotionally attached to the mother, who often acts as a go-between in communication with the father. Abudabbeh (1996) points out that this style of parenting tends to encourage acting out and triangulation within the family. Of course, in many Arab and/or Muslim American families, these traditional patterns are challenged and often adjusted after immigration and over time in the United States. As we shall learn from Dwairy, respect and awareness for the collective nature of the Arab and/or Muslim family and psyche is critical to successful therapy.

15-3Our Interviewee

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Marwan Dwairy, D.Sc, received his doctorate from the Faculty of Medicine at the Technion University, Israel, in 1989. He is associate professor of psychology at Oranim Academic College, supervises three of their areas of study (educational, medical, and developmental psychology), and has also taught internationally. He is also a licensed clinical psychologist. In 1978, he established the first psychological services center for Arabs in Nazareth, Israel. Professor Dwairy carries out cross-cultural research on identity, individuation, parenting, and mental health and has developed and standardized several psychological tests for Arab populations. Finally, he has published several books, including his most recent, Counseling and Psychotherapy with Arabs and Muslims: A Culturally Sensitive Approach (New York: Teachers College Press, Columbia University, 2006).

15-3aThe Interview

Question:

Can you first talk about your own ethnic background and how it has impacted and shaped your work?

Dwairy:

I am a Palestinian-Arab citizen of Israel. This is the way I like to label my complex identity. Palestinians are the Arab peoples who live in Palestine and share national and cultural bonds with the Arab nations that live in different Arab countries in North Africa and Southeast Asia. My family is part of the 15 percent of Palestinians who remained in their homeland after the establishment of the State of Israel in 1948. As such, we became Israeli citizens. Unfortunately, the vast majority of Palestinian Arabs, including many members of my extended family, fled or were expelled from their homeland and then prevented from coming back to their homes in the area that became the State of Israel. They lost their properties and still continue to live as refugees outside their homeland. After several waves of Jewish immigration to Israel, Palestinian Arabs who became citizens of Israel in 1948 now constitute about 18 percent of its population. The vast majority are Muslims, followed by Christians, such as my family, also the Druze, who were diverted from Islam. I was raised in Nazareth, the biggest Arab town in Israel, among Muslims and Christians and studied in Israeli universities with Jewish students and teachers. Not surprisingly, national and cultural affiliation was a major lens through which I identified myself and those around me. Because of the conflict over statehood, nationality also became a major aspect of identity. Add to this mix the fact that Arabic culture is more collective and authoritarian, with the family or tribe holding priority over the individual. Within this political and cultural climate, the Western psychology that I was being exposed to in my education that tended to focus on the individual and to emphasize the self and self-actualization was both enlightening and fascinating to me.

During the early years of my work, I tried to “educate” the people to fit the theories I learned and believed to be universal. I gave many lectures and wrote many articles to make people understand their life and stresses according to “my” theories.

It was a period of “fighting the wind” and took many years to free myself of the illusion that the theories I learned were universal and to realize that they just did not fit these people. With this realization, I started to study and understand the psychology of people in collective cultures. And it was amazing to realize that despite the hegemony of the Western individualistic values in the media and social science, the vast majority of the people on earth live and think collectively.

Question:

This historical relationship is frequently brought into the therapeutic encounter between Arab and/or Muslim clients and Western providers. It may take the shape of unconscious transference in which the client views the Western therapist as superior and powerful and at the same time as associated with the oppressor who enjoys the fruits of the colonialism without taking responsibility for the suffering it has caused. Providers need to be aware of the existence of this psychology of oppression—to understand and acknowledge it. Therapists also must make special efforts to understand the collective experience of their Arab and/or Muslim clients and to show an awareness and empathy for the differences in their worldviews. This kind of joining is crucial in establishing genuine trust with these clients. Keep in mind that for non-Western people, the experience of the personal is not differentiated from the collective. Communicating personally within the collective experience is very helpful in breaking down many barriers during therapy.

Providers also need to pay attention to issues associated with immigration and to understand and explore the conflicts around leaving one’s homeland and starting a new life in a foreign country. Complex mixtures of feeling love, commitment, disappointment, anger, and guilt upon leaving as well as admiration, frustration, and anger towards the United States and one’s new home are not uncommon. Transitioning from a traditional to a Western culture is also problematic, as is dealing with the daily conflicts around assimilation or differentiation accompanying one’s new lifestyle. The way each immigrant deals with these conflicts is different, and clients often need help in finding the best way for them and their family.

These conflicts typically exist between members of the family. Children are eager to become assimilated and adopt American values and norms, while their parents struggle to keep them tied to tradition and religion. Husbands become more quickly adapted to American life and spend much of the day at work and away from home, while their wives are expected to remain at home, as was the case in their homeland. But here they feel lonely without the larger family and the traditional company of other women. Because of these conflicts, many emotional and behavioral problems may emerge in the family.

Can you next discuss some of the factors that influence the ways that members from Arab and Muslim communities seek mental health and helping services?

Dwairy:

In order to understand the help-seeking behavior of Arabs and Muslims, we need to understand that they do not adopt the same dualism of the mind and body as Westerners do. Arabs and Muslims live their life holistically; therefore, most psychological distress is accompanied by somatic complaints. Western researchers tend to conceptualize this as somatization, implying a psychological distress that is expressed somatically. I disagree with this characterization because it is based on a clear-cut distinction between psychological and somatic processes, which is not the inner experience of most Eastern people.

Arabs and Muslims are not psychologically minded; rather, they give more attention to the body as the basis for living life. One of the famous proverbs in Arabic says ala’ql alsaleem fi aljesm alsaleem (healthy mind depends on healthy body). Within these cultures, bodily complaints draw more attention than emotional complaints and provoke sympathy and support. Psychological complaints are not viewed as deserving attention or help. Rather, the person is expected to tolerate them. The person who cannot do so both feels ashamed by their weakness and may be looked down upon by others because of it.

Due to the centrality of physical health and shame and when facing various distresses of life, Arabs and Muslims tend to seek help first from a physician and expect to receive medications to cure their bodily complains. As a by-product, it is assumed that the mind will be cured as well. Typically, they do not seek help from mental health professionals because they do not pay much attention to emotions nor believe that talking therapy is of any value. They also avoid psychiatrists because they are believed to be associated with madness.

Many Arabs and Muslims attribute psychological disorders to external entities such as the “evil eye” or “bad soul” that possess the body. That is why madness is called Jinnoon in Arabic. Again, this reflects their tendency to attribute their problems to external entities and avoid taking responsibility for the unaccepted behavior, thoughts, or feelings. These same people may seek help from religious healers (Shekhes) in order to undo the evil eye or to exhort the Jin. Believing in this system of cure, many patients find relief in such superstitious practices.

Because physicians and religious healers are the first sought out by Arab and Muslim clients, there is a real need for social workers, psychologists, and psychiatrists to develop cooperative relationships with them and seek appropriate referrals. Such cooperation is needed in order to legitimize clients seeking health from mental health clinicians as well as assuring that the full range of clients’ spiritual, physical, social, and psychological needs get addressed.

What do providers need to understand about the nature of Arab and Muslim American families and communities?

Dwairy:

Question:

What are some of the common problems that might bring members of your community into treatment?

Dwairy:

All psychological disorders are found among Arabs and/or Muslim people, but their clinical pictures may be different from what is described in Western psychopathology texts. For instance, depression, which is considered a mood disorder in the West, may appear among Arab and/or Muslims with only somatic complaints, such as pain or fatigue, but without any major depressive mood or sadness. Many problems and psychological symptoms can be understood as the result of bicultural conflicts within the family or as a consequence of the immigration process. Psychotic symptoms often appear mixed with symptoms of dissociation, where unaccepted drives are projected on an external entity such as “voices,” bad Jin, or thoughts placed in one’s head by Satan. Because Islam calls people to pray five times a day and follow strict rituals of prayer and ablution, anxiety and OCD (obsessive-compulsive disorder) symptoms are frequently colored by religious ideas related to purification and negative thought, called Waswas, associated with Satan. At that same time, many symptoms or states, considered abnormal in the West, are not considered as a problem among Arab and/or Muslims. For instance, what is called dependent personality disorder in the DSM-5 may be considered normal for Arab and/or Muslims, especially among women. Many sexual dysfunctions, such as premature ejaculation in men or sexual arousal problems of women, are not considered problems in need of treatment.

Question:

In carrying out an assessment of an Arab or Muslim American client, what factors are most important to attend to?

Dwairy:

Unlike general Western theories of psychopathology that attribute disorders to intra-psychic processes—such as conflicts, irrational or dysfunctional thoughts, or distortion of the self—the main distresses and conflicts of Arab and/or Muslim clients are associated with intrafamilial conflicts and problems in dealing with social expectations and norms. Before pursuing any intervention with such clients, the clinician must assess the balance between the conflicting parties; that is, the client and their family. Understanding this balance is crucial in helping the client fulfill their needs, become appropriately assertive, and assess in advance how best to bring about such a change given what the family can functionally tolerate. It is necessary to first ensure that the family will be able to absorb the changes and that the client can reach an acceptable level of individuation as well as possesses the strength to do so and face the pressure of the family. To accomplish this, I suggest—before any intervention—an assessment of three main factors: the client’s level of individuation, ego strength, and the family’s level of strictness.

Individuation concerns attitudes toward individualistic values that differ among Arab and/or Muslims. Some clients (such as students studying in the United States) have already developed relatively individuated, autonomous personalities and identities, while others (such as more traditional housewives) are more likely to have retained collective values and dependent personalities. What we must find out is to what extent and how the attitudes, motives, and values of each differ from those of their family. This can be done through questionnaires or an interview. In both, the client is asked to describe their attitudes, motives, and values concerning various life areas, such as gender roles, freedom of personal choice, and religion, and to compare these with where their family stands on each issue. From this, one can begin to assess where discrepancies exist.

Family strictness can be subjective since some families are just too strict and not ready to accept any change in their lifestyle, norms, and values, while others are more open to change. Readiness for change is an important factor in determining what goals can be set for the intervention. Within strict families, goals should be adaptive within the family structure and norms. In cases of extreme abuse, the client should receive support and protection, and if this cannot be accomplished, then temporarily move away from the family. With more flexible families, family therapy can be helpful in creating new familial structures so as to enable the client to have more freedom of choice within the family system. The more individuated and stronger the client and the more open and flexible the family, the more likely it will be to help the client fulfill herself. When the client possesses little individuation and lacks ego strength and the family is strict, such direct therapy should be avoided. Instead, interventions should help the client better adapt to the family system as it exists—through behavior therapy, relaxation training, and culturally sensitive indirect methods such as metaphor therapy, or what I call “culture-analysis.”

Question:

What do you mean by indirect interventions?

Dwairy:

It refers to therapy that deals with intra-psychic conflicts without bringing unconscious content—that is, typically forbidden in collective family systems—to consciousness. Prematurely introducing such content is likely to create counterproductive confrontations between this kind of client and their family. In what I call indirect methods, such as art therapy and bibliotherapy, clients can begin to address their conflicts symbolically through colors and shapes or with the use of stories, tales, and myths. The use of such metaphors is particularly suited to Arabs and/or Muslims since the Arabic language and the Arab mind are especially attuned to metaphors. Typically, clients tend to describe their problems in the same manner, and this invites the therapist to also work in a metaphoric mode.

As to culture-analysis, it is a term I coined for work that precedes psychological analysis or in some cases avoids confrontations that may be generated in the family when forbidden content is brought to consciousness. In such therapy, instead of digging deep to reveal unconscious content, such as sexual or aggressive attitudes toward parents, therapists explore the client’s belief system in order to reveal hidden values that may be useful in facilitating change. It is based on the assumption that every believe system or culture has many inner inconsistencies. Many times, this is reflected in contradictory proverbs. For instance, some proverbs in Arabic encourage the client to hurry and others to slow down; some suggest seeking help from people and others warn against it. Such opposing attitudes can be used and applied to facilitate therapeutic change. For instance, in Islam, one may find Quraan verses that call for strictness and fanaticism and others that call for diversity, tolerance, and respect for women. One of my religious, depressive clients attributed his negative experiences to his belief that God did not love him. He tried hard to fulfill all the religious obligations to please God—but with no success. I suggested that the basis of all religion is to appreciate the grace of God, even before fulfilling any formal obligation. In his religious belief system, this appreciation had been overlooked and forgotten. Once he realized this, he was able to think positively about all he had in his life and to minimize his bitterness over what he did not have. To apply culture-analysis, therapists must learn about their clients’ culture but not necessarily become experts. Sometimes, therapists can consult religious or culture experts to find such alternative attitudes or references. Or they may ask their client to seek advice from religious leaders.

Question:

What suggestions do you have for developing rapport with members of your community, and are there therapeutic styles with which Arab and Muslim American clients are most comfortable?

Dwairy:

The Arab and/or Muslim American family tends to be more authoritarian with clear power distances between its members. Typically, husbands and fathers are recognized as the authorities within the family while wives and children are expected to respect this structure. I generally have found that, in the United States, such authority is often eventually challenged among immigrant families, and as a result, husbands and fathers feel threatened with a loss of status and authority. I do not think it wise for therapy to challenge this threat. Rather, I suggest that therapists find ways to join with that authority. Joining means to respect it within certain boundaries. It clearly does not mean neglecting the experience or needs of other family members. But rather listening to these within a recognition and respect for the authoritarian structure of the Arab and/or Muslim families. Challenging the father or husband is likely to lead to the end of therapy and an escalating of conflicts within the family.

Joining with the familial authority may be best accomplished by inquiring about and listening to the concerns of the figures of authority and acknowledging their help. This may include appreciating the father’s efforts in accompanying his wife or children in seeking help despite the stigma associated with it; by making him feel needed in the therapeutic process and that his support in crucial to the process; by listening to his experience of what has been going on in the family; and by expressing genuine desire to learn from him about how “his people think.” Successfully joining with the familial authority is frequently the first step on the way to change. In most cases, I do not think that therapy can successfully proceed without it.

Question:

Lastly, could you present a typical case to give us a sense of how some of these various factors come together in treatment?

Dwairy:

A married Arab Muslim woman, twenty-three years old, who lived in one of the Arab villages in Israel, had experienced a panic attack after one month of studying education at a university in a large Israeli city. This experience had been her first exposure to the freedom of student life. Her first attack occurred while she was sitting with other students in the cafeteria. Subsequent attacks had come in class, in the library, and other university settings. She was now afraid to go back to the university.

She came to my clinic with her husband, who was a high school teacher. I interviewed them together. She described in detail her experience of the panic attacks, her fears of returning to the university, and other concerns. The husband seemed reserved and wanted her to abandon her university work and rest up at home. I asked him to “help me understand her problem.” He said he had not been supportive of her choice to go to college. He believed his wife should be home taking care of the house and children. He eventually submitted to her insistence that she stay in the university, but only after she promised to limit her time there and focus only on learning and not to spend time with other students, especially males. I encouraged him to explain to me his worries about his wife spending time with other students. For several minutes, he explained to me that such behavior was not accepted according to his family tradition and Islamic values. I was empathic and respectful of his values and expressed appreciation for his readiness to consider allowing her to stay in school in spite of his worries. He was touched by this and went on to explain how much he loves her and was ready to do “anything that might help her.” At this point, he agreed to allow me to work with her on her panic disorder and discuss what was “best for her.”

Based on her narrative, I learned that she continued to be emotionally dependent upon her family and did not have the ego strength to confront their very strict and traditional norms and values. Based on this assessment, I realized that helping her explore her need to spend time with boys and girls at the university would be counterproductive. She was trapped not only by her obligations to her husband and family, but also by her own traditional belief system. During her narrative, she had made several references to an Islamic religious maxim: “When a man and woman meet together, the Devil is the third party with them” (Itha Igtama’a rajul wamra’a kan alshaytan thalethhuma). Based on my model of culture-analysis, I decided to challenge this belief and brought to her attention another Islamic idea: “Doings are dependent on intentions” (Inama ala’a’mal benneyat), implying that it is not the meeting between a man and a woman that is sinful but rather their intentions. She did not respond well to this type of intervention. I decided instead to try a technique from metaphor therapy in which I asked her to describe her problem metaphorically. She said it is like “climbing a high tree,” which she described as “scary and dangerous.” I asked her how she might be able to make this experience less scary. She said she could be very careful, not go too high, and make use of climbing apparatuses, such as ropes and a safety net. I encouraged her to describe the scene and experience it in her imagination. I asked her to again imagine this metaphor and see if she could allow it to make her calm. Before ending that session, I asked her to think about what she learned from this metaphoric process. At the next session, she came wearing a scarf hijab on her head and told me she had made up her mind to change to a college in a nearby Arabic city. She said, “When I am within an Arab college with a scarf on my head and Qur’an in my bag, I feel safe and able to fulfill my wish to study and be together with Arab students.”

Working with South Asian American Clients: An Interview with Sumana Kaipa

16-1Demographics

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According to the 2010 Census, South Asian Indians have become the second-largest Asian group in the United States after the Chinese, overtaking the Filipinos, who previously held that position. The South Asian Indian population grew from almost 1.7 million in 2000 (0.6 percent of the U.S. population) to over 2.8 million in 2010 (0.9 percent of the U.S. population): a staggering growth rate of 69.4 percent, making them one of the fastest-growing ethnic groups in the United States, second only to Hispanic Americans.

These facts are reflected in economics statistics such as how South Asian Indians have continued to outpace most other ethnic groups socioeconomically. For example, 67 percent of all South Asian Indians have earned bachelor degrees or higher, compared to 44 percent for all other Asian American groups collectively. In addition, almost 40 percent have masters, doctorates, or professional degrees—five times the national average for all Americans. While Friedman (2006) attributes these statistics to a “brain drain,” with the brightest and best in India emigrating to the United States for greater financial and job opportunities, more recent statistics seem to show that increasingly such people are staying in India because of the American outsourcing phenomenon.

By the beginning of the twentieth century, several thousand South Asian Indians, primarily male Sikhs from the Punjab region, had settled on the west coast of America, working in manual labor in the fields and construction. Many joined the Chinese in 1907 in building the Western Pacific Railroad in California and other railroad projects. Between 1910 and 1920, many turned to the agricultural opportunities that were becoming abundant in California. At about the same time, strong anti-immigrant sentiments grew. These in turn led to violence against South Asian Indians, much of it displaced from the large numbers of Chinese and Japanese workers already present, and in time, anti-immigration laws were passed in 1913, 1917, and 1923. The latter was of special significance because it included anti-miscegenation provisions that prevented Sikhs from marrying anyone who was not their same color. As a consequence, many intermarried with the Mexican or Mexican America populations, with a substantial hybrid Mexican-Sikhs community still in existence near Yuba City, California.

The Luce-Celler Act of Congress in 1946 restored naturalization rights for South Asian Indians in the United States. The first major wave of immigration occurred in 1965, and those who came were very different from their working-class predecessors. The majority lived in cities, were professionals, and were highly educated. There were those, however, who chose more rural areas of Georgia, Arkansas, and Texas to fill a need for rural doctors and educators. It is estimated that over 100,000 individuals and families entered the United States during the decade that followed. Of this population, almost 40 percent were students and visitors with exchange visas. The majority pursued graduate-level education, found jobs, and became permanent residents.

16-2Acculturation

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First-generation Indian-Americans were acutely aware of readily apparent cultural differences. The family became a battlefield where modernity clashed with tradition, where Indian culture clashed with American culture, and where theory clashed with practice. American culture became the basis for interactions outside the home. Inside the home, first-generation Indian-Americans attempted to preserve their cultural and religious heritage and expected to live according to Indian cultural values. Women maintained the household (cooking, cleaning, childrearing, etc.) in addition to holding part-time or even full-time jobs. They were also the first generation of women to benefit from mandated education in America.

16-2aFamily Organization and Values

Indians believe in connectedness of all living things and in immortality maintained by reincarnation. This belief is reflected in the notion that when we die, the soul is born again into another human being or animal. Thus, patience and compassion toward all beings and the universe are essential human qualities. These values are embodied in the concepts of karma (destiny), caste (a hierarchy organization of human beings), and dharma (living life in accordance with the principles that order the universe), essential ideas for understanding the worldview of Asian Indian families, whether they are Hindu, Christian, Muslim, or Parsi. (p. 383)

South Asian Indian families generally adopt nuclear family structures in the United States, but it is not uncommon for extended family, especially grandparents, to visit or reside with the family for long periods. It is also typical for established families to encourage relatives in India to emigrate to America and provide them support until they have established themselves there. Families are very close-knit and feel strong obligations of responsibility to each other, especially in situations of financial need. As a consequence, one finds few South Asian Indians seeking public aid or assistance, with the exception of some elderly receiving disability benefits.

Traditionally, South Asian Indian parents arrange marriages and select partners for their children from within the larger ethnic enclave and with the consent of both families. Selecting a suitable mate is serious business. Potential partners are fully examined and vetted—in relation to education, family, and status—by family and close community friends before the two young people even meet. It is a strong cultural belief that similarities in traditions, social customs, and background make for the happiest and most stable marriages, and in turn create cultural continuity. Marrying outside the group was generally frowned upon, but with assimilation and acculturation, much of this has softened, with dating before marriage increasingly commonplace, as are interracial/intercultural marriages among the second and third generations.

Finally, Almeida (2005) offers the following observations about the challenges of parenting among South Asian Indian parents:

Parenting for most mainstream Americans is complex, given the current context of violence in schools and little to no support for mothers in the workforce. Added to these stressors for Indian parents is their desire to maintain traditional family patterns while upholding high expectations for their children. Lack of knowledge about developmental changes as they pertain to setting limits, for a child, differentiating between the positive and the harmful sources of information gathered from the Internet, music, TV, and the like, and the various ways in which children can socialize (sports for girls, sleepovers for all children) are among the many challenges they face. “Philosophical talks” are favored over behavioral consequences. Because of the collective psychology, single interventions such as time-out procedures, or rewards for positive behaviors, are not consistent with cultural or family values. (pp. 387–388)

My process of healing had much to do with coming to terms with aspects of my identity and integrating these parts in a way that was less compartmentalized, less secretive, and more whole. Though I know now that there were and are many other South Asian Americans going through the same process that I went through, I felt very alone at the time. I don’t know what I would have done if I had not had my brother, who lent perspective to my parents’ quirks and kept me sane in the process.

Though sometimes I regret having had to take such a difficult and anxiety-provoking journey in order to arrive at the place I am now; without it, I don’t think I would have ever become a psychologist. It was my own experience that led me to feel that South Asian American providers were needed to lend understanding and support to this community, and it is my hope that more and diverse providers of South Asian American descent will build understanding of South Asian American clients and de-stigmatize mental health issues and seeking of services among this community. In my own journey of cross-cultural work, I’ve also discovered that being of the same cultural background as your client is not necessarily the only or most important factor in help and healing. As much as cultural and identity struggles are specific to the client, there is frequently the universal experiences of feeling different, alone, and rejected. An informed and open-minded human service provider, who seeks to understand a client’s problems from the client’s perspective, is in all likelihood more important than a culturally matched client-therapist relationship.

Question:

How would you define South Asian Americans as a group, and what characteristics do they share?

Kaipa:

The most widely spoken languages are Hindi, Bengali, and Urdu, but many other languages are spoken throughout the region. In India alone, there are 16 major languages and over 200 additional dialects. Also, a number of people in South Asia (particularly those who are of a higher socioeconomic status or living in urban areas) are conversant or fluent in English, which became a key language in this region due to British colonialism. In some regions, language can be a very strong indicator of tribal identity (such as Pashto in Afghanistan), in other areas it may indicate a religious affiliation (such as Urdu in Pakistan and India), and for others, language may be an important part of familial lineage despite where the person or family may reside (identifying as Tamil despite living in the English and Hindi dominated city of Bombay). Another thing that might be important to know is that many people from South Asia speak multiple languages because they frequently need to know the more dominant languages of industry or commerce (English, Bengali, Urdu, and Hindi), may also need to know the language of a nearby area (where an entirely different language is spoken), and also wish to retain their family’s traditional language.

After describing all the differences, one might wonder what similarities these disparate groups share. The countries that comprise South Asia did not have the boundaries that they now do, and their histories and ways of life were significantly intertwined, despite the diversity of people in this region. Colonialism, too, affected the collective history of the people of this area, and it also largely shaped the way the region was eventually divided. Though seemingly ephemeral, South Asians share similar ideas around the importance of family and community, especially over the value of the individual. As a result, many of these communities have emphasized family name, family pride, and family legacy as an important part of their identities. By and large, South Asian families have lived in extended family networks. Such a family structure can be very positive since it can provide strong community support and protect against isolation. Moreover, the elderly have a role in generational family life and are accorded respect.

South Asian family roles can sometimes be perceived as rigid with women having significant domestic and familial responsibilities without the respect and rights accorded to men. With increased education and work outside the home, women’s roles have changed somewhat. There may also be differences between South Asian groups, and some families, regardless of region, may be more conservative or progressive in their views about women. Marriage and children continue to be central to South Asian family structure and because family reputation is important, many South Asian groups strongly discourage dating or premarital sex and still favor arranged marriages over choosing one’s own partner. However, the nature of arranged marriages has changed over time, with some families introducing but not necessarily choosing ideal candidates and women having more of a voice in the arrangement. Nevertheless, women are often not held to the same standards as men with respect to marriage and coupling, in that men may be chastised but likely not ostracized for their sexual conduct (such as premarital sex) and can remarry after a divorce or death of a spouse without criticism from their families or community.

Question:

Could you now talk about the various names that different South Asian American subgroups use to describe and identify themselves?

Kaipa:

Acculturation plays a role in using the term South Asian, too. One reason for this might be that the more American-identified individuals become, the more likely they are to feel that they are treated similarly in the face of dominant American society, who may make erroneous assumptions about their identity based on the way that they look (such as believing Sikhs are the same as Muslims). Experience of discrimination or oppression by the dominant group may fuel a sense of solidarity among more acculturated South Asians, who then feel, regardless of their various self-identifications, that they are a part of a group of South Asian Americans.

Finally, if things weren’t already confusing, individuals from this community aren’t likely to be terribly uniform in their descriptions of themselves, calling themselves different things in different contexts or communities. For instance, I identify as (sometimes in this order and sometimes not) Telugu, Indian, Hindu, American, South Asian American, and Californian (and probably more things that I can’t think of right now), and these identities become more or less prominent or important depending upon who I’m with and what their group affiliation or experience is. There are also subdivisions within these identities (i.e. different kinds of Telugu people or Californians), so you can see how it can get pretty complicated.

Question:

Could you describe some of the shared history that South Asian Americans bring with them to the United States? Could you give us a nutshell version of historical events of which a provider should be aware?

Kaipa:

Prior to 1965, the few South Asian immigrants who came to the United States did so for circumscribed educational opportunities (under a specified student visa) or were recruited as laborers, such as men who came to the United States in the late nineteenth century and early twentieth century to work in logging, mining, construction of railroads, and agriculture in the Pacific Northwest and California.

Restrictions on immigration were reinstated in the early 1990s, when limits on the annual number of immigrants were once again instituted and reasons for immigration were more strictly limited to family reunification or the need for specific classes of workers. For instance, several Indians who came in the 1990s did so under work visas to fill the need for employees trained in informational technology, but some of these populations left the United States after being laid off and returned to their respective countries.

On the one hand, more recent immigrants have benefited from coming to the United States at a time when the South Asian American community is larger and, thus, they have more opportunities to socialize with others from their culture and maintain cultural ties. For example, South Asian Americans have the opportunity to take classes in order to learn their family language, classical dance, or music from their cultural tradition, have more exposure to food and popular media from their family’s cultural background, and can practice in an established religious community (such as a mosque or temple). South Asian Americans are also a more visible community, appearing much more regularly in media, and there are now examples of successful South Asian American politicians, actors, writers, and scientists. The events of September 11, 2001, on the other hand, were a significant setback to South Asian Americans, many of whom experienced racial, ethnic, and religious discrimination; were victims of hate crimes associated with the anti-Muslim, anti-brown person backlash that resulted from the attacks; or experienced significant fear that they might be targeted or perceived as being anti-American.

Question:

Let’s switch our focus and begin to look at issues related to providing services to the South Asian American community. Could you talk about factors that influence how South Asian Americans go about seeking help when they have problems?

Kaipa:

However, the family-centric orientation can also mean that an individual’s behavior within the community reflects on the family or community as a whole. If the individual is succeeding, it can bring pride and respect to the family. But if the individual is suffering from problems, especially if they are not medical problems, this can become a cause of embarrassment or shame, and the family may deal with this issue by denying or hiding the problem from others. Additionally, when there is dysfunction in a family, such as abuse, the family may discourage or prevent help seeking for fear of the entire family or community being exposed or shamed. Because the family may not acknowledge problems, it may also lead to South Asian Americans to be unable to perceive or understand the psychological difficulties they or others around them are experiencing. The cultural belief that events and circumstances are preordained, or fated, may also make South Asian Americans more likely to believe that outside help cannot change their circumstances.

Acculturation is a key factor in whether individuals and families will seek help. Less acculturated South Asian Americans may be referred to therapy or to a psychiatrist through a primary physician who believes there is a mental health or stress-related issue. These individuals are usually unfamiliar with psychological diagnoses, the roles of mental health providers, what types of support or interventions are available, and how to negotiate getting help. More acculturated individuals will be more familiar with Western psychological concepts but may still feel nervous about seeking help, believing that their problems are not worthy of seeking outside help, feeling discomfort or fear in airing family problems, or worrying about being judged by providers who do not understand their particular issues.

Question:

What are some of the common problems that South Asian American clients might bring to you as a counselor? Are any subgroups within the South Asian American community at particular risk for mental health problems?

Kaipa:

Again, level of acculturation strongly affects the sorts of problems that South Asian Americans clients encounter. These individuals may be experiencing significant difficulties in adjusting to the demands of American culture (such as understanding how to find a job, an apartment, or other resources in the United States), difficulty negotiating situations due to poor English language skills, difficulty findings jobs or experiencing financial stresses as a result of caring for multiple families members (and supporting family who remained in the home country), feeling isolated from a community of family and friends, having witnessed or experienced political trauma in their country of origin or being displaced, domestic violence, and alcoholism abuse. It is also possible that the family may bring a loved one with more severe mental illness, such as a schizophrenia or psychosis, to the attention of a psychiatrist. Sexism and issues related to the historical treatment of women often make domestic violence a significant issue in the South Asian American community, and several organizations exist throughout the country to help women in abusive relationships.

Intergenerational misunderstandings and tensions are also likely to be a reason for family problems. Parents might complain, as my parents did, of their children not being compliant or becoming too Americanized in their values; children may complain that parents are too rigid or do not understand their experiences. In adolescence, these problems may manifest more for girls since families are more likely to impose strict restrictions on dating and/or socialization with non-South Asians, and the girls may feel that they cannot fit in with their peer group. Outside of family, South Asian American adolescents may also struggle to fit in with peers or feel stress related to being stereotyped.

Even when conforming to their family’s ideas of appropriate behavior or success, individuals may still experience stress and difficulties related to their parents or families lacking the ability to understand the cultural terrain that they must negotiate. A South Asian American young woman I saw briefly in therapy struggled with depression related to very high parental expectations about education and achievement. Her family could not understand how her depression affected her academic achievement or her future plans for law school. They also could not see how they might be contributing to the problem by holding her to very high standards, focusing on her failure to get good grades in her final year and trouble studying for the LSAT rather than encouraging her, and imposing restrictions on her behavior that did not exist for her male siblings.

Question:

How do socioeconomic and class issues affect the psychological lives of South Asian Americans? Do class or other socioeconomic issues play any role in these various problems?

Kaipa:

Socioeconomics and class definitely affect South Asians and their problems. Some groups, like my family, had the privilege of immigrating to the United States as professionals (who received a free or very cheap education in South Asia) at a time when America was in need of an immigrant work force, and they came voluntarily to find opportunity. It is likely that these individuals and their children may experience stress related to achievement and financial success, believing strongly in model minority stereotype and thinking that they have failed if they do not achieve as professionals.

Question:

Next, let’s talk about some of the factors that you see as important in assessing a South Asian American client. What kind of things would you look for? What kinds of information do you feel it is important to collect from a South Asian American client? What suggestions might you have for providers about developing rapport with South Asian American clients?

Kaipa:

When working with South Asian American clients, I tend to want to know the exact nature of the client’s cultural background (including what they consider to be their country of origin or countries they lived in before coming to the United States and what name they would give to themselves), their immigration history (when they arrived to the United States and whether they immigrated voluntarily or under significant duress, trauma, or financial hardship), religion and, if relevant, caste (as well as how important religion and/or caste is in their day-to-day lives), socioeconomic status (both the client’s as well as their family status, how this may have changed in the immigration process), and generational status. I would also want to know if the client lives in an extended family and if family members strongly influence a client’s decisions. Additionally, it is important to get a sense of whether the client and the client’s family are more conservative with respect to family roles (such as gender), cultural and familial expectations, and adherence to religion. Though the client may not be forthright about domestic violence or substance abuse, a good assessment should also be mindful that these issues might be impacting the client or the client’s family and could easily be overlooked.

Given that assessing level of acculturation is very important, I also want to mention that some practitioners utilize acculturation measures in their work before planning interventions. Individuals rate themselves in terms of speaking South Asian languages or preferring South Asian food, music, cultural activities, friends, and values in contrast to speaking predominantly English and preferring American food, music, cultural activities, friends, and values. These measures can provide information about whether a person is highly identified with their culture of origin, highly acculturated to American norms and values, or somewhere in-between and likely bicultural. They can serve as a good starting point for understanding what issues the client might be experiencing, and responses can be a springboard for other questions about their experience. For instance, if you find that the client is more identified with their culture of origin and is not highly acculturated to American norms, this may indicate that the client may or may not be familiar with therapy or counseling and it may be good to give education about therapy and other interventions to avoid any misunderstandings. However, providers should be careful not to assume total understanding of the client based on acculturation scales, and it would be important to ask the client about any beliefs or values before assuming that they follow specific trends or patterns. As an example, with respect to behaviors, I would likely rate in the bicultural to more “American” range, but I am likely to place a greater emphasis on values that may be associated with those who are less acculturated, such teaching my daughter my family’s language and cultural stories and Indian classical dance and music.

Question:

Do you feel that there are any therapeutic approaches that are better matched with certain South Asian American groups? Are there any subgroups within the South Asian American community that are at particular risk for mental health problems?

Kaipa:

Given that South Asian Americans tend to have a better understanding of interfacing with the medical system, they may be more receptive to those therapies that appear to be more concrete, solution-oriented, and “medical” in nature, such as cognitive behavioral therapy. Also, psychodynamic therapies that focus on talking about family dynamics might cause clients to become very uncomfortable, as there may be a concern about airing the family’s problems and, worse yet, to what they perceive to be a stranger. Taking psychiatric medication is a complicated subject, too. At times, it might feel less shameful, stigmatizing, and threatening to South Asian Americans since the problem can be externalized as a medical problem and doesn’t involve talking with a stranger about personal things. South Asian American clients may also be likely to present with a more “tell-me-what-to-do” kind of attitude, which may lead providers to give advice rather than explore questions or seek more information. On the one hand, the advice-giving therapy relationship may be successful, but therapists may miss important family patterns or cultural information that would lead to be a better understanding of the problem and inform the best therapeutic intervention. In fact, providers should generally be mindful that South Asian American clients might downplay aspects of stress related to family and interpersonal dynamics. If possible, exploring all aspects of the system and cultural values and behaviors in which the clients live are an important part of working with this population. For example, in some cases, spiritually informed practices may be of paramount value to creating positive change.

Again, acculturation is a critical factor in how receptive clients will be to various styles of therapy and intervention. For instance, I think that more acculturated or assimilated groups of South Asians are likely to behave like dominant groups in the United States in that they might feel more comfortable sharing about difficult personal or family circumstances, are less likely to view the therapist as a “stranger,” and may better understand the role of therapy. They may also adopt some of the dominant stigma about medication since they are less likely to frame it as helping with a “medical” issue. Nevertheless, in contrast to the dominant group, they may feel nervous about how their cultural or family experiences will be perceived by providers who may not be familiar with their cultural background, values, and responsibilities.

Question:

Last question. You’ve shared a lot of rich information with us. Could you finish by presenting a case that shows how it comes together in work with a client?

Kaipa:

When I entered graduate school, I was confident that I would not see a South Asian American client until starting a private practice (with a focus on this population). But I’ve already had worked with several South Asian American clients. I think this is, in part, because I trained in hospital settings, and as I mentioned earlier, clients may be more likely to seek help in this context.

Rani initiated therapy and came to the intake appointment alone and, in her opinion, the major problems that she and Raj were experiencing were that Raj drank alcohol excessively and had a gambling problem. According to her, Raj had depleted their savings and caused significant financial and emotional strain in their relationship. Additionally, Rani’s relationship to Raj’s parents had taken a turn for the worst. She stated that they had gotten along well in the first few years of the relationship, but over the years, she felt that they expected her to serve and respect them without returning the respect, were very critical of her, and complained about her to other family members. In Rani’s view, she felt that Raj’s parents did not help with household chores even though they spent the most time at home while the couple worked, and, though they knew of the couple’s financial struggles, they did not contribute to the household financially. Rani understood that the problems that she was struggling with were ones that needed to be addressed in couples counseling.

When Raj joined Rani in couples therapy the next time, he was very quiet and not very forthright about the troubles they were experiencing. It appeared to be Rani’s goal to provide a “wake-up call” to Raj about how his drinking and gambling were becoming significant problems for the family. As I got to know the couple, it became clear that Rani was right about these issues, which Raj also acknowledged, but he was not yet ready to make significant changes in his behavior. Raj had a family history of alcohol abuse, and his brothers both drank excessively. Additionally, Raj’s friends socialized by drinking excessively and gambling, so these behaviors were considered to be normal ways of “unwinding.” Talking about the addictive behaviors took the form of “motivational interviewing” in that I felt that all that could be done was to seek information about how he felt his behaviors might be impacting him and his family. It was difficult for this discussion to take place in the context of couples therapy since Rani wished for the therapy to bring an immediate change to Raj’s behavior. Additionally, I believe that she was hoping that if the recommendation came from outside (from providers at a medical institution), it would lend credence to the problem, and Raj would change his ways. It was as if she was hoping for a prescription from a doctor to cure Raj.

Already, you can probably see how some of the things I’ve discussed about South Asian Americans were very relevant to this case. There were differences in levels of acculturation between Rani and Raj, and this impacted many aspects of their day-to-day lives, including their beliefs and values. For instance, it was clear to me that Raj would never have sought outside services or even considered it to be an option had Rani not initiated the process, and Rani, being somewhere between first and second generation, was not only aware of counseling resources but felt empowered enough to seek help for their problems. Even still, her expectation was that the medical establishment “prescribe” what was needed for his problem, asking for more top-down and less exploratory intervention. Moreover, Raj’s lack of interest in working with a counselor, as well as being in an early stage of change with respect to alcohol and gambling addiction, made engagement in the therapeutic process lopsided and of limited utility at times. It also appeared that addiction problems had a cultural component, as working in a liquor store with sometimes violent customers appeared to be a stressor common to more newly immigrated South Asians of lower socioeconomic status. Among South Asians, Punjabi men are commonly considered more alcoholic than other groups. I was not certain whether this was merely a stereotype, but I definitely got the impression that Raj socialized with men who considered it normal to drink excessive amounts of alcohol. Had I felt that Raj and Rani were open to the conversation and the relationship we had was more solid, I would further explored this issue.

Finally, I want to talk about my own work with this couple in terms of being a South Asian American therapist. On the one hand, I think I had a fairly good understanding of some of the cultural issues at play and knew what information to obtain from them in order to gain a more comprehensive understanding of the problems, but I think one issue that I’ve had in working with South Asian Americans, which I think also played out in the context of working with this couple, is how easy it can be to focus on characteristics that make South Asians similar and subsequently miss the subtle differences between groups that might help in building rapport and more thoroughly inform the work. I think this might happen less with my cross-cultural work, in which I’m acutely aware of what I don’t know and that I can’t speak for the issues of this group. I also think it is easy to feel that problems are unsolvable because issues feel more insurmountable if there are cultural values and beliefs that strongly determine worldviews and are difficult to change or reconcile with other beliefs. I definitely felt this way in my work with Raj and Rani.