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Understanding Familial/Cultural Factors in Adolescent Depression:

A Culturally-Competent Treatment for Working With Chinese American Families

ALEXANDER L. HSIEH Couples and Family Therapy, Alliant International University, Sacramento, California, USA

ROY A. BEAN School of Family Life, Brigham Young University, Provo, Utah, USA

A significant challenge for researchers and clinicians is in the pro- cess of determining culturally sensitive strategies to ensure treat- ment effectiveness with ethnic populations in the United States. This article highlights key aspects of treating Chinese American fami- lies where a child is struggling with adolescent depression. Relevant literatures associated with adolescent depression and effective treat- ment of Chinese Americans are reviewed and organized according to the dimensions of therapist knowledge, awareness, and skills. Therapist guidelines are provided using key aspects of cognitive behavioral therapy. Additional suggestions are presented for cul- turally competent therapy with Chinese American youth and their families.

As a population-of-color, Asian Americans are the third largest ethnic group in the United States and the third fastest-growing group behind Latinos and African Americans (U.S. Current Population Survey, 2000). At present, the Asian American population is estimated to be at least 14 million, up from 11.9 million in 2000 (U.S. Current Population Survey, 2008) and estimates suggest an average, continued growth rate of 3.2% per year. Although Asian Americans include considerable diversity in terms of cultural practices and national origin, the largest subgroup is Chinese Americans—one of the fastest

Address correspondence to Alexander L. Hsieh, Couples and Family Therapy, Alliant International University, 2030 West El Camino Avenue, Suite 200, Sacramento, CA 95833. E-mail: [email protected]

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growing ethnic groups in the United States, at 5% per year (Ta, Holck, & Gee, 2010).

Accompanying the population growth estimates for this group is a con- cern about the lack of clinical literature focused on Asian Americans, and on Chinese Americans, in particular (Fogel & Ford, 2005). As a partial ex- planation for this shortage, the scarcity of clinical studies and conceptual articles focusing on Chinese American families can be tied back to their under-utilization of mental health care (Ta et al., 2010). Unfortunately, in reciprocal fashion, with reduced information available regarding appropri- ate treatments, clinicians are less able to effectively treat Chinese Americans which further deters members of this ethnic group from seeking out mental health assistance.

The overall lack of clinical knowledge about Chinese Americans is es- pecially egregious because families are often caught in the middle between traditional cultural values (e.g., parental duty to facilitate child development; Ho et al., 2004; Lee & Mock, 2005) and a number of genuine clinical and/or relational issues (e.g., suicide risk; Abright & Chung, 2002). As another ex- ample, although cultural values emphasize both supporting and challenging children, there are many parents who are not able to attain or maintain the necessary balance of encouragement and demandingness. As it relates to academic achievement, Chinese American parents may default to the strategy of pushing and challenging adolescent children, rather than giving adequate support. Unfortunately, this can then lead to an increase in stress and family- level conflict which then results in depressive symptoms or clinical levels of depression for the adolescent. In its most extreme form, Abright and Chung (2002) found that Chinese American adolescents undergo a great deal of stress during this stage of their life, resulting in higher suicide rates when compared to their European American peers. Regrettably, as a function of the aforementioned lack of research, clinicians working with this group are often left without clear treatment guidelines for treating Chinese American adolescents struggling with depression.

In addressing this need, this review article examines key factors re- lated to the culturally-competent and therapeutically viable treatment for Chinese American adolescents struggling with depression (Sue, 2001). Specif- ically, treatment recommendations will be organized and presented here in terms of (a) therapist knowledge—about the culture and worldview of their clients; (b) therapist awareness—of their own culture, values, biases, and assumptions regarding the clients’ ethnic/cultural group; and (c) therapist skills—therapeutic strategies and interventions, relevant and appropriate for working with clients, given their culture and other contextual factors. In an effort to address aspects of both the Chinese American culture and the limitations imposed on the individual/family by depression, this approach follows Bean and Titus (2009), focusing on a “target that is simultane- ously culturally and clinically relevant—the intersection of the client’s ethnic

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culture and the culture of the presenting problem” (p. 40, emphasis in original).

THERAPIST KNOWLEDGE

In terms of general knowledge about adolescent depression, it is important for clinicians to understand that many teens experience and express de- pression differently than do adults (Kaslow, Mintzer, Meadows, & Grabill, 2005). In fact, independent of ethnic background, depressed youth present with the symptoms typical of adult-onset depression, along with higher fre- quencies of irritable or angry moods, unexplained aches and pains, ex- treme sensitivity to criticism, withdrawal from some but not all people, and slowing of movement and speech (Kaslow, Mintzer, Meadows, & Grabill, 2005).

Although sometimes conceptualized differently by culture, adolescence represents a critical developmental stage, where the individual initiates a self-image and manages perceptions from the immediate environment (Sun & Shek, 2009). During these significant years, there are a number of key factors have been found to negatively impact adolescent well-being. In or- der to more specifically orient the discussion to depression among Chinese American youth, several key contextual factors will be presented as they relate to this ethnic group.

Academic Achievement

Throughout the history of Chinese culture, one can observe the strong emphasis placed on achievement and expertise (Leong, Wagner, & Kim, 1995). In fact, the primary motivation for many Chinese American families in immigrating to western countries is to provide children with better educational opportunities (Ho & Hau, 2008; Yeh et al., 2008). Not surprisingly, significantly higher levels of parental expectations for academic success are held by Asian American parents when compared to their European American peers (Crystal et al., 1994). On the other hand, for more wealthy and/or educated Chinese American families, academic achievement may symbolize a continued tradition of preserving family status and wealth (Ho & Hau, 2008).

Although academic achievement is important to the family’s future well- being, the pressure to succeed has been found to be associated with high levels of stress, depressed moods, academic anxiety, aggression, and somatic complaints (Crystal et al., 1994). Academic failures among some Chinese adolescent may quickly lead to perceptions of shame being brought upon oneself and the entire family (Crystal et al., 1994). This heavy and sometimes

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unreasonable burden placed on youth in Chinese American families, cou- pled with a lack of resources to defuse this pressure, may lead some youth to manifest major depressive symptoms.

Cultural Factors

Although Chinese American adolescents may experience the same depressive symptoms as other U.S. youth, there are culturally-specific characteristics that help frame their experience of depression. For instance, given the importance of “saving face” or protecting the family’s reputation and honor in Chinese American culture, the teen’s departure from normalcy into depression can be shaming for the family. In fact, the idea of a teen being depressed would be difficult for some family members to accept as a viable, and therefore, treatable condition (Lee & Mock, 2005). It could even appear as laziness or selfishness when the teen is acting depressed instead of keeping with family traditions related to academic achievement, learning social rules, and respecting one’s elders (Lee & Mock, 2005).

Given these cultural values, it is not surprising that Fogel and Ford (2005) found that Chinese Americans tended to stigmatize depressive ill- nesses more than European Americans. Taken together, it is important for therapists to understand that some families may be so shamed about their child’s depression (and accompanying academic problems) that they would be hesitant about therapy. This further complicates treatment because the depressive somatization can be fairly severe by the time the family decides on treatment (Fogel & Ford, 2005; Lee & Mock, 2005). As a result, more in- tensive treatment may be required in these instances, which further increases the likelihood that therapeutic services will be alienating or even ineffective.

Other key cultural factors that help organize Chinese American families include: collectivism, family gender roles, and the emphasis on hierarchy and structure (Atwood & Conway, 2004; Lee & Mock, 2005; Liu & Iwamoto, 2006). These principles or values are discussed briefly as they heavily impact the organization of the Chinese American family, and because they can appear to be maladaptive for family members if a clinician is not aware of their relevance.

COLLECTIVISM

Before venturing into the treatment aspect of working with Chinese American adolescents, it is important to understand the rules that govern interactions in traditional Chinese families. One of the primary governing standards is collectivism which is based on Confucianism, a set of both cultural and religious beliefs (Weatherley, 2002). According to collectivism, the greater good of the entire system (e.g., family or society) is emphasized rather than

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pursuits that only advantage the individual (Lee & Mock, 2005). As noted above, when working with this population, it is important to consider that the family may hold a stigmatized view of the depression, as many traditional Chinese Americans hold the belief that when a family member suffers from a mental illness that the status and strength of the entire family is shamed. This idea correlates with the value of a collective identity being primary, even in the face of a family member’s individual adversity (Lee & Mock, 2005).

GENDER ROLES

Another aspect of Chinese American culture that has significance in terms of this topic is the gender biases that exist, especially with regard to the different expectations placed on children. In traditional Chinese culture, male offspring have been more valued than female offspring partly because of the “one family-one child” rule in China, but also because of the family legacy syndrome (Liu & Iwamoto, 2006). In traditional Chinese families, male children are heavily favored because males are able to continue the family’s relevancy in society by carrying on the family’s name and legacy. Although Chinese adolescents already have great expectations placed upon them from traditional Chinese cultures, more demands for achievement (academic and otherwise) are placed on boys because of this gender bias (Liu & Iwamoto, 2006).

With the overt emphasis on achievement directed at sons in traditional Chinese culture, many daughters are steered toward child-care and daily household duties (Atwood & Conway, 2004). However, this gender division only serves to encourage some girls to outdo their male counterparts aca- demically as they seek parental approval and more societal status. Accord- ingly, rather than be passive and submissive in a male-dominated society, many girls demonstrate an apparent internalized and self-appointed desire for academic achievement (Liu & Iwamoto, 2006). Therefore, through both direct and indirect means, the gender preference in Chinese culture translates into externalized (for males) and internalized (for females) expectations to succeed academically.

FAMILY HIERARCHY/DYNAMICS

When observing the dynamics of Chinese American families, it is important to focus on family structure and adherence to hierarchical rules (Lee & Mock, 2005). In many Chinese American families, there is a distinct parent-child boundary and strict obedience to parents is stressed. In fact, from an early age, children are taught to respect their elders, regardless of the situation.

When looking at family structure and hierarchy, the culturally compe- tent therapist must also realize that achievements and failures are translated

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across the parent-child subsystems. Because of the rigidity associated withz hierarchical influences, younger generations are faced with the constant ex- pectation to be more prosperous than their parents, leading to higher stan- dards and expectations. Mistry and colleagues (2008) found that Chinese par- ents, struggling to provide financially for the family, send the message that the future of the family will be more prosperous and stable when children succeed in academics. Adding another stressful dimension to the emphasis on school performance, parents are usually esteemed higher or lower in tra- ditional Chinese communities based on their children’s achievements. When school performance not only reflects on oneself, but also on the entire fam- ily, academic failures carry more weight (Mistry, Tan, Benner, & Kim, 2008), leading to more perceived stress, which subsequently makes adolescents more susceptible to depressive symptoms.

The dynamics in many Chinese American families emphasize cohesion and closeness (Lee & Mock, 2005), which can restrict disclosures about emo- tional/psychological well-being to outsiders because intimate information is to be disclosed only within the family (Lee & Mock, 2005). The concept of “saving face” is another relevant cultural factor to consider in relation to adolescent depression among Chinese Americans as it relates to the cus- tom of not wanting one’s family characteristics to differ from social and cultural norms (Atwood & Conway, 2004). In fact, even though internal con- flict and struggles are present, the image presented to the outside world is of a well-maintained household, organized so that the family’s “dirty laun- dry” goes undetected by others in the community. Furthermore, although research demonstrates the usefulness of social support in assuaging stressors (Lin, 2002), Chinese Americans are less likely to utilize external support sys- tems such as the school system, church counseling, peers, and community resources. It is important for clinicians to be aware of this possibility, be- cause the lack of an external social support system could be detrimental to depression recovery.

Acculturation

A traditional Chinese family has strong cultural trends that can differ dras- tically from that of the European American majority culture. Assessing the family’s level of acculturation can aid the therapist in accounting for cer- tain family characteristics (Yeh et al., 2008) that may be representative of an adaptation to the American lifestyle or continued adherence to Chinese traditional norms. If one simply assumes a high level of acculturation, the therapist could neglect cultural influences that strongly impact the family. Similarly, if one assumes a lack of acculturation, the therapist would be confused by incongruences with traditional values.

It is also essential for the therapist to understand that different members of the family may have different levels of acculturation (Yeh et al., 2008),

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instead of assuming that the family is governed by a single cultural identity. In fact, it is more likely that children will be more acculturated than their parents and that these differences may create conflictual interactions within the family system (Yeh et al., 2008). When adolescents are more acculturated than parents, it may lead them to value extracurricular activities the same or more than academics. The difference between child and parents’ perception of what is more essential (academic achievement or extracurricular and social involvement) can drive a wedge between parent and child, leading parents to add additional pressure for the adolescent to achieve academically when the child already has a full plate. When the difference in acculturation leads the adolescent to becoming more stretched in balancing traditional Chinese values (focus on academic achievement) and Western values (academics and extracurricular activities), the overwhelming factor can cause adolescents to become depressed because of the added pressures.

Sexual Development and Dating

In a traditional Chinese American family, adolescent dating is not priori- tized. Parents demand their adolescents to focus on academic achievement rather than socializing and dating (Hahm, Lahiff, & Barreto, 2006). Chinese American families typically allow time for studies, club activities, entrance exam preparation, and other college application building strategies as op- posed to adolescent dating. Prolonged exposure to these habits may lead cer- tain Chinese American adolescents to become increasingly isolated socially, and thus, lead to increased exposure to adolescent depressive tendencies.

Acculturation also plays a tremendous role in sexual development and dating because more acculturated Chinese American adolescents are more likely to be sexually active (Hahm, Lahiff, & Barreto, 2006). A large accul- turation gap between parental and adolescent may lead to a lack of under- standing in regards to sexual development and dating. This physical and emotional distance created by different perspectives would become a deficit for the adolescent in terms of family support. The lack of familiar support disadvantages adolescents into developing increased liability for depressive symptoms.

The conservative nature of traditional Chinese values also limits the terms of adolescent dating (Hahm, Lahiff, & Barreto, 2006). Meanwhile, the dominant culture promotes adolescent dating as an indication of popularity in the adolescent development. Chinese American teens may be inclined to hide such behaviors and lack the parental advice needed to make better choices on dating. The lack of involvement between parents and adoles- cents in the adolescent’s dating realm creates more distancing between the adolescent and parents. The gap created by traditional Chinese values and Western perspectives on sexual development and dating must be dealt with

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as clinical therapists in order to bridge the distance created between parents and adolescents so that adolescents dealing with depression may perceive their parents as a healthy and helpful resource rather than a burden because of the lack of understanding. Therapists must address these specific issues as well as understand the source of the distance in order to successfully treat Chinese American families. These issues can be effectively handled with suggestions from the cognitive behavioral therapy methods.

THERAPIST AWARENESS

Along with developing a thorough understanding of the respective eth- nic/cultural group, Bean and Titus (2008) also suggest that culturally compe- tent therapists should be aware of possible biases about the client/family as a function of: (a) differences in cultural values and (b) their own beliefs about the presenting problem (in this case, depression). A careful self-evaluation by the therapist allows for a better therapeutic relationship to develop with the client system. Self-awareness will, of course, need to occur across a va- riety of dimensions for a given therapist; however, the following topics are deemed most important to consider in order to avoid countertransference issues with a Chinese American family struggling with the presenting issue of adolescent depression.

Adolescent Autonomy

Even when equipped with a good understanding of hierarchy and its role in Chinese American families, there is the possibility that western-trained clinicians will operate from a position of ethnocentrism on the topic of ado- lescent autonomy. For this reason, it is imperative that the clinician evaluates how much autonomy he or she believes an adolescent should have. Western culture generally allows for much more adolescent independence and au- tonomy as compared to Chinese culture (Moshman, 2009), a difference that may create a cultural division between clinician and family. If this bias is left unchecked, a tremendous divergence will be created between the clinician and parental subsystem, complicating the process of inviting the parents to support their adolescent in future sessions.

An ethnocentric therapist may encourage the adolescent’s self- exploration beyond culturally sanctioned bounds and, in doing so, disregard the effects that this behavioral shift may have on more traditional parents. On the other hand, the culturally competent therapist perceives the adoles- cent’s self-identity and family identity as two closely interrelated concepts. Because of how closely the adolescent’s identity is tied to the family’s iden- tity in Chinese culture, the two are consistently joined. By valuing adolescent

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autonomy development, as well as the role that parents have in it, therapists can engage the entire family in a common goal which is likely to lessen the impact of family-level stressors. Two questions the therapist would ask oneself before entering therapeutic sessions would be: (1) What are my bi- ases towards adolescents’ identity in families? and (2) What stereotypes do I already hold about how adolescents’ self-identity should be reflected in families and how can I check them?. In addition, possible questions the ther- apist may want to bring up with the clients are: (1) What do I know about adolescents’ identity in Chinese families?, (2) What more should I learn about adolescents’ role in a Chinese family?, and (3) How can I be open and learn more about adolescents’ self-identity within my client’s family context?.

Degree of Acculturation

Despite experiencing similar adversities as other minorities, Chinese Americans and other Asian Americans have been labeled “model minori- ties” because of their focus on overcoming difficulties through educational achievement and diligence (Ho & Hau, 2008). These successes have led many to believe that the population has acculturated well with the dominant culture. However, in the more complicated reality, many adolescent Chinese Americans struggle because they have to develop a necessary bi-cultural identity with traditional customs emphasized at home and strong pressures to “blend in” with the dominant culture experienced at school (Shi & Lu, 2007). Clinicians need to evaluate their own cultural beliefs and expecta- tions in regards to the adolescent’s cultural identity. Although the adolescent may show signs of an adaptation to the dominant culture, an internal strug- gle of merging the dominant culture with the traditional one may still exist. Similarly, the parents may be struggling with similar cultural negotiation regarding parenting, where they are feeling pulled between the dominant culture’s approach to parenting and more traditional parenting methods. When the adolescent and parents do not operate on the same frequency in terms of acculturation, it can cause one to focus more on traditional values and the other on the Western, dominate values. As a result, both the exter- nal (parents versus adolescent) and internal (adolescent versus self) turmoil can lead adolescents to become overwhelmed and overworked; and thus, adding extensive pressures leading to depression.

Therapists who are not attuned to acculturation and assimilation factors could easily disregard the clients’ struggle with a bi-cultural identity, and mis- takenly assume that an individual must align oneself with only one cultural identity. This lack of awareness on the clinician’s part will further increase the client’s internal struggle, driving a wedge between therapist and client. The therapist needs ask self of the therapist questions such as: (1) What are my biases towards acculturation? (2) Do I have a personal preference

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for one culture over another? (3) What stereotypes do I already hold about Chinese culture in terms of values and how can I check those biases?. In addition, possible questions the therapist may want to bring up with the clients are: (1) What do I know about the acculturation differences within Chinese families?, (2) What more should I learn about acculturation in my client’s family?, and (3) How can I be open and learn more about my clients’ level of acculturation within their family context?.

Role of Academics

The clinician should also reflect on their personal values about academic achievement and its relative importance to healthy adolescent development when compared to other areas such as extracurricular activities, work, and socializing with friends. As presented previously, academics will be heav- ily emphasized by Chinese American parents; whereas, in many European American and other westernized families, importance is also given to sports, the arts, and social relationships (Moshman, 2009). Therefore, to a western- ized clinician, the overwhelming and exclusive importance placed on edu- cation by Chinese American families may seem unreasonable and unwise. The process of evaluating one’s own biases and being open to a discussion with the family creates a therapeutic environment where cultural differences are allowed to be presented openly. This meeting of two, potentially diver- gent opinions is crucial to the process of therapy as they relate to the mixed messages that the adolescent is receiving from both cultures. Before meet- ing with clients, the culturally competent therapist should ask the following questions: (1) What biases do I have towards academic achievement versus extracurricular activities and social relationships?, (2) How might these biases effect my treatment of my clients?, and (3) What stereotypes of academics do I have towards my clients before I even meet them?. In addition, the therapist should follow-up with these questions when assessing the Chinese family client: (1) What do I think I know about how academics functions within this family context?, (2) How do I let my clients know what I do know and how do I learn more about what I do not know?, and (3) How do I make this topic open and not neglect either sides when discussing the matter with my clients?.

THERAPIST SKILLS

Cognitive behavioral therapy (Chen & Davenport, 2005; Lin, 2002; Sandil, 2006) is presented here as this family therapy model appears to be well suited for the treatment of depression and for working with families of Chinese American ethnicity/culture. In relation to these and other topics, great care

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should be taken by the clinician to respect the family’s culture without push- ing his/her values on the family. The clinician is not expected to completely understand all of the client system’s cultural influences as they relate to family dynamics and mental disorder development, but the therapist is expected to provide time and space to discuss cultural disparities. In addition, the Chinese American family should not be expected to be suppressed by the dominant Western culture simply because mental health services may be a Western form of treatment. Instead, the culturally competent clinician helps the fam- ily explore the best forms of treatment that is both empirically sound and culturally sensitive. The therapist’s careful assessment and awareness of the function of the family’s emphasis on academic success will help him/her join with the family better and gain a better understanding of family dynamics.

Perception of Therapy

Considering that Chinese Americans underutilize mental health services and strongly adhere to stigmas associated with mental disorders, the family may have a different perception of what therapy entails and what the role of the therapist will be (Ta et al., 2010). Most often, Chinese Americans treat therapists as any other physician (Chen & Davenport, 2005; Ta et al., 2010); consequently, the therapist may be expected to take more of an expert po- sition with some pressure to quickly resolve the situation. Depending on how open a therapist is to the ‘expert role,’ it may be more efficient to address hierarchical dynamics between therapist and family early. Research has shown that solutions and interventions generated collaboratively with the family prove to be more effective and longer lasting than those given by the therapist alone (Chen & Davenport, 2005; Ta et al., 2010). The therapist would then need to deflect the expert role, and consult the family in setting goals and solutions. In order to do so, the therapist must elicit solutions from a top-down perspective, encouraging parents to generate solutions followed by giving opportunity to the adolescent as well. In doing so, the therapist respects the hierarchy of the Chinese American family and empowers col- laboration within the family unit. When faced with the resistance from the family to take the lead in generating solutions, the therapist can respectfully give the power back to the family by alluding to the power of the Chinese American family in family cohesion and better understanding of their own family characteristics.

Cognitive Behavioral Therapy

In terms of a treatment modality, cognitive behavioral therapy (CBT) resonates with Chinese American clinical populations and has been

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demonstrated to be an effective method of treatment due, in part, to its direct approach in challenging the problem (Chen & Davenport, 2005). In addition, the CBT model has also shown efficacy in adolescent depression (Sandil, 2006). Although, research on the effectiveness of CBT with the Chi- nese American population is lacking, there are several key conceptual rea- sons for the argued appropriateness of this therapy approach.

The directedness in confronting the presenting problem in CBT coin- cides with a value consistent with Chinese American culture. Because of the heavy stigma that is already associated with the depression, therapists are advised to confront the symptoms directly and quickly. In addition, since initial CBT sessions can focus on just the depressed individual, the rest of the family can be more or less exempt from any stigma, allowing them to “save face.” By equipping the adolescent with better coping strategies in the early stage of treatment, they will be less depressed and shamed and better equipped to participate in family sessions later.

When it comes to academic pressures and adolescent stressors, much of the time unrealistic expectations are placed upon the adolescent by him- self/herself (Leong et al., 1995). Often, the biggest obstacle for the adolescent becomes his or her own cognitive manifestations. When academic perfor- mance is involved, a heavy burden is placed on the adolescent in Chinese American culture to perform up to expectations of the parents. As a result, a significant portion of the depression is internalized and develops into the negative cognitive schemas that CBT addresses. By utilizing the cognitive re- structuring methodology to challenge those negative schemas, therapists can help adolescents battle those maladaptive thoughts. In addition, the positive thought training, time management, and goal setting exercises provides a means for challenging and/or substituting the negative schemas. In particu- lar, time management and goal setting are modules of treatment that would be directly applicable towards academic achievement pressures.

During the final stages of CBT treatment for adolescent depression, there is increased attention to the greater system such as the family and social networks (Chen & Davenport, 2005). In this stage of therapy, the therapist looks for areas in which the adolescent, who has been struggling with the depression alone, can gain social and family support to help maintain the changes that he or she has made. Systemic therapy proposes that a change in the individual will foster change within the family system (Lin, 2002). In this situation, the adolescent’s improvements can change the way the once- identified patient was perceived in the family system. An essential task by the therapist is helping the family recognize the cognitive changes the adolescent has made, and help the adolescent gain support from other familybreak; members.

Circular questioning allows for identifying how specific adolescent changes reflect the family and how positive change creates positive change within the family context. This intervention not only highlights the

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importance of how individual changes affect the family, but also helps the family rally behind the adolescent in support tapping into the family cohesion trait of Chinese American families. Cognitive restructuring techniques can be used to help the family create a dual-schema rather than only a singular per- spective on academics. When doing so, the therapist should allow both the parents and adolescent discuss their perspectives on academics in regards to the dominant culture and traditional values. The goal of this exercise would be for the therapist to facilitate a sense of empathy and understanding in re- gards to traditional and dominant cultural norms. Once both the parents and adolescent understand the original schemas held by the respective party, the therapist can better help them accept a more dual-schema, one built around incorporating both traditional and dominant cultural values into con- sideration. This technique helps family members change biased schemas by facilitating open discussion about one’s own schemas, shedding light into the inevitable biculturalism the family lives in.

CONCLUSION

Adolescent depression continues to be a constant issue for the mental health fields and all clinicians need to be aware of these factors as they treat this problem from a systemic perspective. In particular, therapists need to be aware of cultural sensitivities that would be unique to Chinese American families throughout the process of therapy with this population. The CBT model presented offer strategies and interventions that would be adaptive when combating depression brought on by academic pressures in Chinese American families. Although further research and development needs to be conducted for applying family therapy to this population, there are clear clinical recommendations presented here that can be used to better treat Chinese American adolescents struggling with academic pressures and de- pressive symptoms. It is our hope that these ideas will help aid an ethnic population has been under-utilizing the mental health system in generations past.

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