World Congress of Psychotherapy 2018, Amsterdam Multicultural Group Therapy for Asian Immigrants with Severe Mental Disorders Stephen Cheung, Psy.D. Department of Clinical Psychology Azusa Pacific University Azusa, CA 91702 Email: scheung@apu.edu Phone: 626-815-5008 ext. 5206
Introduction n I was a program director and a clinical psychologist at Asian Pacific Counseling and Treatment Centers (APCTC) in Los Angeles for 12 years. n Am a professor of clinical psychology at Azusa Pacific University (APU) in Los Angeles. n Have been teaching group therapy, family therapy, & brief therapy full-time for 14 years n Mentoring students in clinical family psychology and multicultural psychotherapy n Maintaining a private practice and 2
n Writing about clinical family psychology and multicultural psychotherapy especially on Asian American immigrant mental health, etc. 3
Your Background & Expectations of Group Therapy with Asian Immigrants n Who are conducting group therapy with Asian immigrants? Or individual therapy with them? n What kind of group therapy have you provided? n What kind of training on group therapy with Asian immigrants have you received so far? n Do you have any burning questions for me in this workshop? 4
Outline of Workshop n Asian immigrants in group therapy n Multicultural group therapy for Asian immigrants with severe mental disorders n Clinical examples n Experiential exercises n Questions and answers 5
Asian Immigrants in Group Therapy/Mental Health Treatment Some personal and interpersonal characteristics: n Don t know much about mental health services and are skeptical of the therapeutic process, etc. n Are willing to pay for their physical health services, but may be less willing to spend their financial resources on mental health services. n Family orientation: Collectivist worldviews (e.g., seeing personal problems in a familial context, tendency to avoid conflict to preserve harmony, 6 etc.).
n Defer to authority (the therapist as the expert) n Practical and outcome-oriented Want you to fix their problems and want an instant cure. n Find seeing a therapist stigmatizing, and may want to save face and may not disclose their serious problems to the therapist. n Less expressive of emotions and may be more comfortable with thoughts and behaviors. n Written homework likely prefer action-oriented tasks versus self-reflective ones, etc. (Cheung, 2016; Hong & Ham, 2001; Lee, 1997). Certainly there are variations in Asian immigrant communities. 7
What are the help-seeking patterns of Asian Immigrants? They tend to underutilize mental health services; they are difficult to reach and serve because of: n Familism n Stigma in seeking mental health help n Lack of knowledge of mental health and its service delivery system n Language and cultural barriers n Resource accessing problems, etc. (Cheung, 2009a). 8
What else does the literature say about Asian immigrants (AI) in group therapy? n The earlier clinical literature reported that Asian immigrants either did not volunteer to participate in mental health services including group therapy or they would drop out of them prematurely. n It was because of the cultural stigma of mental illnesses and such cultural value as familism in the Asian immigrant communities. 9
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n In recent decades, multicultural psychotherapy indicated that Asian immigrants would receive mental health services and benefit enormously from group therapy, if these services are provided in a culturally congruent manner (Cheung, 2001, 2005, 2009; Hong & Ham, 2001). 11
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How can we provide culturally congruent mental health services to Asian immigrants? n By being informed by multicultural therapy. 13
What is multicultural therapy? n Multicultural therapy takes into consideration diversity in race, ethnicity, spirituality, sexual orientation, disabilities, and class, as well as the potential cultural bias of practitioners. n There is no single multicultural therapy, but multicultural theory has influenced many psychotherapeutic approaches to be more sensitive to the history of the oppressed and marginalized, acculturation issues, and the politics of power (Vasquez, 2010). 14
6 Propositions of Multicultural Counseling & Therapy (MCT) 1. MCT is an integrative metatheory of counseling & therapy Each helping theory represents a different worldview and can foster psychological health in different ways. 2. Counselor and client identities are formed and embedded in multiple levels of experiences (individual, group, and universal experiences) and contexts (individual, family, and cultural). The totality and interrelationship of these experiences and contexts need to be considered in any treatment plan. 15
3. Cultural identity development is a major determinant of both the counselor s and the client s beliefs and attitudes toward oneself, other persons in the same group, and other persons in different cultural/racial groups The level or stage of a client s cultural/racial identity development influences how the client and counselor define the problem presented in therapy and dictates what they believe to be appropriate goals in counseling. 16
Cultural/Racial Identity Development n Naiveté n Encounter n Naming n Reflection on self as a cultural being, and n Multiperspective internalization (Ivey et al., 2007; Sue & Sue, 2016). 17
4. Counseling and therapy s effectiveness is enhanced when the counselor uses techniques, strategies, and goals that are consistent with the client s cultural/racial identity, life experiences and values. No single helping approach or intervention strategy is equally effective across all populations and client situations. 18
5. MCT stresses the importance of multiple helping roles and strategies that are employed by many culturally diverse individuals, groups, and societies The conventional Western counseling and psychotherapy represents only one of many theoretical techniques and strategies available to the helping professional. These additional helping approaches extend beyond one-on-one therapy and include traditional healing practices, outreach strategies, systems interventions, and prevention interventions involving persons in the client s family, cultural community, and larger social units in which she or he is situated. 19
6. The liberation of consciousness is a basic goal of MCT MCT emphasizes the importance of expanding personal, family, group, and organizational consciousness of self-in-relation, family-in-relation, and organization-in-relation. Thus, MCT is ultimately contextual in orientation and draws from traditional methods of healing as well as knowledge presented by feminist and relational-cultural theorists (Ivey et al., 2007, pp. 363, 369, 379, 384, 387, 388, & 392). 20
*Some Therapeutic Principles n Multicultural competence n Triple A: -Assessment of cultural identity & Acculturation (a dynamic process and can move from one point on a continuum to another over time) -Adaptation of Western therapy concepts and skills to AI n A Some-knowing and a Not-knowing therapeutic stance (Cheung, 2009a, 2011, 2013, 2016). 21
n Awareness Multicultural Competence n Knowledge, & n Skills (Pedersen, Draguns, Lonner, & Trimble, 2002; Sue & Sue, 2016). 22
Awareness n Oneself, others, and the relationship between oneself and others. n Would help one avoid personal, cultural, and theoretical countertransference 23
Knowledge n Asian immigrants collectivist cultural worldviews, values, customs and practices, etc. (McGoldrick, Giordano, & Garcia-Preto, 2005). n Impact of migration on the family life cycle. n Socio-emotional reality of Asian immigrants (Cheung, 2009a, 2016; Sluzki, 1979, 2008). n Acculturation and acculturative stress. n Expectations of therapy, the therapist, and themselves in therapy. n More culturally congruent therapeutic elements and how to adapt them in a culturally competent 24 manner (Cheung, 2015, 2016, 2018, in submission).
Impact of Migration on Family Life Cycle Experiences for Asian Immigrants n When Asian immigrants immigrate to the host countries, they experience multiple material and emotional losses. For instance, they have to leave behind their loved ones, possessions, familiar lifestyle, and cultural norms and practices, etc. 25
n Upon arrival in the host countries, AI adjust to the socio-cultural reality of the host country without their customary social support network. n In addition, they encounter multifarious forms of acculturative stress (e.g., linguistic challenges, cultural shock, under-employment, or even unemployment, role redefinition in one s family, migration effects on one s identity, etc.) (Cheung, 2009a, 2013, in submission). 26
n Simultaneously, they continue to make transitions in their family life cycle with much less social support and cultural validation, but with more cultural dissonance. n Like others, they also have adapt to the expected and unexpected life cycle events. n They are often confronted with a two-fold challenge: -What part of their cultural heritage to keep and -What part of social customs and cultural values of the host country to adopt. 27
Socio-emotional Reality of Asian Immigrants In addition to the multiple losses and adjustments to the host country, Asian immigrants may have to deal with n Impact of their pre-, actual, and post-migration experiences n Unique acculturative stress n Interpersonal and macro-systemic dynamics, etc. (Certainly there are individual/intragroup differences.) 28
Unique Acculturative Stress n Cultural shock and more immense adaptation depending on the similarities and differences between the host country and their country of origin. n Language and cultural barriers. n A myriad of adjustments to school, work, daily life, relationships, etc. n Acculturation gap between generations are quite common and can lead to intergenerational conflict (Cheung, 2001, 2009a, 2013, 2014, 2016). 29
Expectations of Therapy n Seeing a shrink is their last resort because mental disorders are enormously stigmatizing. They have their own expectations of n *Therapy goals, process, and outcomes n *The therapist and n *Themselves (Cheung & Hong, 2005; Cheung, 2009a, 2016) 30
Skills n To assess the cultural identity and acculturation of Asian immigrants (AI) and adapt our Western psychotherapy approaches to their problems, needs, and expectations in a culturally relevant manner. n Perspective-taking n To use oneself and one s relationship with AI. n To achieve a working relationship and results for them. 31
Assess your client s cultural identity and acculturation to the Western psychotherapy By observing and by listening and asking for their n Preferred food n Preferred language used at home n Preferred TV programs watched at home n Festivals and holidays observed n Cultural identification n Ethnic and cultural pride n Child rearing practice 32
n Pre-migration, migration, and post-migration experiences n Immigration status temporary or permanent n Age at the time of immigration n Past and present exposure to Western cultures n Ethnic density of the neighborhood n Socioeconomic status and profession, etc. (Cheung, 2009a). n According to your findings, adjust your Western psychotherapeutic knowledge and skills to your AI client in a culturally competent manner. 33
Know How to Use the Therapy Components that are More Culturally Congruent with Your Clients n Structured group therapy component n Psycho-educational group component n Modified interactional support group component (Cheung, 2005, 2016). 34
Structured Group Therapy Component n The therapist would impose a structure such as a didactic lecture, teaching some skills, providing some questions for discussion, and experiential activities, etc. n The goal of teaching the group members some knowledge or skills is to give them some skills to use outside of the group. 35
n The rationale: Providing structure will meet Asian immigrants cultural expectations of a therapist: --The client with Asian cultural identification expects the therapist (the expert) to help the client to solve his/her problems like an elder/teacher/ mentor. --The client expects the therapist to teach him/her some skills and/or instruct him/her to engage in some action-oriented solutions to solve his/her problems. 36
--Therefore, when engaging the client in some didactic lectures, structured learning activities, experiential exercises, skills acquisition efforts, etc., the therapist would show the client (who seeks relief of his/her symptoms/suffering) that: -The therapist as the expert is in charge; -The therapist knows what s/he is doing and is directing. -The client is receiving some direct help from the expert; -The client is learning something practical and concrete like knowledge and skills from the expert. 37
An example of the therapist killers n Select and prepare members n One-stop service n Culturally appropriate accommodation n Some structure n Some supportive process 38
Psychoeducational Group Therapy Component n The therapist would provide some psychoeducation on the mental disorders or issues in the name of education or a class to Asian immigrants. n The goal of the psychoeducational group component is to engage the client and offer him/ her some useful information on his/her issues and ways to manage them. 39
n The rationale: It is less culturally stigmatizing to attend a class than to go for mental health treatment. n The group process: The client will feel supported, encouraged, and helped through the group process. n An example of the family support group for family members who have a member who suffers from severe mental disorders parenting support group, etc. 40
An example of Family Support Group n Invited a Japanese professor and his wife to speak in order to jump start a family support group for Chinese family members who have a member that is dealing with severe mental disorders. n Provided psychoeducation as a structure component for the group. n Employed supportive group processes. 41
Modified Interactional Support Group Component n Overview: --Irvin Yalom promulgated his well-known interactional group therapy model that utilizes therapeutic factors in group therapy. --He stresses the importance of bringing group members to the here and now and illuminating the here-and-now interactional processes between and among members. 42
n Compatibility with Asian Cultural Expectations: --Powerfully therapeutic as Yalom s outpatient interactional group therapy is for European Americans, in its purist form, it is incompatible with Asian immigrants cultural expectations. --In order to be effective, the therapist will have to adapt Yalom s interactional group therapy model in a culturally competent fashion to meet the client s expectations and needs. 43
To be culturally consonant, the therapist may n Emphasize support rather than free expression of the here-and-now feelings. n Take charge more at least initially by providing some group structure (e.g., asking questions to give some directions, initiating structured activities/exercises such as Tai Chi, etc.) rather than promoting free floating and confrontational interactions among group members. n Encourages support, learning, and sharing among members. n Models and teaches effective communication as a teacher/mentor/coach, etc. 44
n Supportively and actively connects members to one another via similarity bridging, etc. n Provides psycho-education, education, questions, process commentaries, a group historian s perspective, and timely encapsulated summaries, if appropriate, etc.) in the group sessions. n Knows what, when, and how to inquire more information from members in a culturally compatible manner 45
n One can develop cultural competence via Paul Pedersen s tripartite model of awareness, knowledge, and skills. n Through *immersion, training, reading, supervised practice, and consultation, one can examine one s biases, stereotypes, and prejudices and acquire cultural knowledge and skills in order to better serve one s clients. n This requires some time and effort to attain cultural competence: *To take a humble onedown position to learn from one s clients; admit one s mistakes, learn from them and move forward with them. 46
An example of a support group for various mental disorders n Select and prepare group members n Invited an older member to teach Tai Chi as a structured activity in the beginning of each group session n Facilitated support and encouragement for group members by utilizing the therapeutic factors of universality, instillation of hope, altruism, group cohesiveness, etc. 47
More Clinical Examples n *How to adapt to a CBT group for depression. n Just discussed how to provide support to a group of Asian immigrants struggling with depression, schizophrenia and social isolation. n Discussed earlier about how to select, prepare and implement treatment in a culturally congruent manner with a group of therapist killers. n Reported earlier on how to provide support to a group of family members who have a family member that is suffering from schizophrenia or depression. 48
Experiential Exercise: Planning for Groups & Preparing Members n 20 Korean/Vietnamese/Filipino/Asian Indian/ Chinese clients with mood, anxiety and posttraumatic stress disorders. n Design a group treatment program with different groups for them: --Assign different clients to different groups. --Plan for the purpose, content, format, title, procedures, location, frequency, etc. of each of the groups. 49
n Think through the rationale and the steps of what you would do in the group. n Consider the assets and liabilities in your cotherapy team, group members, and your agency, etc. in designing your program. n Please feel free to change the diagnoses, preferred language, age and characteristics of the clients to form your groups. 50
Group Planning Discussion n The key elements to consider are: --Language --Culture and ethnicity including religion --Age --Gender --Purpose of the group based on the needs of your clients (e.g., characteristics, symptoms, behaviors, diagnosis, presenting problems, and specific life challenges, etc.) --Inter-ethnic conflict --Political tension, world events, etc. 51
Do you have any creative ideas for groups for your clients? 52
Conclusion Continue to develop cultural competence on the one hand and group therapy skills on the other. To develop cultural competence is a life-long process. You can develop it by studying relevant materials on your own, attending training, immersion, supervision, and consultation, etc. 53
Selected References Beck, A., Rush, A., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Beck, J. S. (2011). Cognitive therapy: Basics and beyond. New York: Guilford Press. Cheung, S. (2001). Problem-solving and solutionfocused therapy for Chinese: Recent developments. Asian Journal of Counselling, 8(2), 111 128. 54
Cheung, S. (2009a). Asian American immigrant mental health: Current status and future directions. In Jean Lau Chin (Ed.), Diversity in mind and in action (Vol. 1, pp. 87-104). New York: Praeger Press. Cheung, S. (2009b). Solution-focused brief therapy. In J. Bray & M. Stanton (Eds.), The Wiley-Blackwell handbook of family psychology (pp. 212-225). United Kingdom: Wiley-Blackwell. Cheung, S. (2013, August). Solution-focused therapy for immigrant families at critical life cycle stages. Paper presented at the American Psychological Association Annual Convention, 55 Honolulu, HI.
Cheung, S., Lesser, I., & Cheung, F. (2014). Training in Asian American Mental Health: Past, Present, and Future. In M. Lin, S. Keo, & J. Kim (Eds.), Commemoration of the Twentieth Anniversary of the Annual Asian American Mental Health Training Conference (pp. 26-28). Los Angeles: Consortium on Asian American Mental Health Training. Cheung, S. (2014, October). Family therapy with Asian Americans: Principles and practice. Workshop presented at the 20th Annual Asian American Mental Health Training Conference, Alhambra, CA. 56
Cheung, S. (2015, April). Treating depression among Asian American communities. A training workshop presented at the Los Angeles County Department of Mental Health (LACDMH), Los Angeles, CA. Cheung, S. (2015, August). Family therapy for intergenerational conflict in Asian American immigrant families. Paper presented at the American Psychological Association Annual Convention, Toronto, ON, Canada. 57
De Jong, P. & Berg, I. K. (2013). Interviewing for solutions (4th ed.). Belmont, CA: Thomson Higher Education. McFarlane, W. R. (2002). Multifamily groups in treatment of severe psychiatric disorders. New York: The Guilford Press. Yalom, I. D. (2005). The theory and practice of group psychotherapy (5 th ed.). New York: Basic Books. 58