Academic Psychiatry
Journal Home Search Current Issue Past Issues Subscribe All APPI Journals Help Contact Us
 
Quicksearch
Advanced Search
Or Search All APPI Journals
This Article
* Abstract Freely available
* Full Text (PDF)
* Alert me when this article is cited
* Alert me if a correction is posted
* Citation Map
Services
* Email this article to a Colleague
* Similar articles in this journal
* Similar articles in PubMed
* Alert me to new issues of the journal
* Add to My Articles & Searches
* Download to citation manager
* reprints & permissions
Citing Articles
* Citing Articles via Google Scholar
Google Scholar
* Articles by Lu, F. G.
* Articles by Lin, K.-M.
* Search for Related Content
PubMed
* PubMed Citation
* Articles by Lu, F. G.
* Articles by Lin, K.-M.
Related Collections
* Cross-Cultural Psychiatry
* Education, Psychiatrists
Academic Psychiatry 26:225-236, December 2002
© 2002 Academic Psychiatry

A Psychiatric Residency Curriculum About Asian-American Issues

Francis G. Lu, M.D., Nang Du, M.D., Albert Gaw, M.D. and Keh-Ming Lin, M.D., M.P.H.

The authors are members of the Committee of Asian-American Psychiatrists of the American Psychiatric Association. Dr. Du is Associate Clinical Professor and Drs. Lu and Gaw are Clinical Professors of Psychiatry at the University of California, San Francisco. Dr. Lin is Professor of Psychiatry at the University of California, Los Angeles. Address correspondence to Dr. Du, San Francisco General Hospital, Unit 7C, 1001 Potrero Avenue, San Francisco, CA 94110.


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 RATIONALES
 DEMOGRAPHIC AND CULTURAL...
 EDUCATIONAL OBJECTIVES
 LEARNING EXPERIENCES
 SPECIAL CONSIDERATIONS
 CONCLUSION
 REFERENCES
 
Asian Americans constitute the third-largest and the fastest-growing minority group in the United States, with a population of 10.2 to 11.9 million in Census 2000. It is a heterogeneous group that includes at least 43 ethnic subgroups with different languages and dialects, immigration patterns, and religious beliefs; varying socioeconomic status; and different traditional patterns of seeking health care. These social and cultural variables affect Asian Americans' help-seeking behaviors, development of psychiatric disorders, manifestation of psychiatric symptoms, treatment strategies, compliance, and outcomes. This article reviews experiences of Asian Americans relevant to their mental health, including migration patterns to the United States, socioeconomic status, and cultural variables. It proposes educational objectives in the assessment and treatment of Asian-American patients that are essential for the training of psychiatric residents. In particular, it addresses special considerations in implementation of a psychiatric curriculum directed to the care of Asian-American psychiatric patients.

Key Words: Residency Curricula • Asian-American Issues • Culture and Ethnicity

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
RATIONALES
 DEMOGRAPHIC AND CULTURAL...
 EDUCATIONAL OBJECTIVES
 LEARNING EXPERIENCES
 SPECIAL CONSIDERATIONS
 CONCLUSION
 REFERENCES
 
During the past two decades, numerous studies in cross-cultural anthropology, social sciences, and psychiatry with regard to Asian cultures have collectively provided a better understanding of how sociocultural influences and biological factors affect Asian-American mental health. Unfortunately, this body of new knowledge has not yet been fully incorporated into psychiatry residency training programs. Many graduating residents have not acquired adequate basic knowledge and skills to reliably diagnose and treat Asian-American patients. The recent advances in the areas of anthropology, social sciences, and ethnopsychopharmacology in the care of Asian-American patients have seldom been translated into systematic teaching of these subjects in psychiatric training curricula.

In this article we propose a biopsychosociocultural approach to understanding and caring for Asian-American patients. Consistent with the format of published residency curricula written by members of the American Psychiatric Association's committees on minority and underrepresented populations (1–4), we synthesize the information about mental health care for Asian-American patients and propose a curriculum that includes Asian-American demography, immigrant experience, and socioeconomic and cultural issues. In addition, we outline educational objectives and learning experiences and discuss special considerations in implementing such a curriculum in a general residency training program.


  RATIONALES

 
TOP
 ABSTRACT
 INTRODUCTION
 RATIONALES
DEMOGRAPHIC AND CULTURAL...
 EDUCATIONAL OBJECTIVES
 LEARNING EXPERIENCES
 SPECIAL CONSIDERATIONS
 CONCLUSION
 REFERENCES
 
There are several reasons to include an Asian-American psychiatric curriculum in psychiatric residency training programs.

First, the Asian-American population is the fastest-growing minority group in the United States. The past two decades have seen the number of Asian Americans in the United States nearly double in each decade. This trend of population growth is likely to continue in the 21st century. Asian-American population in 2050 is projected to be approximately 37.6 million (5). Psychiatrists who are planning to practice in states along the West and East Coasts of the United States and in metropolitan areas where a substantial number of Asian Americans reside need to learn how to provide reliable assessments and treatments for this population.

Second, Asian Americans constitute one of the most diverse minority groups in the United States. There are at least 43 Asian American and Pacific Islander subgroups in the United States (6). Although many of these subgroups share an important cultural heritage, there are striking diversities among them. Cultural factors such as religions and cultural beliefs (7–9), degree of acculturation, socioeconomic adaptation, educational achievements (10–12), patterns of immigration (13), traumatic experiences (14,15), family dynamics (16,17), and help-seeking behaviors (18–20) strongly influence patterns of aberrant behaviors and psychopathology of each group. Biologically, Asian-American psychiatric patients have been found to respond to psychotropic medication in ways that differ from responses in Caucasian, Hispanic, and African-American groups as a result of their genetic enzymatic makeup (21–23). Knowledge about these issues will assist psychiatrists in providing culturally competent care.

Third, recent advances in communication technology, the expansion of the global economy, and ease of travel have drawn peoples from different continents closer. Future psychiatrists will be called upon for assessment and treatment of people of various cultural backgrounds in different geographic settings. Because Asians comprise more than 50% of the earth's population, knowledge of Asian-American issues becomes significantly more relevant for psychiatrists who may assume global practices (18).

Fourth, several public policy papers and educational reports have highlighted the importance of addressing sociocultural diversity in health care in the U.S. society. In 1978, the President's Commission on Mental Health, Subpanel on Asian and Pacific Islanders, urged the incorporation of Asian-American and Pacific Islander issues in the training curriculum of mental health professionals (24). In 1991, the Council on Medical Education and Career Development of the American Psychiatric Association emphasized the requirement that residency training in psychiatry ensure competency in the care of patients from diverse cultural backgrounds and to provide residents with knowledge of American culture and subcultures (25). In 1993, the American Medical Association's Directory of Graduate Medical Education Programs recommended integrating cultural issues into residency training programs and teaching residents how to conceptualize illnesses from biological, psychological, and sociocultural perspectives (26). Finally, the 2001 Accreditation Council for Graduate Medical Education (ACGME) Program Requirement for Psychiatric Residency Training required that didactic curriculum include topics such as ethnicity, especially when they are relevant to the programs' local communities.


  DEMOGRAPHIC AND CULTURAL VARIABLES

 
TOP
 ABSTRACT
 INTRODUCTION
 RATIONALES
 DEMOGRAPHIC AND CULTURAL...
EDUCATIONAL OBJECTIVES
 LEARNING EXPERIENCES
 SPECIAL CONSIDERATIONS
 CONCLUSION
 REFERENCES
 
Although Asian Americans and Pacific Islanders comprise more than 43 ethnic groups (6), limitation of space allows us to focus on only the largest Asian groups as categorized in the 1990 and 2000 U.S. Census (27). Yet we hope that an understanding of sociocultural factors in these groups can be extended to other Asian groups as well.

Overview of the Asian-American Population
In 1970, the Asian-American population was reported to be 1.5 million. By 1980, this population had exploded to 3.5 million. Between 1980 and 1990, it grew by 95% to 7.2 million. In Census 2000 this group reached 10.2 million (Asian alone) to 11.9 million (Asian alone or in combination with other races) (28). Most Asian Americans are concentrated in metropolitan areas and in populous states such as California, New York, Hawaii, Texas, New Jersey, Illinois, Washington, Florida, Virginia, and Massachusetts. Los Angeles County, California, and Honolulu County, Hawaii, are the U.S. counties with the largest numbers of Asian Americans. Some locales in Hawaii and California have shown a significant rise in Asian-American population. In Honolulu, Kauai, and Maui, for example, Asian Americans comprise more than 50% of the population. Thirty-six percent of San Francisco's population and 22% of the population of the "Silicon Valley" (vicinity of Santa Clara, CA) consist of Asian Americans (5).

Immigration Patterns
Asian Americans have come to the United States at different periods, by different routes, and under different circumstances. Furthermore, U.S. domestic and foreign policies and the global political and economic events have strongly influenced Asian-American immigration and population growth in the United States. Some came for economic reasons, others for freedom and safe haven. Many Asian Americans who fled their home countries suffered traumatic experiences caused by famine, war, political imprisonment, and persecution. In general, Asian-American immigration history can be roughly divided into three periods:

The Period of Pioneer Asian Immigrants (1849–1945):
The Chinese were the first Asians to immigrate to the United States, beginning in 1849. Next came large numbers of Japanese immigrants, beginning in 1880 (16,17,29). Waves of Filipinos began to come to Hawaii and the West Coast during the 1900s (13). These early Asian immigrants came to escape the economic hardships and political turmoil in their home countries and to seek better lives for themselves and their families. They were employed as hand laborers by sugar plantations in Hawaii; by farms in Oregon, Washington, California, and Hawaii; by gold mines during the Gold Rush; and by railroad companies during the construction of the U.S. transcontinental railway. Economic and political changes in the United States led to imposition of discriminatory laws and harassment of these first Asian Americans, a pattern that was to continue for nearly 100 years. Several Exclusion Acts and Immigration and Naturalization Acts from 1866 to 1945 forbade the Chinese and Japanese and other Asian immigrants to bring their wives and children, to possess land, or to become American citizens. These discriminatory policies resulted in a population decline among Asians in the United States, a shattering of their traditional family structures, and a disruption of the balance of genders in their communities. Many Asians were prevented from obtaining jobs commensurate with their skill levels. The most traumatic discriminatory event occurred with the implementation of Executive Order 9066 in 1942 that forced more than 100,000 Japanese Americans into internment camps during World War II. The traumatic concentration camp experiences have had a lasting emotional effect on the first (Issei), second (Nisei), and later generations of Japanese Americans (13,29,30).

The Period of Reunion and Reform (1945–1965):
World War II provided an opportunity for great numbers of Asian Americans to demonstrate their loyalty to the United States. Despite harsh treatment from the government, thousands of Chinese, Filipino, and especially Japanese Americans joined the military to fight (13). Asian Americans' participation in the Allied war campaign against Nazi Germany and Japan led to a more favorable attitude toward Asians in America. The U.S. Congress eventually repealed the Chinese Exclusion Acts in 1943. The subsequent enactment of the War Brides Act in 1945 allowed many Chinese and Japanese wives of Asian-American and American servicemen to come to the United States. These reunions resulted in the restoration of family units and relieved the disruption of family structure experienced by earlier Asian communities. The Refugee Relief Act in 1953 facilitated the acceptance of Chinese refugees who had escaped from Communist China. Many of these refugees were highly educated Chinese (13,17).

The Period of Economic Immigrants and Political Refugees (1965–present):
The civil rights movements of the 1960s had a significant beneficial influence on U.S. immigration policy (13). The Immigration and Naturalization Act Amendments of 1965 equalized immigration quotas between the Eastern and Western hemispheres, established a fair system for admission of immigrants, and allowed especially young, well-educated, professional worker immigrants from the Philippines, Korea, and India to come to the United States (13,31–33). These new skilled immigrants assisted in the expansion of the U.S. economy during the late 1960s and the 1970s. From 1980 to the present, the number of Asian Indians in the United States has increased by more than 100%. This new wave of South Asian immigrants comprises mostly family members of the Asian Indian professionals who came to the United States during the 1960s (33,34).

This period also witnessed the influx of war refugees and political refugees. At the end of the Vietnam war in 1975, hundred of thousands of Indochinese refugees fled the Communist forces. Indochinese refugees from Vietnam, Cambodia, and Laos experienced untold trauma both during the war and in being uprooted from their war-torn countries. They risked their lives on dangerous journeys to escape Communist regimes. After the massacre in Tiananmen Square in June 1989 and subsequent crackdown on democratic movements in China, many Chinese scholars and students sought political asylum in the United States. Recently, many Hong Kong immigrants chose to come to the U.S. for fear of living under the Chinese Communist regime when the British government returned Hong Kong to China in 1997 (35). Refugees who seek asylum in the United States face tremendous stress in adjusting and adapting to life in America (11,13,36–41).

Socioeconomic, Educational, and Cultural Variables
Asian Americans are a large, heterogeneous group whose subgroups differ in socioeconomic status, educational achievements, and cultural characteristics. Other important cultural identity variables include age, gender, sexual orientation, and religious/spiritual beliefs. These variables have influenced Asian Americans' acculturation processes, development of mental health problems, help-seeking behaviors, access to health care, and compliance with treatment.

In terms of socioeconomic status, Asian-American families, as a whole, have higher median family income ($51,205) than all other U.S. ethnic groups ($40,816), primarily as a result of higher educational achievement and having more family members in the labor force (5,28). However, as individuals, the average per capita income of Asians is lower than national per capita income. Recently the poverty rate of Asian Americans decreased to 10.2% in 1999 from 12.5% in 1998 (28). In 1990, information on poverty rates showed variation among specific groups. The poverty rates were 6% for Filipino, 7% for Japanese, 10% for Asian Indian, and 14% for Chinese and Korean Americans. The Southeast Asian Americans were the poorest, with 64% among Hmong, 43% among Cambodian, 35% among Laotian, and 26% among Vietnamese individuals (27).

Although Asian-American cultures highly value educational achievement, its attainment differs widely among different Asian groups. The percentage of completion of high school or higher is 88% for Japanese, compared with 31% for Hmong. At the college level, 38% of Asian Americans receive a bachelor's degree or higher, compared with 20% of the total population. Asian Indians have the highest achievement rates, and Cambodians, Laotians, and Hmong have the lowest (27).

Asian-American subgroups share many characteristics but also have great diversity. They speak different languages and follow various religious beliefs. The majority of Asian-American subgroups are influenced by two distinct civilizations: Chinese and Indian cultures. Chinese Confucian, Buddhist, and Taoist philosophies exert a strong influence on social, family, and individual values, literature, art, and languages among Japanese, Korean, Vietnamese, Mien (Laotian), and Hmong traditional societies. The Japanese, Korean, and old Vietnamese (chu nom) scripts were derived from Chinese ideographs. The current Vietnamese romanized written language was not developed until the 17th century, when French and Portuguese missionaries introduced it for use in evangelism (36). The Mien and Hmong have no indigenous written script. They rely on oral history and tradition to transmit their culture from one generation to another. Their shamans keep their intellectual and cultural records in written Chinese characters (38). Cambodian and Laotian cultures are deeply rooted in Asian Indian civilization. The Cambodian written language is derived from Sanskrit script, and the Laotians use Pali script (37,38).

In terms of religion, many Chinese, Japanese, Koreans, and Vietnamese worship their ancestors and believe in Mahayana Buddhism. Many Japanese Americans follow Shintoism and Zen Buddhism. Filipino Americans are mostly Catholic. More than 70% of Koreans in the United States are Protestant Christians. The Hmong and Mien mostly believe in animistic and supernatural causes. The Cambodians and Laotians are followers of Brahmanism of the Hindus and Theravada Buddhism (37,38). Among Asian Indians, Hinduism is the major religion (33,42). The Pakistanis are mostly followers of Islam.

In summary, Asian-American groups have many common socioeconomic, educational, and cultural characteristics, but they also show distinctive differences. Understanding Asian-American diversities will help to dispel stereotypes about Asian Americans as a homogeneous group. Each Asian-American ethnic group has its own unique characteristics, and each person must be assessed individually.


  EDUCATIONAL OBJECTIVES

 
TOP
 ABSTRACT
 INTRODUCTION
 RATIONALES
 DEMOGRAPHIC AND CULTURAL...
 EDUCATIONAL OBJECTIVES
LEARNING EXPERIENCES
 SPECIAL CONSIDERATIONS
 CONCLUSION
 REFERENCES
 
By the end of their residency training, all residents should successfully acquire the following essential knowledge, skills, and attitudes concerning the psychiatric care of Asian-American patients and their families. (For suggested core readings for use in teaching, see Appendix A.)


View this table:
[in this window]
[in a new window]
 

APPENDIX A. Suggested core readings in Asian-American issues



Knowledge
The resident should be able to demonstrate an adequate understanding of the following:

  1. The history of major groups of Asian Americans in the United States and their immigration histories, experiences, and stresses in adjustment and acculturation in the U.S. (13,17,29).
  2. The diversities of Asian-American population based on country of origin, language, religious/spiritual beliefs, age, gender, sexual orientation, and socioeconomic status (13,27).
  3. The histories and experiences of migration of recent Asian-American immigrants and refugees. This should include their premigration, migration, and postmigration histories and experiences (11–13,39–41,43).
  4. Asian-American family life cycles and dynamics in the process of adaptation as well as maladaptation (17).
  5. Asian-American individual life cycles. This should include the following:
  6. Psychological development of immigrant and refugee children (44).
  7. The generation gap issues such as those concerning the Japanese Issei (1st generation), Nisei (2nd), Sansei (3rd), and Yonsei (4th) (30).
  8. The "1.5" Korean generation (45).
  9. The Southeast Asian refugee children who witnessed and experienced traumatic events in their homelands (46–48).
  10. Psychiatric issues involving elderly Asian Americans (49,50), including the intergenerational conflicts (51,52).
  11. Asian-American explanatory belief systems for illness and psychiatric disorders (8,9). These beliefs are thought to be associated with the expression of illness, such as the pattern of somatization and the concept of neurasthenia (53,54), and with help-seeking behaviors (19,20).
  12. Asian-American culture-bound syndromes that appear exotic and confusing to Western psychiatry and can cause misdiagnosis. Some of the better-studied syndromes are koro, hwa-byung, amok, latah, taijin kyofusho, and dhat (55–58).
  13. Cultural issues in the assessment of Asian-American patients (16); the use of interpreters (59–61); limitation and use of existing psychological tests (62); use of culturally oriented psychological tests for depression and anxiety (63,64); and posttraumatic stress disorder (PTSD) (65).
  14. Cultural issues in individual, family, and group psychotherapy with Asian Americans (16,17); proposed models of psychotherapy for Asian Americans (66,67); and awareness of transference and countertransference issues in therapy with Asian Americans (68).
  15. Awareness of Asian indigenous and alternative treatment methods such as Morita and Naikan therapies (69,70), traditional herbal medication, acupuncture, coining, meditation, use of shaman, religious rituals, and mourning rituals (7,8,71–78).
  16. Knowledge of Asian-American ethnic differences in psychopharmacology, including pharmacogenetics, pharmacokinetics, and pharmacodynamics, and their effects on dosages and side-effect profiles (21–23,79,80).
  17. Knowledge of cultural factors such as cultural beliefs, family dynamics, adaptation to stresses, and expectations that affect clinical courses and outcomes of psychiatric disorders among Asian Americans (9,81,82).
  18. Knowledge of the variations of prevalence rates for major psychiatric disorders among Asian Americans. For instance, severe depression and PTSD are prominent among the Indochinese groups (43).
  19. Substance abuse issues among Asian Americans, especially among Asian-American youth and the mentally ill (83–85).
  20. Gay and lesbian issues among Asian Americans (86,87).
  21. Asian-American women's issues. Asian-American women have not yet received the attention they deserved in studies and research even though they face tremendous stress during the acculturation process (88,89).

Skills
Psychiatric residents should demonstrate competence in the following skills in working with Asian-American patients:

  1. Interviewing technique for elicitation of pertinent psychosocial data, family history, migration experience, and cultural beliefs used to explain psychiatric symptoms (90).
  2. Appropriate use of interpreters to obtain clinical information from non–English-speaking Asian patients (59–61).
  3. Administration of culturally sensitive psychological questionnaires as tools for diagnosis (62–65).
  4. Ability to apply Asian cultural knowledge to provide comprehensive assessments of psychopathology among Asian Americans and to formulate the case based on the DSM-IV Outline for Cultural Formulation (90).
  5. Ability to provide culturally competent psychotherapeutic and appropriate psychopharmacologic interventions (16,17,21).
  6. Ability to provide culturally competent psychoeducational and social approaches for Asian-American patients and their families.

Attitudes
The residents should demonstrate the following through their behavior and demeanor:

  1. Sensitivity to current Asian-American-directed cultural, ethnic, and racial stereotypes and know-how to counteract these biases in contacts with Asian-American patients. Cultural-sensitivity experiential groups based on the work of Elaine Pinderhughes have been very useful in allowing residents to explore their own ethnic backgrounds as well as assumptions and stereotypes about others (91).
  2. Awareness of the countertransference and transference issues that may affect evaluation and treatment while working with Asian-American patients (68,92).
  3. Provision of compassionate and respectful care for Asian-American patients.


  LEARNING EXPERIENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 RATIONALES
 DEMOGRAPHIC AND CULTURAL...
 EDUCATIONAL OBJECTIVES
 LEARNING EXPERIENCES
SPECIAL CONSIDERATIONS
 CONCLUSION
 REFERENCES
 
Didactic Experiences
Didactic courses are essential in introducing Asian-American issues to residents. These courses can be implemented either through a separate cross-cultural track (in a series of seminars on cultural psychiatry that includes Asian-American cultures along with issues of other minority groups) or by the incorporation of Asian-American content materials into existing core curricular topics. Both approaches will be expedient ways of teaching Asian-American issues as well as other cross-cultural psychiatry issues.

For example, a seminar on the impact of immigration and acculturation on mental health could highlight the unique aspects of the experience of Asian Americans. Asian-American cultural beliefs could be introduced in the psychiatric assessment and evaluation seminars. These incorporations help the residents understand how Asian-American patients use cultural beliefs to explain their psychiatric symptoms, help-seeking behaviors, and compliance with treatment. A course on psychopathology could include frequently encountered culture-bound syndromes in Asians.

Asian-American women's issues can be a part of seminars on gender and topics affecting women. The cultural aspects of the roles of Asian-American women, Asian-American relationships in domestic violence, and various psychosocial adaptation stresses of Asian-American women should be given particular consideration in discussions of women's issues.

Asian-American gay and lesbian issues can be incorporated in seminars on concerns for minority groups or sexuality.

Psychotherapy seminars should include the topic of Asian-American individual and family life cycles in Asian cultural contexts, as well as Asian alternative therapies and healing systems. Issues of transference and countertransference with Asians in individual and group therapies should be discussed (68,92).

Special consideration should be given to Asian-American survival of mass violence and its unique features in seminars about PTSD. Many psychiatric patients of this group have developed severe PTSD symptoms with psychotic features that are resistant to treatment (43,93,94).

In seminars on biological treatments, discussions should include alternative treatments in Asian-American communities, especially herbal medicines and the interaction of herbal medicines with psychotropic medications. Asian-American genetic differences as related to pharmacogenetics, pharmacokinetics, and pharmacodynamics can be incorporated in a course on psychopharmacology. Special emphasis should be placed on the sensitivity of Asian-American patients to psychotropic medications and their vulnerability to severe side effects.

Courses on substance abuse can incorporate Asian-American concerns. The rise of alcohol and drug use among Asian-American youth is an alarming, emerging issue in Asian-American communities and should be addressed within the topic of substance abuse.

Aside from seminars, other educational formats can be useful didactically. Videotapes and films on Asian-American cultures are powerful teaching tools to explore sensitive issues. When feasible, field trips to Asian-American community clinics are good ways to enhance learning and exposure to Asian-American cultures. Journal clubs can provide up-to-date literature reviews of Asian-American mental health problems. Grand Rounds are excellent opportunities to invite local and national speakers to present challenging and innovative materials on Asian-American patient issues.

Clinical Experiences
Clinical components of training should integrate knowledge of Asian-American cultures with practical, hands-on experiences.

  1. Residents should have opportunities to do at least two assessments of Asian-American patients and their families based on the DSM-IV Outline for Cultural Formulation. They should acquire experience in using interpreters to interview Asian-American patients.
  2. Residents should be able to incorporate their knowledge of Asian-American cultures into a biopsychosociocultural approach in formulating diagnosis and treatment plans for Asian-American patients.
  3. When possible, residents should be supervised by faculty members who are knowledgeable about Asian-American cultures or cultural psychiatry. These faculty members can also be used for consultations or case discussions to provide guidance for assessment, treatment, and management of Asian-American patients.

As pointed out in the demographic data, the majority of Asian Americans are clustered on the West and East Coasts and in metropolitan areas in the United States. Thus, many psychiatric residents from other parts of the country may not have opportunities to work with Asian-American patients during training. In situations where the Asian-American population is small, consideration should be given to the use of elective training in locations where Asian-American patients can be seen. Some residencies and programs with a specific Asian-American focus are the psychiatric residency programs at the University of California, San Francisco (95); the University of California, Davis, in Sacramento; UCLA-Harbor in Los Angeles; the University of Hawaii in Honolulu; the Elmhurst Hospital Center at the Mt. Sinai Medical Center in New York City; and the Intercultural Psychiatric Program at the Oregon Health Sciences University in Portland (96).

Faculty Supervision
Asian and non-Asian faculty members who are knowledgeable in cross-cultural psychiatry and experienced in working with Asian-American patients should be recruited to supervise residents on Asian-American mental health issues. Qualified faculty members can serve as role models or mentors for residents. They can also function as sources of information and expertise for consultations or case discussions on Asian-American psychiatric patients. Asian-American residents and non–Asian-American residents should have equal opportunities to work with Asian-American patients. Faculty supervisors should be culturally sensitive to residents' cultural backgrounds to help them overcome their biases regarding Asian-American patients, if present, and to address transference and countertransference issues (97,98).

Resident and Program Evaluation
Residents' input into program evaluation is essential to ensure that educational goals are achieved.

  1. Residents' knowledge, clinical skills, and attitudes can be evaluated by observing and discussing their assessments and formulations of Asian-American patients. Tandem working with qualified supervisors to formulate Asian-American patient cases and then presenting to resident groups in departmental case presentations or seminars are ways of stimulating the residents to study Asian-American dynamic issues in depth. This provides a venue for evaluation.
  2. Feedback on the effectiveness of the teaching methods and the clinical value of the seminar information related to Asian-American issues should be obtained, through either verbal comments or written evaluations.
  3. An overall program evaluation may include measurements of Asian-American patients' satisfaction with residents' care as well as measurements of quality of care delivered by the program.


  SPECIAL CONSIDERATIONS

 
TOP
 ABSTRACT
 INTRODUCTION
 RATIONALES
 DEMOGRAPHIC AND CULTURAL...
 EDUCATIONAL OBJECTIVES
 LEARNING EXPERIENCES
 SPECIAL CONSIDERATIONS
CONCLUSION
 REFERENCES
 
Several special considerations need to be addressed to facilitate the implementation of this curriculum.

  1. Asian Americans are so diverse that it is almost impractical to include all Asian-American subgroups in the core curriculum. The programs should first focus on major Asian-American subgroups frequently encountered in residents' local areas. The process learned through in-depth teaching of a few Asian-American subgroups can then be extended to other Asian groups.
  2. Asian-American residents and non–Asian-American residents should have the same opportunities to work with Asian-American patients and their families. One should not assume that an Asian-American resident would automatically have the knowledge to work with Asian-American patients. For example, a Chinese-American resident will need to learn how to provide psychiatric care for a Cambodian-American patient. In general, all residents should have equal opportunities to work with patients from different ethnic backgrounds.
  3. Cultivation of biopsychosociocultural approaches in evaluation and treatment of patients offers a comprehensive, culturally competent framework for the care of all patients.


  CONCLUSION

 
TOP
 ABSTRACT
 INTRODUCTION
 RATIONALES
 DEMOGRAPHIC AND CULTURAL...
 EDUCATIONAL OBJECTIVES
 LEARNING EXPERIENCES
 SPECIAL CONSIDERATIONS
 CONCLUSION
REFERENCES
 
We have proposed a model curriculum that provides the residents with basic knowledge, clinical skills, and behavioral parameters for working with Asian-American patients. Support from program directors and departmental leadership is essential to ensure success in implementation.


  ACKNOWLEDGMENTS

 
This work was adapted from A Psychiatric Residency Curriculum for Learning About Asian-American Issues, prepared by F. Lu, N. Du, A.C. Gaw, and K. Lin for the Committee of Asian-American Psychiatrists, American Psychiatric Association, 2000.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 RATIONALES
 DEMOGRAPHIC AND CULTURAL...
 EDUCATIONAL OBJECTIVES
 LEARNING EXPERIENCES
 SPECIAL CONSIDERATIONS
 CONCLUSION
 REFERENCES
 

  1. Stein TS: A curriculum for learning in psychiatric residencies about homosexuality, gay men, and lesbians. Academic Psychiatry 1994; 18:59–70[Abstract]
  2. Spielvogel AM, Dickstein LJ, Robinson GE: A psychiatric residency curriculum about gender and women's issues. Academic Psychiatry 1995; 19:187–201[Abstract]
  3. Thompson JW: A curriculum for learning about Indians and Alaska natives in psychiatry residency training. Academic Psychiatry 1996; 20:5–14[Abstract]
  4. Garza-Trevi ES, Ruiz P, Venegas-Samuels K: A psychiatric curriculum directed to the care of the Hispanic patient. Academic Psychiatry 1997; 21:1–10[Abstract]
  5. U.S. Census Bureau: Asian Pacific American Heritage Month: May 1–31, 2000. U.S. Census Bureau Public Information Office, May 5, 2000. Retrieved September 3, 2001, at www.census.gov/Press-Release/www.2000/cb00ff05.html
  6. Lee SM: Asian Americans: diverse and growing. Population Bulletin 1998; 2:53
  7. Boehnlein JK: Clinical relevance of grief and mourning among Cambodian refugees. Soc Sci Med 1987; 25:765–772
  8. Kleinman A, Kunstader P, Russel EA, et al: Culture and Healing in Asian Societies: Anthropological, Psychiatric and Public Health Studies. Cambridge, MA, Schenkman, 1978
  9. Kleinman A: Rethinking Psychiatry: From Cultural Category to Personal Experience. New York, The Free Press, 1988
  10. Durvasula RS, Mylvaganam GA: Mental health of Asian Indians: relevant issues and community implications. Am J Community Psychol 1994; 22:97–108
  11. Lin K-m, Masuda M, Tazuma L: Adaptational problems of Vietnamese refugees, III: case studies in clinic and field: adaptative and maladaptive. Psychiatric Journal of the University of Ottawa 1982; 7(3):173–183
  12. Westermeyer J, Neider J, Vang TF: Acculturation and mental health: a study of Hmong refugees at 1.5 and 3.5 years postmigration. Soc Sci Med 1984; 18:87–93
  13. Takaki RT: Strangers From a Different Shore: A History of Asian Americans. Boston, Little, Brown, 1998
  14. Kinzie JD: Posttraumatic stress disorder among survivors of Cambodian concentration camps. Am J Psychiatry 1984; 141:645–650[Abstract/Free Full Text]
  15. Kinzie JD: Cultural aspects of psychiatric treatment with Indochinese refugees. American Journal of Social Psychiatry 1985; 5:47–53
  16. Gaw A (ed): Culture, Ethnicity, and Mental Illness. Washington, DC, American Psychiatric Press, 1993
  17. Lee E (ed): Working With Asian Americans: A Guide for Clinicians. New York, Guilford, 1997
  18. Lin K-M, Cheung F: Mental health issues for Asian Americans. Psychiatr Serv 1999; 50:774–780[Abstract/Free Full Text]
  19. Tracy TJ, Leong FTL, Gildden C: Help-seeking and problem perception among Asian Americans. Journal of Counseling Psychology 1986; 33:331–336[CrossRef]
  20. Westermeyer J, Vang TF, Neider J: Refugees who do and do not seek psychiatric care: an analysis of premigratory and postmigratory characteristics. J Nerv Ment Dis 1983; 171:86–91[Medline]
  21. Lin K-M, Poland RE, Nakasaki G (eds): Psychopharmacology and Psychobiology of Ethnicity. Washington, DC, American Psychiatric Press, 1993
  22. Pi EH, Wang AL, Gray GE: Asian/non-Asian transcultural tricyclic antidepressant psychopharmacology: a review. Prog Neuropsychopharmacol Biol Psychiatry 1993; 17:691–702[CrossRef][Medline]
  23. Pi EH, Gray GE: A cross-cultural perspective on psychopharmacology, in The Hatherleigh Guide to Psychopharmacology. New York, Hatherleigh Press, 1999, pp 327–358
  24. Asian American Subpanel to the President's Commission on Mental Health: Report to the President. Washington, DC, U.S. Government Printing Office, 1978
  25. American Psychiatric Association Counsel on Medical Education and Career Development: Directory of Psychiatry Residency Training Programs 1991, Appendix C. Washington, DC, American Psychiatric Press, 1991, pp 863–866
  26. American Medical Association: Directory of Graduate Medical Education Programs, 1992–1993. Chicago, American Medical Association, 1993
  27. U.S. Department of Commerce, Economics and Statistics Administration, Bureau of the Census: We the Americans: Asians. Washington, DC, U.S. Department of Commerce, 1993
  28. U.S. Census Bureau: Asian Pacific American Month: May 1–31, 2001. U.S. Census Bureau, May 4, 2001. Retrieved September 3, 2001, at www.census.gov/Press-Release/www/2001/ cb01ff06.html
  29. O'Brien DJ, Fugita S: The Japanese American Experience. Bloomington, IN, Indiana University Press, 1991
  30. Nagata DK: Transgenerational impact of the Japanese-American internment: clinical issues in working with children of former internees. Psychotherapy 1991; 28:121–128
  31. Arameta EGJ: Psychiatric care for Pilipino Americans, in Culture, Ethnicity, and Mental Illness. Edited by Gaw A. Washington, DC, American Psychiatric Press, 1993, pp 377–412
  32. Kim LIC: Psychiatric care for Korean Americans, in Culture, Ethnicity, and Mental Illness. Edited by Gaw A. Washington, DC, American Psychiatric Press, 1993, pp 347–376
  33. Prathikanti S: East Indian American families, in Working with Asian Americans: A Guide for Clinicians. Edited by Lee E. New York, Guilford, 1997, pp 79–100
  34. Juthani NV: Immigrant mental health: conflicts and concerns of Indian immigrants in the U.S.A. Psychology and Developing Societies 1992; 4:133–148[Abstract/Free Full Text]
  35. Lee E: Chinese American families, in Working with Asian Americans: A Guide for Clinicians. Edited by Lee E. New York, Guilford, 1997, pp 46–77
  36. Cima RJ: Vietnam: A Country Study. Washington, DC, Library of Congress, Federal Research Division, 1989
  37. Ross RR: Cambodia: A Country Study. Washington, DC, Library of Congress, Federal Research Division, 1990
  38. Savada AM: Laos: A Country Study. Washington, DC, Library of Congress, Federal Research Division, 1995
  39. Aylesworth LS, Ossorio PG: Refugees: cultural displacement and its effects. Advances in Descriptive Psychology 1983; 3:45–93
  40. Lee E: Overview: the assessment and treatment of Asian American families, in Working with Asian Americans: A Guide for Clinicians. Edited by Lee E. New York, Guilford, 1997, pp 3–36
  41. Nicholson BL: The influence of pre-emigration and post-emigration stressors on mental health: a study of Southeast Asian refugees. Social Work Research 1997; 21:19–31
  42. Juthani NV: Understanding and treating Hindu patients, in Handbook of Religion and Mental Health. Edited by Koenig HG. San Diego, CA, Academic Press, 1998, pp 271–278
  43. Mollica RF, Wyshak G, Lavelle J: The psychosocial impact of war trauma and torture on Southeast Asian refugees. Am J Psychiatry 1987; 144:1567–1572[Abstract/Free Full Text]
  44. Powell GJ, Yamamoto J: Transcultural Child Development: Psychological Assessment and Treatment. New York, Wiley, 1997
  45. Lee JC, Cynn VEH: Issues in counseling 1.5 generation Korean Americans, in Multicultural Issues in Counseling: New Approaches to Diversity. Edited by Lee CC, Richardson BL. Alexandria, VA, American Association for Counseling and Development, 1991, pp 127–140
  46. Kinzie JD, Sack W, Angell R, et al: A three-year follow-up of Cambodian young people traumatized as children. J Am Acad Child Adolesc Psychiatry 1989; 28:501–504[CrossRef][Medline]
  47. Kinzie JD, Sack WH, Angell RH, et al: The psychiatric effects of massive trauma on Cambodian children. Journal of the American Academy of Child Psychiatry 1986; 25:370–376
  48. Williams CL, Westermeyer J: Psychiatric problems among adolescent Southeast Asian refugees: a descriptive study. J Nerv Ment Dis 1983; 171:79–85[Medline]
  49. Kao RS-K, Lam ML: Asian American elderly, in Working With Asian Americans: A Guide for Clinicians. Edited by Lee E. New York, Guilford, 1997, pp 196–208
  50. Yee BW: Elders in Southeast Asian refugee families. Generations 1992; 16:24–27
  51. Rick K, Forward J: Acculturation and perceived intergenerational differences among Hmong youth. Journal of Cross-Cultural Psychology 1992; 23:85–94[Abstract]
  52. Yau J, Smetana JG: Chinese-American adolescents' reasoning about cultural conflicts. Journal of Adolescent Research 1993; 8:419–438[Abstract]
  53. Lin EHB, Carter WB, Kleinman AM: An exploration of somatization among Asian refugees and immigrants in primary care. Am J Public Health 1985; 75:1080–1084[Abstract/Free Full Text]
  54. Kleinman A: Neurasthenia and depression: a study of somatization and culture in China. Cult Med Psychiatry 1982; 6:117–190[CrossRef][Medline]
  55. Akhtar S: Four culture-bound psychiatric syndromes in India. Int J Soc Psychiatry 1988; 34:70–74
  56. Hughes CC, Littlewood R, Wintrob RM, et al: Culture-bound syndromes, in Culture and Psychiatric Diagnosis: A DSM-IV Perspective. Edited by Mezzich JE, Kleinman A, Fabrega H, et al. Washington, DC, American Psychiatric Press, 1996, pp 289–323
  57. Lin K-m, Lau JK, Yamamoto J, et al: Hwa-byung: a community study of Korean Americans. J Nerv Ment Dis 1992; 180:386–391[Medline]
  58. Russell JG: Anxiety disorders in Japan: a review of the Japanese literature on Shinkeishitsu and Taijinkyofusho. Cult Med Psychiatry 1989; 13:391–403[CrossRef][Medline]
  59. Lee E: Cross-culture communication: therapeutic use of interpreters, in Working With Asian Americans: A Guide for Clinicians. Edited by Lee E. New York, Guilford, 1997, pp 477–489
  60. Marcos LR: Effects of interpreters on the evaluation of psychopathology in non-English-speaking patients. Am J Psychiatry 1979; 136:171–174[Abstract/Free Full Text]
  61. Westermeyer J: Working with an interpreter in psychiatric assessment and treatment. J Nerv Ment Dis 1990; 178:745–749[CrossRef][Medline]
  62. Yee J: Psychological testing of monolingual Asian American clients, in Working With Asian Americans: A Guide for Clinicians. Edited by Lee E. New York, Guilford, 1997, pp 364–387
  63. Kinzie JD, Manson SM, Vinh DT, et al: Development and validation of a Vietnamese-language depression rating scale. Am J Psychiatry 1982; 139:1276–1281[Abstract/Free Full Text]
  64. Mollica RF, Wyshak G, de Marneffe D, et al: Indochinese versions of the Hopkins Symptom Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry 1987; 144:497–500[Abstract/Free Full Text]
  65. Mollica RF, Caspi-Yavin Y, Bollini P, et al: The Harvard Trauma Questionnaire: validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis 1992; 180:111–116[Medline]
  66. Kim SC: Ericksonian hypnotic framework for Asian-Americans. Am J Clin Hypn 1983; 25:235–241[Medline]
  67. Weiss BS, Parish B: Culturally appropriate crisis counseling: adapting an American method for use with Indochinese refugees. Social Work 1989; 34:252–254
  68. Kinzie JD: Countertransference in the treatment of Southeast Asian refugees, in Countertransference in the Treatment of PTSD. Edited by Wilson JP, Lindy JD. New York, Guilford, 1994, pp 249–262
  69. Aldous JL: Cross-cultural counselling and cross-cultural meanings: an exploration of Morita psychotherapy. Canadian Journal of Counselling 1994; 28:238–249
  70. Leung ACN: Psychotherapy a la Chinese: forms of folk psychotherapy practiced by the Chinese. The Independent Practitioner 1993; 13:25–28
  71. Aronson L: Traditional Cambodian health beliefs and practices. Rhode Island Medical Journal 1987; 70:73–78
  72. Canada ER, Phaobtong T: Buddhism as a support system for Southeast Asian refugees. Soc Work 1992; 37:61–67
  73. Gilman SC, Justice J, Seapharn K, et al: Use of traditional and modern health services by Laotian refugees (the Mien). West J Med 1992; 157:310–315[Medline]
  74. Kutz I, Borysenko JZ, Benson H: Meditation and psychotherapy: a rationale for integration of dynamic psychotherapy, the relaxation response, and mindfulness meditation. Am J Psychiatry 1985; 142:1–8[Abstract/Free Full Text]
  75. Laderman C, Esterik PV: Techniques of healing in Southeast Asia. Soc Sci Med 1988; 27:747–750
  76. Lin K-M: Traditional Chinese medical beliefs and their relevance for mental illness and psychiatry, in Normal and Abnormal in Chinese Culture. Edited by Kleiman A, Lin TY. Boston, Reidel, 1980
  77. Nguyen D: Culture shock: a review of Vietnamese culture and its concepts of health and disease. West J Med 1985; 142:409–412[Medline]
  78. Westermeyer J, Wintrob R: Folk explanations of mental illness in rural Laos. Am J Psychiatry 1979; 136:901–905[Abstract/Free Full Text]
  79. Pi EH, Gutierrez MA, Gray GE: Tardive dyskinesia: cross-cultural perspectives, in Psychopharmacology and Psychobiology of Ethnicity. Edited by Lin K-M, Poland RE, Nakasaki G, et al. Washington, DC, American Psychiatric Press, 1993, pp 153–167
  80. Chien C-P: Ethnopsychopharmacology, in Culture, Ethnicity, and Mental Illness. Edited by Gaw A. Washington, DC, American Psychiatric Press, 1993, pp 413–430
  81. Lin K-M, Miller MH, Poland RE, et al: Ethnicity and family involvement in the treatment of schizophrenic patients. J Nerv Ment Dis 1991; 179:631–633[CrossRef][Medline]
  82. Lin K-M, Kleinman A: Psychopathology and clinical course of schizophrenia: a cross-cultural perspective. Schizophr Bull 1988; 14:555–567
  83. Bachman JG, Wallace JM, O'Malley P, et al: Racial/ethnic differences in smoking, drinking, and illicit drug use among American high school seniors, 1976–89. Am J Public Health 1991; 81:372–377[Abstract/Free Full Text]
  84. O'Hare T, Van Tran T: Substance abuse among Southeast Asians in the U.S.: implications for practice and research. Social Work in Health Care 1998; 26(3):69–80
  85. Varma SC, Siris SG: Alcohol abuse in Asian Americans: epidemiological and treatment issues. Am J Addict 1996; 5:136–143
  86. Nakajima GA, Chan YH, Lee K: Mental health issues for gay and lesbian Asian Americans, in Textbook of Homosexuality and Mental Health. Edited by Cabaj RP, Stein TS. Washington, DC, American Psychiatric Press, 1996, pp 563–581
  87. Chan CS: Issues of identity development among Asian-American lesbians and gay men. Journal of Counseling and Development 1989; 68:16–20
  88. Homma-True R: Asian American women, in Working With Asian Americans: A Guide for Clinicians. Edited by Lee E. New York, Guilford, 1997, pp 420–427
  89. Lovell ML, Tran T, Nguyen CD: Refugee women: lives in transition. International Social Work 1987; 30:317–325[Free Full Text]
  90. Lu FG, Lim RF, Mezzich JE: Issues in the assessment and diagnosis of culturally diverse individuals, in Review of Psychiatry, vol 14. Edited by Oldham JA, Riba M. Washington, DC, American Psychiatric Press, 1995, pp 477–510
  91. Pinderhughes E: Understanding Race, Ethnicity, and Power. New York, The Free Press, 1988
  92. Comas-Diaz L, Frederick M: Ethnocultural transference and countertransference in the therapeutic dyad. Am J Orthopsychiatry 1991; 61:392–402[Medline]
  93. Kinzie JD, Boehnlein JK: Post-traumatic psychosis among Cambodian refugees. J Trauma Stress 1989; 2:185–198
  94. Du N, Lu FG: Assessment and treatment of posttraumatic stress disorder among Asian Americans, in Working With Asian Americans: A Guide for Clinicians. Edited by Lee E. New York, Guilford, 1997, pp 275–294
  95. Zatzick DF, Lu FG: The ethnic/minority focus unit as a training site in transcultural psychiatry. Academic Psychiatry 1991; 15:218–225[Abstract]
  96. Kinzie JD, Tran KA, Breckenridge A, et al: An Indochinese refugee psychiatric clinic: culturally accepted treatment approaches. Am J Psychiatry 1980; 137:1429–1432[Abstract/Free Full Text]
  97. Fong ML, Lease SH: Cross-cultural supervision: issues for the white supervisor, in Multicultural Counseling Competencies: Assessment, Education and Training, and Supervision. Edited by Pope-Davis DB, Coleman HLK. Thousand Oaks, CA, Sage Publications, 1997, pp 387–405
  98. Matinez RP, Holloway EL: The supervision relationship in multicultural training, in Multicultural Counseling Competencies: Assessment, Education and Training, and Supervision. Edited by Pope-Davis DB, Coleman HLK. Thousand Oaks, CA, Sage Publications, 1997, pp 325–349