Counselling Chinese Canadian Women

Demographics

The Chinese community is an important element of Canada’s multicultural medley.  Chinese Canadian women include individuals of Chinese origin who immigrated to Canada and their descendents.  Most Chinese immigrants came from China, Hong Kong, and Taiwan (Chui, Tran, & Flanders, 2005).  In 2001, 565,300 Chinese women lived in Canada, representing 51.7 % of the Canadian Chinese community, which is Canada’s most sizable visible minority accounting for over 1 million Canadians (Lindsay, 2001).  Various countries of birth, different primary and home languages, and numerous religious affiliations demonstrate the diversity of Chinese Canadians, although they all have common ethnic links (Chui et al., 2005).  Generally, members of Canada’s Chinese community were not born in Canada; however, 28% were born in Canada (Lindsay, 2001).  Over 85% can converse in one or both official languages, although 15% are unable to speak either English or French (Lindsay, 2001).

Roughly, one-quarter of Chinese Canadian women have a university education, compared to 15% of the general population (Lindsay, 2001).  However, in 2001, the average income for Chinese Canadians was approximately $25,000, compared to $30,000 for all Canadians (Lindsay, 2001).  Canadian women of Chinese origin also have lower average incomes than Chinese Canadian men (Lindsay, 2001).  The employment rate for Chinese Canadian women is higher (83%) than Canadian-born women (76%), which suggests that Chinese Canadian women are becoming economically integrated (Chui et al., 2005).  Although most elderly Chinese Women live with family, 74% of senior Chinese Canadian women living alone have very low-incomes (Lindsay, 2001).

Historical Influences

Canada’s first Chinese settlers immigrated to Canada in 1860 to work in the gold fields (Chui et al., 2005).  After the gold depleted, they changed to domestic service, agriculture, and railway building (Chui et al., 2005).  After enduring hardships and disasters such as dynamite blasting accidents, collapsing tunnels, and drowning while building the Canadian Pacific Railway, most surviving Chinese workers lost their jobs (Chui et al., 2005). 

After the railway’s completion in 1885, government policies such as the 1885 Act to Restrict and Regulate Chinese Immigration discouraged Chinese immigration by introducing a “head tax” of $500 (Chui et al., 2005).  The 1923 Chinese Immigration Act restricted those living in the country and prevented Chinese immigration by denying them the right to vote, citizenship, and denying work in certain occupations (Chui et al., 2005).  Sponsoring family members or wives was very expensive; therefore, many Chinese men were bachelors.  In fact, in 1891, for every Chinese Canadian women, there were 28 Chinese men (Chui et al., 2005).  Only wealthier Chinese merchants were married due to the expenses involved (Chui et al., 2005).

The Chinese Immigration Act written in 1947permitted children and wives of Chinese Canadian residents to enter the country (Chui et al., 2005).  The Chinese presence in Canada amplified as immigration policies focused on humanitarian and occupational grounds, as ethnicity was no longer a selection criterion (Chui et al., 2005).  More Chinese immigration in the 1980s and increased birth rates among Chinese Canadians resulted in the Chinese population becoming Canada’s largest visible minority (Chui et al., 2005). 

Chinese immigrants faced many barriers due to racial biases in Canada (Ong, 1999, as cited in Pon, 2005).  Daily challenges include the resentment of white neighbors for moving into their neighborhoods, exclusion from prestigious social events, and the persistent stereotyping of Chinese Canadians as laborers, laundry workers, and restaurant workers (Ong, 1999, as cited in Pon, 2005).  Chinese Canadian women also admit they receive “double jeopardy” discrimination because they are both female and a visible minority (Pon, 2005).  Workplace power imbalances are the most frequent complaint from Canadian Chinese woman as inequality due to sexism and racism is interlocking and oppressive (Pon, 2005).

Cultural Trends

     Most Chinese Canadian women do not have a religious affiliation, although several philosophies and religions influence their lives (Chui et al., 2005; Waxler-Morrison, Anderson, Richardson, & Chambers, 2005).  Traditionally, Confucianism has been the most influential philosophy in China, which strives for harmony based on moral discipline (Waxler-Morrison et al., 2005).  Politeness, moderation, equilibrium preservation, obedience to parents, and loyalty to state and family are highly valued (Waxler-Morrison et al., 2005).  Status is achieved through a strong work ethic and education (Waxler-Morrison et al., 2005).  Viewing the world holistically with interdependent life and karma are beliefs taken from Buddhism that apply to daily functioning (Waxler-Morrison et al., 2005).  Health is perceived holistically as disease is an expression of disharmony (Waxler-Morrison et al., 2005). 

Daoism is the belief in the harmony of all elements of existence, including heaven and earth, and it has also influenced Chinese culture (Waxler-Morrison et al., 2005).  The opposing forces of yin and yang influence Chinese beliefs, as many believe these forces are the universe’s foundation (Waxler-Morrison et al., 2005).  Yin represents emptiness, the feminine, darkness, coldness, and negative energy while yang represents fullness, light, warmth, and male qualities (Waxler-Morrison et al., 2005).  This concept is essential to traditional Chinese medicine and is an important component of understanding Eastern therapies (Waxler-Morrison et al., 2005).

Chinese Canadian women hold the family in high regard as 93% reside in a family household although family members may be separated due to education, work, and immigration policies (Waxler-Morrison et al., 2005).  Respecting elders and caring for aging parents is a family responsibility and many generations often live in the same house (Chui et al., 2005).  Intergenerational conflicts may arise if younger children speak English and adopt Western culture while parents or grandparents speak Chinese and have traditional beliefs (Waxler-Morrison et al., 2005).  The division of roles in the Chinese Canadian household often exists and men often manage the finances, discipline children while the wives are responsible for everyday family needs and taking care of the household (Waxler-Morrison et al., 2005). 

Chinese Canadian women often balance childcare and housework with employment, which can result in feelings of inadequacy in trying to manage both roles (Waxler-Morrison et al., 2005).  Traditionally, the mother or grandmother cares for a young child and daycare is often utilized if the mother works (Waxler-Morrison et al., 2005).  If the father is a strict disciplinarian, the mother may become an intermediary between the child and the father, developing a much closer relationship with the child (Waxler-Morrison et al., 2005).  Chinese Canadian women thus often find themselves subtly assuming the role of the major decision maker due to their closer relationship with the child (Waxler-Morrison et al., 2005).  Additionally, women are typically responsible for day-to-day health decisions although major health decisions often involve the whole family, including extended family members (Waxler-Morrison et al., 2005).  

Chinese Canadian women typically choose their marriage partner, although arranged marriages sometimes occur, sometimes for immigration purposes (Waxler-Morrison et al., 2005).  Chinese women may also immigrate to Canada because of the one-child policy in China, and pregnancies are common immediately after immigrating (Waxler-Morrison et al., 2005).  Divorce is a rarity among Chinese Canadians, even in a deteriorated relationship (Waxler-Morrison et al., 2005).  The elderly typically discourage interracial marriages, although they are becoming more common (Waxler-Morrison et al., 2005).  As well, if parents do not approve of the child’s spouse, excommunication is sometimes threatened (Waxler-Morrison et al., 2005). 

Confucianism continues to effect cultural values and behaviors in everyday life (Waxler-Morrison et al., 2005).  Behaviors such as abiding the law, respecting authority, and heeding the wishes of the elderly are highly regarded (Waxler-Morrison et al., 2005).  Chinese Canadian women may greet one another by smiling and bowing their head, avoiding eye contact as a sign of respect, and projecting humility by gazing downwards (Waxler-Morrison et al., 2005).  Smiling and nodding represent civility rather than agreement. Body contact with strangers, with the exception of handshaking, is generally avoided and the informal manners of North Americans may be perceived as rude (Waxler-Morrison et al., 2005).  Confrontation is typically avoided and situations are often managed diplomatically (Waxler-Morrison et al., 2005). 

Basic family needs are highly valued, such as housing, food, and clothing, though it may be difficult for parents to understand the additional needs of the child such as their emotional needs (Waxler-Morrison et al., 2005).  Tasks must be completed to the best of one’s ability and deficiencies are focused on more than achievements.  Academic achievements and careers are typically emphasized and extracurricular activities, including arts and sports, are not typically promoted (Waxler-Morrison et al., 2005).  Wealth, education, and age are measures of social status (Waxler-Morrison et al., 2005).  Typically, the Chinese enjoy surrounding themselves with many family and friends (Waxler-Morrison et al., 2005).

Special Mental Health Issues

It is a common perception that Chinese Canadian women experience few psychosocial or social difficulties when adjusting to Canadian life, although research suggests mental health problems do exist (Sue & Morishima, 1982, as cited in Leong & Lau, 2001).  Chinese scientific papers also suggest a low mental illness prevalence rate (Waxler-Morrison et al., 2005).  Psychosis is typically ignored or unreported and neuroses are typically under-reported (Waxler-Morrison et al., 2005).  For example, schizophrenia has a 1 percent worldwide prevalence rate (Waxler-Morrison et al., 2005).  However, in China the reported rate is approximately 100 times lower (Waxler-Morrison et al., 2005).

Similar to other ethnic minorities, Chinese women underutilize mental health services (Leong & Lau, 2001).  Additionally, treatments sought are often prematurely terminated at a higher rate than among clients of an ethnic majority (Leong & Lau, 2001).  Initiating medical treatment is strongly influenced by acculturation. Studies suggest highly acculturated individuals with a positive attitude regarding seeking psychological assistance have a higher likelihood of acquiring psychological assistance than individuals who are not acculturated and have negative attitudes (Atkinson & Grim, 1989; Tata & Leong, 1994; Ying & Miller, 1992 as cited in Leong & Lau, 2001).

Traditionally, the emotions are associated with organs, such as the liver is associated with anger (Waxler-Morrison et al., 2005).  External factors such as cold wind, evil spirits, and transgressions are often blamed for mental illness (Waxler-Morrison et al., 2005).  Typically, psychological issues present themselves in somatic symptoms (Waxler-Morrison et al., 2005).  Many Chinese Canadian women find it acceptable to seek medical assistance for a somatic complaint but not to talk about emotions (Waxler-Morrison et al., 2005).  For example, an elderly Chinese Canadian women may complain of chest pain when they are actually experiencing depression (Waxler-Morrison et al., 2005). 

Chinese Canadian women may encounter bicultural identity conflict, particularly if they are second generation Chinese Canadians.  They may be simultaneously “enculturated” within the Chinese and Canadian cultures, potentially experiencing conflict in attempting to bring together unique values and norms while identifying with both cultural groups (Stroink & Lalonde, 2009).  Common conflicting domains include sexual openness, appropriate aggression levels, and the importance of education and sports (Stroink & Lalonde, 2009).  Stroink & Lalonde (2009) found second generation Chinese Canadians who perceive both cultures as highly contrasting weaken their cultural associations.  Although a simple contrast of two cultures is not directly linked with well-being, possible links with decreased cultural identification may suggest an increased adjustment (Hogg, 2003; Taylor & Moghaddam, 1994; Vignoles et al., 2006, as cited in Stroink & Lalonde, 2009).

Treatment Barriers

The Chinese avoid uncomfortable emotions while attempting to harmonize their emotions with the social and natural environments (Chan-Yip & Kirmayer, 1998).  Inner strength is a strong Confucian value that may influence responses to illness (Waxler-Morrison et al., 2005).  Many Chinese women are thus raised to endure suffering and pain through mental strength and self-discipline; therefore, it may be difficult to confirm whether pain is present (Waxler-Morrison et al., 2005). 

Some illnesses are thought to be caused by sins and transgressions committed by the family or patient, which often results in the patient or family concealing the illness (Waxler-Morrison et al., 2005).  Some conditions are mislabeled or normalized such as developmental disorders labeled as disobedience or laziness, depression labeled as boredom, addiction identified as lack of strength, and anxiety attributed to nervous exhaustion (Waxler-Morrison et al., 2005).  Mental illness is often attributed patient or family misdeeds therefore, the family or patient is often reluctant to seek help in order to avoid shame (Waxler-Morrison et al., 2005).  Special attention is not directed to mental illnesses, particularly minor illnesses (Chan-Yip & Kirmayer, 1998).  In Canada, health professionals frequently encounter Chinese Canadian women who lack an understanding, awareness, and acceptance of mental illness (Waxler-Morrison et al., 2005). 

Self-medication, using Chinese and Western medicine, is a common practice among Chinese Canadian women.  As well, the discontinuation of Western prescription medication may occur if results are not immediate because it is perceived as “stronger” than traditional treatments (Waxler-Morrison et al., 2005).  The prolonged use of medication, especially for illnesses without physical symptoms, may not be accepted readily (Waxler-Morrison et al., 2005).  Furthermore, patients often associate a cure with the practitioner’s skill rather than the pharmaceutical intervention; therefore, Chinese Canadian women may feel health care providers must be changed if success is not achieved immediately (Waxler-Morrison et al., 2005).  

Chinese Canadian women generally have difficulties accepting counselling, although “talk therapies” such as cognitive behavioral therapy, lifestyle modification, and stress management are more likely to be accepted (Waxler-Morrison et al., 2005).  Mental illness stigmas hinder many Chinese Canadian women from obtaining psychological assistance (Chan-Yip & Kirmayer, 1998).  Payment for psychological services may also be challenging (Waxler-Morrison et al., 2005).

Treatment Resources

It is crucial for counsellors to recognize the importance of cultural factors when assessing and treating the mental health problems of Chinese Canadian women.  Depending on the client’s beliefs, combining traditional Chinese therapy with Western psychotherapy may be a way to connect with the client in a therapeutic alliance.  Utilizing an interpreter to minimize language barriers may also be useful.  According to Sue, Fujino, Hu, and Takeuchi (1991, as cited in Leong & Lau, 2001), Asian clients that do not speak English as their primary language have better treatment outcomes and longer therapeutic duration when the mental health worker is also Chinese.  A lack of bilingual and bicultural staff may be a notable reason for the underutilization of psychological services (Leong & Lau, 2001).  Bilingual and bicultural staff with the same ethnicity may be able to provide more culturally sensitive services (Leong & Lau, 2001).

Ethnic-specific services (ESS) need to be created to provide culturally responsive psychological therapy for ethnic communities (Leong & Lau, 2001).  ESS agencies are now focusing on recruiting bilingual, bicultural personnel, modifying treatment practices to increase cultural relevancy, and fostering an environment providing services in a familiar cultural context (Leong & Lau, 2001).  Takeuchi, Sue, and Yeh (1995, as cited in Leong & Lau, 2001) found that ethnic clients attending ethnic-specific programs stayed in treatment longer and had a higher chance of returning to treatment than ethnic clients attending mainstream health services.

Educating the client regarding their mental health issues may help improve awareness, as many Chinese Canadian women are highly educated.  Accessing scientific literature, explaining how the literature is personally applicable, emphasizing potential biological causes, and creating a treatment plan integrating Western and traditional practices may help ease the transition from traditional to Western medicine.  Collaborating with a cultural advisor to develop a combined Western and a traditional treatment plan for a Chinese Canadian woman may alleviate apprehension, misinterpretations, and achieve mental health treatments with desired outcomes.  Having the cultural advisor present during a session with the client may also be beneficial.  Introducing the client with a Canadian Chinese woman who has successfully dealt with mental illness through counselling or a cultural support group may help normalize seeking psychological services.  Additionally, reinforcing the client’s personal strength in their decisions to seek mental health treatment may ease feelings of shame.

Treatment Strategies

Additional research is required to discover which therapies are most effective for Canadian Chinese women with mental illnesses.  Health professionals must ensure good care for Chinese Canadians is easily accessible (Waxler-Morrison et al., 2005).  Earning the trust of Chinese Canadian women and their family requires patience (Waxler-Morrison et al., 2005).   Chinese Canadian women and their families also need to be reassured that the client is not possessed or crazy, as mental illnesses are fairly commonly determined to be “treatable brain dysfunctions” (Waxler-Morrison et al., 2005, p. xx).  Comfort levels may also be improved with frequent reassurances of confidentiality (Waxler-Morrison et al., 2005). 

Medicinal interventions that improve negative symptoms are the most acceptable form of treatment (Waxler-Morrison et al., 2005).  It is important that families and patients understand that time is required for pharmaceuticals to become effective and instructions must be followed carefully (Waxler-Morrison et al., 2005).  As well, individuals of Chinese descent are often more sensitive to side effects and typically require smaller doses (Waxler-Morrison et al., 2005). 

An awareness of threats to cultural validity is critical when examining assessment clinical diagnosis problems (Leong & Chou, 1997, as cited in Leong & Lau, 2001).  Therapists need to be aware of possible clinical misdiagnoses or erroneous assessments when using Western-based evaluations (Leong & Lau, 2001).  The lack of reliability, validity, incidence, and prevalence of mental disorders among Chinese Canadian women may lead to inappropriate treatment resulting in the premature termination of services (Leong & Lau, 2001).  Furthermore, diagnostic assessments are further complicated because the DSM-IV-TR only uses a Western nosological system (Leong & Lau, 2001).  As well, Chinese Canadian women may express problems differently due to communication methods and cultural patterns (Leong & Lau, 2001).  Practitioners thus need to have flexible methods of defining the presence and manifestation of psychological disorders (Leong & Lau, 2001).  Li-Repac (1980, as cited in Leong & Lau, 2001) found white Chinese clients were perceived as more inhibited and depressed in comparison to Chinese American therapists.  This study suggests the therapist’s worldview and social norms influences assessments (Leong & Lau, 2001).  Therefore, it is critical therapists are aware of their cultural biases and worldview while incorporating their self-awareness with a knowledge of their client’s culture.

Mental health practitioners must use caution when using personality and diagnostic tests.  Assessments utilized with diverse cultural populations must be investigated conceptually and linguistically while examining the metric or scale equivalence to consider cross-cultural equivalences (Leong & Lau, 2001).  Even with linguistic translation, concepts and semantics may not be equivalent (Leong & Lau, 2001).  It is important that assessments be researched, including the samples used for standardization and cultural validity, and that results not be interpreted as absolute.  Assessments should also be used in combination with other assessment methods (Hood & Johnson, 2007).

The client’s cultural background may influence symptom expression, potentially threatening the cultural validity of clinical diagnosis (Leong & Lau, 2001).  Somatization tendencies are one of the strongest cultural factor influences on clinical validity (Leong & Lau, 2001).  Holistically understanding the Chinese organ-oriented schema of pathology and the connections between mind, body, and nature may decrease the likelihood of misdiagnosis while establishing rapport (Leong & Lau, 2001).  Additionally, using subtler forms of communications may alleviate the reluctances to openly express emotions (Leong & Lau, 2001). 

Providing a therapy plan, explaining the required changes, and incorporating family can enhance the establishment of trust (Root, 1993 cited in France, Rodriguez, & Hett, 2004). Also, considering the importance of modesty is important when collecting information - clinicians should use restraint (Sue & Sue, 1999, as cited in France, Rodriguez, & Hett, 2004).  Explaining the roles of the client and counsellor, working specifically on the problem, providing structure and direction, and establishing goals focused on resolution will reduce the chance of imposing the therapist’s worldview on the client (Sue & Sue, 1999 as cited in France, Rodriguez, & Hett, 2004).  The duration of therapy should also be as short as possible focusing on the near future or present (Sue & Sue, 1999 as cited in France, Rodriguez, & Hett, 2004).  Structure- and action-based counselling methodologies, such as behavioral and cognitive therapies, may be more effective than psychodynamic or client-centered interventions (Lin & Cheung, 1999 as cited in France, Rodriguez, & Hett, 2004).  Asian-based psychotherapies including Morita, Naikan, and meditation can also be incorporated while providing a positive and respectful experience (France, Rodriguez, & Hett, 2004). 

Overall, the client’s cultural context must be carefully assessed and incorporated into counselling Chinese Canadian women, as with any minority group.  Unfortunately, there is an absence of controlled clinical studies determining the effectiveness of Chinese psychotherapy (Sue, Zane & Young, 1994, as cited in Leong & Lau, 2001).  Additional research is required to determine the reliability and validity of diagnoses, assessments. 

 

References

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