Cultural Competence Standards in Managed Care Mental Health Services for Asian and Pacific Islander Americans

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Asian Pacific Islander Americans (APIA) are often misunderstood to be a homogeneous ethnic group. Unfortunately, failure to make distinctions among the diverse ethnic, cultural, and language groups that comprise APIAs, and tendencies to generalize their economic, social, and political circumstances, can lead to faulty conclusions related to mental health needs among APIAs. Thus, the intent of this preamble is to demonstrate the diversity of the groups and concerns that APIAs represent, in order for administrators, clinicians, educators, and researchers to better understand APIA mental health concerns, and thereby effectively implement these standards for culturally competent mental health care to APIAs.


Who are Asian Pacific Islander Americans?

APIAs are the fastest growing racial group in the United States, in terms of percentage increase. The APIA population experienced a 108 percent growth from 3,726,440 in 1980 to 7,273,662 in 1990, thus comprising 2.9 percent of the entire U.S. population, according to the 1990 U.S. Census.1,2 Projections are that by the year 2020, the APIA population will be approximately 20.2 million, or about 8 percent of the total U.S. population.3 According to the 1990 census, the six largest APIA groups are Chinese Americans (1,645,472), Filipino Americans (1,406,770), Japanese Americans (847,562), Asian Indian Americans (815,447), Korean Americans (798,849), and Vietnamese Americans (614,547). 2 Significant numbers of other Southeast Asian Americans (e.g., Cambodian Americans, Hmong Americans, Laotian Americans) and Pacific Islander Americans (e.g., Hawaiian Americans, Samoan Americans, Guamanian Americans) contribute to the total APIA population.2 Although APIAs reside throughout the U.S., 11 of the 15 most APIA populated areas are located in Western U.S. (Los Angeles-Long Beach, Honolulu, San Francisco, Oakland, San Jose, Anaheim-Santa Ana, San Diego, Seattle, Houston, Sacramento, and Riverside-San Bernardino).4 Only one region of the top 15 is located in the mid-West (Chicago), and three are in the Eastern part of the country (New York, Washington, D.C., and Philadelphia).4

The APIA population is not only the fastest growing but also the most diverse group in terms of ethnic origin, cultural background, immigration history, and acculturation to U.S. culture. APIAs comprise at least 31 ethnic groups.5 Chinese Americans began the first large wave of APIA immigration to the U.S., arriving over a 150-year period, followed by Japanese Americans whose immigration began in the late 1800s.6,7,8 While the presence of Chinese in the U.S. linked to trade and educational missions has been documented as far back as the late 1700s, massive Chinese immigration was spurred by accounts of gold being discovered in California.6 Most arrived via the indenture system and accounted for a significant proportion of the laborers in the mining and railroad industries.6 The earliest Japanese immigrants were brought to this country to fulfill the need for cheap contract laborers in Hawaiian sugar plantations, and later comprised a high percentage of the Hawaii-California transmigration that substantially contributed to the agricultural success on California soil.7,8 However, since the late 1800s, the government strictly controlled the flow of Asian immigrants to the U.S. through various legislation.9  The Chinese Exclusion of Act of 1882 restricted the admission of unskilled Chinese workers.9 Not long after, the Gentlemen’s Agreement of 1907-1908 placed similar restrictions on Japanese and Koreans, as did the 1917 Immigration Act to Asian Indians.9 Not until the Tydings-McDuffie Act in 1934 were Filipinos included in the list of those who were denied entry, allowing for a significant wave of Filipino immigration to begin in the early 1920s from which many Filipino Americans today have descended.9,10,14 Many of these earliest Filipino immigrants worked as daily wage laborers in California agriculture. 10

Then in 1942, President Franklin Roosevelt ordered Executive Order 9066 which incarcerated over 120,000 people of Japanese heritage, including more than 70,000 U.S.-born citizens, in concentration camps and federal prisons.11,12,13 This imprisonment was in reaction to the unsubstantiated fear that Japanese Americans presented a threat to national security. 11,12,13 It was not until the 1965 Immigration Act that systematic discrimination against Asian immigration began to diminish, and favored family reunification as well as gave priority to immigrants with special skills.9,14 Soon after, in 1971, new legislation eliminated all hemispheric distinctions and replaced it with a worldwide ceiling of 290,000 people, which was reduced to 270,000 in 1980.9

Consequently, whereas in 1965, when APIAs accounted for less than 7 percent of the total immigrants to the U.S., APIAs comprised nearly 25 percent of total immigration just five years later.2 Recent immigrants from the People’s Republic of China, Hong Kong, Taiwan, Philippines, Japan, and Korea have come in search of better education and economic opportunities.14 Most Korean Americans today do not descend from the first wave of immigration in the early 1900s, but are part of the 30,000 per year that have come to the U.S. every year since 1965.14 Similarly, Filipinos have immigrated in the tens of thousands annually since 1965, to seek better employment and futures for their offspring.14 Thus, most Filipino Americans today are first or second generation.14 Due to American colonization in the Philippines and the long standing U.S. military presence until 1992, Filipino immigrants are more acculturated to American culture than other Asian immigrants.14

In addition, the influx of Southeast Asian refugees during the late 1970s and early 1980s, has contributed to the tremendous APIA population growth.9 For political and humanitarian reasons, the U.S. has accepted thousands of Southeast Asian refugees.9 In 1975 alone, 130,000 Southeast Asian were admitted to the U.S.14 Most of these refugees were Vietnamese who were fairly well-educated and proficient in English, and were familiar with an urban lifestyle.14 However, since 1978, most Southeast Asian refugees have been comprised of people escaping persecution in their home countries, and have been less educated, of lower social status, and less familiar with urban and American cultures.14 The diversity in history, culture, and acculturation among APIAs is needless to say, astonishing. Japanese Americans being the only exception, all APIA groups today are comprised of a majority who are born abroad.15 Compared to the largely American born APIA composition prior to 1965, by 1990, 68 percent of APIAs were born outside of the U.S.5

It is impossible to globally summarize the economic status of APIAs because of the economic diversity among this group. In 1990, the national median household income for APIAs was $36,000, higher than for non-Hispanic Whites ($31,000), Latino/a ($24,000), and African American ($19,000).16 A higher proportion of APIA households at 16 percent had annual incomes greater than $75,000, compared to all other groups (10 percent non-Hispanic White, 5 percent Latino/a, and 3 percent African American), and APIAs had the third lowest rates of poverty (14 percent compared to 29 percent African American, 25 percent Latino/a, and 9 percent non-Hispanic White) and annual household incomes below $10,000 (14 percent compared to 30 percent African American, 20 percent Latino/a, and 13 percent non-Hispanic White).16 While these figures demonstrate the relative success of APIAs overall, it is important to note that APIA families also tend to have more workers per household contributing to the household income. Twenty percent of APIA households, compared to only 13 percent in the general population, had 3 or more workers contributing to the household income.5 Unfortunately, these global statistics also mask profound differences among APIAs. The number of APIA households with an annual income above $75,000, roughly matches the number of APIA household with an annual income below $10,000.16 This economic polarity is largely a product of a complexity of issues surrounding immigration history. For instance, median household income varied greatly along ethnic and native lines, with Filipino and Japanese Americans each at only 7 percent below poverty level compared to nearly 50 percent of Southeast Asians below the poverty threshold.16 Language proficiency and educational attainment clearly contributed to this economic polarity, with unemployment among those disadvantaged by limited education and English language proficiency doubling those who were not disadvantaged in terms of education and language.16 Only 6 percent of all APIAs compared to 55 percent Southeast Asians had minimal or no English language proficiency).16

Similarly, while it is true that APIAs have high educational attainments in terms of group averages, only 23 percent of the total APIA population over the age of 25, compared to 64 percent Southeast Asians had less than a high school degree.16 The federal government has attempted to facilitate Southeast Asian refugee adjustment to this country through public assistance programs. Consequently, Southeast Asians had the highest rate of welfare dependency than any ethnic or racial group, with more than half of all Southeast Asians being supported by public assistance.17 Unfortunately, this population is now so enmeshed in the public assistance system that their well-being is greatly determined by welfare reform. Recently, federal appropriations for refugee assistance dropped from $421 million to $411 million, a reduction that after adjusting for inflation and newly admitted refugees, amounted to a drastic 27 percent decline overall, and 64 percent drop in terms of federal dollars per person.17

Lastly, in addition to understanding the economic diversity within the APIA population, it is also important to be aware of the context and changing structure of opportunity in this country when interpreting these global economic statistics. In particular, the consequences of differential treatment based on race are startling. In 1990, APIA adult males working full-time and year-round, consistently earned 10 percent less than their non-Hispanic White male counterparts.16 Meanwhile, APIA females earned 70 percent less than non-Hispanic White males.16


Asian Pacific Islander American Mental Health Issues

Accumulating evidence suggests that APIAs are experiencing significant mental health problems. The diversity of APIAs -- the many ethnic groups, languages, cultures, value and belief systems, and immigration histories, as well as differences in present day social, economic, and political circumstances -- manifest into an equally diverse range of mental health concerns. Among the most commonly documented dynamics underlying mental health concerns pertaining to APIAs, are: intergenerational conflicts,18,19 family system and role relationship changes,18,19 acculturation conflicts,18,19 ethnic/racial identification and social isolation,19 and particularly among Southeast Asian refugees, pre-migration trauma.20,21 The extent to which these issues become problems and the nature of how such distress is expressed, are thought to be largely affected by multiple factors that may include but are not limited to: area of residence, generational status in the U.S., degree of acculturation, religious beliefs and value orientations, native language facility, English language proficiency, age, education, economic status, family composition, degree of family dispersion, immigrating as an unaccompanied minor, degree of identification with one’s country of origin, perception of choice in emigrating to the U.S., social-political identification, and connection with local formal and informal networks.22

Rates of psychopathology have been difficult to assess. It is believed that estimates based on utilization rates among clinical samples seriously underestimate the actual need in the general population. However, surveying a more representative sample of the population is very costly and so is seldom conducted, especially among APIA populations. Moreover, it is not known to what extent Western diagnostic criteria may overlook cultural-specific symptom expression and culture bound syndromes. Thus, while the reports available on APIA psychiatric prevalence rates are few, and are based on selected samples or on selected disorders, the data consistently support that psychiatric disorders among APIAs have been underestimated.23 Among several studies that have reported rates of known psychiatric disorders based on psychiatric inventories rather than utilization rates, high prevalence and severity levels were found among APIA samples.23 Moreover, recent immigrants displayed greater psychopathology than immigrants who had been in the U.S. longer.23

There is convergent evidence that APIAs underutilize mental health services, regardless of service type, based on reports that compare APIA service use rates to their proportion in the general population.23,24,25 Several studies also report that APIAs exhibit more severe disturbances compared to non-APIAs, suggesting that APIAs are more likely to endure psychiatric distress for a long time, only coming to the attention of the mental health system at the point of acute breakdown and crisis.26 Further studies show that APIAs are more likely to drop out after initial contact or terminate prematurely from mainstream service settings.22,27 Studies have linked such underutilization to the shame, stigma, and other cultural factors that influence symptom expression and conceptions of illness,23 as well as to limited knowledge about the availability of local mental health services,23 and a tendency to seek more culturally congruent care, which may include herbalist, acupuncturist, and other forms of indigenous healing.22,28,29 Increased utilization, length of treatment, consumer satisfaction, and therapy outcomes have been attained by culturally responsive, ethnic specific services for APIAs that emphasize flexible hours, community-based facilities, bicultural and bilingual staff, and implementation of culturally congruent treatment plans.30


Asian Pacific Islander American Mental Health Service Delivery Issues

A number of issues pertinent to mental health service delivery and managed care have emerged in recent attempts to provide effective treatment to the APIA population.

    • Because of cultural factors (e.g., shame and stigma), unfamiliarity with mental health services, and the lack of cultural responsiveness of some health care systems, APIAs frequently avoid treatment in the mental health system and their utilization rates are below those of African Americans, Native Americans, Latino/a Americans, and European Americans. Yet, they experience significant mental health problems.

    • Because of the tendency to avoid the use of mental health services, APIAs with mental disorders frequently use these services only after exhausting whatever other resources exist. Those consumers tend to be severely disturbed and require greater time and effort from service providers.

    • The APIA population is predominantly foreign born, and thus many APIAs have limited English proficiency. Providers of services need to have bilingual and bicultural providers and trained interpreters available.

    • Agencies that can provide culturally competent services for APIAs are few in number. Those agencies shall frequently deliver services to APIA consumers outside of the agency’s geographic service area. In these cases, the agencies shall receive reimbursement for clients who come from outside of the service area.

    • A critical mass of culturally competent APIA providers is necessary. Even when the proportion of the APIA population in a geographic area is small, the numbers of individuals may be fairly large – requiring a critical mass of these providers.

    • In view of the great need for culturally competent providers, it should not be assumed that these providers are competent to render effective treatment only to APIA consumers.

    • Many behavioral health care organizations lack culturally competent services for APIAs. They should include on the provider list or panel those culturally competent APIA providers from local agencies.

    • Care shall be taken not to eliminate from treatment benefits those disorders that disproportionately affect APIAs. For example, the elimination of PTSD from reimbursable conditions for which treatment is provided has a significant impact on Southeast Asian refugees who have a relatively high prevalence for the disorder.

    • Services should be provided to all APIAs regardless of citizenship status.

    • Medication effects are not solely biological in nature. Thus, the cultural and psychosocial context of the consumer shall also be considered.

    • Despite the capitated model and limitations in the services provided, managed care shall emphasize prevention, outreach and health promotion because these are cost effective strategies.

    • Holistic forms of treatment and healing should be considered because they are culturally appropriate for many APIAs.

    • The benefits of using alternative or traditional healers as providers should be examined. Use of such indigenous treatments in the consumers’ natural setting, as well as help-seeking in primary care settings, are frequently observed among APIAs with psychiatric disorder, and are often the first treatment approaches attempted.

    • While it is necessary for providers to be culturally competent in working with APIA consumers, they shall guard against the formation of cultural stereotypes and against the assumption that ethnicity is the only important factor to consider in the treatment of APIAs.

    • Family involvement in the treatment of a client is often valuable. However, caution should be exercised when involving the family because of issues pertaining to confidentiality and privacy. Family involvement should occur only when appropriate to the situation.

    • Much more research should be conducted in order to provide important data on APIAs broken down by particular APIA subgroup.

    • Data collected should be culturally valid and employ culturally appropriate methods.



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