This past week, my mom had a fall and had to consult our doctor about a swollen left foot. She was able to do so within the confines of our home in suburban New Jersey. The doctor had her self-assess the injury while continually asking her about her pain tolerance. He was able to write and fax a prescription for her to get an x-ray, which was promptly done only 1.5 hours later. By the end of the day, the doctor received the results of the x-ray and was able to identify the type of injury and lay out the next steps.
Telemedicine technology has been drastically changing since its inception. Given the current restrictions placed on our lifestyles due to COVID-19, telemedicine is becoming more common.
What is Telemedicine?
Medical professionals who use technology to diagnose patients remotely are practicing telemedicine. Today most use video conferencing. However telemedicine has been around since the days of radio transmissions and landline phones.
The Cold War brought more advancements to telemedicine because of the scientists who were plagued with medical questions sparked by the removal of gravity during the “Space Race.” NASA’s program, Integrated Medical and Behavioral Laboratories and Measurement Systems (IMBLMS), was founded in 1964 specifically to help with the monitoring of spaceflight on the human body. A few years later, 911 was commissioned as an emergency communication service, which, by extension, helped to increase access to medical care.
In addition to faxes and phone calls in the early 2000s, other methods of telemedicine started to rise, including store-and-forward kiosks (asynchronous telemedicine) and remote monitoring. In general, practices of telemedicine were seen between facilities (like faxes), among rural populations with limited access to healthcare.
“Telemedicine was used in the outpatient setting as a way of following up chronic conditions instead of mandating people to come into the clinic. However, telemedicine was more of a luxury than a necessity,” said Dr. Bhavik Gupta, a medical resident at Georgetown Hospital.
Since telemedicine was perceived as a luxury, there weren’t as many resources that went into supporting the technology or building its use.
Newer concepts of telemedicine include tech-enabled mental health and on-demand services, where you can video chat or message a physician at any time for generic medical advice. Of course, using anon demand service may require an additional appointment for a specialist to evaluate the medical condition further.
Telehealth is the generic term that encompasses telemedicine and other nonclinical forms of communication, such as tech-enabled mental health. In addition to traditional in-person therapy appointments, end users can video chat with their therapists. Patients can also talk with mental health services rather than book in-person sessions (ex. Talkspace).
Ranga Jayawardena, the co-founder of HIPAA compliant telemedicine platform BeamHealth, views telemedicine as a solution that should be implemented across the nation as a general practice. “To me, it was a no brainer. If you want to improve access to care and make doctors more efficient, just give patients the ability to connect with the healthcare provider conveniently. The lowest hanging fruit is telemedicine,” said Jayawardena.
The enabling factor of telemedicine is the internet and many Americans either own devices that have access to the internet or have access to government-funded internet services (ex. Link NYC). Even in rural areas, there are increasing numbers of individuals that have access to high-speed Internetat home.
In addition to being a convenient outpatient service option, telemedicine can be viewed as the first line of defense in preventative care. When patients can access the care they need more readily, it enables them to be active participants in their healthcare. “Instead of waiting for something terrible to happen, they’ll come ahead of time, which can be a real positive,” Jayawardena says.
Telemedicine can help bring doctors closer to patients and encourage the use of health resources like it to support efforts in preventative care. In the long run, preventive care has proven to lower costs and benefit the patient. There is truth in the idiom, “An ounce of prevention is worth a pound of cure.”
Access to providers is crucial to the success of telemedicine, as well as monetary relief. Telemedicine proves to be a fiscally conservative solution to get minor problems checked. A telemedicine appointment costs approximately $70 less on average than an in-person office visit. “It’s a great screening tool. If I have a cold or if something feels wrong, and I want some quick medical advice, telemedicine can be beneficial,” says medical student Ishaan Jain.
The Surge of Telemedicine during COVID-19
It is no surprise that the pandemic required an urgent coronavirus-safe response from the healthcare industry to supply a method of communication between patients and medical professionals. Telemedicine was the saving grace, and the relaxed Center for Medicare and Medicaid Services (CMS), Department of Health and Human Services (HHS), and Drug Enforcement Administration (DEA) guidelines helped the industry to jumpstart giving care. “Now, we are using telemedicine to decrease exposure risk and try and still see the backlog of patients that need to abide by a stay at home orders. For most primary care practices, telemedicine is beneficial because it allows frequent follow-up and averts the need to schedule an appointment that can often change the last minute,” says Gupta. Although a needed technology today, many hospitals and healthcare systems didn’t necessarily indulge in the idea before.
“Big players in healthcare didn’t take a more serious look at telemedicine before COVID. So when COVID hit, a lot of them had to scramble to get some sort of solution up and running,” Jayawardena comments.
Mount Sinai, an extensive medical system in New York City, responded to the coronavirus byimplementing MediSprout. Echoing Jayawardena’s sentiments, Laurie Keefer, health psychologist and director of subspecialty medical, explains the benefits of telemedicine. “We have seen that the more tele-visits to have with our patients, the less likely they are to visit the emergency department or be hospitalized for care,” Keefer said. “This drastically reduces healthcare costs, as an average hospitalization can cost $50,000.”
While healthcare costs are saved, investments are also being made in this industry. Per Fierce Healthcare, “Venture capital funding for telemedicine companies surged in the first quarter of 2020 to $788 million.”
The boom in investments and interest in telehealth not only combated unemployment in those spaces but also resulted in technology companies pivoting their product capabilities to address the current consumer needs somehow. For example, ZocDoc, a prominent healthcare technology platform, moved to include video appointment options for patients and providers.
Of course, not all procedures can be aptly addressed with telemedicine. Jain says, “There is always the concern that things might get missed. A lot of times, people will come in, and they won’t even realize something’s wrong, and you’ll notice their fibroids enlarged so they may have a heart murmur.”
Many conditions require follow-ups involving scans, tests and other in-person procedures that cannot be replaced by virtual communication. The extent to which telemedicine proves to be beneficial are often still in outpatient settings but stretch to include more common practices associated with primary care visits, including my mother’s visit.
On the other hand, some patients are routinely receiving check-ins due to the nature of their condition. “There are a lot of patients who have diabetes and might be coming in every two months or so. A lot of times, things don’t change on a physical exam all too much for a diabetic patient,” says Jain.
The follow-ups for the labs and any prescription refills can be done using telemedicine, with in-person appointments sprinkled in for any necessary tests.
Insurance, an industry associated with disgruntled customers calling about ridiculous claims, is changing its policies surrounding coverage for telemedicine appointments. Government insurances will cover telemedicine services. Many large providers also have begun to include theories surrounding telemedicine coverage. “Once you give something to the population at large, you can’t take it away. I suspect that this will happen with commercial insurances as well. So, one of the good things about COVID is that telemedicine should be much easier to get a covered post this pandemic,” Jayawardena says.
While this may paint a rosy picture, many are still struggling to get fees waived. Once viewed as a mostly unsympathetic industry to many consumers, insurance can rise from the pandemic with the potential to help keep money in people’s pockets.
In a Post-COVID-19 World
The pandemic placed telemedicine on the map.
“We used to have to spend time explaining to doctors and hospital administrators why telemedicine was essential and why it would be a part of the future. That entire conversation is no longer necessary,” says Jayawardena.
The pandemic has proven that telemedicine can make an adequate, if not a more convenient substitute to confident in-person appointments. More individuals are empowered to think about their health activities and can access many health services through apps on their phones. The variety of telemedicine available, from mental health appointments, chat rooms for any minor skin rash, to video calls with your PCP, have proven that medicine is closer to our fingertips than ever before.
At the start of this pandemic, many people simply didn’t trust the value of telemedicine.
“Some patients aren’t fans of telemedicine because they feel they’re not getting the proper amount of care, even though they may be getting the same care,” said Jain. “A lot of times, the perception is that they may not be getting the same care because they’re limited by technology.”
It comes as no surprise that many healthcare professionals and patients see the value in in-person appointments. Gupta believes that sitting face-to-face with your doctor is a large part of the healing process.
“Overall, I think there has been no greater experiment with telemedicine than now. Now, out of necessity, I think we have realized that telemedicine works equally as well and, in some cases, can reduce the large burden that was previously being experienced in the healthcare system as a whole.”
The Covid-19 pandemic and feelings of uncertainty, which have been prevalent across the globe, had lasting effects on all of us. One of the more positive impacts has been on the mental health industry, particularly the normalization of mental health challenges and a more open dialogue about mental health. There have been discussions in the workplace, in schools, and even on Hinge profiles, but what about in South Asian communities? Though some progress has been made, mental health stigma is still widely prevalent among South Asians, impacting individuals’ desire and comfort in seeking help. As a result, the South Asian community reports lower rates of seeking mental health services. And of the individuals who do seek out mental health services, many face challenges in finding therapists who are equipped with a multiculturally competent skill set to understand the South Asian client’s concerns. This is why it’s important to recognize and become aware of the intersections of mental health and South Asian communities.
Although there is an overlap between the mental health concerns of South Asians and other communities of color, there are also unique intersections between culture and mental healththat I want to bring to the forefront of this conversation. As a South Asian psychologist, who is both a researcher and clinician, I have firsthand experience examining how our individual cultural context impacts our emotional experience. If we can understand, or at least consider, how the cultural context impacts us, we can better understand ourselves and feel seen by others too. We, South Asians, are a diverse group in terms of ethnicity, language, food, religion, traditions, and so much more. So, while learning about the “state of mental health in South Asian communities” is much more complex and nuanced than what I can cover in just one editorial, I believe starting the conversation about issues that don’t get talked about nearly enough is an important first step towards destigmatization.
What is the state of mental health in the South Asian community?
Here are some numbers to set the stage, based on research done on South Asian communities. One in 5 South Asians currently reports experiencing mood or anxiety disorders. South Asian youth and young women, in particular, are at greater risk of having suicidal thoughts and behaviors compared to other groups. Only 24 percent of South Asians diagnosed with a substance abuse problem sought treatment. And South Asian Americans express greater stigma toward mental illness than other ethnic groups. How often are facts like these discussed? Not often. Since South Asians are often mixed in with the larger Asian American population, these issues and their nuances are rarely discussed within mental health communities. This underrepresentation can make the reality of our emotional experiences easily misunderstood and make our needs feel invisible. Relatedly, concepts like “model minority” lead outsiders to often assume that South Asians are well-adjusted. And even within the South Asian community, stigma and beliefs about the causes of mental health issues (e.g., mental illness indicates problems within the family, a sign of weakness, etc.) lead all these facts to continue being ignored.
How do mental health concerns intersect with South Asian culture?
While mental health concerns are prevalent among my clients from all backgrounds, these common concerns intersect with culture to create an individualized version of the issue that requires specialized attention and care.
Within the South Asian community, there are cultural differences in alcohol and drug use and the discussion of these topics. Alcohol is prohibited in Muslim and Jain faiths which makes open dialogue about substance abuse and its prevalence even more of a challenge within these communities. Admitting you have a problem can be hard and adding the cultural taboo can make it more difficult.
There is a tendency in the South Asian community to highlight that only linear careers in financially stable or ‘reputable’ fields — such as medicine, engineering or finance — will lead to success. This expectation not only impacts career decisions but also mental health, self-esteem, and self-confidence. Even if we think we are not influenced by outside factors in our career choices, how do we know that subconscious messaging is not impacting our decisions? I personally was pre-med for as long as I can remember and was apprehensive if my parents were going to accept my desire to go into psychology and mental health instead of medicine.
Caring for loved ones, who are aging or ill, is emotionally challenging for most people. What makes this stress unique for the South Asian community? South Asian communities are collectivistic and therefore rely strongly on interdependence well into adulthood. Therefore, caretaking and providing for elders is an integrated part of our lifestyles. Pursuing personal goals can sometimes be seen as selfish and therefore South Asians feel the need to sacrifice personal desires. This can make setting boundaries in relationships or making decisions focused on one’s own needs especially difficult and not as straightforward as may be suggested by Western psychotherapy interventions.
Romantic relationships can be especially stressful for South Asians because of the need to navigate between one’s own desires and family expectations. Older generations pass down messages that people should focus on their careers instead of dating, which can lead to not dating or secret dating and youth navigating romantic relationships on their own. Then, suddenly, the conversation shifts to the need to get married by a certain age, which seems especially difficult when you have not been allowed to date or when it is not something you want in your 20s. South Asians may also experience family expectations about their partner being from the same ethnic/religious background, working in a specific industry, or having a specific family background. These family or cultural expectations and issues also impact the LGBTQI+ South Asian community and South Asians often feel the need to sacrifice personal desires for the expectations that their families or deep-rooted social norms have set for them.
Being able to communicate the complexity of our emotional experience is especially challenging when being emotional is considered a weakness. This cultural sentiment further perpetuates emotional suppression and increases the barrier to seeking support. Also, South Asian languages have limited vocabulary to describe mental health and the emotions involved. It is not only challenging to identify our emotions, but it is difficult to communicate the complexity due to the lack of words in South Asian languages to describe those emotions. Let’s take the word, “gussa,” which means “angry” in Hindi. The only way to explain the level of anger you are feeling is to describe the full situation. While in English, you can use variations of the word “anger,” such as “annoyed” or “furious” to describe the emotions with more nuance.
Culture is integrated in small and big ways into how South Asians experience their body. It can be common for family members, especially older women or “aunties,” to comment on one’s body weight in direct ways like telling someone they have gotten fat or thin. There are also unspoken rules about food that impact one’s relationship with food and potentially overeating, including “it is rude to not finish all the food on your plate,” or if you don’t go up for seconds that means you didn’t like the food. Research has also found South Asian women in particular often struggle with the pressure to conform to Western beauty norms (e.g. removing dark hair, and lightening skin color).
We all are constantly evolving and understanding who we are and what we value. What makes this unique for South Asians? Culture intersects with other parts of our identity, including generational status (1st, 2nd, or 3+ generation), religious beliefs, gender identity, and age which impact the way we make sense of who we are. Being born in the US makes one American, but are you still American if you primarily connect with your South Asian ethnic identity or maybe your religious identity? Or what messages does culture pass down about what it means to be female? Are you supposed to do all the cooking and cleaning? Do you have to have children? Culture intersects with identity development in complex ways.
How can you get support with what you may be feeling and experiencing?
I believe the first step in breaking the barriers, is shifting your mindset about seeking mental health support from something that means you have a “character flaw” to something that you do for your overall well-being. Taking care of your emotions and processing your emotional experiences is as important as your weekly workouts, annual physicals, or that apple a day. One way to start this process on your own is to spend 10 minutes a day engaging in mental hygiene practices (meditation, gratitude journal, positive experience journaling, writing a thought log, prayer, or deliberate time in nature).
If any of the concerns I discussed earlier resonated with you, consider signing up for Anise Health by filling out this short intake form; you’ll get matched to a culturally-responsive clinician within two business days. I’ve also listed a few additional resources below that aim to address mental health needs in South Asian communities.
I hope we can continue to bring the ways our South Asian culture impacts our well-being into the forefront of the conversation around mental health. By highlighting the South Asian community’s experiences,we can feel more seen and create a more accepting environment that allows us to get the help that we all deserve.
If you or someone you know is in an emergency, call The National Suicide Prevention Lifeline at 800-273-TALK (8255) or call 911 immediately.
Mental health is quite the subject these days, its troubles affect everyone; it knows no gender, orientation, race — it strikes upon one’s inner journey. But specifically, what have not been put in the same sentence are men, mental health and vulnerability. Too often it is seen that men are not allowed to show their emotions. But the aftermath shows that this repression of emotions bleeds into relationships, substance abuse, domestic violence, and more. It is seen time and time again in films, books, art — it’s all too familiar.
And it is beyond the point of “let’s talk about it.”
Time for action.
Mental health hits close to home for me. As a filmmaker, I will always share my journey with others. – Jacquile Singh Kambo
Men, mental health and vulnerability often aren’t talked about enough. “Embrace” is a short film that seeks to change that. It is a short animated film about Arty, a well-dressed man who has no face, gets ready for his date until he meets a younger version of himself. Arty and this younger version of himself delve into a surreal world where he learns to embrace himself. It’s him versus himself.
The façade self; the feeling of wanting to be somebody — are all things people are dealing with especially in adult life. From the dating world to the social media world — it feels like different masks are worn only to make us feel faceless, feel numb or a nobody. Too many masks could make people feel like a lost identity amidst everything that is going on in this crazy world. Out of touch, and out of life — with others and with themselves. The masks are metaphorical, the story is internally about men and mental health. Arty learns to ’embrace’ himself and to overcome his internal struggles.
Not often is it discussed that men should have a safe environment to be vulnerable, amongst others or even other men. Perhaps this is because men are wired to put on a façade when things go wrong, when things get difficult, or when true emotions are not expressed. If these are not dealt with, it can lead to other relationships, including romantic relationships. Further it becomes a cycle: suppression could lead to aggression, substance abuse or self-sabotaging behaviors and could create a toxic environment. Many of these arise from childhood trauma. Quite often childhood is repressed or ignored, and one may take their troubles along with them into adulthood. Perhaps revisiting the roots of the past can help one become successful in a better tomorrow. “Embrace” is an example of how important it is for men to embrace their past.
“Embrace” was meant to be a live-action film — until animation was considered. Seven years of re-writing, re-working, and digging down deep with the characters for the story to better fit the message at its core. Animation is an underrated avenue for a universal story that became the key pillar for “Embrace”. What many do not know about animation is that you can create a serious subject matter in a light-hearted way that is universally acceptable. Men and mental health are heavy subjects for some, but animation allows the exploration to become innovative, creative and fun. Animation allows the experimentation of entering surreal worlds.
For example, in “Embrace” Arty enters a surreal world where he has to go up against a younger version of himself — to unmask the root cause of his internal struggles and give himself the “big hug” he needs. This heart-throbbing metaphor is captured in animation that a live-action film couldn’t have captured. The freedom of animation helps tackle tough subject matters about self-love, and how we must embrace the soul, the child, the person within.
The Story Behind The Story
There are many inspirations behind “Embrace”. Film noir, the silent film era, surrealism and the works of Christopher Nolan and David Lynch — the film is able to articulate something far more special. This is more than just a mental health piece for educational purposes. This is a classical narrative from beginning to end; a story of important themes and beloved characters that needed to be shared with the world.
It is not often the words mental health and men and vulnerability are discussed under the same umbrella — especially with growing hypermasculinity, and the likes of social media where facades are put up and the vulnerable parts of ourselves aren’t as expressed. It is here where the film encourages men to look within themselves, and allows them to be vulnerable to themselves. Perhaps this is an important step to better themselves on the journey to have successes (whatever success means to them), and to enlighten and lift those around them. The first step should always begin with “you.”
It’s tough to find places where men have access in ways of improving their mental health without feeling like a patient or a victim in the institutionalized realm. It’s tough to find places where men can talk to other men about their struggles among peer groups, educational groups, and more.
The “Let’s Talk” phase and awareness is long overdue; it is indeed time for action. Perhaps creating seminars or group-related events and activities to help create vulnerable environments. Art or art therapy can be a great way of producing something stemming from the inner journey. Or maybe it is time to look at “sick days” as “mental health days” as well. Perhaps more can be done to simply just talk about it. It’s time to give ‘doing’ a chance to start in our close-knit communities.
Maybe if one learns to ’embrace’ themselves, only then, perhaps one can fully understand others and their pain — and have the vision of empathy for others. “Embrace” took seven years to write and a year of animation for a four-and-a-half-minute short film. The film is about self-love, embracing one’s self before one can see empathy for others. It is produced by Raman K Fenty and Jayesh Kodwani and his team, directed and written by Jacquile Singh Kambo, co- written by Sidartha Murjani and stars Jenna Berman. “Embrace” has received numerous international accolades including Best Audience choice at the Emerging Lens Cultural Film Festival of Halifax, Nova Scotia, as well as acceptances in hometown Vancouver, Canada; Goa, India and Chicago, United States.
If you are struggling with your mental health, please call your regional crisis hotline. These are a few non-crisis mental health resources for men’s mental health.
Traditionally, psychotherapy has let women down. This is not to say that women and other minority group members have never received help, but rather that the therapy they received made little attempt to address the root causes of their problems. In focusing narrowly on the personal and individual, which a lot of mainstream approaches focus on, they ignore the big picture and miss the point. An alternative approach — feminist therapy — can help challenge the norms and support South Asian women in a more comprehensive way.
A therapy which fails to address power issues in people’s lives automatically reinforces oppression. Feminist therapy is a way to look at people as part of society and not merely as individuals. As more people of marginalized identities realize that the cause of their mental and emotional difficulties are not individual factors but structural, they are seeking more thoughtful therapists and counselors. Feminist therapists are aware of the cultural dynamics that uniquely affect women and keep these at the center of their practice.
Feminist therapy has a lot to offer to women of color, particularly South Asian women. It is formed on the assumption that social forces impact, and these forces include the many identities that a South Asian woman holds — including race, ethnicity, caste, etc. Feminist therapy can help support our clients and us as therapists to conceptualize the client’s difficulties, as not just stemming from internal sources, but as an outcome of the deep-rooted patriarchal system.
Feminist therapy is the key to a progressive approach towards mental health care. There is a lot of awareness about feminism nowadays and women encourage feminist approaches to therapy. Feminist approaches look at how social and political forces interact with our own identities. Feminist therapy especially puts in a lot of emphasis on how our intersectional identities such as religion, family dynamics and social class plays a role in our own gender identity. Feminist therapy can help support our clients and ourselves as therapists to conceptualize the client’s difficulties as not just stemming from internal sources, but rather face the impact of the deep rooted patriarchal system.
Here are some important aspects of a feminist approach to therapy, whether you are a therapist or someone who wants to start therapy themselves:
Therapists’ own biases
Therapists, while working with South Asian women, as with any other client, need to put in their own personal work in understanding the assumptions and biases that they may hold towards these identities. If a counselor holds bias that a South Asian woman is timid, or doesn’t know what she wants, it may cause the counselor to take in a more direct approach rather than a collaborative one.
South Asian women are often being told what to do. Hence, therapists who may choose to be more directive rather than collaborative, may often reinforce the position of power and authority onto a South Asian woman reflecting what she faces in the world. South Asian women, especially who may have not been exposed to therapy, may look at counselors from a view of receiving advice or guidance. It is through our own ability to explore and process our biases that we can help challenge this narrative for the client, and help take a more collaborative approach.
Exploring identity work
It is important for a therapist to be aware about gender, sexuality and the intersectional aspects of feminism; about how sexual minorities, caste, religion impact gender in influencing the kind of experiences that women face. The counseling relationship is a space for clients to process the identities that are the most salient to them. We can start off with providing some context and psycho-education around the purpose of understanding these identities. Helping the client process different identities that are important to her can help take a more holistic approach to understand her difficulties. We can help provide information around how every identity that we hold impacts us in some way or the other, because of its interaction within the social context. This can also be a time when a client may self-disclose about their own identities, if comfortable and appropriate, to model this understanding.
Ask instead of assume
It is considered best practice with every client to ask their preferred pronouns; as well as identities they would like to highlight at the beginning of the counseling relationship.
Asking, instead of presuming, can help clients hold their voice from the beginning of the counseling relationship and create a safe environment. Processing identities that are salient to them and opening up space to share other identities can help clients share openly about how they choose to identify with their gender/sexual identity. It creates space for clients in the process of exploring their identities, to get curious about their identified gender/sexual identities for the first time.
One of the initial and ongoing processes of feminist therapy is educating women from a collaborative aspect. Providing psycho-education about their rights, consent, impact of patriarchy and other systemic factors promotes empowerment. While providing psycho-education, it is important to process the power dynamics in the relationship and model consent within the relationship by exploring the question: “What is it like for you to hear this information from me?”
We as therapists can be considered as guiding forces, but we should also be mindful that we are providing this guidance and information from a collaborative aspect rather than enforcing authority or being direct. South Asian women are often asked to respect people in authority and not defy them. We, too, as therapists may end up reinforcing these patterns, and instead need to do our own exploration by engaging in psycho-education with collaboration and continuing to check in with the client’s internal process.
Hold context around starting therapy
A South Asian woman puts a lot of thought into seeking therapy. The cultural stigma towards mental health can have an imperative impact on her recognising that therapy could be a potential need to take care of herself. Along with the courage that it takes to reach out to a therapist, either openly or whilst keeping it hidden from her family, there may also be a potential element of what kind of therapist do I want to see. Especially for South Asian women living in the US/UK or other Western countries, there may be a significant deliberation that goes into seeing a white therapist v/s a person of color therapist v/s a south asian therapist.
Can we think of potential factors that may prevent a South Asian woman from reaching out to a therapist who may hold similar cultural identities ?
Can we think of potential factors why a client may want to work with a South Asian therapist?
Explore reasons that led them to choose you
When a client comes in for therapy, she has probably considered the therapist’s background. She may choose to see a non-South Asian woman because of past and internalized fear of being judged by other South Asian women in her life. Or a client may deliberately choose to work with a South Asian woman therapist for perceived similarities in identity. For therapists, it’s important to create space at the beginning of the relationship to ask the client what led them to choose you as their therapist. For clients, it’s important to ask questions about your therapist that are important to you.
Fostering environment for all their identities
Clients are fully seen and valued for all aspects of their identity, background and experiences. It also means that we ground our interventions from a systemic and anti-oppressive approach.
We constantly learn and evolve to provide responsiveness, humility and respect to our clients and really redefine the standard of care based on the identities and background of South Asian women.
Background of the client
Particularly while working with South Asian immigrants, it is important to know the background of the client we work with in order to design culturally-appropriate interventions. As a lot of research has asserted, not all Asians are alike and group differences within Asian groups is often overlooked.
There’s a lot of information and knowledge around Indian groups that tend to be generalized across other communities from South Asia such as those from Pakistan, Sri Lanka, Bangladesh, etc. It is important for counselors to be aware about similarities and differences across these cultures, and create interventions that are more specific to the client’s cultural background.
It is important to check in about how the interventions land with the client. We may use certain strategies from a Western perspective that go into exploring a client’s relationship with her parents or caregivers. This can particularly bring guilt or shame for the client as it may be in conflict with her cultural value of holding respect for her parents.
A lot of the deep respect and regard towards family comes in the form of loyalty and not speaking “ill” about the family with strangers. Reflecting on family, based on Western interventions, can sometimes make it challenging for clients based on their values. Checking in with clients on how these interventions feel, and making space for the guilt and shame to surface can once again help clients to hold value in her own voice.
Examining values and beliefs
Therapy can support South Asian women in differentiating between their own values and society’s expectations. Even though collectivism is a value within South Asian culture, it may not necessarily be an individual value to our clients.
South Asian women very often bear the burden of the value of collectivism where they have to meet family’s expectations, be in touch with other family members and engage in other collective activities. It is an expectation that has been imposed upon them. A therapy space can be a space for clients to explore what their own individual values look like. It can be a space for counselors to collaboratively work with clients in choosing what matters to them, even if what matters to them is to take care of the family.
In this essence, she now has had a voice in choosing how she wants to move forward as v/s feeling stuck in expectations set by others. When the client recognizes that she has a choice in exploring her own values and beliefs, there can be support around how to engage in behaviors that are based in these values. Sue and Sue (2008) has recommended discussion about values, beliefs and behaviors of their family and culture, so that clients can discover those that are for them, those with which they identify and those with which they are ambivalent.
The reason why a South Asian woman may choose to work with a South Asian therapist is to feel understood and not hold the burden of having to explain different cultural norms and expectations. When working with a therapist from a different racial background, clients may feel the need to explain and defend their own culture. It may feel difficult to hear about certain norms being toxic or problematic from someone who doesn’t share the same background as you.
When we as South Asian therapists work with South Asian women clients, we have the unique opportunity to validate the importance/meaning of these cultural norms, as well as challenge its problematic impact on our mental health. We have the context and ability to hold the community and cultural system accountable. It is important to hold the value of one’s desire to have a community and fellowship, as well as hold the impact of this collectivism on the mental health of South Asian women.
It is important to pause and explore: What about the culture feels impactful? How does this impact self-esteem and the way they view the world?
South Asian women are bound by the cultural value of adjustment and acceptance. Accepting our culture the way it is and moving on is what they have been taught to do across generations. The therapy room can be a good space for us to pause and help them choose what aspects of the community are helpful and what feels unacceptable.
This, in turn, can help with increasing their voice and control on their own value system. When they come to you looking for that cultural connection, you can hold space to both empathize with their cultural upbringing and to be able to challenge it. There’s more likelihood that they need it to be challenged and from someone who understands what they are going through.