An Asian American Student’s Reticence

A Filipino American medical student cannot speak in class for fear that she will be criticized and humiliated. She postpones dealing with this and other personal issues during college in order to focus on her goal of being admitted to medical school. Once she begins medical school, she realizes that it is time to address her speaking anxiety, since she will soon be required to give regular presentations on hospital rounds. She goes to a student counseling office and asks to be seen by a female Asian American clinician.

This case demonstrates the usefulness of the DSM-IV-TR Outline for Cultural Formulation (American Psychiatric Association 2000, Appendix I), which led to a more thorough understanding of the various factors contributing to the patient’s anxiety. The cultural formulation also provides a springboard for a richer understanding of the patient’s inner dynamics, presenting fields of exploration that would have been unseen if culture were not considered.

Special considerations in the diagnosis and treatment of social phobia in Asian Americans are addressed. This is an especially pertinent topic, given the overlap between symptoms of this disorder and normal culturally appropriate behavior in many Asian cultures. Finally, the case raises questions about the larger sociocultural implications of diagnosing and treating social phobia in Asian Americans.

Identifying data

Ms. C was a 24-year-old single Asian American female medical student who was born in the Philippines and who immigrated with her family to the United States when she was 6 years old.

Reason for evaluation

Throughout high school and college, Ms. C had coped with her public speaking anxiety by avoiding it. Knowing that avoidance would no longer be possible when she would be required to give presentations on hospital rounds, she knew that it was time to seek help.

History of present illness

Ms. C stated that her anxiety about speaking in class was so severe that, to the best of her recollection, she had never done it. She feared that professors and peers would call her stupid and that they would humiliate her, make her an outcast, and eventually ostracize her from school. Sometimes she would become so anxious she would feel dizzy.

She had known since her early college years that she had a problem. However, she postponed seeking help in order to focus on getting good grades so that she could be admitted to medical school. She reached her objective, but during her first semester there she became so disturbed about her public-speaking anxiety that she stopped attending classes. She felt extremely depressed and hated herself. She felt lethargic, slept too much, and had frequent crying spells. At one point she did not leave her home for 2 weeks. There were no thoughts of suicide, but this was the first time Ms. C had been so depressed that it interfered in a significant manner with her functioning. These symptoms resolved spontaneously within 8 weeks while Ms. C was on a Christmas vacation.

During the second semester Ms. C decided to seek help, realizing that in order to complete medical school she would need to speak in front of others. She was especially concerned that during her third year she would need to make presentations regularly in different settings and practically all the time. She went to the Student Counseling Center and requested help, stating that she preferred to be seen by a female Asian American clinician. She felt that an Asian American might have an understanding of the aspects of her personality and values that she attributed to her Asian cultural upbringing. She also felt that an Asian American therapist would be less likely to see her problems as weird.

At the time of the evaluation, her depressive symptoms and crying spells had resolved and her energy and sleep patterns had returned to normal. However, her anxiety about speaking in class and her low self-esteem related to this matter remained unchanged. In addition, Ms. C complained of other related problems, such as difficulty in asserting herself in laboratory groups, especially when it would involve contradicting classmates. For example, during one laboratory assignment, Ms. C’s group had decided to proceed in a manner that she knew would fail. However, she could not bring herself to tell them. After her group had gone through multiple failures, Ms. C finally expressed her ideas on how to handle the project. They followed her suggestions, and their next attempt was successful. According to Ms. C, she would never want to assume a leadership position from the start. However, if for some reason it was necessary for her to do so, then she would do it for the good of the group.

Ms. C also experienced anxiety in a variety of other social situations. She envied the way some of her classmates would have casual conversations with her professors. Whenever she would see a professor by chance at school, she would either go to great lengths to avoid him or her, or she would make a quick greeting and then scurry away. Ms. C realized that she felt especially uncomfortable in small groups led by a male professor, and she wished she could “chum” with her professors the way her classmates did. At lunchtime, she usually ate with one of her classmates, another Asian American woman. When this classmate was unavailable, she ate alone, all the while feeling anxious about others observing her doing so. Ms. C would join others only if asked, since she would not want to intrude upon them otherwise. A similar anxiety would occur at parties, when she would be very anxious about socializing. She would sit with her boyfriend and join others only when asked. Often she would go home wondering why she bothered to go to parties.

Past psychiatric history

This was Ms. C’s first contact with a mental health care professional. Actually, it can be said that her past psychiatric history weaves into the history of her present illness.

General medical history

Ms. C had no significant medical history, was taking no medications, and had no known drug allergies.

Ms. C used alcohol rarely, and she had never tried any illegal substances.

Developmental history

Ms. C was born in the Philippines and moved with her family to the United States when she was 6 years old. She was the youngest of four children. Her father, a man in his late fifties, worked as a supervisor in a local government agency. Her mother, a woman in her early fifties, worked in a factory. Ms. C had three older siblings: two sisters and a brother. All were within 6 years of her age, were college graduates with some graduate education, and had successful professional careers. Their father had decided that the family should emigrate to the United States, as he thought opportunities for his children would be greater. The family had moved to a suburban community in California and had lived there ever since.

Adjusting to life in the United States was difficult for Ms. C’s father, who started drinking heavily and became irritable at home. Ms. C recalls once asking at the dinner table how to say a certain word in Tagalog. Her father became angry that his children had forgotten how to speak Tagalog and raged that from then on, only Tagalog could be spoken in the house. After he left the dinner table, her siblings criticized her for having asked this question. At another time she asked her father to help with her homework. He became angry and called her stupid. She never asked him for help again. In retrospect, she realized that he had probably felt inadequate to help her and that he was being defensive. She suspected that her relationship with her father might be related to her anxiety about speaking in class.

Her mother was a nurturing and consistent figure in the family’s life. She would often dissipate her husband’s anger and smooth over potential or actual conflicts. Her devotion to her family was illustrated in one of Ms. C’s recurring dreams. In this dream, Ms. C and her mother would hide behind the living room sofa, dodging enemy gunfire. Sometimes her mother would leave their sofa foxhole to walk toward the kitchen. She would get shot, and Ms. C would run out and hold her bleeding mother in her arms. Then her mother would get up and continue toward the kitchen to prepare dinner for her family. This scenario would repeat itself continuously.

Ms. C states that her parents put pressure on her oldest sister to go to medical school and become a doctor. However, she did not excel enough academically and became a pharmacist instead. Ms. C stated that she did not believe the other children underwent the same parental pressures as her oldest sister did. All, however, were far better educated than their parents.

Ms. C lived at home during her first 2 years of college, then transferred to a more prestigious university away from home for the remainder of her studies. As another sister lived near the university, Ms. C moved in with her. They shared cooking and cleaning chores. At the time of presentation, Ms. C had never lived independently.

Ms. C had met her boyfriend when they were both age 16. He was Caucasian American, and they attended the same high school. Following high school, he worked in the computer field; he had never attended college. According to Ms. C, this discrepancy in their educational levels was disturbing to him but not to her. They had a supportive relationship, and Ms. C found him comforting when she felt distressed about her difficulties at school.

Social history

Ms. C felt guilty about having moved away from home even though she recognized the necessity for it. She worried that her parents were lonely and sad without their children at home, particularly as she was the last child to leave. She and her sister had frequent contact with their parents by phone and visited them almost every weekend. Often these visits would occur when their mother asked them to come home and do domestic chores. Ms. C believed her mother used the chores as a way of asking her children to visit and that the chores themselves were not important. This was a source of conflicting feelings for Ms. C: as she became busier with medical school, she felt increasingly burdened by visiting her parents so regularly. When she began her clinical rotations, she would have few free weekends, and she did not want to spend them working at her parents’ home.

Occupational history

During the first summer of medical school, Ms. C did research as part of a fellowship she had earned. Other than this, she had never been employed and was financially supported by her parents.

Family history

Ms. C’s parents had met and married in the Philippines, where her father belonged to a large family working mostly in manual and field labor. His family considered him unusual because he felt education was important, and when he earned his bachelor’s degree, his family failed to attend his graduation. According to Ms. C, the desire for his children to be educated was a main factor in her father’s decision to emigrate.

When Ms. C’s family came to the United States, her father became separated from relatives and lifelong friends. According to Ms. C, her father was popular and well connected in the Philippines. Whenever he returned to visit, there would be many parties welcoming him. Through his government connections he was able to help relatives get jobs in the Philippines, even though he lived in the United States. In the Philippines, her father often drank socially with groups of male friends, but in the United States he no longer had this group of friends, so he drank alone. Ms. C recalls him drinking shots of hard liquor in the morning, before afternoon naps, and after dinner. She believed that all the men she knew in the Philippines drank but that the stresses of dislocation probably caused her father to drink more heavily and even excessively. He had no history of treatment for this drinking problem.

While her family lived in the Philippines, her older brother was treated by a “witch doctor.” He was about 10 years old, and it was believed that he was possessed. Ms. C remembered her mother burying items beneath a mango tree as part of his treatment. In adulthood, her brother underwent psychotherapy in the United States. However, Ms. C did not believe that he was treated with medication. She did not know the nature of the symptoms for which he sought treatment.

Review of systems

A review of systems revealed only the dizziness that often accompanied her anxiety episodes.

Physical examination

The physical examination was deferred, because Ms. C was seen as an outpatient and because she had no significant medical history or physical complaints.

Mental status examination

Ms. C was a petite woman who looked younger than her age. She was always neatly groomed and wore casual, inconspicuous clothing, such as jeans and shirts in shades of brown and tan. She wore glasses with large plastic frames that hid her face. She wore no makeup. She appeared anxious in the first interview, but in subsequent sessions she showed a more relaxed demeanor. Her speech was of normal rhythm, rate, and volume. She was articulate and quite verbally expressive.

Ms. C described herself as usually being a happy-go-lucky person and denied any chronic mood symptoms. Indeed, she was usually bright, cheerful, and congenial, but she expressed self-deprecating feelings in regard to her inability to speak in class. Her thoughts were coherent and of normal form and content. There was no history of psychotic symptoms and no history of suicidal ideation. She was alert, with a clear sensorium, and seemed to function at a high intellectual level with good cognitive abilities. Memory and ability to abstract were excellent. She had a good fund of knowledge and appeared to have excellent judgment. She also appeared to have a good amount of psychological insight.

At the time of evaluation, there were no vegetative symptoms of depression such as sleep or appetite disturbance, nor were there symptoms consistent with a history of mania, such as periods of increased energy or decreased need for sleep.

Functional assessment

Ms. C functioned at a high level and had earned good grades and a fellowship in medical school. Socially, she also functioned well, having supportive relationships with her family and her long-term boyfriend. Her social anxiety, however, interfered with her performance at school as well as with relationships with peers. In the context of medical school, there was a significant impairment whenever she was required to speak in front of others.

Diagnostic tests

Routine laboratory values were within normal limits. They included thyroid function tests, complete blood count, electrolytes, liver function tests, and urinalysis.

DSM-IV-TR diagnosis

Differential diagnosis

Under the conventional DSM-IV-TR diagnostic system, Ms. C met full criteria for the diagnosis of social phobia: her anxiety about speaking in front of others, her fear of negative evaluation, her own recognition that her fear was excessive, the anxiety interfering with her performance in medical school, the persistence of this anxiety for all of her years of schooling, and her avoidance of anxiety-provoking social situations such as speaking in class.

Other anxiety disorders were considered and excluded, as her anxiety was limited to social performance situations. She experienced dizziness but no other physical symptoms of anxiety. Therefore, she did not meet criteria for panic attacks or panic disorder. There was no clear history of trauma, which would be essential for the diagnosis of post-traumatic stress disorder. In fact, she seemed to have managed appropriately her father’s unpredictable behavior, even though she attributed at least part of her anxiety symptoms to such factor.

The diagnosis of adjustment disorder with anxious and depressed mood was excluded because of the long-standing nature of Ms. C’s problem. Before the evaluation, Ms. C had undergone an episode of depression, which lasted less than 8 weeks and which prevented her from attending class or even leaving her home for 2 weeks. This episode had apparently resolved spontaneously.

Other mood disorders were considered. Ms. C had never experienced symptoms consistent with mania. The possibility of chronic dysthymia was also dismissed, since her discontent was limited to school-related performance situations. On weekends, she enjoyed herself with her boyfriend, friends, and siblings.

There was no evidence of a personality disorder. Her avoidance was limited to social performance situations, and she never avoided school or family responsibilities. She had a stable relationship with her boyfriend of 8 years.

Cultural formulation

Cultural identity of the individual

Ms. C was born in the Philippines and considered herself an American. She has a Spanish first name and surname and chooses friends who are Asian American, not necessarily of Filipino heritage. None of this should be considered unusual. Historical and cultural factors contributing to the complexity of her Filipino American identity will be addressed in the Discussion section.

Cultural explanations of the individual's symptoms

Within the context of many Asian cultures, Ms. C’s anxieties and behaviors would not be considered outside the range of normal. Three concepts central to many Asian and Asian American cultures should be taken into account whenever considering the diagnosis of social phobia in an Asian American: 1) The concept of “face” and the importance of not losing it; 2) respect for elders, a deeply rooted value in Asian cultures; and 3) group-oriented thinking, which is a norm in Asian and Asian American cultures rather than the rugged individualism that is so stressed in mainstream American culture. In the Philippines, two terms reflecting this belief are pakakisama (the value of conceding to the wishes of the group) and kapwa (the concept of shared identity).

Cultural factors related to psychosocial environment and levels of functioning

Many of Ms. C’s anxieties reflected culturally appropriate values in Filipino, Chinese, and other Asian cultures. For example, her anxiety about being humiliated in class was consistent with the preoccupation with “saving face.” Her reticence about having casual conversations with professors reflected the value of respect for elders. Her reserve about assuming leadership reflected her valuing pakakisama. With her laboratory group, Ms. C deferred to the wishes of the group, whereas other group members were more aggressive and assertive, as might be expected in the culture of an American medical school. Much of Ms. C’s discomfort in group situations also reflected her cultural dislocation, since group etiquette in Asian and American cultures differs. For example, during the times she ate lunch alone, if she had been in an Asian cultural setting, someone eating with a group might ask Ms. C to join them, as part of kapwa. Overall, Ms. C was behaving in ways appropriate to Asian culture. However, she was trying to function in the aggressive psychosocial environment of an American medical school.

Cultural elements of the relationship between the individual and the clinician

On a very basic level, Ms. C and the therapist shared many cultural commonalities, because both were Asian American, sharing the experience of being Asian, and therefore different, in America. This was true even though Ms. C’s ancestry, from the tropical islands of the Philippines, differed in many respects, from the therapist’s ancestry in the mountains of snowy northern China. Although distinct and heterogeneous, Chinese, Filipino, and other Asian cultures often have such commonalities. Ms. C and the therapist also shared the common experiences of immigrating to the United States at a young age in the post-1965 Asian immigration wave, following the lifting of anti-Asian immigration quotas.

Ms. C requested an Asian American therapist out of the fear that someone who was not Asian American might think her “weird.” The therapist found Ms. C’s anxieties quite understandable, having had many Asian American patients, friends, and relatives with similar perspectives and similar problems.

Of interest also is that both the patient and the therapist had Latin roots within their cultural backgrounds: Spain has had centuries of influence upon Filipino culture, and the therapist’s family was Chinese-Brazilian—her mother was mostly raised in Brazil, where her family had settled after the civil war in China. The therapist was born in Brazil, and during most of her childhood in the United States, her family thought of Brazil as home. The convergence of backgrounds is an example of the fluid nature of culture and the increasingly blurred boundaries between cultural identities today.

Overall cultural assessment for diagnosis and care

Although Ms. C exhibited many symptoms which met criteria for social phobia, it was also apparent that she was constantly negotiating between the Asian cultural values of her home and family and the more American values of her school environment. This was made evident throughout the cultural assessment.

Not only were Ms. C and her family separated from relatives and friends in the Philippines, they were also enduring the stress of constantly negotiating between cultures. She not only had to cope with her own losses but also absorbed the unhappiness of her parents. For example, her father had endured the loss of family, close friends, a familiar way of life, and an influential social status. The losses and trauma of the parent generation can be transmitted to children, who must compensate for the anxieties of their parents. Often these children incur double losses, as they not only lose the nurturing of their parents but also must give comfort to soothe their parents’ anxieties.

Clinical course

Treatment consisted of weekly psychotherapy, which addressed issues of adjustment and focused most prominently on Ms. C’s social phobia symptoms as the most pressing issue. Cognitive-behavioral techniques targeting social phobia symptoms as well as psychodynamic approaches to exploring adjustment issues were employed. Through the course of cognitive-behavioral therapy, Ms. C realized that her automatic thoughts consisted of cognitive distortions, such as jumping to conclusions that she would be criticized, seeing things through a mental filter portraying everything in a negative light, and catastrophizing: thinking that small errors would result in far-reaching consequences, such as failing school and being ostracized by her peers. Ms. C began to recognize her cognitive distortions; she began to make brief comments in class and to be able to participate in small-group discussions. However, she still had significant anxiety about speaking up in front of larger groups.

Ms. C’s treatment became urgent when she was asked to present her summer research project at a national conference. She realized that this was an honor, since most presenters would be faculty, and few students were invited. However, the prospect of standing next to her poster and answering questions for several hours seemed insurmountable. In addition, she was anxious about traveling alone to an unfamiliar city. In the past when had she traveled alone, she had avoided contact with people and isolated herself in her hotel room. She strongly considered refusing the invitation.

At this point, antianxiety medications were discussed. Ms. C agreed to a trial of propranolol, 10 mg po before social performance situations. Her first use was during a lecture in a large classroom. To her surprise, when she thought of a question, she quickly raised her hand and asked it. Her question was well received, and classmates complimented her afterward.

She attended the conference. With the use of propranolol, she presented her poster without difficulty. She also enjoyed a party without her usual anxiety and reticence. She went to a restaurant and enjoyed eating lunch alone. At another point, she telephoned student presenters from other medical schools and organized an outing. Toward the end of the conference, she volunteered to participate in a panel discussion and did so without the use of propranolol. Ms. C returned home satisfied that not only had she successfully presented her research, but that she had made new friends.

When she returned to school, she continued to participate regularly in classes without the use of the medication. When clinical rotations began, Ms. C started with 8 weeks of surgery. She completed the clerkship, regularly made presentations, and tolerated critical remarks from surgery attendings and house staff.

From the cultural perspective, Ms. C also resolved many issues with her family during the course of treatment. She realized that her inner turmoil about how much time she should spend with her family constituted retaining Filipino cultural ideals, but living in the reality of American culture. She realized that in the Philippines village where her family had lived, children would usually grow up and build homes in the same neighborhood as their parents. This would result in large extended family networks that had frequent contact. She realized that in the United States, most families lived differently, and children usually moved away from their parents. Moreover, given her situation, it would not have been possible for her to meet the same family expectations as she would if her family still lived in the village. She informed her mother of this insight and her mother received it well, pleased that Ms. C had been so concerned for the happiness of her parents.

At times the therapist tried to bring up other issues of culture with Ms. C. However, she usually seemed reluctant to discuss them. This was interpreted not as denial or avoidance but as her reticence about engaging in a discussion that seemed artificial. Just as a therapeutic dyad of Caucasian American therapist and patient would not need to dwell on issues of American culture, this therapeutic dyad did not need to overemphasize culture: cultural understanding was implicit during the sessions. However, the therapeutic relationship benefited from common understandings. For example, as an Asian American, the therapist was able to empathize with Ms. C’s predicament about her loyalty to her parents, as well as her ambivalence in social situations.

When the decision to terminate therapy was made because Ms. C was beginning her busy clerkship year and because the therapist was planning on relocating to another state, the therapist asked Ms. C if she would like the therapist’s new phone number should Ms. C need help. She declined. Instead, she requested a prescription for a small quantity of propranolol, which she had not used in approximately a year. Asking for the medicine was symbolic of Ms. C’s desire to seek support only if she needed it. The therapist gave her the prescription and also the new phone number, understanding that Ms. C had originally refused it out of pakakisama, and perhaps even out of respect for the therapist as an elder, as well as her desire to not impose herself. Perhaps Ms. C thought that the therapist had originally offered the phone number also out of pakakisama and politeness. Later, however, she understood that the therapist’s offer was heartfelt, and she took the phone number eagerly and appeared relieved. This type of exchange is typical among Asians and Asian Americans: one person may make an offer; the other refuses out of politeness. A round (or often several rounds) of offers and polite refusals will ensue as the two parties feel each other out. Each round allows the parties involved to discover empathetically what would be in the best interest of both involved. Each offer and refusal is highly symbolic, and more is at stake than simply goods or services. Each offer and refusal is an expression of one’s desire to think of the other’s welfare and to anticipate the other’s needs. The good of the group is valued over an individual’s wants. The wants of one person are not separable from the wants of others. A quite typical Asian and Asian American view is that what is best for the group is ultimately what is best for the individual as well.

Discussion

The following is a discussion of three values (face, respect for elders, and group-oriented thinking) common to many Asian and Asian American cultures. These values should be taken into account whenever the diagnosis of social phobia is considered in an Asian American patient. An assessment of other clinical and cultural issues of the case will follow.

Face

In Filipino culture this concept is called hiya; in Chinese culture it is called lian. It is often translated into English as face, although there is no real English equivalent. If one does something to shame oneself, it is said that one has “lost face.” Great extremes will be endured in order to save face, as the loss of face may imply dire consequences.

Because of the strong cohesion of families, one person’s shameful act may reflect on the entire family. Honor is important, and if an individual is shamed, then “both the individual and the family are placed in a position of hiya or loss of face” (Pido 1986, p. 45). An extreme example of the consequence of losing face would be to remove the shame from the family by removing oneself through the act of suicide. Whereas in Western cultures, suicide is considered a sin or a crime against society, it has a different connotation in Asian cultures: suicide may be viewed as an honorable way to save face and to save one’s family from shame. In the United States, stories of Asian American students committing suicide over a bad grade are unfortunately not uncommon.

Although suicide is an extreme example of the lengths to which Asians will go to save face, it nevertheless emphasizes the gravity and importance of face in Asian cultures. For Asian American students, making an embarrassing comment in class or being criticized in class carries the additional monumental weight of possibly losing face. When considering the diagnosis of social phobia in an Asian American such as Ms. C, the importance of face must be taken into account.

Respect for elders

This value is deeply ingrained in most Asian cultures, and it stands in stark contrast to the youth-oriented culture of the United States:

Filial piety, an English phrase that can serve as an extraordinarily awkward translation of an Asian concept with no real Western equivalent today, governs parent-child relationships. Good sons and daughters are expected to be all-sacrificing toward their parents and to put the good of their parents above all, including career, spouse, and their own children. They should never argue with their parents or display rebelliousness. They should obey unquestioningly.

In the classroom, this concept of respect for elders applies to the teacher-student relationship. In Filipino culture, one uses the term of respect po when addressing an elder. One would never address a professor by a first name, as is common in the United States, and one would not behave in a familiar fashion with professors. In a traditional Chinese classroom, for example, students may often avoid eye contact with teachers as a sign of respect. Casual conversations do not occur. This traditional value of respecting elders explains much of Ms. C’s socially reticent behavior toward her professors.

Group-oriented thinking

As noted previously, Filipinos value the concept of pakakisama, or conceding to the wishes of the group (Araneta 1993; Pido 1986). This complements the previously mentioned core Filipino value of kapwa (shared identity), which is considered at the foundation of human values, and without which one ceases to be Filipino and human (Strobel 1994). Chinese children are brought up with the concept of hu xiang bang zu, or group thinking and helpfulness. According to philosopher Tu Wei Min, in classical Confucian thought, the self is considered the sum of one’s relationships, and one develops the self through interactions with others (Tu 1984).

Asians tend to function more as members of a group than as individuals separate from a group. The assertive individualism that is so valued in the United States has no place in many Asian cultures. Whereas Americans can view aggressiveness as a positive trait, Asians value humility and smooth interpersonal relationships with members of the group. In fact, if one acts overly confident and is later humiliated by failure, it would be a cause for loss of face for the individual and his or her family. A Filipino who is viewed as acting mostly in his or her own interest would be viewed with distrust and suspicion (Pido 1986). Ms. C deferred to others in her opinions when someone else assumed leadership, yet she was willing to assume leadership when no one else would. This reflects her priority to act in the best interest of the group and to preserve smooth interpersonal relationships. She was demonstrating the value of pakakisama.

Clinical issues

Many scholars, including psychologists and literary writers, have explored a perceived social reserve among Asian Americans. A survey of Asian American college students found that more than 90% felt that members of their minority group should be more assertive. Moreover, they personally expressed interest in assertiveness training programs (Sue 1977). A study of social anxiety comparing Chinese American and Caucasian American women indicated that Chinese American women had a significantly higher fear of negative evaluation (Sue et al. 1989). Going from the sciences to literature, in her autobiographical novel The Woman Warrior, Maxine Hong Kingston writes: “When I went to kindergarten and had to speak English for the first time, I became silent. A dumbness—a shame—still cracks my voice in two.… The other Chinese girls did not talk either, so I knew that the silence had to do with being a Chinese girl” (Kingston 1977, p. 62). In Ms. C’s case, her family’s migration story adds to the experience that Grinberg and Grinberg (1989) call “cumulative trauma,” emphasizing that migration precipitates a series of ongoing and enduring stressors. As noted before, the concept of double losses also applies here as a pathogenic and pathoplastic element. Although it originated from studies of children of Holocaust survivors, double loss is a valuable theory with potentially widespread applications. It can be applied to children of parents who have endured significantly difficult circumstances such as the experience of migration (Brown and Shanahan 1995).

Is the incidence of social phobia higher in Asian Americans than in the general United States population? Studies of this topic have yet to be carried out. However, before exploring this question, it would be worthwhile to examine Asian American cultural values and judgments—that is, the elements of countertransference. As mental health care practitioners who apply the principles of psychiatry, psychology, and social sciences—with predominantly Western civilization roots—it is important to examine countertransference and cultural biases when passing judgment on other cultures. Does the whole concept of social phobia reflect Western ideals and Western concepts of mental health? In Asian cultures, where social interactions occur in a more structured fashion and where the fear of negative evaluation (or fear of losing face) may be an ingrained cultural value, is the concept of social phobia relevant?

Another important question concerns the implications of the changes Ms. C underwent in the course of her treatment for symptoms of social phobia. She became less fearful of being shamed in class, more willing to contradict teachers, and more independent and detached from her family. It can be argued that treatment enabled her to become less Asian and more American.

That psychiatry’s role is to decrease discomfort caused by emotional conflicts is well accepted. However, the ethical implications of altering a patient’s cultural values has yet to be extensively explored in the field of mental health.

In any case, Ms. C. benefited from the treatment of symptoms of social phobia, because the change resulting from her treatment enabled her to function more comfortably in American culture and because it allowed her to continue striving toward her goal of becoming a physician.