Hospitals in urban areas in the U.S. are generously staffed with Asian doctors and nurses. In some hospitals Asian care providers are over 50% of the medical staff. These immigrants continue to make significant contributions to health care in this country. Their numbers are far lower, however, in the mental health field. There Asian therapists, psychiatrists, and counselors are a minority. Asian clients are also in the minority. A brief sketch of the issues behind these low percentages in mental health care follows.

Shame is an important factor. An Asian student pursuing a graduate degree in clinical psychology admits that even though he is in the field himself, he still is affected by the Asian cultural dictum that "if you go to a therapist, there is something wrong with you." Counseling is an issue of shame— the kind of negative-disgrace shame that involves humiliation, dishonor, a loss of face or respect, writes David Augsburger. Shame is based on the priority of communal harmony rather than the western-based commitment to individual moral autonomy. In a culture shaped by shame controls, "the expectations, sanctions and restraints of the significant others in a person's world become the agent of behavior control," according to Augsburger.

Shame has value, but it can keep Asian clients from the help they need. For example, in many marital situations where there is known emotional or physical abuse by the husband, shame has often prohibited the wife from seeking outside help. Similarly, shame can keep families from seeking help because mental illness is not seen in the same neutral light as physical illness. Problems are closely guarded to protect the family reputation. Among Asian young adults this stigma is lessening, but what one Chinese psychologist in the Chicago area noted is still true: "Asian Americans wait much longer to get help than Caucasian clients, so when they finally seek help, they are in a much more serious condition."

Communal identity also has a bearing on mental health care. First generation immigrant Asians will try to find elders or relatives within their own community who can arbitrate a dispute, help in marital conflicts, or deal with an individual's personal problems. The details of the problem are kept within the community so as not to cause shame in the outside world. Many immigrants also feel that members of their own culture can understand the dynamics and complexities of a situation far better than a mental health professional outside the community.

Ethnic solidarity is actually a great strength in most immigrant communities. Their connectedness may be misunderstood by outsiders, as people wonder why immigrants don't often socialize outside their own group, but communal identity, strength, and extended family ties serve a vital function in psychological well-being.

Many will recall the recent story of a Korean woman in the Midwest who killed her Caucasian husband. She had met and married him during the Korean War and left her family to accompany him to the U.S. All marriages require mutual adjustments, but cross-cultural marriages multiply the scope of those adjustments. When there is not an adequate support system for each partner, misconceptions, accusations, and failed expectations can become disastrous. In this case the wife believed her husband unfaithful. She felt alienated, isolated, and misunderstood in this culture and was not well connected to her local Korean subculture. By the time they sought outside help, neither partner was willing to deal with the serious issues that engulfed the marriage.

Different concepts of wellness operate in Asian immigrant communities. One culture's wholeness is another's dysfunction. Different values are attributed to individuation, to connection and independence, to sharing or withholding one's emotions. Dr. Kasandra Ma, a Chinese therapist, uses ancient paintings to illustrate the differences. Western paintings may focus just on a person's face against a subtle background whereas Chinese paintings often depict a huge landscape with a very small person. Psychologically, the art illustrates Asian expectations that an individual must adapt his or her personal issues to blend in with the larger reality and the need for communal well-being.

There are also differences between the generations within the same family or cultural group. First generation parents may adhere to the perception of mental health from their culture of origin, whereas their children raised here may incorporate more western values into their thinking. The disparity can lead to significant conflict between generations in any disclosure of pain or dysfunction. It can also complicate clients' recovery. Adult children with mental illness differ with their parents in such a way that they feel wounded by parental dominance or values yet are unable to speak. They internalize guilt over the disagreement and shame because of their own mental illness. It is hard to be a counselee—or even a counselor—when the assumptions about wholeness differ between the counselor and the counselee, or between the counselee and a significant other!

Language is also a barrier. For recent refugees, counseling is often impossible because they don't know English. Even immigrants who have been in this country for decades may worship in their native tongue and speak in their native language at home. Their English is more than adequate to handle their careers and casual social interaction within mainstream America, but they are not equally comfortable to discuss conflicting emotions in the complexities of a second language. Thus they prefer, if not require, a therapist who speaks their native language.

Two large Chinese churches on the east coast have faced this problem. One church in Queens, New York, has four pastors (a Mandarin, a Cantonese, and two English-speaking pastors) for its diverse Chinese population. Even these pastors have trouble finding therapists for their parishioners. They say that Chinese-speaking Christian therapists in their area are rather rare. Therefore, many parishioners have only their pastors for help. In the other 2,000-member church the counseling load for the pastors is great. That church hopes to develop a counseling center, staffed by Mandarin and Cantonese speaking trained counselors.

A growing number of second and third generation Asian immigrants are now being trained in the mental health field. However, more extensive education is needed to erase the stigma Asian clients and their families feel regarding counseling. Better-trained cross-cultural counselors and far more Asian therapists are needed. And there is a specific need for more Asian churches to establish counseling centers to serve those who see the church as a safe place. Asians have contributed significantly to physical health care in the U.S. Their contributions in the mental health field in years to come may prove to be of even greater importance for Asian communities themselves.