discrimination - The Professional Counselor

Mental Health Equity of Filipino Communities in COVID-19: A Framework for Practice and Advocacy

Feb 26, 2021 | Volume 11 - Issue 1

Christian D. Chan, Stacey Diane Arañez Litam

The emergence and global spread of COVID-19 precipitated a massive public health crisis combined with multiple incidents of racial discrimination and violence toward Asian American and Pacific Islander (AAPI) communities. Although East Asian communities are more frequently targeted for instances of pandemic-related racial discrimination, multiple disparities converge upon Filipino communities that affect their access to mental health care in light of COVID-19. This article empowers professional counselors to support the Filipino community by addressing three main areas: (a) describing how COVID-19 contributes to racial microaggressions and institutional racism toward Filipino communities; (b) underscoring how COVID-19 exacerbates exposure to stressors and disparities that influence help-seeking behaviors and utilization of counseling among Filipinos; and (c) outlining how professional counselors can promote racial socialization, outreach, and mental health equity with Filipino communities to mitigate the effects of COVID-19.

Keywords: Asian American, Filipino, mental health equity, COVID-19, discrimination

Asian Americans represent the fastest-growing ethnic group in the United States (Budiman et al., 2019). Following the global outbreak of COVID-19, many Asian Americans and Pacific Islanders (AAPIs) have experienced a substantial increase in race-based hate incidents. These incidents of racial discrimination have included verbal harassment, physical attacks, and discrimination against Asian-owned businesses (Jeung & Nham, 2020), which multiply the harmful effects on psychological well-being and life satisfaction among AAPIs (Litam & Oh, 2020). According to Pew Research Center trends (Ruiz et al., 2020), about three in 10 Asian adults reported they experienced racial discrimination since the outbreak began. Proliferation of anti-Chinese and xenophobic hate speech from political leaders, news outlets, and social media, which touted COVID-19 as the “Chinese virus,” further exacerbate instances of race-based discrimination (U.S. Department of Justice, 2020) and echo the Yellow Peril discourse from the late 19th century (Litam, 2020; Poon, 2020).

Although the community is often aggregated, Asian Americans are not a monolithic entity (Choi et al., 2017; Jones-Smith, 2019; Sue et al., 2019). The term Asian American encompasses over 40 distinct subgroups, each with distinct languages, cultures, beliefs, and migration histories (Pew Research Center, 2013; Sue et al., 2019). It is no surprise, therefore, that specific ethnic subgroups would be more affected by the pandemic than others. For example, instances of COVID-19–related racial discrimination disproportionately affect East Asian communities, specifically Chinese migrants and Chinese Americans. An analysis of nearly 1,500 reports of anti-Asian hate incidents indicated approximately 40% of Chinese individuals reported experiences of discrimination as compared to 16% of Korean individuals and 5.5% of Filipinos (Jeung & Nham, 2020). Although Chinese individuals disproportionately experience overt forms of COVID-19–related discrimination, Filipino migrants and Filipino Americans are not immune to the deleterious effects of the pandemic.

With over 4 million people of Filipino descent residing in the United States (Asian Journal Press, 2018), it is of paramount importance for professional counselors to recognize how the Filipino American experience may compound with additional COVID-19 exposure and related stressors in unique ways that distinctively impact their experiences of stress and mental health. The current article identifies how the racialized climate of COVID-19 influences Filipino-specific microaggressions and the presence of systemic and institutional racism toward Filipino communities. The ways in which COVID-19 exacerbates existing racial disparities across social determinants of health, help-seeking behaviors, and utilization of counseling services are described. Finally, the implications for counseling practice and advocacy are presented in ways that can embolden professional counselors to promote racial socialization, outreach, and health equity with Filipino communities to mitigate the effects of COVID-19.

Health Disparities Among Filipino Americans

The unprecedented emergence of COVID-19 has affected the global community. As of January 5, 2021, a total of 21,382,296 cases were confirmed and 362,972 deaths had been reported in the United States (Worldometer, n.d.). Although information about how racial and ethnic groups are affected by the pandemic is forthcoming, emerging data suggests that specific groups are disproportionately affected. Professional counselors must be prepared to support communities that may be more vulnerable to pandemic-related stress and face challenges related to medical and mental health care access because of intersecting marginalized identities, such as age, race, ethnicity, gender identity, sexual identity, social class, and migration history (Chan & Henesy, 2018; Chan et al., 2019; Litam & Hipolito-Delgado, 2021). For example, the AAPI population may be especially in need of mental health support because of ongoing xenophobic sentiments from political leaders that combine with intergenerational trauma, racial discrimination, and racial trauma (Litam, 2020).

Underutilization of Mental Health Services
Compared to other Asian American subgroups, Filipinos are the least likely to seek professional mental health services. In a study of 2,230 Filipinos, approximately 73% had never used any type of mental health service and only 17% sought help from friends, community members, peers, and religious or spiritual leaders (Gong et al., 2003). Since the Gong et al. (2003) study, a multitude of researchers have documented the persistent disparity of mental health usage and unfavorable attitudes toward professional help-seeking among Filipinos (David & Nadal, 2013; David et al., 2019; Nadal, 2021; Tuazon et al., 2019), despite high rates of psychological distress (Martinez et al., 2020).

The experiences of Filipino communities uniquely influence aspects of mental health and wellness. Compared to other subgroups of Asian Americans, Filipino Americans with post-traumatic stress experiences tend to exhibit poorer health (Kim et al., 2012; Klest et al., 2013), and report higher rates of racial discrimination (Li, 2014). As a subgroup, Filipino Americans present to mental health counseling settings with high rates of depression, suicide, HIV, unintended pregnancy, eating disorders, and drug use (David et al., 2017; Klest et al., 2013; Nadal, 2000, 2021). Compared to other Asian subgroups, Filipinos may experience lower social class and employment statuses, which may increase the prevalence of mental health issues (Araneta, 1993). Among Filipinos, intergenerational cultural conflicts and experiences of racial discrimination were identified as significant contributors to depression and suicidal ideation (Choi et al., 2020). The underutilization of professional mental health services and help-seeking among Filipino communities is unusual because of their familiarity with Western notions, systems, and institutions, which surface as traits that are typically associated with mental health help-seeking within the broader AAPI community (Abe-Kim et al., 2002, 2004; Shea & Yeh, 2008).

Distinct Experiences of Oppression
Aspects of Filipino history are characterized by colonization, oppression, and intergenerational racial trauma (David & Nadal, 2013) and have been rewritten by White voices in ways that communicate how America saved the Philippines from Spanish rule through colonization (Ocampo, 2016). These sentiments remain deeply entrenched within the mindset of many Filipinos in the form of colonial mentality (David & Nadal, 2013; Tuazon et al., 2019). Colonial mentality refers to the socialized and oppressive mindset characterized by beliefs about the superiority of American values and denigration of Filipino culture and self (David & Okazaki, 2006a, 2006b). Colonial mentality is the insidious aftermath galvanized through years of intergenerational trauma, U.S. occupation, and socialization under White supremacy (David et al., 2017). Professional counselors must recognize the interplay between colonial mentality and the mental health and well-being of Filipino clients to best support this unique population.

The internalized experiences of oppression perpetuate the denigration of Filipinos by Filipinos as a result of the internalized anti-Black sentiments and notions of White supremacy that remain at the forefront of American history (Ocampo, 2016). The Filipino experience is one that is characterized by forms of discrimination by individuals who reside both within and outside of the Filipino community (Nadal, 2021). For example, Filipinos who espouse a colonial mentality disparage those with Indigenous Filipino traits (i.e., dark skin and textured hair) as unattractive, undesirable, and worthy of shame (Angan, 2013; David, 2020; Mendoza, 2014). Filipinos also experience a sense of otherness within the AAPI community and from other communities of color because their history, culture, and phenotype combine in ways that “break the rules of race” (Ocampo, 2016, p. 13). Although Filipinos are sometimes confused with individuals from Chinese communities, they are not typically perceived as Asian or East Asian (Lee, 2020) and are often mistaken for Black or Latinx (Ocampo, 2016; Sanchez & Gaw, 2007). These pervasive experiences render the Filipino identity invisible (Nadal, 2021). Ultimately, Filipinos remain among the most mislabeled and culturally marginalized of Asian Americans (Sanchez & Gaw, 2007). Professional counselors who work with Filipino clients must obtain a deeper understanding of how these unique experiences of invisibility and colonial mentality continue to affect the minds and the worldviews of Filipinos and Filipino Americans.

Risk Factors for COVID-19 Exposure
The burgeoning rate of COVID-19 cases has devastated hospitals and medical settings. The overwhelming strain faced by medical communities uniquely affects Filipino migrants and Filipino Americans who are overrepresented in health care and disproportionately at risk of COVID-19 exposure (National Nurses United, 2020). The overrepresentation of Filipinos in health care, particularly within the nursing profession, is directly tied to the history of U.S. colonization. Following the U.S. occupation of the Philippines from 1899 to 1946, the Filipino zeitgeist became imbued with profound cultural notions of American superiority and affinity for Westernized attitudes, behaviors, and values (David et al., 2017). For example, the introduction of the American nursing curricula by U.S. Army personnel during the Spanish-American war (McFarling, 2020) instilled pervasive cultural influences that positioned the nursing profession as a viable strategy to escape political and economic instability in pursuit of a better life in the United States (Choy, 2003). These cultural notions have culminated to make the Philippines the leading exporter of nurses in the world (Choy, 2003; Espiritu, 2016). Of the immigrant health care workers across the United States, an estimated 28% of registered nurses, 4% of physicians and surgeons, and 12% of home health aides are Filipinos (Batalova, 2020). About 150,000 registered nurses in the United States are Filipino, equating to about 4% of the overall nursing population (McFarling, 2020; National Nurses United, 2020). According to the National Nurses United (2020) report, 31.5% of deaths among registered nurses and 54% of deaths among registered nurses of color were Filipinos. Based on these statistics, Filipinos face disproportionate exposure to pandemic-related stressors and death that may increase the risk for mental health issues.

Individuals of Filipino descent may also face significant COVID-19–related challenges, as they are predisposed to several health conditions that have been linked with poorer treatment prognosis and outcomes (Ghimire et al., 2018; Maxwell et al., 2012). Compared to other racial and ethnic subgroups, Filipinos residing in California had higher rates of type II diabetes, asthma, and cardiovascular disease (Adia et al., 2020). High rates of hypertension, cholesterol, and diabetes were also noted in studies of Filipino Americans residing in the greater Philadelphia region (Bhimla et al., 2017) and in Las Vegas, Nevada (Ghimire et al., 2018). One study of Filipinos residing in the New York metropolitan area indicated rates of obesity significantly increased the longer Filipino immigrants resided in the United States (Afable et al., 2016). The Centers for Disease Control and Prevention (2021) associated each of these underlying medical conditions with a greater likelihood for hospitalization, intensive care, use of a ventilator, and increased mortality. Filipino Americans also tend to report lower social class and employment statuses as compared to other Asian Americans, which may contribute to higher rates of mental health issues and create barriers to health care access (Adia et al., 2020; Sue et al., 2019).

Cultural Barriers to Professional Mental Health Services
Filipinos face culturally rooted barriers to seeking professional mental health services that may include fears related to reputation, endorsement of fatalistic attitudes, religiousness, communication barriers, and lack of culturally competent services (Gong et al., 2003; Nadal, 2021; Pacquiao, 2004). The presence of mental illness stigma is also deeply entrenched within Filipino communities (Appel et al., 2011; Augsberger et al., 2015; Tuazon et al., 2019). In many traditional Filipino families, mental illness is mitigated by addressing personal and emotional problems with family and close friends, and through faith in God (David & Nadal, 2013). Rejection of mental illness is based on the belief that individuals who receive counseling or therapy are crazy, dangerous, and unpredictable (de Torres, 2002; Nadal, 2021).

Connection and Kinship
Given the central prominence of family, it is no surprise that Filipino individuals’ mental health begins to suffer when their connection to community and kinship is compromised. Although relatively few studies on Filipino mental health exist, Filipinos and Filipino Americans consistently report family-related issues as among the most stressful. In one study of Filipino and Korean families in the Midwest (N = 1,574), the presence of intergenerational family conflict significantly contributed to an increase in depressive symptoms and suicidal ideation (Choi et al., 2020). In another study of Filipino Americans, quality time with family, friends, and community was identified as an important factor in mitigating the effects of depression (Edman & Johnson, 1999). The centralized role of Filipino families uniquely combines with a group mentality in ways that may additionally hinder rates of professional help-seeking.

Hiya and Amor Propio
Notions of hiya and amor propio each represent culturally specific barriers to seeking mental health care. According to Gong and colleagues (2003), hiya and amor propio are related to the East Asian notions of saving face. While hiya emphasizes the more extensive experience of shame that arises from fear of losing face, amor propio is associated with concepts of self-esteem linked to the desire to maintain social acceptance. A loss of amor propio would result in a loss of face and may compromise the cherished position of community acceptance (Gong et al., 2003). Filipino Americans may thus avoid seeking professional mental health services because of combined feelings of shame (hiya) linked to beliefs that one has failed or is unable to overcome their problems independently, and fears of losing social positioning within one’s community (amor propio). To experience amor propio would put a Filipino—or worse, their family—at risk for tsismis, or gossip. Indeed, avoiding behaviors that may lead others within the Filipino community to engage in tsismis about the client or their family is a significant factor that guides choices and behaviors. Engaging in behaviors that result in one’s family becoming the focus of tsismis is considered highly shameful and reprehensible among Filipino communities.

Bahala Na
The Tagalog term bahala na refers to the sense of optimistic fatalism that characterizes the shared experiences of many Filipinos and Filipino Americans. Bahala na can be evidenced through Filipino cultural expectations to endure emotional problems and avoid discussion of personal issues. This core attitude may have deleterious effects on mental health and help-seeking, as many Filipinos are socialized to deny or minimize stressful experiences or to simply endure emotional problems (Araneta, 1993; Sanchez & Gaw, 2007). A qualitative analysis of 33 interviews and 18 focus groups of Filipino Americans indicated bahala na may combine with religious beliefs to create additional barriers to addressing mental health problems (Javier et al., 2014). For example, virtuous and religious Filipinos and Filipino Americans may endorse bahala na attitudes by believing their higher power has instilled purposeful challenges that can be overcome by sufficient faith and endurance (Javier et al., 2014).

Hindi Ibang Tao
Moreover, many Filipinos and Filipino Americans demonstrate hesitance to trust individuals who are considered outsiders. When interactions with those considered other cannot be avoided, traditional Filipinos tend to be reticent, conceal their real emotions, and avoid disclosure of personal thoughts, needs, and beliefs (Pasco et al., 2004). Filipino community members place a large value on in-group versus out-group members and largely prefer to seek support from helping professionals within the Filipino community, rather than from others outside of the group (Gong et al., 2003). Individuals who are hindi ibang tao (in Tagalog, “one of us”) are differentiated from those who are ibang tao (in Tagalog, “not one of us”), which influences interactions and amount of trust given to health care providers (Sanchez & Gaw, 2007). White counselors may be able to bridge the cultural gap with Filipino clients to become hindi ibang tao by exhibiting respect, approachability, and a willingness to consider the specific influences of Filipino history and the importance of family (Sanchez & Gaw, 2007). Professional counselors who overlook, minimize, or disregard these cultural values risk higher rates of early termination and may experience their Filipino clients as exhibiting little emotion (Nadal, 2021). Filipino clients who are not yet comfortable with professional counselors may interact in a polite, yet superficial manner because culturally responsive relationships and trust have not been developed (Gong et al., 2003; Pasco et al., 2004; Tuazon et al., 2019).

Pakikisama and Kapwa
Another Filipino cultural barrier is pakikisama, or the notion that when one belongs to a group, one should be wholly dedicated to pleasing the group (Bautista, 1999; Nadal, 2021). Filipino core values extend beyond the general notion of collectivism and include kapwa, an Indigenous worldview in which the self is not distinguished from others (David et al., 2017; Enriquez, 2010). Thus, Filipinos do not solely act in ways that benefit the group; they are also expected to make decisions that please other group members, even at the expense of their own desires, needs, or mental health (Nadal, 2021). The cultural notions of pakikisama and kapwa interplay with amor propio in ways that have detrimental effects on Filipinos in dire need of mental health support. For example, a second-generation Filipino American may recognize that their suicidal thoughts and experiences of depression may be worthy of mental health support, but recognition of cultural mistrust toward those deemed other may risk their family’s social acceptance (amor propio). Risking the family’s social acceptance could ultimately violate group wishes (pakikisama) and may subject their family to stigma and gossip (tsismis).

Implications for Practice and Advocacy in Professional Counseling

The COVID-19 pandemic and increased visibility to discrimination against Asian Americans illuminates the importance of addressing the presence of mental health barriers among Filipino communities. Filipino communities face complex barriers rooted in colonialism, racism, and colorism that negatively affect their overall mental health (David & Nadal, 2013; Tuazon et al., 2019; Woo et al., 2020). The combination of educational, health, and welfare disparities culminate in poorer health outcomes for Filipino American communities compared to other ethnic Asian groups (Adia et al., 2020). Many of these identifiable barriers and forces of oppression increase the racial trauma narratives incurred among Filipino communities (David et al., 2017; Klest et al., 2013); deny the impact of microaggressions and discrimination (Nadal et al., 2014); divest resources that support economic, educational, and social well-being (Nadal, 2021; Smith & Weinstock, 2019); and discourage the utilization of needed counseling spaces (Tuazon et al., 2019).

Cultivating cultural sensitivity in health care providers can buffer the psychological toll and emotional consequences of negative health care encounters for historically marginalized communities (Flynn et al., 2020), including Filipinos. Findings associated with health equity and help-seeking behaviors (e.g., Flynn et al., 2020; Ghimire et al., 2018) have significant ramifications for Filipino communities that face a litany of barriers to counseling services (Gong et al., 2003; Tuazon et al., 2019). In light of COVID-19, professional counselors are encouraged to employ culturally responsive interpersonal and systemic interventions that promote the sustainable mental health equity of Filipino communities.

Promoting Racial Socialization and Critical Consciousness
Reducing barriers for mental health access is connected to protective factors, actions, and cultural capital instilled across generations of Filipino communities (David et al., 2017). Filipino communities draw from several generations of colonization, which continues to affect second-generation Filipinos living in the United States (David & Okazaki, 2006a, 2006b). Experiences of historical colonization, forced assimilation into other cultures, and the erasure of Filipino cultural values have resulted in a range of Eurocentrically biased and historically oppressive experiences (Choi et al., 2020; David & Nadal, 2013). These experiences have prepared Filipino communities, intergenerationally and collectively, to respond to experiences of discrimination in ways that preserve their cultural values (David et al., 2017). The preservation of Filipino cultural values across generations has bolstered a type of protective factor through racial socialization, where parents and families teach future generations of children about race and racism (Juang et al., 2017). Ultimately, preparing future generations of Filipinos to respond to racial oppression can protect cultural assets (David et al., 2017). In fact, a study by Woo and colleagues (2020) indicated Filipino parents who prepared their children to respond to racial discrimination prepared them for bias and strengthened their ethnic identity.

One strategy that professional counselors can use to infuse social justice in their work is to help Filipino clients raise their critical consciousness. Critical consciousness is an approach that helps clients to recognize the systemic factors contributing to their barriers with mental health utilization and mental health stressors (David et al., 2019; Diemer et al., 2016; Ratts & Greenleaf, 2018; Seider et al., 2020) and to feel empowered to take part in action (Ratts et al., 2016; Watts & Hipolito-Delgado, 2015). Professional counselors can raise Filipino clients’ critical consciousness by engaging in conversations about how the history of colonization, endorsement of colonial mentality, and systemic factors continue to marginalize Filipinos (David et al., 2019). Connecting critical consciousness to COVID-19, professional counselors can highlight how public anti-Asian discourse echoes centuries of oppression and leads to cultural mistrust of health care providers, particularly professional counselors (Litam, 2020; Ratts & Greenleaf, 2018; Tuazon et al., 2019). Similarly, professional counselors can raise the critical consciousness of Filipino clients by discussing the effects of race-based trauma and racial violence as a result of COVID-19 (Litam, 2020; Nadal, 2021). Including these topics during counseling can be instrumental for detecting the effects of race-based trauma, such as somatic symptoms, while grasping the manifestation of pandemic stress (Taylor et al., 2020). As health care providers focus predominantly on wellness, professional counselors play a significant part in deconstructing the connections and nuances among race-based traumatic stress and pandemic stress (Ratts & Greenleaf, 2018).

Additionally, professional counselors can raise the critical consciousness of Filipino clients by examining the intersection of underlying health disparities, Filipino core values, and overrepresentation of Filipinos working in health care positions during COVID-19 through a trauma-informed lens. Aligned with this perspective, professional counselors can identify and discuss how intergenerational trauma narratives may have persisted across generations of Filipino communities (David & Okazaki, 2006b; David et al., 2019; Nadal, 2021; Tuazon et al., 2019) in ways that have adverse effects on mental health. For example, professional counselors may support Filipino clients to critically reflect on how socialized messages from parents and elders with intergenerational trauma may have contributed to the internalization of colonial mentality. Professional counselors may also broach these cultural factors by promoting discussions within clients’ families and communities about the cultural preservation of Filipino identities (Choi et al., 2017, 2020; David et al., 2017).

Culturally Congruent Coping Responses Among Filipino Clients
Professional counselors can help Filipino clients who seek counseling during COVID-19 by empowering them to engage in coping responses that cultivate their cultural assets and strengthen their ethnic identity (David et al., 2017, 2019; Woo et al., 2020). Before implementing these culturally sensitive strategies, professional counselors must reflect on whether they hold individualistic notions and Western attitudes about which coping responses are deemed helpful or unhelpful to mitigate the effects of racial discrimination (Oh et al., in press; Sue et al., 2019). Following experiences of racial discrimination and stress, Filipinos tend to use disengagement coping responses (Centeno & Fernandez, 2020; Tuason et al., 2007). Following an assessment of coping responses, professional counselors can support Filipino clients by reinforcing culturally responsive disengagement coping strategies, such as tiyaga (Tagalog for “patience and endurance”) and lakas ng loob (Tagalog for “inner strength and hardiness”), to promote resilience and demonstrate flexibility.

Given these central cultural values, professional counselors must be cautioned from solely using emotion-centered counseling strategies that center experiences of stress, racial trauma, or COVID-19–related discrimination (Litam, 2020). Instead, Filipino clients may benefit from interventions that draw from their cultural values of endurance (tiyaga) and inner strength (lakas ng loob) to refocus energy toward cultivating meaningful relationships and roles (David & Nadal, 2013; David et al., 2017). For example, Filipino clients who are concerned about the wellness of their community may experience a heightened sense of purpose and inner strength by reflecting on how their actions have already benefitted their families rather than focusing on their fears. Indeed, when stressful experiences occur, Filipinos have a long history of demonstrating resilience. Empowering Filipino clients to reflect on the historical ways that the Filipino community has evidenced resilience and inner strength may cultivate a strong sense of Filipino pride and strengthen ethnic identity as protective factors to mental health distress (Choi et al., 2020; David et al., 2019; Tuazon et al., 2019).

Filipinos may also benefit from engagement coping strategies, such as prayer, employing religious and spiritual resources, and responding with humor, to promote health and wellness (Nadal, 2021; Sanchez & Gaw, 2007). Counselors can help Filipino clients leverage engagement coping strategies by reflecting on existing responses to stress. Counselors may ask, “How have you intentionally responded to stressful events in the past?” and “How did these ways of coping impact your levels of stress?” Counselors can also demonstrate culturally sensitive strategies and lines of questioning that move from general, shared Filipino values to specific client experiences. For example, counselors can state: “Many Filipinos find peace of mind through prayer, religious practices, and humor. I’m wondering if this is true for you?” Because of the community orientation and collectivism embedded within Filipino culture, it may be helpful for counselors to elaborate on cultural contexts and relationships that inform coping strategies: “I am wondering how you may have seen some of these coping strategies in your home, family, or community. How might you have experienced a coping strategy like humor within your own community?” This statement communicates a familiarity with Filipino cultural values and creates an invitation for clients to explore their coping resources.

Creating Outreach Initiatives and Partnerships
For counselors placed in school and community settings, challenging the systemic effects of COVID-19 among Filipino communities necessitates community partnerships and integrated care settings to achieve health equity (Adia et al., 2019). Health equity initiatives call for two types of overarching efforts to sustain long-term benefits and changes. One aspect of health equity relates to developing community partnerships as a method to intentionally increase health literacy within the community (Guo et al., 2018). Increasing mental health literacy, including education about counseling services and a comprehensive approach to wellness, operates as a direct intervention to cultural and linguistic barriers that precede negative health care experiences (Flynn et al., 2020). Increasing mental health literacy in Filipino communities may also normalize the process of professional mental health services, challenge the cultural notion that those who seek mental health care are crazy, and offer strength-based language related to counseling services (Ghimire et al., 2018; Maxwell et al., 2012; Nadal, 2021). Expanding on recommendations by Tuazon and colleagues (2019), professional counselors can challenge the systemic effects of COVID-19 in Filipino communities by helping community stakeholders understand culturally responsive practices for seeking professional mental health services. Professional counselors employed in community settings can leverage opportunities to liaise with Filipino community organizations and leaders to increase the utilization of counseling services as a preventive method (Graham et al., 2018; Maxwell et al., 2012), especially in response to the increased mental health issues in Filipinos following COVID-19. Professional counselors employed in community settings are therefore uniquely positioned to broach cultural factors of colonialism and systemic racism while addressing the urgency of mental health services for Filipino communities during COVID-19 (Day-Vines et al., 2018, 2020).

Increasing Visibility of Filipino Counselors
The second aspect of health equity initiatives focuses on increasing representation in the pipeline of providers. Although Flynn and colleagues (2020) documented the importance of culturally responsive practices to buffer negative health care experiences, public health scholars have generally identified that the representation of professional counselors is crucial for encouraging historically marginalized communities to seek services (Campbell, 2019; Graham et al., 2018; Griffith, 2018). According to Campbell (2019), historically marginalized clients are more likely to pursue services and demonstrate an openness to speak with professional counselors who are representative of their communities. In addition to increasing Filipino counselors and counselor educators in the pipeline (Tuazon et al., 2019), professional counselors can enact community-based initiatives that position Filipino leaders to support the larger Filipino community (Guo et al., 2018; Maxwell et al., 2012; Nadal, 2021). For example, professional counselors can train Filipino leaders and community members to share information about coping responses (e.g., mindfulness, yoga, and diaphragmatic breathing) that mitigate the deleterious effects of racism, colonialism, and COVID-19–related stress. Professional counselors can also work with community members to establish Filipino-led wellness groups that frame discussions about stress within the broader context of health and wellness. Assessing for previous assumptions about mental health literacy may be helpful to normalize group discussions about stress and mental health. As outreach initiatives and community partnerships are established within the context of COVID-19, professional counselors must consider how they develop marketing materials for counseling services that appropriately reflect the cultural and linguistic diversity of Filipinos and invite input from Filipino community leaders (Campbell, 2019; Graham et al., 2018).

Conclusion

The cumulative effects of colonialism and racism continue to influence the mental health and visibility of Filipino communities within the global crisis of COVID-19. Unlike other AAPI subgroups, experiences of pandemic-related distress in Filipinos are additionally compounded by their distinct history of colonization, cultural values, and low levels of help-seeking behaviors. Specific interventions for culturally responsive counseling and outreach for Filipino communities are critical (Choi et al., 2017; David & Nadal, 2013; David et al., 2017; Tuazon et al., 2019) and were outlined in this article. Professional counselors, especially those in community settings, have numerous opportunities to enact a systematic plan of action that integrates culture, health, and policy (Chan & Henesy, 2018; Nadal, 2021). These interventions illuminate a longstanding and never more urgent call to action for extending efforts and initiatives to increase the visibility of Filipino communities and support individuals of Filipino descent in counseling.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

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Christian D. Chan, PhD, NCC, is an assistant professor at the University of North Carolina at Greensboro. Stacey Diane Arañez Litam, PhD, NCC, CCMHC, LPCC-S, is an assistant professor at Cleveland State University. Correspondence may be addressed to Christian D. Chan, Department of Counseling and Educational Development, The University of North Carolina at Greensboro, P.O. Box 26170, Greensboro, NC 27402, cdchan@uncg.edu.

“Take Your Kung-Flu Back to Wuhan”: Counseling Asians, Asian Americans, and Pacific Islanders With Race-Based Trauma Related to COVID-19

Apr 30, 2020 | Volume 10 - Issue 2

Stacey Diane Arañez Litam

Following the outbreak of COVID-19, reports of discrimination and violence against Asians and Asian Americans and Pacific Islanders (AAPIs) have increased substantially. The present article offers a timely conceptualization of how public and societal fears related to COVID-19 may contribute to unique mental health disparities and the presence of race-based trauma among AAPIs residing in the United States. The relationships between media, increasing rates of xenophobia and sinophobia, and racial discrimination are provided. Next, the deleterious effects of race-based discrimination on the emotional and physical well-being of people of color and Indigenous groups (POCI) and AAPIs are described. Finally, the article identifies the clinical implications of counseling AAPI clients, encourages a decolonization of current trauma-focused interventions, and presents specific strategies to heal race-based trauma in AAPI client populations.

Keywords: race-based trauma, discrimination, microinterventions, xenophobia, sinophobia

The outbreak of novel coronavirus (COVID-19) has led to unparalleled events across the United States and worldwide. Hospitals, nursing homes, and medical settings were quickly overwhelmed, and the vulnerability of these systems became apparent. A lack of federal consistency and political infrastructure resulted in differences across levels, quality, and types of state support. On January 31, 2020, the World Health Organization (WHO) declared COVID-19 a public health emergency of international concern. This sentiment was echoed by U.S. President Donald Trump on March 13, 2020, who warranted the pandemic an emergency for all states, tribes, territories, and the District of Columbia (Federal Emergency Management Agency [FEMA], 2020). A “shelter-in-place” order was instituted for many states and people were encouraged to stay home to prevent the spread of COVID-19. Indeed, the presence of COVID-19 has led to unprecedented times. However, the sociopolitical disparities illuminated by COVID-19 are not solely limited to institutional and political problems.

Asian Americans and Pacific Islanders (AAPIs) represent the fastest growing ethnic or racial group in the United States. In 2015, approximately 20.9 million people identified as AAPIs (Lopez et al., 2017). As a group, AAPIs encompass 40 distinct subgroups, each of which demonstrates heterogeneity across language, educational background, religion, immigration/migration history, beliefs about mental health, and attitudes toward help-seeking behaviors. For the purpose of this article, AAPIs are people who have origins rooted in East, South, and Southeast Asian countries. The present article offers a timely conceptualization of how public and societal fears related to COVID-19 may contribute to unique mental health disparities and race-based trauma in AAPIs residing in the United States. The relationships between media, increasing rates of xenophobia and sinophobia, and racial discrimination are provided. Next, the deleterious effects of race-based discrimination on the emotional and physical well-being of people of color and Indigenous groups (POCI) and AAPIs are described. Finally, the article identifies the clinical implications for counseling AAPI clients, encourages a decolonization of current trauma-focused interventions, and presents specific strategies to heal race-based trauma in AAPI client populations.

Xenophobia and Sinophobia in Media
The emergence of new infectious diseases historically has led to discrimination against groups of people of non-European descent (White, 2020). Indeed, the history of international infectious disease has predominantly been framed from a distinctly European perspective, which has focused on how disease negatively impacted post-colonial sites and affected trade (White, 2020). Experiences of fear and anxiety related to infectious disease often occur when people become threatened by an illness perceived as originating from outside one’s community (Taylor, 2019). Thus, the resurgence of attitudes characterized by xenophobia, or a fear of foreigners (Sundstrom & Kim, 2014), and sinophobia, which can be understood as the “intersection of fear and hatred of China” (Billé, 2015, p. 10), perpetuates a legacy of discrimination against non-White groups because of fear of illness. AAPIs have experienced a long tradition of blame and discrimination in the United States. Scapegoating AAPIs in light of COVID-19 echoes the racist “Yellow Peril” stereotype, which vilified Asian groups as a threat to job and economic security in Western nations (Kawai, 2005). The Chinese Exclusion Act of 1882, which effectively banned the immigration of Chinese persons to the United States for 10 years, further evidences historical anti-Chinese sentiments and an extensive history of discrimination against AAPIs in America (Lee, 2002).

The problematic, biased, and misleading media coverage of COVID-19 has led to increased rates of racial discrimination and sinophobic attitudes toward Chinese nationals and people of Asian origin (Wen et al., 2020). Health-related fears and phobia have been linked to misinformation fueled by sensationalist headlines (Taylor & Asmundson, 2004). Media, especially social media and the internet, are indispensable resources for information, communication, and entertainment. Following the outbreak of COVID-19, reports of discrimination and violence against Asian Americans have increased substantially across the United States (Congressional Asian American Pacific American Caucus [CAPAC], 2020).

COVID-19–related fears have resulted in the persecution of AAPIs through violent attacks (CAPAC, 2020), discrimination against their businesses, and sinophobic portrayals in media and from elected leaders (National Association for the Advancement of Colored People [NAACP], 2020). The dissemination of racially targeted content in media includes hate speech toward Chinese people, harassment, discriminatory stereotypes, and conspiracy theories (CAPAC, 2020; Schild et al., 2020; United Nations Human Rights, Office of the High Commissioner, 2020). A data analysis of two popular web platforms found a significant rise in racial slurs, invoking earlier attitudes of sinophobic propaganda. To better understand the emergence of sinophobic attitudes within online communities, Schild and colleagues (2020) collected and analyzed 222,212,841 tweets and 16,808,191 posts from Twitter and 4chan imageboards, respectively, from November 1, 2019, to March 22, 2020. The results revealed a significant increase in the presence of racial slurs that targeted Asians and Asian Americans, including “Kung-Flu,” “Ching Chong,” and “asshoe,” a term used to denigrate the accent of Chinese people speaking English (Schild et al., 2020). “Chink” was the most popular sinophobic slur and increased substantially after Donald Trump referred to COVID-19 as “the Chinese virus” (Schild et al., 2020).

Marginalized Groups Uniquely Affected
Social inequities and policies related to COVID-19 may disproportionately affect people of color and other marginalized groups, including individuals who are homeless, people with non-dominant racial and ethnic identities, undocumented individuals, people in lower socioeconomic groups, and individuals with limited access to health care. Individuals who lack shelter, reside in congregate living settings, or lack regular access to basic hygiene supplies may be at higher risk for exposure and transmission of COVID-19 (Devakumar et al., 2020; Tsai & Wilson, 2020). Given the increased prevalence of homelessness for lesbian, gay, bisexual, and transgender (LGBT) adolescents compared to their heterosexual counterparts (Cochran et al., 2002), persons with non-dominant sexual and gender identities additionally may be at greater risk. POCI may be disproportionately vulnerable to COVID-19 exposure because of greater rates of existing medical and mental health conditions. Higher rates of hypertension in African American and Black individuals (Go et al., 2014) and diabetes in South Asian populations (Unnikrishnan et al., 2018) have been identified as pre-existing health conditions that negatively affect the prognosis of COVID-19 treatment (Centers for Disease Control and Prevention, 2020). Undocumented persons may also face unique challenges because of fears associated with seeking medical assistance. Consequently, by the time undocumented persons arrive to medical settings, the disease has reached an advanced stage and physical health is significantly compromised (Devakumar et al., 2020).

Effects of Racial Discrimination on Wellness
Racial microaggressions are the everyday slights, insults, invalidations, and offensive behaviors experienced by POCI through interpersonal verbal and nonverbal communication, media, educational curriculum, mascots, monuments, and other forms (Sue et al., 2007). Indeed, the experiences of racism, discrimination, and microaggressions faced by POCI negatively affect their mental and physical health (Alvarez et al., 2016; American Psychological Association, 2016) and increase their risk factors for developing mental and physical health problems (Carter, 2007; Carter et al., 2005; Clark et al., 1999; Harrell, 2000; Pieterse et al., 2012). Although many Indigenous, Latinx, and Asian populations face racial discrimination and suffer from race-based stress, African American and Black individuals are disproportionately affected (Chou et al., 2012). Experiencing racial discrimination has been linked to increased rates of depression in African Americans (Chou et al., 2012; Jones et al., 2007), Pacific Islanders (Allen et al., 2017), Indigenous women (Benoit et al., 2016), and Latinx populations (Araújo & Borrell, 2006; Chou et al., 2012; Pieterse et al., 2012). Indeed, ongoing experiences of racial discrimination have been described as resulting in a chronic state of “racial battle fatigue” that taxes the mental and emotional resources of people of color (Smith et al., 2011, p. 64).

In one study of 12 common mental health disorders, including major depressive disorder, dysthymic disorder, panic disorder, separation anxiety disorder, social anxiety, generalized anxiety, post-traumatic stress, alcohol abuse, drug use, attention deficient hyperactivity disorder, oppositional defiant disorder, and conduct disorder, using a national sample (N = 5,191), perceived discrimination was positively associated with each mental health diagnosis in African American and Afro-Caribbean adults (Rodriguez-Seijas et al., 2015). Perceived racial discrimination also has deleterious effects on Asian Americans’ wellness. Studies have consistently linked race-related stress and perceived discrimination in AAPIs to increased rates of psychological distress, suicidal ideation, anxiety, and depression (Gee et al., 2007; Hwang & Goto, 2008; Wei, Alvarez, et al., 2010). Additional studies have evidenced how the presence of race-based stress significantly and negatively correlates to feelings of self-esteem (Liang & Fassinger, 2008), social connectedness (Wei et al., 2012), and overall well-being (Iwamoto & Liu, 2010) in Asian American populations. The daily experiences of racial microaggressions, combined with the current political climate (Potok, 2017), represent a source of significant stress for POCI and may lead to racial trauma.

Racial trauma refers to the events or danger related to real or perceived experiences of racial discrimination (Carter, 2007). These experiences include threats of harm and injury, humiliating and shameful events, and witnessing harm to other POCI because of real or perceived racism (Carter, 2007). The effects of racial trauma parallel symptoms of other trauma-based disorders, including acute stress disorder and post-traumatic stress disorder. POCI may experience hypervigilance, avoidance, flashbacks, and nightmares related to the events of racial discrimination (Comas-Díaz et al., 2019) and somatic expressions, including headaches, heart palpitations (Comas-Díaz et al., 2019), dizziness, confusion, and difficulty concentrating (Hinton & Jalal, 2019). Healing race-based trauma requires counselors to consider the intersectional identities that uniquely influence experiences of oppression and discrimination for marginalized groups. Because POCI experience race-based stress throughout their lives (Gee & Verissimo, 2016) and the nature of discrimination lies within sociocultural contexts (Comas-Díaz et al., 2019), healing these racial wounds can be difficult.

Although facing the daily onslaught of microaggressions and racial discrimination clearly contributes to the presence of race-based stress and trauma across POCI, specific strategies to address each of these racial groups is beyond the purview of this article. The increased rates of sinophobic attitudes, behaviors, and racial slurs fueled by COVID-19 fears, internet activity, and media misinformation are specific stressors that may uniquely affect AAPI groups. The following sections outline the clinical implications for counseling AAPIs who face racial discrimination resulting from COVID-19 fears and the current sociopolitical climate.

Clinical Implications for Counseling Asian Americans and Pacific Islanders

In the United States, an ideology of White supremacy exists, which justifies policies and practices that maintain the subordination of people of color through social arrangements using power and White privilege (Huber & Soloranzo, 2015). Addressing disparities in racial wellness thus requires counselors to challenge these existing inequalities embedded in the current social zeitgeist. The combined fear of infectious disease, misrepresentation in media, and current sociopolitical climate have illuminated the importance of identifying culturally sensitive strategies to heal race-based trauma in AAPIs. Beginning from initial assessment and intake, counselors must consider how intersectional identities such as ethnicity, country of origin, affectional identity, gender identity, age, socioeconomic status, and other statuses influence the social positioning, experiences, and worldview of their AAPI clients. Counselors must additionally be prepared to navigate language barriers, undocumented status, and challenges related to health care access with cultural humility.

As counselors prepare to screen for race-based trauma, it becomes of paramount importance to consider how Southeast Asian and Chinese populations are more likely to report somatic complaints that differ from Eurocentric trauma symptoms, including difficulty sleeping, dizziness, difficulty concentrating, and physical complaints such as headaches, stomach problems, and chronic pain (Dreher et al., 2017; Grover & Ghosh, 2014; Hinton & Good, 2009; Hinton et al., 2018). As with all clients, counselors are called to reflect on how their own internalized biases and attitudes may compromise treatment effectiveness and to avoid imposing their values onto clients (American Counseling Association, 2014). The experiences of racial oppression and discrimination toward AAPIs are often overlooked because of the model minority stereotype that portrays Asian Americans as achieving high educational and societal success (Ocampo & Soodjinda, 2016). In reality, AAPIs face explicit experiences of racism and physical and emotional harassment related to accents and physical appearance (Choi & Lim, 2014; Qin et al., 2008). Counselors are thus encouraged to pursue their own counseling and engage in dialogue with supervisors, friends, and colleagues to identify and challenge the presence of implicit biases or preconceived notions held about AAPI groups. Counselors must consider ways to deliver treatment within the cultural settings in which clients feel most safe and comfortable (Helms et al., 2012) to effectively heal race-based trauma in AAPIs.

Decolonizing Trauma-Based Interventions
Constructs related to trauma, traumatic stress, and trauma-based interventions are largely embedded in European perspectives and historically have failed to consider the influence of intersectional identities in trauma treatment and recovery (L. S. Brown, 2008; Hernández-Wolfe, 2013; Mattar, 2011). The importance of contextualizing trauma-based interventions when working with people of color has been identified in the literature (Helms et al., 2012), and the extant literature on trauma-based interventions has identified a lack of cultural relevance for most POCI (Bryant-Davis & Ocampo, 2006; Hinton & Good, 2016; Hinton & Lewis-Fernández, 2011). Many existing theories and trauma-based interventions may therefore lack cultural relevance for AAPI groups. Counselors must therefore decolonize trauma-based interventions and consider whether trauma treatments are culturally sensitive and appropriate for Asians and Asian Americans who present with COVID-19–related trauma symptoms.

Healing Race-Based Trauma in AAPIs
When racial discrimination occurs, people of color, including AAPIs, may experience rumination about the situation and negative self-evaluation because of lack of action (Shelton et al., 2006; Sue et al., 2007). POCI who respond passively, ignore, or do not stand up for themselves may experience greater feelings of helplessness or hopelessness, or be more likely to endorse the fatalistic belief that racism is normative and must be accepted (Williams & Williams-Morris, 2000). For many AAPI individuals, facing sinophobic attitudes and behaviors may result in problematic outcomes. Because Asian cultures tend to discourage conflict and demonstrate a preference for maintaining interpersonal harmony (Ting-Toomey et al., 2000; Yum, 1988), AAPIs may be more likely to employ the use of indirect and subtle approaches (Lee et al., 2012). Compared to other racial groups, AAPIs may be more likely to use maladaptive coping strategies linked to poorer mental health outcomes, including avoidance (Edwards & Romero, 2008), internalization of events in ways that lead to self-blame and self-criticism, social isolation (Wei, Heppner, et al., 2010), and substance use (Pokhrel & Herzog, 2014).

Promoting Mindfulness and Self-Compassion
Increasing self-compassion through mindfulness and compassion meditation represents a culturally sensitive strategy to heal race-based trauma in AAPIs. Originating from Buddhist psychology, compassion meditation helps people release feelings of anger and decrease suffering by cultivating compassion and unconditional regard toward the self and others (Germer & Neff, 2015). Increasing self-compassion may decrease feelings of guilt and shame following instances of racial discrimination by fostering feelings of love and kindness toward oneself. As an emerging clinical intervention, compassion meditation has yielded positive results in decreasing experiences of shame and self-criticism (Gilbert & Procter, 2006; Kuyken et al., 2010), reducing symptoms of depression (Graser et al., 2016; Kearney, 2015), and promoting overall psychological wellness (Hofmann et al., 2011; Shonin et al., 2015). Notably, compassion-based mindfulness interventions show promise as a culturally sensitive strategy to heal race-based trauma (Au et al., 2017; Germer & Neff, 2015; Kearney, 2015). Mindfulness interventions such as compassion meditation may additionally address societal limitations related to health care access and financial barriers. Compassion meditation can be practiced anywhere and does not require expensive books, seminars, or the use of tools.

Counselors can support AAPI clients who present with race-based trauma to cultivate self-compassion by encouraging them to focus on their immediate needs, without judgment, in the present. According to Germer and Neff (2015), the main question when cultivating self-compassion is “What do I need now?” (p. 50). This inquiry is intended to help people connect with their emotional wants, needs, and desires, in the moment, without judgment. Turning awareness toward oneself may illuminate the need for community support or peer support, or point to a physical need, such as fatigue or hunger. Counselors may promote self-compassion through the meditative Hawaiian prayer, Ho’oponopono. Clients may practice the Ho’oponopono meditation by directing four statements toward themselves: “I love you,” “I’m sorry,” “Thank you,” and “Forgive me.” Counselors may help clients begin to heal race-based trauma by empowering them to reflect on their phenomenological experiences as each statement was made. Counselors are encouraged to engage in their own experiences of mindfulness and self-compassion to deepen their understanding of how to modify the practices for clients (Germer & Neff, 2015).

Microinterventions
Counselors may empower AAPI clients facing racial discrimination by providing psychoeducation about microinterventions and creating opportunities for behavioral rehearsal using role plays. Microinterventions are everyday words, deeds, or actions that communicate validation of experiential reality, value as a person, affirmation of racial or group identity, support and encouragement, and reassurance that the receiver is not alone (Sue et al., 2019). Microinterventions seek to empower POCI, White allies, and bystanders to confront and educate perpetrators of microaggressions and have four major strategic goals: making the “invisible” visible, disarming the microaggression, educating the perpetrator, and seeking external reinforcement or support (Sue et al., 2019). Before engaging in microinterventions, it is important to consider the possible positive and negative consequences that may occur. Counselors should discourage AAPI clients from addressing microaggressions when doing so may threaten their physical safety. Engaging in microinterventions in scenarios where a strong power differential exists, such as in workplace or education settings, also requires special consideration (Sue et al., 2019). A full description of each microintervention strategy, goal, objective, rationale, and tactic are beyond the purview of this article, although a few examples for practical application for AAPI clients in counseling are provided below.

Making the “Invisible” Visible. Making the “invisible” visible represents an important component of healing race-based trauma. The first step to liberation necessitates naming the innuendo because it provides language for POCI to describe their experiences and seek mutual validation (Freire, 1970). Counselors may empower AAPI clients to make the “invisible” visible by bringing the microaggression to the perpetrator’s awareness, indicating to the perpetrator that they have spoken or behaved in an offensive way, or forcing the perpetrator to consider the impact and meaning of what has occurred (Sue et al., 2019). These tactics serve to undermine the metacognition, make the metacognition explicit, and broaden the ascribed trait (Sue et al., 2019) and may be helpful for AAPIs who experience race-based discrimination. For example, an Asian American who is accused of having “Kung-Flu” in public may make the metacognition explicit by stating, “You assume I am contagious because of the way I look.” In the same scenario, ascribed traits can be broadened and clarification can be obtained by using statements such as “Anyone can become infected with COVID-19; it is not solely limited to Asians,” and “Are you worried I will get you sick?” Each of these responses are intended to directly identify and address the microaggression while bringing awareness of the metacognition to the perpetrator.

Disarming the Microaggression. Disarming the microaggression may be employed to stop or deflect the microaggression, force the perpetrator to consider their actions, and communicate disagreement (Sue et al., 2019). Helpful tactics AAPIs can use to disarm microaggressions include expressing disagreement, using an exclamation, and stating values and setting limits (Sue et al. 2019). For example, a young Asian American who sees denigrating comments about AAPI individuals on a social media page may respond with the exclamation, “Ouch!” According to Aguilar (2006), this simple exclamation communicates that something offensive has occurred and forces the person to consider the impact and meaning of their behavior. In the same situation, AAPIs may state values and set limits by responding to an offensive comment with, “I have always been respectful of your values and recognize how people are free to hold different attitudes, but I hope you see that what you have written is offensive.”

Educate the Offender. Although it is inappropriate to ask POCI to educate and confront perpetrators, as it exclusively puts the onus of change onto the marginalized person, educating the offender may represent an important strategy to affect societal change. One powerful objective is to facilitate an enlightening conversation that indicates how what has occurred was offensive (Sue et al., 2019). This tactic helps perpetrators differentiate between their intent and the resulting impact (Sue et al., 2019). Because many people become defensive and shift from action to intention when a microaggression is pointed out (Sue, 2015), differentiating between good intent and harmful impact represents a powerful educational strategy (Sue et al., 2019). For example, a Chinese woman may hear COVID-19 incorrectly termed “the Chinese virus” in a conversation among colleagues. In this scenario, she may choose to engage in an enlightening dialogue to educate the offender about how the term “Chinese virus” perpetuates offensive sinophobic attitudes. A helpful conversation starter might be, “I know you may not realize this, but referring to COVID-19 as ‘the Chinese virus’ denigrates Asian individuals and is offensive.” In the same situation, it may additionally be helpful to point out how the term “Chinese virus” violates the WHO (2015) best practices policy for naming new human infectious diseases.

Seek External Reinforcement or Support. The final microintervention is aimed at the promotion of regular self-care, ensuring optimal levels of functioning, and communicating to perpetrators that bigoted behavior is unacceptable (Sue et al., 2019). Self-care and promoting wellness can be employed by pursuing counseling, reporting sinophobic behaviors to appropriate authorities, and seeking the support of one’s spiritual or religious communities (Sue et al., 2019). An increasing number of AAPIs are reaching out to crisis support hotlines. As of March 2020, approximately 13% of AAPIs had contacted crisis text lines compared to 5% of other U.S. callers, respectively (Filbin, 2020). Similar to other POCI, the presence of social support and collective gathering represents an effective coping strategy for Asian Americans (Wei, Alvarez, et al., 2010; Wei et al., 2012; Yoo & Lee, 2005). Indeed, seeking support represents an important strategy AAPIs employ to preserve mental health.

Cultural Proverbs and Analogies
Incorporating proverbs and analogies embedded in AAPI traditions are culturally sensitive strategies to empower clients and strengthen their ethnic identity. Cultural metaphors and stories may additionally strengthen the therapeutic alliance, as AAPI clients may feel their counselor understands and appreciates their cultural background (Hinton & Jalal, 2019). Strong identification with one’s ethnic group promotes wellness and serves as a protective factor in AAPI groups (Iwamoto & Liu, 2010) and Filipino Americans (Mossakowski, 2003). Counselors can empower clients to promote ethnic pride and increase cultural commitment by using proverbs and stories from client culture in counseling. Guiding AAPI clients to embrace their rich and important tradition of knowledge may promote self-esteem and decrease negative affect (Hinton & Jalal, 2019).

Two popular examples of Filipino proverbs may be helpful to promote the importance of social support and cultivate compassion when perpetrators are reluctant to recognize how their behaviors are offensive. A Filipino proverb posits, “A broom is sturdy because it is tightly bound” (in Tagalog, “Matibay ang walis, palibhasa’y magkabigkis”). This message aligns with a collectivistic mentality that people are stronger when standing together. Another Filipino proverb suggests, “It is hard to wake someone up who is pretending to be asleep” (in Tagalog, “Mahirap gisingin ang nagtutulog-tulugan”). This saying cultivates empathy and compassion for perpetrators of microaggressions and sinophobic behavior by reminding clients how it is difficult to educate others when they are not ready or willing to expand their worldviews. Similarly, a Chinese proverb states, “If you are planning for a year, sow rice; if you are planning for a decade, plant trees; if you are planning for a lifetime, educate people.” This saying may motivate clients to engage in dialogue with the people in their lives who have committed hurtful microaggressions. Because AAPI clients tend to terminate counseling at earlier rates compared to other racial groups (Sue & Sue, 2016), counselors can use appropriate cultural analogies to demystify the counseling process. For example, counselors may liken the therapeutic process to cooking a traditional noodle dish (Hinton & Jalal, 2019). Analogous to preparing japchae in Korean culture, pancit palabok in Filipino kitchens, or the Chinese dish zhajiangmian, healing from race-based trauma is a process that necessitates patience, creativity, commitment, and flexibility.

Discussion
The U.S. Surgeon General has recognized how racial and ethnic health disparities are strongly linked to the presence of systemic and ongoing cultural racism (U.S. Department of Health and Human Services, 2000). Counselors who hold dominant social identities (e.g., White, male, heterosexual) are uniquely positioned to use their power and privilege to advocate on behalf of AAPI clients, other POCI, and other marginalized groups by challenging systemic forms of oppression. Indeed, endorsing positive attitudes about diversity (Broido, 2000) and consciously committing to disrupting the cycle of injustice (Waters, 2010) are foundational characteristics of White allies, who seek to end disparity and work to promote the rights of oppressed groups (K. T. Brown & Ostrove, 2013). According to Sue and colleagues (2019), allies actively commit to engaging in actions that dismantle individual and institutional beliefs, practices, and policies that have created barriers for people of color.

AAPIs are facing greater rates of racial discrimination, harassment, violence, sinophobic attitudes, and racial slurs because of fears related to COVID-19 and the current sociopolitical climate. Counselors may help AAPI clients heal race-based trauma through the use of culturally adapted strategies such as promoting mindfulness and self-compassion, employing the use of microinterventions, and incorporating culturally appropriate proverbs and analogies in counseling treatment. Counselors are encouraged to adopt strategies to help AAPIs heal from race-based trauma because experiences of racial discrimination, microaggressions, and sinophobic behaviors are not limited to the current pandemic and instead represent longstanding forms of oppression embedded in American history and culture. AAPIs faced marginalization and racial discrimination before the presence of COVID-19 and will likely continue to experience race-related stress long after the discovery of a vaccination. Just as COVID-19 has illuminated disparities within medical, institutional, and political systems, it has also uncovered the enduring ethnocentric attitudes of many Americans. The proliferation of ongoing discrimination of all racial, ethnic, and marginalized groups is representative of a more insidious form of societal sickness.

Limitations and Future Areas of Research
Although the present article outlines the culturally alert strategies for healing race-based trauma among AAPIs, other marginalized groups face unique challenges related to the unprecedented effects of COVID-19 on social, institutional, and political levels. The deleterious effects of homelessness, social isolation, witnessing of real or perceived racial discrimination or violence, and issues related to LGBTQ individuals because of COVID-19–related issues and policies remain of paramount importance but were not explicitly discussed in this article. Future areas of research may examine the effects of racial discrimination during public health crises and other global events (Wen et al., 2020). Additionally, the ways in which AAPI groups respond to instances of racial discrimination and sinophobia because of COVID-19–related stress remain largely unknown. The manifestation of intergenerational trauma on AAPI families related to COVID-19 also represents an important area of future study. Finally, the national and global effects of COVID-19 on the mental health of diverse groups represents an essential topic of future study.

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

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Stacey Diane Arañez Litam, PhD, NCC, CCMHC, LPCC, is an assistant professor of counselor education at Cleveland State University. Correspondence may be addressed to Stacey Litam, Cleveland State University, 2121 Euclid Avenue, Julka Hall 275, Cleveland, OH 44115, s.litam@csuohio.edu.

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