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

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).

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.

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.


Aguilar, L. C. (2006). Ouch! That stereotype hurts: Communicating respectfully in a diverse world. The WALK THE TALK Company.
Allen, G. K., Conklin, H., & Kane, D. K. (2017). Racial discrimination and psychological health among Polynesians in the U.S. Cultural Diversity and Ethnic Minority Psychology, 23(3), 416–424.
Alvarez, A. N., Liang, C. T. H., & Neville, H. A. (Eds). (2016). The cost of racism for people of color: Contextualizing experiences of discrimination. American Psychological Association.
American Counseling Association. (2014). ACA code of ethics. https://www.counseling.org/docs/default-source/default-document-library/2014-code-of-ethics-finaladdressc97d33f16116603abcacff0000bee5e7.pdf?sfvrsn=5d6b532c_0
American Psychological Association. (2016). Stress in America: The impact of discrimination.
Araújo, B. Y., & Borrell, L. N. (2006). Understanding the link between discrimination, mental health outcomes, and life chances among Latinos. Hispanic Journal of Behavioral Sciences, 28(2), 245–266.
Au, T. M., Sauer-Zavala, S., King, M. W., Petrocchi, N., Barlow, D. H., & Litz, B. T. (2017). Compassion-based therapy for trauma-related shame and posttraumatic stress: Initial evaluation using a multiple baseline design. Behavior Therapy, 48(2), 207–221. https://www.doi.org/10.1016/j.beth.2016.11.012
Benoit, A. C., Cotnam, J., Raboud, J., Greene, S., Beaver, K., Zoccole, A, O’Brian-Teengs, D., Balfour, L., Wu, W., & Loutfy, M. (2016). Experiences of chronic stress and mental health concerns among urban Indigenous women. Archives of Women’s Mental Health, 19, 809–823. https://doi.org/10.1007/s00737-016-0622-8
Billé, F. (2015). Sinophobia: Anxiety, violence, and the making of Mongolian identity. University of Hawai’i Press.
Broido, E. M. (2000). The development of social justice allies during college: A phenomenological investigation. Journal of College Student Development, 41(1), 3–18.
Brown, L. S. (2008). Cultural competence in trauma therapy: Beyond the flashback. American Psychological Association.
Brown, K. T., & Ostrove, J. M. (2013). What does it mean to be an ally? The perception of allies from the perspective of people of color. Journal of Applied Social Psychology, 43(11), 2211–2222. https://doi.org/10.1111/jasp.12172
Bryant-Davis, T., & Ocampo, C. (2006). A therapeutic approach to the treatment of racist-incident-based trauma. Journal of Emotional Abuse, 6(4), 1–22. https://doi.org/10.1300/J135v06n04_01
Carter, R. T. (2007). Racism and psychological and emotional injury: Recognizing and assessing race-based traumatic stress. The Counseling Psychologist, 35(1), 13–105. https://doi.org/10.1177/0011000006292033
Carter, R. T., Forsyth, J. M., Mazzula, S. L., & Williams, B. (2005). Racial discrimination and race-based traumatic stress: An exploratory investigation. In R. T. Carter (Ed.), Handbook of racial-cultural psychology and counseling, Volume 2: Training and practice (pp. 447–476). Wiley.
Centers for Disease Control and Prevention. (2020). Coronavirus disease 2019: People who are at higher risk. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html
Choi, Y., & Lim, J. H. (2014). Korean newcomer youth’s experiences of racial marginalization and internalization of the model minority myth. Studies on Asia, 4(1), 44–78.
Chou, T., Asnaani, A., & Hofmann, S. G. (2012). Perception of racial discrimination and psychopathology across three U.S. ethnic minority groups. Cultural Diversity and Ethnic Minority Psychology, 18(1), 74–81. http://doi.org/10.1037/a0025432
Clark, R., Anderson, N. B., Clark, V. R., & Williams, D. R. (1999). Racism as a stressor for African Americans: A biopsychosocial model. American Psychologist, 54(10), 805–816. https://doi.org/10.1037/0003-066X.54.10.805
Cochran, B. N., Stewart, A. J., Ginzler, J. A., & Cauce, A. M. (2002). Challenges faced by homeless sexual minorities: Comparison of gay, lesbian, bisexual, and transgender homeless adolescents with their heterosexual counterparts. American Journal of Public Health, 92(5), 773–777. https://doi.org/10.2105/ajph.92.5.77
Comas-Díaz, L., Hall, G. N., & Neville, H. A. (2019). Racial trauma: Theory, research, and healing: Introduction to the special issue. American Psychologist, 74(1), 1–5. http://doi.org/10.1037/amp0000442
Congressional Asian American Pacific American Caucus. (2020). As coronavirus fears incite violence, CAPAC members urge colleagues to not stoke xenophobia. https://capac-chu.house.gov/press-release/coronavirus-fears-incite-violence-capac-members-urge-colleagues-not-stoke-xenophobia
Devakumar, D., Shannon, G., Bhopal, S. S., & Abubaker, I. (2020). Racism and discrimination in COVID-19 responses. The Lancet, 395(10231), 1194. https://doi.org/10.1016/S0140-6736(20)30792-3
Dreher, A., Hahn, E., Diefenbacher, A., Nguyen, M. H., Böge, K., Burian, H., Dettling, M., Burian, R., & Ta, T. M. T.
(2017). Cultural differences in symptom representation for depression and somatization measured by the PHQ between Vietnamese and German psychiatric outpatients. Journal of Psychosomatic Research, 102,
71–77. https://doi.org/10.1016/j.jpsychores.2017.09.010
Edwards, L. M., & Romero, A. J. (2008). Coping with discrimination among Mexican descent adolescents. Hispanic Journal of Behavioral Sciences, 30(1), 24–39. https://doi.org/10.1177/0739986307311431
Federal Emergency Management Agency. (2020). COVID-19 emergency declaration. https://www.fema.gov/news
Filbin, B. (2020, March 20). Bob’s notes on COVID-19: Mental health data on the pandemic. Crisis Text Line. https://www.crisistextline.org/data/bobs-notes-on-covid-19-mental-health-data-on-the-pandemic
Freire, P. (1970). Pedagogy of the oppressed. Continuum.
Gee, G. C., Spencer, M., Chen, J., Yip, T., & Takeuchi, D. T. (2007). The association between self-reported racial discrimination and 12-month DSM-IV mental disorders among Asian Americans nationwide. Social Science & Medicine, 64(10), 1984–1996. https://doi.org/10.1016/j.socscimed.2007.02.013
Gee, G. C., & Verissimo, A. D. O. (2016). Racism and behavioral outcomes over the life course. In A. N. Alvarez, C. T. H. Liang, & H. A. Neville (Eds.), The cost of racism for people of color: Contextualizing experiences of discrimination (pp. 133–162). American Psychological Association.
Germer, C. K., & Neff, K. D. (2015). Cultivating self-compassion in trauma survivors. In V. M. Follette, J. Briere, D. Rozelle, J. W. Hopper, & D. I. Rome (Eds.), Mindfulness-oriented interventions for trauma: Integrating contemplative practices (pp. 43–58). Guilford.
Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Clinical Psychology and Psychotherapy, 13(6), 353–379. https://doi.org/10.1002/cpp.507
Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Blaha, M. J., Dai, S., Ford, E. S., Fox, C. S., Franco, S., Fullerton, H. J., Gillespie, C., Hailpern, S. M., Heit, J. A., Howard, V. J., Huffman, M. D., Judd, S. E., Kissela, B. M., Kittner, S. J. . . . Turner, M. B. (2014). Executive summary: Heart disease and stroke statistics—2014 update: A report from the American Heart Association. Circulation, 129(3), 399–410. https://doi.org/10.1161/01.cir.0000442015.53336.12
Graser, J., Höfling, V., Weßlau, C., Mendes, A., & Stangier, U. (2016). Effects of a 12-week mindfulness, compassion, and loving kindness program on chronic depression: A pilot within-subjects wait-list controlled trial. Journal of Cognitive Psychotherapy, 30(1), 35–49. https://doi.org/10.1891/0889-8391.30.1.35
Grover, S., & Ghosh, A. (2014). Somatic symptom and related disorders in Asians and Asian Americans. Asian Journal of Psychiatry, 7, 77–79. https://doi.org/10.1016/j.ajp.2013.11.014
Harrell, S. P. (2000). A multidimensional conceptualization of racism-related stress: Implications for the well-being of people of color. American Journal of Orthopsychiatry, 70(1), 42–57. https://doi.org/10.1037/h0087722
Helms, J. E., Nicolas, G., & Green, C. E. (2012). Racism and ethnoviolence as trauma: Enhancing professional and research training. Traumatology, 18(1), 65–74. https://doi.org/10.1177/1534765610396728
Hernández-Wolfe, P. (2013). A borderlands view on Latinos, Latin Americans, and decolonization: Rethinking mental health. Jason Aronson.
Hinton, D. E., & Good, B. J. (Eds.). (2009). Culture and panic disorder. Stanford University Press.
Hinton, D. E., & Good, B. J. (Eds.). (2016). Culture and PTSD: Trauma in global and historical perspective. University of Pennsylvania Press.
Hinton, D. E., & Jalal, B. (2019). Dimensions of culturally sensitive CBT: Application to Southeast Asian populations. American Journal of Orthopsychiatry, 89(4), 493–507. https://doi.org/10.1037/ort0000392
Hinton, D. E., & Lewis-Fernández, R. (2011). The cross-cultural validity of posttraumatic stress disorder: Implications for DSM-5. Depression & Anxiety, 28(9), 783–801. https://doi.org/10.1002/da.20753
Hinton, D. E., Pollack, A. A., Weiss, B., & Trung, L. T. (2018). Culturally sensitive assessment of anxious-depressive distress in Vietnam: Avoiding category truncation. Transcultural Psychiatry, 55(3), 384–404. https://doi.org/10.1177/1363461518764500
Hofmann, S. G., Grossman, P., & Hinton, D. E. (2011). Loving-kindness and compassion meditation: Potential for psychological interventions. Clinical Psychology Review, 31(7), 1126–1132. https://doi.org/10.1016/j.cpr.2011.07.003
Huber, L. P., & Soloranzo, D. G. (2015). Racial microaggressions as a tool for critical race research. Race, Ethnicity and Education, 18(3), 297–320. https://doi.org/10.1080/13613324.2014.994173
Hwang, W.-C., & Goto, S. (2008). The impact of perceived racial discrimination on the mental health of Asian American and Latino college students. Cultural Diversity and Ethnic Minority Psychology, 14(4), 326–335. https://doi.org/10.1037/1099-9809.14.4.326
Iwamoto, D. K., & Liu, W. M. (2010). The impact of racial identity, ethnic identity, Asian values, and race-related stress on Asian Americans and Asian international college students’ psychological well-being. Journal of Counseling Psychology, 57(1), 79–91. https://doi.org/10.1037/a0017393
Jones, H. L., Cross, W. E., Jr., & DeFour, D. C. (2007). Race-related stress, racial identity attitudes, and mental health among Black women. Journal of Black Psychology, 33(2), 208–231. https://doi.org/10.1177/0095798407299517
Kawai, Y. (2005). Stereotyping Asian Americans: The dialectic of the model minority and the Yellow Peril. Howard Journal of Communications, 16(2), 109–130. http://doi.org/10.1080/10646170590948974
Kearney, D. J. (2015). Mindfulness-based stress reduction and loving-kindness meditation for traumatized veterans. In V. M. Follette, J. Briere, D. Rozelle, J. W. Hopper, & D. I. Rome (Eds.), Mindfulness-oriented interventions for trauma: Integrating contemplative practices (pp. 273–283). Guilford.
Kuyken, W., Watkins, E., Holden, E., White, K., Taylor, R. S., Byford, S., Evans, A., Radford, S., Teasdale, J. D., & Dalgleish, T. (2010). How does mindfulness-based cognitive therapy work? Behaviour Research and Therapy, 48(11), 1105–1112. https://doi.org/10.1016/j.brat.2010.08.003
Lee, E. (2002). The Chinese exclusion example: Race, immigration, and American gatekeeping, 1882-1924. Journal of American Ethnic History, 21(3), 36–62.
Lee, E. A., Soto, J. A., Swim, J. K., & Bernstein, M. J. (2012). Bitter reproach or sweet revenge: Cultural differences in response to racism. Personality and Social Psychology Bulletin, 38(7), 920–932.
Liang, C. T. H., & Fassinger, R. E. (2008). The role of collective self-esteem for Asian Americans
experiencing racism-related stress: A test of moderator and mediator hypotheses. Cultural Diversity and Ethnic Minority Psychology, 14(1), 19–28. https://doi.org/10.1037/1099-9809.14.1.19
Lopez, G., Ruiz, N. G., & Patten, E. (2017). Key facts about Asian Americans, a diverse and growing population. https://www.pewresearch.org/fact-tank/2017/09/08/key-facts-about-asian-americans
Mattar, S. (2011). Educating and training the next generations of traumatologists: Development of cultural competencies. Psychological Trauma: Theory, Research, Practice, and Policy, 3(3), 258–265. https://doi.org/10.1037/a0024477
Mossakowski, K. N. (2003). Coping with perceived discrimination: Does ethnic identity protect mental health? Journal of Health and Social Behavior, 44(3), 318–331. https://doi.org/10.2307/1519782
National Association for the Advancement of Colored People. (2020, March 17). Civil rights and racial justice organizations denounce discrimination against Asian Americans and urge unity in responding to coronavirus pandemic. https://www.naacp.org/latest/civil-rights-racial-justice-organizations-denounce-discrimination-asian-americans-urge-unity-responding-coronavirus-pandemic
Ocampo, A. C., & Soodjinda, D. (2016). Invisible Asian Americans: The intersection of sexuality, race, and education among gay Asian Americans. Race, Ethnicity, and Education, 19(3), 480–499.
Pieterse, A. L., Todd, N. R., Neville, H. A., & Carter, R. T. (2012). Perceived racism and mental health among Black American adults: A meta-analytic review. Journal of Counseling Psychology, 59(1), 1–9.
Pieterse, A., & Powell, S. (2016). A theoretical overview of the impact of racism on people of color. In A. N.
Alvarez, C. T. H. Liang, & H. A. Neville (Eds.), The cost of racism for people of color: Contextualizing experiences of discrimination (pp. 11–30). American Psychological Association.
Pokhrel, P., & Herzog, T. A. (2014). Historical trauma and substance use among Native Hawaiian college students. American Journal of Health Behavior, 38(3), 420–429. https://doi.org/10.5993/AJHB.38.3.11
Potok, M. (2017). The Trump effect. Intelligence Report. https://www.splcenter.org/fighting-hate/intelligence-report/2017/trump-effect
Qin, D. B., Way, N., & Rana, M. (2008). The “model minority” and their discontent: Examining peer discrimination and harassment of Chinese American immigrant youth. New Directions for Child and Adolescent Development, 2008(121), 27–42. https://doi.org/10.1002/cd.221
Rodriguez-Seijas, C., Stohl, M., Hasin, D. S., & Eaton, N. R. (2015). Transdiagnostic factors and mediation of the relationship between perceived racial discrimination and mental disorders. JAMA Psychiatry, 72(7), 706–713. https://doi.org/10.1001/jamapsychiatry.2015.0148
Schild, L., Ling, C., Blackburn, J., Stringhini, G., Zhang, Y., & Zannettou, S. (2020). “Go eat a bat, Chang!” An early look on the emergence of sinophobic behavior on web communities in the face of COVID-19. Computers and Society, 1–16. https://arxiv.org/pdf/2004.04046.pdf
Shelton, J. N., Richeson, J. A., Salvatore, J., & Hill, D. M. (2006). Silence is not golden: The intrapersonal consequences of not confronting prejudice. In S. Levin & C. van Laar (Eds.), Stigma and group inequality: Social psychological perspectives (pp. 65–81). Lawrence Erlbaum.
Shonin, E., Van Gordon, W., Compare, A., Zangeneh, M., & Griffiths, M. D. (2015). Buddhist-derived loving-kindness and compassion meditation for the treatment of psychopathology: A systematic review. Mindfulness, 6(5), 1161–1180. https://www.doi.org/10.1007/s12671-014-0368-1
Smith, W. A., Hung, M., & Franklin, J. D. (2011). Racial battle fatigue and the miseducation of Black men: Microaggressions, societal problems, and environmental stress. The Journal of Negro Education, 80(1), 63–82. https://doi.org/10.2307/41341106
Sue, D. W. (2015). Race talk and the conspiracy of silence: Understanding and facilitating difficult dialogues on race. Wiley.
Sue, D. W., Alsaidi, S., Awad, M. N., Glaeser, E., Calle, C. Z., & Mendez, N. (2019). Disarming racial microaggressions: Microintervention strategies for targets, White allies, and bystanders. American Psychologist, 74(1), 128–142. https://doi.org/10.1037/amp0000296
Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271–286. https://doi.org/10.1037/0003-066X.62.4.271
Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse: Theory and practice (7th ed.). Wiley.
Sundstrom, R. R., & Kim, D. H. (2014). Xenophobia and racism. Critical Philosophy of Race, 2(1), 20–45.
Taylor, S. (2019). The psychology of pandemics: Preparing for the next global outbreak of infectious disease. Cambridge Scholars Publishing.
Taylor, S., & Asmundson, G. J. G. (2004). Treating health anxiety: A cognitive-behavioral approach. Guilford.
Ting-Toomey, S., Yee-Jung, K. K., Shapiro, R. B., Garcia, W., Wright, T. J., & Oetzel, J. G. (2000). Ethnic/cultural identity salience and conflict styles in four US ethnic groups. International Journal of Intercultural Relations, 24(1), 47–81. https://doi.org/10.1016/S0147-1767(99)00023-1
Tsai, J., & Wilson, M. (2020). COVID-19: A potential public health problem for homeless populations. The Lancet, 5(4), e186–e187. https://doi.org/10.1016/S2468-2667(20)30053-0
United Nations Human Rights, Office of the High Commissioner. (2020, March 23). States should take action against COVID-19-related expressions of xenophobia, says UN expert. https://www.ohchr.org/EN/News
Unnikrishnan, R., Gupta, P. K., & Mohan, V. (2018). Diabetes in South Asians: Phenotype, clinical presentation, and natural history. Current Diabetes Reports, 18(30). https://doi.org/10.1007/s11892-018-1002-8
U.S. Department of Health and Human Services. (2000). Mental health: Culture, race and ethnicity: A supplement to Mental health: A report of the Surgeon General.
Waters, A. (2010). Book review: Injustice. Local Economy, 25(5–6), 523–525. https://doi.org/10.1080/02690942.2010.525995
Wei, M., Alvarez, A. N., Ku, T.-Y., Russell, D. W., & Bonett, D. G. (2010). Development and validation of a Coping with Discrimination Scale: Factor structure, reliability, and validity. Journal of Counseling Psychology, 57(3), 328–344. https://doi.org/10.1037/a0019969
Wei, M., Heppner, P. P., Ku, T.-Y., & Liao, K. Y.-H. (2010). Racial discrimination stress, coping, and depressive symptoms among Asian Americans: A moderation analysis. Asian American Journal of Psychology, 1(2), 136–150. https://doi.org/10.1037/a0020157
Wei, M., Wang, K. T., Heppner, P. P., & Du, Y. (2012). Ethnic and mainstream social connectedness, perceived racial discrimination, and posttraumatic stress symptoms. Journal of Counseling Psychology, 59(3), 486–493. https://doi.org/10.1037/a0028000
Wen, J., Aston, J., Liu, X., & Ying, T. (2020). Effects of misleading media coverage on public health crisis: A case of the 2019 novel coronavirus outbreak in China. Anatolia: An International Journal of Tourism and Hospitality Research. https://doi.org/10.1080/13032917.2020.1730621
White, A. I. R. (2020). The art of medicine: Historical linkages: Epidemic threat, economic risk, and xenophobia. The Lancet, 395, 1250–1251. https://doi.org/10.1016/S0140-6736(20)30737-6
Williams, D. R., & Williams-Morris, R. (2000). Racism and mental health: The African American experience. Ethnicity and Health, 5(3–4), 243–268. https://doi.org/10.1080/713667453
World Health Organization. (2015, May 8). WHO issues best practices for naming new human infectious diseases. https://www.who.int/mediacentre/news/notes/2015/naming-new-diseases/en
Yoo, H. C., & Lee, R. M. (2005). Ethnic identity and approach-type coping as moderators of the racial discrimination/well-being relation in Asian Americans. Journal of Counseling Psychology, 52(4), 497–506. https://doi.org/10.1037/0022-0167.52.4.497
Yum, J. O. (1988). The impact of Confucianism on interpersonal relationships and communication patterns in East Asia. Communication Monographs, 55(4), 374–388. https://doi.org/10.1080/03637758809376178

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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