While his therapy involved exploring some of the relational patterns that might have led his wife to feel like she was unappreciated, much of our work centered around reflecting the pain and grief he was or might be experiencing.
In one of his early sessions, Michael described having panic attacks while sleeping, waking up sweating and having a hard time breathing. He would also rhetorically ask, “What am I to do next (if she divorces me)?” and “I can’t accept this!” He described his mental state prior to seeing me, saying, “Two weeks ago I was in a dark place, depressed and felt empty.”
I immediately inquired about suicidal thoughts, and he acknowledged passive thoughts of suicide (i.e. thoughts without any concrete plans). I brought up the concept of a safety plan which would include calling 911, calling me and/or going to an emergency room. He said he could contract for safety by calling 911, but I was not convinced he would do it and felt he was just saying that to appease me.
Beyond the main current precipitating factor for suicide (upcoming divorce), I also asked him about protective factors by directly saying, “What’s keeping your alive today?” He shared about wanting to be here for his youngest son, who’s 10 years old.
Michael was mild-mannered and not openly emotionally expressive of his pain in session, although he acknowledged bouts of crying spells at home. He also described a life that appeared isolated and lonely. Playing golf for hours at a time by himself is what he described as his means of coping. It made me worry as he lacked an emotional support system.
While he denied suicidal thoughts in the following weeks, his physical symptoms increased in intensity (i.e. panic attacks and feeling like the “sky is going to fall”). Since Asians are much more comfortable talking about somatic issues than emotional ones, I recognized that he might still be trying to assess the extent to which he could trust me. I gently probed and educated him that his thoughts of “not sure if he could go on” were indeed considered passive thoughts of suicide. He was unaware of this and expressed the belief that feeling suicidal was simply when one had concrete plans.
During this time, I continued to press Michael to determine if he had friends, colleagues or others in whom he could confide about his upcoming divorce. Because of shame, it took a long time before he could even share this with his own parents. He eventually opened up to one friend, which I believed was a courageous first step towards openly expressing vulnerability. He told me that if he felt suicidal, he could and would likely be able to reach out to this friend. I remember feeling relieved that there was at least one person in his life whom he trusted.
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This case example demonstrates the delicate balance that therapists must tread when working with cultural shame and suicide. Over the years, I have learned that despite the shame Asian clients may feel about their lives and related suicidal thoughts, we must be bold enough to directly engage in these conversations.
In the general suicide literature, precipitating and stressful life events include divorce, death of a loved one, job loss and physical health problems. For Michael, it is no different. While divorce is mainstream in America and Caucasians may see this as simply another loss from which to recover, Asian clients may view this quite differently. As Asian identities revolve around familial ties and their place in the family, divorce can propel an Asian into a painful and shame-filled world where he/she may feel ostracized not only from their family, but from the greater Asian community, including friends, colleagues, churches and extended family relatives.
Michael is somewhat atypical in the sense that his thoughts of suicide occurred in mid-life, compared to those aged 20-24 years old, when suicide is the leading cause of death among Asians. However, what links Michael with other Asians is their centuries-old viewpoint on mental health and cultural shame. Shame is what Asians learn to avoid in any form throughout life, so going through a divorce is considered highly shameful. The belief that they have shamed their family and ancestors leads some to feel they have so disgraced their kin that they must hide oneself (physically and/or emotionally) or atone for their actions by ridding themselves from society by suicide.
In the context of younger Asian Americans, shame can emanate from perceived failure in academics (not getting high enough grades), poor career choices (pursuing a less financially secure occupation), or relational mistakes (dating or marrying someone the parents object to).
The fear is far more than one of disappointment, and is instead the concern over outright abandonment. There are innumerable stories of Asian parents disowning their children for not abiding by their parent’s dictate. Even if this were not a reality, the very fear or perception that this threat exists could lead one to suicide, depression, addiction, isolation and a host of other maladaptive coping behaviors.
In addition, mental health is viewed as a weakness, and talking openly about anything emotional such as sadness, disappointment and the stress of various life events is discouraged and rarely emulated in traditional Asian families. Stoicism is desired and the notion of physical touch and verbal affirmation can be seen as coddling.
Even suicide is viewed very differently among traditional Asian cultures. Some view suicide as an opportunity to atone for their misdeeds in this life and return honor to their families. In this regard, there are even extra incentives to die by suicide, including restoring the family’s reputation as well as those of the ancestors. It also can be seen as spiritually elevating oneself, since those who die by suicide become free of criticism.
All this is to say there is much work to be done in the field of mental health and outreach as it pertains to Asian Americans. If you’re working with Asian Americans in any capacity, be aware of their nature to minimize negativity and emotions that are regarded as shameful.
Clinicians should be mindful of life events that Asian clients deem so shameful that suicide becomes an option (job loss, divorce, bankruptcy). Because Asian shame is endemic to the culture, you also have to be wary of the client’s support system (or lack thereof). Is your client isolating from friends, peers, or relatives? Does your client struggle with emotional intimacy and fear that if someone else (besides the therapist) knew of their struggle, they would be abandoned?
Regardless of your therapeutic modality, when working with Asian American clients it’s imperative to find ways to reframe therapy from a shameful, stigma-inducing event to one where the client is working towards health, wellness and growth.
File under: The Art of Psychotherapy