What are Somatic and Socially Focused Symptoms of Depression for Chinese Immigrants? 

By Rose Wong, LCSW, MPA, PHD

San Francisco Bay Area Chinese Community Depression Education Project

What are the implications of not assessing for culture-specific symptoms?

Let’s look at some somatic and social expressions of depression found in research of Chinese-speaking immigrants in the San Francisco Bay Area (Wong et al., 2012). Can the below socially focused expressions be helpful, and what depression severity does each indicate?

• “You feel very helpless. You feel you have no way to change your own fate.”
• “You feel like no matter how hard you try, you can’t be as good as other people.”
• “You feel useless.”
• “You hide your life difficulties from other people.”
• “You feel you don’t have the kind of respect from work and family that you should have.”
• “You think you made your family lose face.”
• “You feel you are a burden to your family and society.”

During the research, most clinicians believed the final few social symptoms in the above list to indicate mild depression. Actually, these indicate moderately severe depression based on psychometric item response modeling. The above list is arranged from mild (top) to severe (bottom). Eight more social symptoms were found for a total of 15.

Can the below somatic symptom expressions be helpful, and what depression severity does each group indicate?

• Feeling very fatigued; being unable to sleep well; feeling physically tired or having no energy; afraid of having health problems.
• Bodily aches and pains; joint aches; heart palpitations or chest discomfort; feeling of heaviness in head.
• Stomach pains or discomfort; tinnitus (ringing sound in ears); throat discomfort or soreness; temporary unclear vision; cold sweat (due to fear); nausea or throwing up.

During the research, most clinicians believed the top group of symptoms to indicate moderate depression. Actually, the top group indicates mild depression. The above groups are arranged from mild (top) to severe (bottom). A total of 30 somatic symptoms were found.

The item response model confirmed the hypothesized three-dimensional—psychological, somatic and social—construct of depression based on data from 227 immigrant participants, half of whom were individuals diagnosed with depression by Chinese American clinicians and the other half were community members. To develop the three-dimensional scale, pilot items were first developed through qualitative interviews with (a) 34 individuals with depression using Arthur Kleinman’s (1986) Explanatory Model of Illness, and (b) 29 physicians, licensed mental health clinicians, and social workers who reviewed a long list of somatic, social and psychological items drawn from old and new depression scales from China and the U.S. and shared their experiences with depression assessment. Below are nine of the 21 psychological items. They include worry, fear, rumination, and irritation.

• “You feel heavy stress living in the U.S.”
• “Many things make you feel very troubled or bothered.”
• “You are very afraid of having health problems. For example, you might have cancer or heart disease.”
• “You think about unpleasant things the whole day and cannot stop.”
• “You have no interest in many things. For example, you used to like to exercise, go shopping, or go out for entertainment, but not anymore.”
• “You feel emotionally irritated.”
• “You have tantrums and get angry very easily.”
• “You feel very afraid.”
• “You have thoughts about hurting yourself.”

If somatic, social as well as psychological symptoms are possibly part of Chinese immigrants’ way of communicating depression, what are the implications of not assessing for them?

As part of the research, Rose developed a 9-item scale by drawing nine items representing low to high severity from the full 59-item scale, calling it the Chinese American Depression Scale (CADS-9). For CADS-9, she chose easier-to-answer (less stigmatizing) items representing all three dimensions. Rose also developed 9-item Social and Somatic scales, drawing items from across the severity continuum from each dimension. Two important findings came from comparing the PHQ-9 with CADS-9 and the 9-item Social and Somatic scales (Wong, R., 2012, unpublished research).

1. All four scales preformed similarly. They all showed moderately strong rates of correct classification (around.75-.80) for the known group (i.e., correctly classifying those with diagnosed depression as depressed and community members as not depressed in the 227 sample). Thus, each of the four scales performed similarly—just as well as the others. However, each scale classified a largely overlapping but not all the same participants as having depression. In other words, each scale would miss some individuals; each scale would miss different individuals. New questions arose, such as would the 9-item Somatic scale perform better than the others in a primary care clinic?
2. Depression is expressed based on dimensions. Some individuals express and emphasize mostly somatic symptoms. Others emphasize mostly social symptoms. Still others emphasize psychological and somatic symptoms to the exclusion of social symptoms. Compare Mrs. Wang, Mr. Leong and Mrs. Wu in the diagram. For example, Mrs. Wang expressed somatic symptoms strongly, and her scores on the psychological and social items were very low. Thus, assessing one dimension alone, depending on the individual, could lead to not recognizing the person’s depression.

Are there any differences in endorsement of symptoms between men vs. women, more acculturated vs. less acculturated, with more vs. less education, etc.?

Those with more education (high school or more) and higher acculturation more easily endorsed items such as not having the expected “respect from work and family” compared with those with less education and lower acculturation. Overall, the more educated and acculturated tended to endorse externalizing symptoms more easily and the less educated and less acculturated expressed items related to “burden to self and society” and feeling “useless” more easily. In other words, taking two individuals with the same level of depression, their education level predicts each of them answering an item differently. A final example of differential endorsement is that individuals with higher English proficiency and higher acculturation more easily endorse “you have thoughts about hurting yourself” and “you think about killing yourself.” See more items that have what’s called ‘differential item functioning’ in Rose’s dissertation article.

The implications of the above summarized findings are vast for disparities and unnecessary suffering among Chinese American and other ethnic minority communities in the U.S. when there is very little research on these communities conducted from an emic or bottom-up perspective. Reports such as the PHQ-9 being reliable and valid for Chinese American immigrants while several of its items appear to function differently, and low rates of mild depression being detected for Chinese immigrant men compared with other groups (Huang et al., 2006) are simply not frequently enough viewed as red flags.

Free Bilingual Educational Materials

Rose Wong and Nancy Lim-Yee, LCSW, started the San Francisco Bay Area Chinese Community Depression Education Project in 2012 with the aim of developing culturally sensitive assessment tools and outreach materials for community members and professionals. Using a community-based participatory approach, the Project’s team of professionals has produced brief educational videos and brochures with symptom checklists that highlight somatic and interpersonally focused symptoms. Check out these free resources!

• Four Videos for Medical Providers (Flyer)
• Watch The Stressed Doctor followed by The Zen Doctor: See how Dr. Pak learns to engage with the patient to reach his goals and address the patient’s needs.
• Six Videos for Community Members (Flyer)
• Watch A Radar for Depression and Signs of Suicide: See Dr. Guan demonstrating how to assess depression and work with patients with suicide risk.
• Outreach Brochures with Culturally Sensitive Symptom Checklists

These brochures emphasize the linkage of physical and mental health, common immigrant stressors, the importance of getting help and having hope, as well as a symptom list for screening. There are three brochures, for teens, adults and older adults with translations to English.

View a webinar slideshow that includes the content of this article here.

References

Huang, R.Y., Chung, H., Kroenke, K., Delucchi, K.L., & Spitzer, R.L. (2006). Using the Patient Health Questionniare-9 to measure depression among racially and ethnically diverse primary care patients. Journal General and Internal Medicine, 21, 547–552.

Kleinman, A. (1986). Social Origins of Distress and Disease: Depression, Neurasthenia and Pain in Modern China. New Haven: Yale University Press.

Wong, R., Wu, R., Guo, C., Lam, J.K., & Snowden, L. (2012). Culturally sensitive depression assessment for Chinese American Immigrants: Development of a comprehensive measure and a screening scale using an item response approach. Asian American Journal of Psychology, 3(4), 230–253.

Rose Wong (she/her), LCSW, MPA, PHD, is Associate Professor of social work at Cal State East Bay. After immigrating from Hong Kong to the East Bay as a young child, she watched her grandmother’s suffering from very severe depression and wished she could reach her grandmother—hear her and communicate with her. This childhood experience stimulated her work on culturally-based assessment for Chinese immigrants. Last year, Rose published a book, Which Evidence-Based Practice Should I Use? A Social Worker’s Handbook for Decision Making, for use in social work practice and research courses and for mental health practitioners to sharpen their skills for using the evidence base from a critical, culturally inclusive perspective. Rose was also the Founding Director of the MSW program at University of the Pacific from 2019-2021.

Turning Red: Seeing and Being Seen

By Dr. Elizabeth 방실 Smith, Ariel Landrum, and Serena Hsie

Storytelling is an ancestral art preserving culture and is often used in healing modalities (Bruchac, J. 1996). We all have stories that are informed by our personal experiences and with larger cultural and societal messages. Within the mainstream, storytelling is primarily conveyed through the entertainment industry.  Recently, there has been a noticeable shift towards increased representation and inclusion of stories previously unseen in mainstream media. With few Asian Americans in leadership positions in the Western film industry, few of our stories are told through our lens. As a result, it is an all too common experience for those who are part of the Asian diaspora to feel unseen or be depicted through negative stereotypes within Western society. Therefore, it’s no surprise that when Pixar released an animated film titled Turning Red, which centers on a primary character of the Asian diaspora, many within the community gravitated toward its narrative. Many clinicians who work with the community and employ narrative in their treatment have found interventions within the movie they can utilize to facilitate healing.

Defining Narrative Therapy

Clinicians who practice through the narrative therapy modality believe that telling one’s story is where change occurs, Narrative therapy emphasizes the stories we develop and carry throughout our lives and helps to separate people’s identities from their problems. It helps clients become—and embrace being—an expert in their own lives (Epston, White, 1990; Madigan, 2011; Morgan, 2000).

Narrative therapists often engage their clients with various interventions crucial for the treatment process. The most common is externalization, unique outcomes, and language. Externalization is the process of objectifying one’s problems. This can be done in a variety of ways, including giving the problem a name, which leads clients to view their issues or behaviors as external instead of an unchangeable part of themselves. The general idea of this technique is that it is easier to change a behavior you do than to change a core personality characteristic.

The intervention of unique outcomes is complex but a vital aspect of narrative therapy. This intervention focuses on changing one’s storyline through shifting perspectives. One example is asking a client to take on the perspective of an onlooker in their story and describe what they believe that onlooker would have seen, felt, or responded to. Asking a client to look at multiple perspectives allows the client to build empathy and develop an understanding of the struggles and solutions they face.

Lastly, language choice is critical in the therapeutic alliance, as the clinician will often use the client's words and phrases to build rapport and validate their story. A common example would include cultural words and phrases that the clinician adopts which the client may connect to. Additionally, the clinician will assist in teaching the client to learn the alternative language to help further develop the richness of their storytelling experience (Epston, White, 1990; Madigan, 2011; Morgan, 2000).

Narratives Themes in Turning Red

Turning Red highlights many complexities for the Asian diaspora community in a way that most of us are not accustomed to seeing in a mainstream movie. These complexities are found in character-driven themes and cultural representation in the film. This fantastic movie touched on various meaningful themes, characters, and relational dynamics in many ways, making it ripe with therapeutic material to review. In reviewing this movie, a few key themes are essential to address and integrate into a clinical session.

Character-Driven Themes

The primary characters within the film are directly informed by their experience as Asian diaspora. Set in Toronto, Ontario, in 2002, Turning Red follows the confident, dorky Meilin "Mei Mei" Lee, a 13-year-old Chinese-Canadian student who, due to a hereditary curse, transforms into a giant red panda when she experiences strong emotions. Mei Mei is torn between being her mother's dutiful daughter and the chaos of her youth.

The Lee family portrays strong values around duty, willingness to achieve, and desire to live honorably. They make active choices within the film that represents their desire to engage with their community and their family, both through the perspective of protection and exploration. These characteristics center the movie around a common struggle that the Asian diaspora experiences: familial and communal expectations versus personal desires. What does it mean to chase your dreams when those dreams do not match what your family expects of you? Mei Mei defies her mother's and father’s wishes as she attempts to exercise her autonomy and prioritize her friendship over her family. Ming Lee and Jin navigate generational trauma as they try to shift away from controlling to understanding their daughter.

Cultural Representation

The movie's cultural representation is groundbreaking for the Western industry and has made many in the Asian community feel seen. The choice of colors, textiles, and textures denote a sense of connection to the Canadian-Chinese community. The main character lives at a temple and engages in many practices around ancestry variation. The filmmakers even made stylistic choices often found in Asian media, such as Kawaii eyes, cultural food animated with detail, and Chuānyuè, the storytelling process of connecting multiple timelines often found in Anime and ancient narratives.

Cultural Stressors

This animated feature also portrays several cultural stressors clients can identify.  Specific themes that the Asian diaspora may also notice depictions of filial piety and a strong sense of duty to honor and serve one’s parents and elders that date back to Confucianism. The strong desire for achievement and themes of the Model Minority Myth, as well as themes of saving face and eating bitterness, are present in the film. Notably, various traumatic themes stemming from war, attachment wounds, bullying, and acculturation are depicted in the film. Trauma can be defined in many terms. Peter Levine, a well-known somatic experiencing practitioner, focuses not on specific events but on activating the central nervous system (CNS). Within the film, when Mei Mei is highly activated, her mighty Panda comes out and can wreak havoc. Addressing the CNS can be an accessible, culturally responsive, and neurodivergent affirming way to discuss trauma, Autistic meltdowns, sensory processing, etc. Just like the Panda, activation of the CNS happens emotionally and physically.

When it comes to cultural stressors, the most prevalent depicted in the film is that of intergenerational trauma. This trauma is passed down through the Lee family generations, beginning with their ancestor, Sun Lee. She was the first to transform into a panda after praying during a time of war, food insecurities, concerns for her children, and overcoming grief and loss. For many Asian diaspora, there are many traumas simply from being “othered” in spaces where assimilation and masking our uniqueness is encouraged. What we know about generational trauma is often what once was a coping skill tool for the past now turns into attachment wounds that are not sustainable for future generations. Intergenerational trauma can contribute to families repressing their emotions, rejecting their authentic selves, and experiencing misstatements with their loved ones (Chen, 2021). So in the movie, we witness Mei Mei out of touch with her deep, colorful, and rich feelings because her family has learned that their panda is a curse, not a blessing. We see the impact this has on Mei’s mother Ming and her relationship with her mother. Unable to hold the complexity of her humanity and multilayered emotional experiences, Mei rebels by embracing her panda in ways that also cause her to dishonor her family's wishes. The story's plot culminates with the basic human desire to connect deeply with ourselves and others, displaying several characteristics of growth (Tedeschi, Calhoun, 2004).

Interventions That Clinicians Can Use

The struggles of the Lee family in Turning Red can efficiently be utilized in session with Narrative Therapy interventions. Often Narrative therapists ask their clients to create a narrative that identifies beliefs, metaphors, and themes. This is the intervention of developing the narrative. Often the question is, "What is the story you're telling yourself?" When pulling in a story from media, such as this film, a therapist may ask a client, "What about the story resonated with you? Do you agree with the character's motivations? Were their voices in the story that need to be amplified? What themes did you notice?" This will give them vital information about how the client may view their world and help them understand how to build their story.

With externalization, the technique is critical in the healing process around this theory. The theme of the Red Panda is a perfect way to contextualize this intervention. Clinicians can ask their clients to choose something such as an animal that represents their struggles. Also, as some of the characters in the film decided to lock their pandas away, clinicians can inquire if their clients would make the same choice and the reasons for or against it.

The unique outcomes technique focuses on a different storyline or storylines than the primary storyteller. Clinicians can have the client look at different characters within the story, to identify their perspective and understanding of what is occurring. For characters they disagree with, the client can encourage them to take on their narrative to access empathy. This can be a helpful way to practice perspective taking with their narrative, as they will have practiced through the characters in Turning Red.

Turning Red has words and phrases that reference pop culture and Asian culture, which clinicians and clients can adapt into session. Mei Mei and her best friends describe themselves as “4-Townies,” because they are fans of the boy band group 4-Town, similar to BTS fans calling themselves “BTS Army.” Clinicians can ask their clients if they are fans of a specific music group similar to Mei Mei and her friends, and if so, what they call themselves. Mei Mei and her friends also use dated slang, like “24/7, 365.” A clinician can use this as an example of slag and ask their clients to share the slang they use with their peers. Adopting these terms and phrases could increase rapport and help meet the client where they are at.

Being Seen

Turning Red allows clinicians to tackle complex topics and themes with their Asian diaspora clients that may be difficult to contextualize. Using media familiar to our clients is a great conversation starter that can spark meaningful dialogue and help build therapeutic rapport. It gives clinicians a template to reflect on why something is critical to a client. Media can encourage people to visualize things we never knew were possible or express parts of ourselves we didn't know could be seen. This can encourage healing validation, acceptance and authenticity, whereas lack of acceptance can encourage masking and inauthentic ways of being (Mudridge, 2021). With Turning Red touching a variety of current sociocultural perspectives and struggles that the Asian diaspora community is facing, it helps bring to light what was initially unseen.

Citations:

• Allen, JG. (2012) Mentalizing in the development and treatment of attachment trauma. London: Karnac Books
• Bruchac, J. (1996) Roots of Survival: Native American Storytelling and the Sacred. Fulcrum Publishing
• Boorstin, J. & Taylor, H. (2022): Here’s Where Hollywood’s Efforts to Improve Diversity Really Stand in 2022. 24, March 2022
• Chadwick, R. (ed.) (2012), The Encyclopedia of Applied Ethics, II Edition, LondonWaltham-San Diego: Academic Press.
• Chen, I. (2020), Untigering: Peaceful Parenting for the Deconstructing Tiger Parent
• Ergos Institute, Inc. https://www.somaticexperiencing.com/about-peter
• Epston, D. & White, M. (1990): ‘Story, knowledge, power.’ In Epston, D. & White, M., Narrative means to therapeutic ends, chapter 1. New York: Norton.
• Madigan, S. (2011). Narrative therapy. American Psychological Association.
• Morgan, Alice. (2000), What is narrative therapy ? : an easy-to-read introduction / by Alice Morgan Dulwich Centre Publications Adelaide
• Mudridge, J. (2021): 'Flourishing Authentically,' Presented at Reframing Autism’s online Symposium on Autistic Flourishing: Acceptance, Authenticity, Autonomy, 5 November 2021
• Newman, T. and Han, S. (2022): All about the Central Nervous System: Medical News Today
• Ryder, G., White, T., & Boland, M. (2022): How Intergenerational Trauma Impacts Families: Psych Central
• Sarah-SoonLing B. (2019): What is the Model Minority Myth: Learning for Justice
• Somatic Experiencing® International  https://traumahealing.org/
• Tedeschi, R.G., & Calhoun, L.G. 2004. Posttraumatic Growth: Conceptual Foundations and Empirical Evidence.

Dr. Elizabeth 방실 Smith PsyD, CCTP-II, ASDCS (she/her/hers), Dr. Smith is a 1.5 generation Korean-Irish Licensed Clinical Psychologist based out of Chicago who speaks English and conversational Korean. She provides care through a relational, collaborative, neurodivergent affirming, social justice, and trauma informed lens. Much of her work includes meeting people where they are while helping individuals and families navigate a variety of stresses, traumas, & relational and developmental challenges. In addition, Dr. Smith proudly serves several nonprofits including the Asian Mental Health Collective and NAAAP-Chicago. For fun, she enjoys collecting Hello Kitty and Tokidoki, joyful body movement, culinary adventures, knitting, art, cosplay, and playing with her puppy, who is currently training for her therapy dog certification.

Ariel Landrum, LMFT (she/her/hers) is a Licensed Marriage and Family Therapist and Certified Art Therapist. She is a proud Filipina American practicing teletherapy out of Reseda, California. She is a self-identified "geek therapist" who uses her client's passions and fandoms to create connections, strengthen self-esteem, and support individuality. She specializes in working with: military members and their families, the 2SLGBTQIA+ community, and survivors of sexual assault and childhood sexual abuse. When she is not helping members of her Coop thrive as private practice clinicians, you can catch her watching Disney+, hosting her Disney-themed podcast, or renovating her house.

Serena Hsieh, LMFT (she/her/hers) is a Licensed Marriage and Family Therapist and Certified Art Therapist working in Los Angeles, California. She is a mother and first generation-Taiwanese American. Serena works with adult and child individuals in supporting them through challenging seasons of life with a culturally sensitive approach. The communities she often focuses her support in are the Asian Pacific Islander Desi American (APIDA) communities and the LGBTQIA2-S community. When not working in her practice, she finds herself watching Disney+ and historical dramas.

Asian Family Caregivers and Dementia Challenges

Dong Li Hou, LCSW

“Can you please tell the government to send someone to my home, to check in on my husband so he can behave better?”  An Asian wife asked her husband’s primary care physician repeatedly, eventually the doctor had no choice but referred the patient (husband) and wife to me, a licensed clinical social worker/case manager for complex chronic condition program at that time.

“For how many times I have to tell him that I am his wife, that his dear mother passed away many, many years ago?” the wife said to me.  The elderly Asian wife was reluctant to talk about it with her daughter who is a health care provider. The wife also avoided neighbors “it is really embarrassing!”  She said.

Yes, the patient had dementia. 

Signs and symptoms of dementia include issues with memory, attention, communication, reasoning, judgment, and problem solving.  Visual perception beyond typical age-related changes in vision as well.¹  Dementia is an umbrella term, Alzheimer’s disease is a specific brain disease.²  Current estimates are that about 5.8 million people in the United States have Alzheimer's disease and related dementias.

Among people ages 65 and older Asian and Pacific Islanders,  8.4 % of them have dementia. ³  Filipino community had the highest rate of dementia, followed by Japanese and Chinese populations. South Asian Americans had the lowest rate of dementia. ⁴ 

Approximately 19.9 million people (6% of all respondents) identified as Asian alone in 2020, up from 14.7 million people (4.8%) in 2010. The Asian alone population grew by 35.5% between 2010 and 2020. ⁵  As APIDA population grows, the dementia population also grows, thus the tasks of APIDA family caregivers grow as well.

Taking care of loved ones who have dementia is very challenging compared to taking care of patients with other types of diseases because you are not just taking care of the bodies, you are also dealing with uncertain cognitive situations which could change from moment to moment.

The responsibilities of dementia caregivers range from assisting with activities and instrumental activities of daily living to coordinating, monitoring, and even navigating health systems and delivering healthcare, and more. 

My social worker career started as a family consultant working with family caregivers, most of them were caring for loved ones with dementia.  My mentor told me then, “many family caregivers die before the care receivers because caregiving is a very, very stressful and hard work.”

An Asian wife told me that one time her husband asked her “who are you?  Why are you here?” Wife collected all of her photos before and after their marriage, showed them to the husband, trying to convince him that she was his wife, only to find out that he had forgotten that he had asked her such a question.  The difficulties of caring for dementia patients including disruptive behaviors, delusions (I had a patient who insisted that there were a few people in his home while in reality, only he and his wife were at home.)  Sleep disturbance and mental fluctuations usually make family caregivers exhausted.

Caregiving burdens seem not evenly divided among all of racial/ethnic groups.  Research indicated that in a 2005 meta-analysis of 116 empirical studies, conducted by Pinquart & Sörensen, suggest further ethnic differences among caregivers:

• Asian-American caregivers made less use of professional support services than did White caregivers.
• Ethnic minority caregivers had a lower socioeconomic status, were more likely to receive support from family members and friends, provided more care than White caregivers, and had stronger filial obligation beliefs than White caregivers.
• All ethnic minority caregiving groups reported worse physical health than the White caregivers experienced.
• African-American caregivers had lower levels of caregiver burden and depression than White caregivers. Hispanic and Asian-American caregivers were more depressed than White caregivers.⁶

Asian family caregivers facing many challenges, including whether to send loved one to the nursing home for custodial care (it may bring guilt feelings to the Asian caregivers), government’s role in assisting family caregivers (lots of Asian caregivers are not well informed), expectation of the family caregivers (how much is enough?), how to utilize mental health service (lots of Asian family caregivers put their lives on hold to care for their loved ones), why children are/aren’t involved in family caregiving (family dynamics), when children are the family caregivers (cultural/generational difference), how are the APIDA family caregivers utilize community resources and provider’s Professional boundary etc.

 During my 8 years of case management for patients with complex medical conditions (2013 to 2021), I had worked with at least 17 Asian dementia patients and their family caregivers. The number is small but I am hoping by reporting this small group study to spark some understanding/discussion regarding today’s Asian family caregivers.  To maintain confidentiality, I will not disclose the 17 patients’ and their family caregivers’ personal information. 

Let me start with patients’ demographic of this study group: 9 out of the 17 patients have both MediCare/MediCal, 1 has both MediCare and Tricare, 1 has MediCal only, 6 had MediCare only. 

There were 7 Chinese patients, 4 Filipino patients, 2 Vietnamese patients, 1 Indian patient, 1 Korean patient and 2 others.

As for these patients’ age range, 1 patient was in 50’s, 2 in 60’s, 4 in 70’s, 8 in 80’s, 2 in 90’s.

I further broke down the study report in the following 8 topics, namely community resources utilization, long term care, government’s role, family caregivers’ expectations, family caregivers’ mental health status, children and caregiving (as caregivers or not involved), provider issues.

1. Community resources utilization:

“Given the difficulty of surveying Asian Americans and their wide economic diversity, Asian Americans are often excluded from conversations about poverty and social services. Without targeted outreach and efforts to accurately sample the entire Asian American population, the needs of Asian Americans, Native Hawaiians, and Pacific Islanders living in poverty might be overlooked when evaluating access to social services.”⁷

In Home Supportive Services (IHSS) is an important community resource for family caregivers as it “provides in-home assistance to eligible aged, blind and disabled individuals as an alternative to out-of-home care and enables recipients to remain safely in their own homes.   However, IHSS recipients must have a Medi-Cal eligibility determination, thus not all of the dementia patients are eligible. 

I am trying to use IHSS/APS as two of the indicators to explore the usage of community resources of APIDA population.  Below is a screenshot of IHSS recipients breaking down by ethnicity for the month of Jan., 2022 (https://www.cdss.ca.gov/Portals/9/IHSS/Data/IHSS_Program_Data-Jan2022.xlsx?ver=2022-02-15-152925-270)

Below is the screenshot by County of Santa Clara Social Services Agency re: Adult Protective Services FY 2021 Annual Report (https://socialservices.sccgov.org/sites/g/files/exjcpb701/files/documents/Adult_Protective_Services_FY_2021_Annual_Report.pdf):

If readers are interested to explore further, you may want to also check out % of APIDA population vs. total population in respective locations, then compare the % of IHSS and APS usage vs. other ethnic groups in that area.

For my study group, 8 of the 17 dementia patients were the IHSS recipients and 2 were reported and investigated by APS).

2. Long term care planning:

People suffering from dementia may experience a long and painful journey, as well as their family caregivers.  Family caregivers may need to plan for the long term care: options are to care at home, to care at a nursing/assisting living facility,  for many immigrants, the alternative care plan also includes to send loved ones to their home countries if more resources are available.

There is a little research done to explore family caregivers’ issues, including the long term care decisions of APIDA population.  There was a study regarding Karean  family caregivers: “Despite difficulties they dealt with on a daily basis, many KA caregivers expressed a desire to take care of PWD at home, using care facilities as the very last option. Some had negative views on care facilities and nursing homes. This was mostly out of familism or familial piety, love, and appreciation for the patients. Spouses and children of PWD stated they would regret not trying every available option before placement. They said that dealing with caregiving at home would be easier than living with guilt and what-ifs later.” ““planning to move out of country for affordable long-term care. One of them said, “I think it’s most practical to stay in Seoul. It’s inconvenient to stay here.” ⁸

Family caregivers in my study group made similar decisions regarding long term care plan for their loved ones, there were 6 patients cared for by family caregivers alone, 4 patients cared for by family caregivers with the help of IHSS caregivers, 1 cared for by family caregiver and hired helper while 3 went back to their home countries and cared for by family caregivers, thus total 14 out of 17 dementia patients were cared by family caregivers, 1 patient was cared for at an assisted living facility as she has no family left (after her only child passed away due to illness), 2 were cared for at skilled nursing facilities as custodial care, the above data showed below:

It may worthwhile to point out that the two cases of skilled nursing facilities (SNF), one was due to family caregiver’s mental health issue (anxiety/depression) while the other case was due to family dynamic. Both family caregivers claimed that they can’t take care of their loved ones thus the patients had to be placed at a SNF.  Unfortunately, the placements had not helped or improved family caregivers’ pre-existing issues, the family caregiver with anxiety/depression was still anxious/depressed who then made high care demands which was impossible for the SNF staff to complete.  The family caregivers who had dynamic issues not only continued to have that issue, but also developed conflicts with the staff at the SNF, which led to visitation restrictions requested by the SNF staff.

Assisted living facilities had been underutilized by my study group due possibily to lack of or reluctant to use financial resources as most assisted living facilities are not covered by MediCal.

3. Government’s role

The comments that I heard the most from APIDA family caregivers of my study group had been:

“Tell me what is available”

“Send someone to my home to help out”

“Make him/her (the demented patient) listen”

“Financial assistance”

“I don’t understand”

“Can someone make the decision for me?”

Below are the responses from family caregivers in my study group, 12 of 17 family caregivers hope to receive some financial support, 8 of 17 hope they can receive “tailormade support” - - whatever and whenever they need it.  There were 5 family caregivers hoping to make him/her (dementia patient) listen while 2 didn’t want any help.

Some APIDA family caregivers are not familiar with available supportive resources, and it was hard for them to tell their expectations of resources since they have no idea what might be there for them. However lots of APIDA family caregivers, especially Chinese family caregivers, focus on what is available from government (federal and local) rather than from community. Financial assistance is very important, a government official or whoever authority figure to “make him/her (the demented patient) listen” was a unique request from some APIDA family caregivers which I rarely heard from other ethnic groups. 

Community resources such as family caregiver support groups seemed underutilized as APIDA family caregivers felt they were too busy to do it or it was not very helpful because it was all about talks but no “real” benefits.

4. Self expectations/perceptions of the family caregivers

“A majority of Asian American and Pacific Islander caregivers (61 percent) feel they had no choice in taking on their caregiving responsibility.” ⁹ per report of “CAREGIVING IN A DIVERSE AMERICA” published on Nov., 2021, which was somewhat in line with my study group.

Data also showed that “AAPI caregivers were less likely to receive information from medical care providers compared to Non-Hispanic White caregivers  Specifically, Asian American and Pacific Islander caregivers reported needing guidance in filling out forms, navigating through information on choosing a home care agency, assisted living facility, or nursing home, managing their own emotional or physical stress, or finding non-English language materials regarding the care of the care recipient. ⁹ 

In my study group, there were 7 felt that they had to do it, 4 felt that they are doing the best they can, thus that made the number be total 11 out of 17, there were 3 family caregivers felt that they are almost at the point of collapse, two patients had nieces or nephews as the closest family members however these niece or nephews didn’t feel that they should carry the family caregivers’ roles, one had no family left thus had to stay at an assisted living facility, it is showed below:

It is worth to point out that for the three “I am about to collapse” cases, 2 patients out of the 3 were sent to cSNF, caregivers still feeling the same, while in the 3rd case,  family caregiver chose retirement so felt less stressed.  It seemed that the family caregivers who had the perception of “I am doing the best I can” were the least self critical. 

It seems to me that quality of family relationships are one of the key factors when family  caregivers make long term care decisions as persons with dementia usually can’t make that decision cognitively at that point of their lives.  I had a 85+ years old APIDA wife who took care of elderly husband by self with the help of an IHSS caregiver, she declined help offered from children stating “they have their lives.”   She explained to me why she made that decision to care for husband by self, knowing that he could have stayed at a skilled nursing home for custodial care. “He was very caring to me during our long marriage, this is what I owed him, I need to do this for him.”  She had been in bed for over a month, recovering from the physical and emotional exhausts after he passed away.

5. Family caregivers’ mental health issues:

There was some research published regarding mental health issues of family caregivers, including APIDA family caregivers.  

“All KA caregivers shared difficult moments of dealing with progressing symptoms of dementia. Examples were: decreased social awareness and subsequently inappropriate behaviors in public; personality changes; anger and agitation; refusal to cooperate, especially with hygiene and appetite; wandering; disrupted communication; and poor judgment leading to safety concerns.“In the midst of changes and adjustments when dealing with PWD’s symptoms on their own, several KA caregivers revealed experiencing intense, mostly negative emotions. Getting upset, angry, and frustrated was frequently mentioned when caregivers had to deal with similar challenging situations repeatedly. Other commonly reported negative emotions included depression, anxiety, uncertainty, loneliness, grief and loss, guilt, or regrets. KA caregivers also talked about feeling scared, exhausted, and overwhelmed. “The most concerning response associated with this negative emotional experience was the ideas of suicide and death reported by four KA caregivers. ”⁸ 

It is interesting to note that “These (disruptive) behaviors (of the persons with dementia) may also cause distress partly by engendering a sense of loss of control, which may explain why they are more problematic for Asian caregivers, but no data are available to speak to this point yet.”¹⁰

My impression regarding APIDA family caregivers’ mental health issues based on my working experience, is that there are not sufficient APIDA specific data, some of the APIDA family caregivers tend to put self care on hold, they may lack of mental health awareness, they don’t have good understanding of the mental health services, many of them don’t follow up after they started receiving mental health services, however APIDA family caregivers seemed having high acceptance of medicines if they have sleeping issues.

In my study group, 6 out of 17 family caregivers accepted mental health services while 5 acknowledged that they may have mental health issues but declined to seek for help, one didn’t want to discuss it, there were 3 family caregivers feeling fine, denied that they have mental health issues while one patient didn’t have a family caregiver.

It seemed to me that from the family caregivers of my study group’s view point, medications are more effective than talk therapy, as medications may improve certain symptoms such as insomnia, anxiety while talk therapy is “just talks”.   None of the 6 family caregivers who received mental health counseling continued their “talk therapy”  after a few sessions.

6. Why children are not involved in family caregiving

There were 9 out of 17 persons with dementia were not cared for by children, main reason (6 out of 9) was not wanting to burden the children while 1 family caregiver thought children were not interested in helping out, 2 were due to no children or children didn’t want to be involved.

I wonder whether the cultural values of some APIDA group have, namely “family Recognition through Achievement, and Conformity to Norms”¹¹ was one of the roots of not want to burden children, as I have heard from many senior APIDA caregivers “my children are doing important jobs, they have no time for this and their works should not be interpreted.” 

Communication between generations may be another issue, language barrier exists. I have heard from seniors that they can’t fully understand their children, they also can’t fully express themselves due to language limitations. I was even asked to interpret among family members.   

Some of the Chinese family caregivers may lack of help from son/daughter due to one child policy because this only child and spouse (may also be an only child) needed to take care of own family as well as 4 seniors (parents and parents-in-law)

Data showed the fertility rates have fallen around the world over the last decade, “Among Asians, there are over 210,000 missing births, making 2019 births 15% below their expected value, yielding about 47,000 missing Asian-American births per year.”¹²  If this trend continues, future generation may have more difficulties to obtain help from their children.

7. When children are the family caregivers: cultural/generational difference 

“Various socio-cultural factors encourage Asian American caregivers to take on the responsibility of caring for their aging relatives. In particular, the Chinese belief of filial piety focuses on respect to family elders. Children are responsible for supporting their parents to ensure their well-being.  Such cultural beliefs, values, and practices carry mental health effects that may lead to ineffective and unhealthy ways of coping to stress. Caregivers consistently report higher levels of depressive symptoms in addition to lower levels of physical self-care, such as missing doctor’s appointments, worsened eating habits, and lack of exercise.” ¹³ 

In my study group, most issues arose when children were primary family caregivers were role reversal, when children became the ones to give instructions to parents, some of the parents had issues to listen to the children, as they felt their authorization of life time were taken away by their children, or they didn’t trust children because of their young age and lack of seniority. 

Other issues children as primary family caregivers included children felt their parents didn’t understand (communication issue), relationship between primary caregiver child and the children of long distance, language barriers, etc. 

Family dynamic is a difficult one, especially when the primary caregiver child felt his/her parent favored other children during his/her childhood, and the favored child likely is not the primary family caregiver (because parents don’t want to burden the favored child), therefore it seemed the unfavored child felt he/she had been forever treated less fairly by the demented parent.  Therapy is difficult because when parents have dementia, they may not fully understand what is going on.  Sometimes when the less favored primary family caregiver child finally had the courage to talk to parents, only to find out that his/her parent had been confused or unable to express themselves, thus the expected apology was mission impossible.  It also happened that when the parent was alert and oriented x3, he/she denied the favoritism ever happened, the primary caregiver child had to carry on the caregiver duty with hurt feelings, which made the caregiving job even more stressful.     

Summary

This writer attempted to use the data of 17 cases of APIDA family caregivers based on writer’s own work experience to explore issues with APIDA family caregivers who cared for persons with dementia, issues addressed including utilization of resources, long term care planning, government’s role (from caregivers’ viewpoint), family caregivers’ exception/perceptions, family caregivers’ mental health, why children are not involved or whey they are the primary caregivers, provider’s issues. 

This writer may have been biased as the writer is limited to personal viewpoint, experience and education.   

Reference:

1. https://www.cdc.gov/aging/dementia/index.html
2. https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/alzheimers-and-dementia-whats-the-difference/faq-20396861#:~:text=While%20dementia%20is%20a%20general,memory%2C%20thinking%20and%20reasoning%20skills.
3. https://www.cdc.gov/media/releases/2018/p0920-alzheimers-burden-double-2060.html
4. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5568954/)
5. https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-measures-reveal-united-states-population-much-more-multiracial.html
6. Pinquart, M. & Sörensen, S. (2005). Ethnic differences in stressors, resources, and psychological outcomes of family caregiving: A meta-analysis. The Gerontologist, 45, 90-106.
7. https://www.urban.org/urban-wire/asian-americans-are-falling-through-cracks-data-representation-and-social-services
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6445682/)
9. https://www.caregiving.org/wp-content/uploads/2021/12/NAC_AmgenDiverseCaregiversReport_FinalDigital-112121.pdf
10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5550537/
11. https://digitalcommons.uri.edu/cgi/viewcontent.cgi?article=2721&context=theses
12. https://www.aei.org/articles/5-8-million-fewer-babies-americas-lost-decade-in-fertility/
13. https://cbwchcblog.wordpress.com/2019/11/29/young-asian-americans-talk-about-caregiver-burnout-in-zine-and-podcast/

Support for Dementia, Family Caregivers, and Direct-Care Workers

by Ana Reyes, MSW

We need to pay attention to Dementia, family caregivers, and direct-care workers

After 4 years as a professional in the elderly care field, as well as 2 years caring for my own grandmother who had cancer and Dementia, I can confidently determine that we as a society are severely underestimating the financial, mental, and physical burden Alzheimer’s and Dementia is on caregivers - both paid and unpaid. 

In the United States, Alzheimer’s is prevalent among 5% of people ages 65 to 74, 13% of people ages 75 to 84, and 33% of people ages 85 and older. Currently there are about 6.5 million people over 65 with Alzheimer’s.  By 2060, this number will more than double to about 14 million (Alzheimer’s Association, 2022). 

The reality of these numbers is this: if you yourself are lucky enough to avoid Alzheimer’s or Dementia, then you will probably find yourself helping to care for someone who was not as fortunate -- perhaps a sibling, parent, or spouse. If this is the case, we all need to be sounding the alarm because neither our workplaces, nor our welfare systems are prepared for the burdens of Alzheimer’s and Elderly Care. 

During the height of the COVID-19 pandemic, news reports highlighted issues surrounding childcare - mainly that childcare is expensive, hard to come by, and pays workers very little. Often when it comes to media coverage of workplace leave policy, or family policy, it centers around children. This is despite the fact that there are four times as many Americans out of work to take care of an adult than to take care of a child (Bhattarai, 2022). Almost half of all unpaid caregivers caring for adults are caring for adults with Dementia (Alzheimer’s Association, 2022).

The lack of attention in the media and news about caregiving for the elderly, especially those with Alzheimer’s, Dementia, or significant mobility issues, makes those who are not already caregiving woefully ignorant about the realities of caregiving. This matters because caregivers are then put in very strained situations, trying to juggle caregiving, work, house chores, and relationships - often unbeknownst to their bosses, friends, and family.

While caring for my grandmother, my uncle was in his 50’s and I was in my 20’s, and we were intentionally living together with my grandmother to work as a team. What about those who are working full time and have no additional family or friends able to help? Or who are disabled themselves? For example, about 30% of caregivers are themselves elderly (Alzheimer’s Association, 2022) which means that tasks such as bathing or transferring a loved one in and out of bed are extremely difficult or even dangerous without extra assistance. Caregivers of various ages and relationship status face other obstacles as well. About 25% of primary caregivers to individuals with Dementia are also caring for a child (called the “sandwich generation”), while about 40% of caregivers are not married or are in a partnership, which can mean the caregiver themself may lack natural, in-home support (Alzheimer’s Association, 2022). 

There are also significant financial burdens in caring for a loved one with Dementia. On average, family caregivers spend 25% of their income on out of pocket expenses related to meeting the needs of their loved one. These numbers become more shocking when broken down by race: Hispanic/Latino and Black caregivers spend about 47% and 34% of their income on caregiving expenses, respectively (Accuis and Hado, 2022). These costs do not include lost wages due to forgoing paid work. As the Alzheimer’s Association’s “2022 Alzheimer’s Disease Facts and Figures” reported, caregivers for those with Dementia provided about 16 billion hours of unpaid caregiving work in 2021, the value of which is $271.6 billion. Individuals who are diagnosed with some form of Dementia live on average about 8 years after diagnosis (Stages of Alzheimer’s, 2022). In the time between diagnosis and death, the total average out of pocket expenses for someone with Dementia is $113, 286. This is all while family caregivers provide about $264,334 of unpaid care (Alzheimer’s Association, 2022). 

When caregivers are eventually in need of additional support with providing care, they turn to hiring in-home caregivers, utilizing day center programs, or placing their loved ones in an assisted living community. In these cases, caregivers are placing their trust and loved ones in the hands of severely underpaid, overworked, and under-appreciated direct-care workers, despite paying anywhere between $200 a week for in-home assistance to an average of $6,000 a month for assisted living - often out of pocket (Crouch, 2021). 

The median income of personal-care aides and in-home health aides was $27,080 in 2020 (Alzheimer’s Association, 2022). Often, many of these direct-care workers are paid minimum wage, and do not receive health insurance or paid time off from their employers. Statistics from 2018 show that 90% of direct-care workers are women, 60% are people of color, and 25% are immigrants (Meyer, 2020). Direct-care workers are the most important aspect of care that companies can provide, yet the industry only functions off of the exploitation of these workers. Though companies that provide these services do play a role in enabling this phenomenon, the reality is that to keep services financially accessible to families and also avoid their exploitative nature, companies that provide these services most likely need more government funds to buttress expenses. 

My time working with the elderly and their families, especially those navigating the difficult and heartbreaking journey of Alzheimer’s and Dementia, made it clear to me that each and every one of us will be touched by these emotionally draining and financially straining realities. Fighting for increased minimum wage and labor rights, and fighting for more robust family care policies that specifically target relieving the burden and costs of family and professional caregiving is crucial for providing our growing elderly population and their families a dignified existence. 

• “2022 Alzheimer’s Disease Facts and Figures.” Alzheimer’s Association. 2022.
• Accuis, Jean and Hado, Edem. “Reimagining and Transforming Long-Term Care.” Generations Journal. April 27, 2022.
• Bhattarai, Abha. "Caring for aging parents, sick spouses is keeping millions out of work." Washington Post. April 4, 2022.
• Crouch, Michelle. “Memory Care: Specialized Support for People With Alzheimer's or Dementia.” AARP. December 6, 2021. Accessed on web: https://www.aarp.org/caregiving/
  basics/
• basics/info-2019/memory-care-alzheimers-dementia.html
• Meyer, Harris. “No one to care: Long-term care providers scramble to hire and retain personal care aides.” Modern Healthcare. Vol. 50, Issue 4. January, 27, 2020. 
• “Stages of Alzheimer’s: Overview of disease progression.” Alzheimer’s Association. 2022. Accessed on web: https://www.alz.org/.

Ana Reyes has 6 years of professional and personal experience working with the elderly, specifically those with Alzheimer’s and Dementia. While living in the San Diego area, she worked as a direct-care aide in both assisted living communities and in-home care agencies. After completing her Master’s in Social Work degree at San Diego State University, she worked as a Program Director, overseeing two adult day centers for those with memory impairments. She now works with youth on probation as a Multisystemic Clinician in the Bay Area.

Real talk: Awakening Through Activism, and How that Guides my Therapy Work

By Michelle Jaquish, LICSW

“Pakikipagkapwa. It means connecting myself with others, feeling myself in the other and having a sense of shared identity and a shared inner self. That sense of having a common human identity, community and destiny lies deep in our psyche…It’s the translation in our particular culture and history of a universal truth that tells us to treat others the way we ourselves want to be treated because at our innermost core we have a shared humanity.” -Karina Lagdameo-Santillan, “Roots of Filipino Humanism”

The year is 2016, and I had just graduated with a Master’s of Social Work from the University of Washington. To reconcile my own identity as a Filipino, I undertook a Southeast Asian Department fellowship in my final year of graduate school to study the history of feminism in the Philippines and strengthen my Tagalog language skills. I traveled with a community organizing group I had previously worked with called GABRIELA-Seattle, a local affiliate of the National Democratic organization for advancing the women’s movement in the Philippines, and also attended the International Conference for People’s Rights in the city of Davao.

2016 was a very politically charged year, with the United States and the Philippines experiencing divisive presidential elections; in the Philippines, the election of Rodrigo Duterte had particularly dark implications for human rights (Angelica-Reyes, 2016). At the end of the aforementioned people’s rights conference, to highlight the issues of landlessness and poverty in the Philippines, participants walked through a nearby slum where residents lived in makeshift huts. I was already feeling overwhelmed, emotionally from the extensive and heavy content of the conference and physically from the constant mosquito bites, and was struggling to remain present. When I looked into the faces of the displaced native children and elders expressing joy and holding up their fists, and witnessed the visible solidarity between Filipino activists and allies from other national organizations, I broke down in tears. It was painful to see humans having to live in those conditions, and at the same time I was trying to wrap my brain around what I could do as a US-born Filipino in this larger global struggle. This was a traumatic experience for me, and it took me many years to come to terms with it.

In August of 2022, at the first APIDA (Asian, Pacific Islander and Desi American) conference organized by the California Society for Clinical Social Work, that I re-told this story during my presentation “Somatics from Therapy, Activism, and Lived Experience.” In that moment, I finally was able to reframe that memory from a deep ingrained trauma around the real-time horrors and struggles of the Filipino people to an awakening of the shared collective experience of struggle and healing through activism. I found grounding in the pain of the mosquito bites, and activated the frameworks I now use in therapy when working with Filipino clients and US-residing clients from the Asian diaspora: lived experience, activism, building a sense of self, autonomy, and ownership around my Filipino identity.

I use my personal experiences in activism and the concept of “Kapwa” often when working with Filipino clients. Kapwa is a pre-colonial concept in Filipino culture of supporting other Filipinos through a shared sense of identity and community support in a mindful way that elevates self and our resilience as a people (Lagdameo-Santillan, 2018). My activism experiences with GABRIELA and at the International Human Rights Conference helped me better embody stories of struggle, as well as gain resilience in fighting for the liberation of our people in the US and globally. In my therapy work, this shared sense of identity takes on many different forms. I use tarot and oracle decks with native Filipino plants/words/phrases. I connect clients to local Filipino organizations as they start their own identity journeys. I teach Tagalog to US-born Filipinos so they may better communicate with their native Filipino parents and grandparents. This is how I embody Kapwa in my work, and in my life.

A Filipino peer gifted me the book Brown Skin, White Minds: Filipino -/American Postcolonial Psychology by E.J.R David. This book defines “Kapwa” as “quick to lend a hand and share their skills and knowledge freely by teaching children, working with the poor. . .Community building is second nature to the people of such a bearing, as kapwa inspires them to facilitate in meetings, organize events, participate in civic affairs and so on” (Guia, 2005 as cited in David, 2014). This quote perfectly sums up why the concept of Kapwa guides my previous activism work as a therapist and clinician; the relational aspect of being in community with other US-born Filipinos. The calling as a therapist to support them on their awakening journeys about their culture; co-creating spaces like that Human Rights Conference in Davao did for me for clients on their own terms unapologetically. Little did I know that this human rights trip was a transformational experience that in 2022, I still continue to reflect on, unpack, and integrate into my therapy work to this day.

References:

• Gabriela Seattle (@gabrielaseattle) • instagram photos and videos. Login •     Instagram. (n.d.). Retrieved September 19, 2022, from https://www.instagram.com/gabrielaseattle/?hl=en
• Angelica-Reyes. (2016, August 25). International conference for peoples' rights in the Philippines 2016: Fight For Peoples' Rights. IBON INTERNATIONAL. Retrieved September 19, 2022, from https://iboninternational.org/2016/08/25/international-conference-for-peoples-rights-in-the-philippines-2016-fight-for-peoples-rights/
• Lagdameo-Santillan, K. (2018, July 24). Roots of filipino humanism (1)"Kapwa". Pressenza. Retrieved September 19, 2022, from https://www.pressenza.com/2018/07/roots-of-filipino-humanism-1kapwa/
• R., D. E. J. (2014). Brown skin, White Minds Filipino -/ American postcolonial psychology. Information Age Publishing.

Michelle Jaquish is an LICSW and has an MSW with a concentration in Community-Centered Integrative Practice. She has 10 years of experience practicing social work in Seattle, WA as an AmeriCorps mentor, a tutor with elementary, middle, and high school youth, within outpatient mental health settings providing case management, intake assessments, and as a clinical supervisor working with homeless and unstably housed adults struggling with mental health and substance use issues from 2016-2021 during the height of statewide lockdown during the COVID-19 pandemic. She has extensive experience working with Filipino and Asian Pacific Islander communities through her previous activism work with GABRIELA-Seattle which gave her the opportunity to travel to the Philippines on a Human Rights-focused trip after completing her MSW studies and is now a practicing telehealth therapist working with LGBTQ, BIPOC, API, and Filipino-identified clients. She recently accepted an adjunct teaching position at the UW School of Social Work where she graduated and will be teaching an introductory course on social work practice within community-based settings. She lives in Seattle, Washington, and loves foraging in nature for items to embellish jewelry and other clothing pieces.

Cartoon:  Meditation at home

By Monica Moon

Cartoon:  Motivational Interviewing

By Monica Moon

Monica is the Resource and Referral Manager at Social Advocates for Youth (SAY) San Diego. When she's not analyzing processes, codifying procedures, and interacting with the community, she's stuffing her face and cracking jokes.

Cartoon:  Squirrel

By Jean Rosenfeld

Cartoon:  Phone and cell phone

By Jean Rosenfeld

Update on BBS Liaison Role

Please follow the following link for BBS / Law Changes for 2022.

The BBS recently added a couple FAQ's to their website due to AB 1759 being signed recently.    This bill has few major items to make note of

Beginning January 1, 2023:

New annual continuing education requirements for registration renewal 2. Changes to the California law and ethics re-exam process https://bbs.ca.gov/pdf/ab_1759_faq_registrant.pdf

Beginning July 1, 2023:
Training or Coursework in the Provision of Mental Health Services via Telehealth (3 Hours) https://bbs.ca.gov/pdf/ab_1759_faq_telehealth.pdf

Additionally, please remember AB 1758 was also signed recently Supervision of Applicants for Licensure via Videoconferencing https://bbs.ca.gov/pdf/ab1758_faq.pdf

We have also updated our Continuing Education page to include the new Associate requirements as well as update the Telehealth and Suicide Risk one time requirements under the Mandatory Coursework heading.https://bbs.ca.gov/licensees/cont_ed.html

The long-awaited AB 1758<https://www.bbs.ca.gov/pdf/ab1758_faq.pdf> allows face-to-face direct supervisor contact between a supervisor and a supervisee in all settings to be either in-person contact, contact via two-way, real-time videoconferencing, or some combination of these.

Supervision-Related Regulation Changes<https://www.bbs.ca.gov/pdf/law_changes_2022/supervision_reg_changes.pdf> became effective January 1, 2022, and addresses various issues, including deceased or incapacitated supervisors, required documentation, supervisor self-assessment (new), substitute supervisor requirements, etc.

As a reminder, AB 468<https://www.bbs.ca.gov/pdf/law_changes_2022/ab_468_faq.pdf> addresses changes related to emotional support animals and requires health care practitioners to comply with new rules if they provide documentation relating to an individuals need for an emotional support dog.

For additional information, please see the complete list of Statues and Regulations<https://www.bbs.ca.gov/pdf/publications/lawsregs.pdf>, which was published January, 2022.