The U.S. Census Bureau projects that the non-Hispanic White population in the United States will decline from 198 million in 2014 to 182 million in 2060[125]. This 182 million will represent 43% of the total population, making the United States a majority-minority country [125]. Hawaii, New Mexico, California, the District of Columbia, and Texas are regions in the United States that already consist of a "majority-minority," meaning that more than half of the areas' populations consist of individuals who are an ethnicity other than non-Hispanic White [189]. The Hispanic population accounted for 71% of the overall growth between 2022 and 2023 [90]. By 2060, it is expected that there will be 119 million Hispanics in the U.S. population; by that same year, African or Black Americans will comprise 18.4% of the U.S. population [10,11]. By 2065, Asians will be the largest immigrant group (38% of new immigrants) in the United States, surpassing Hispanic immigrants (31%) [12].

These data, in part, argue for the need for culturally competent practices. Betancourt et al. identified three other reasons [21]. First, clients and patients often present with problems or symptoms that do not necessarily conform to textbooks; this may, at least in part, be attributed to the presentation and manifestation of symptoms being influenced by cultural and social backgrounds. This may be more pronounced if clients'/patients' ability to communicate their problems is impeded due to limited English proficiency. Second, practitioner-client/patient relationships and communication strongly influence treatment outcome. When communication styles, patterns, and differences are perceived to be irreconcilable, clients/patients are more likely to terminate treatment prematurely. Finally, there has been a concerted movement in the general health and mental health fields to decrease the disparities and inequities in the access and delivery of care and services [21].

Cultural competence is a professional mandate and a dynamic process [14]. It entails an understanding of cultural context in shaping health beliefs and behaviors [51]. Cultural competence involves more than reviewing a specific culture or ethnicity [91]. Instead, it requires that care and services are provided in such a way that the patient/client is central and is allowed and encouraged to express themselves and their experiences [91]. It is also not merely completing a curriculum or training to be "culturally competent." Rather, cultural competence involves continual learning throughout one's professional career in four different areas [13,112]:

Cultural competence is a professional mandate and a dynamic process [14]. It entails an understanding of cultural context in shaping health beliefs and behaviors [51]. Cultural competence involves more than reviewing a specific culture or ethnicity [91]. Instead, it requires that care and services are provided in such a way that the patient/client is central and is allowed and encouraged to express themselves and their experiences [91]. It is also not merely completing a curriculum or training to be "culturally competent." Rather, cultural competence involves continual learning throughout one's professional career in four different areas [13,112]:

The terms "multiculturalism" and "diversity" are often used interchangeably. Multiculturalism is a very broad and encompassing term and simply refers to anything involving multiple cultures [202]. Multiculturalism "reflects the nature of American society, which entails the coexistence of many cultures within one society" [112]. Diversity, on the other hand, is literally defined as different identities [344]. It "encompasses differences in and among societal groups based on race, ethnicity, gender, age, physical/mental abilities, religion, sexual orientation, and other distinguishing characteristics" [112]. Diversity is often thought of in singular dimensions as opposed to multiple and intersecting factors [15]. Race, class, gender, and ethnicity are the most commonly identified components of diversity.

In the field of psychology, three forces, or perspectives, have historically been predominant in explaining human behavior: psychoanalysis (the first force), behaviorism (the second force), and humanism (the third force). Pedersen asserted that there was a fourth force: multiculturalism [139]. As noted, the concept of multiculturalism is based on the belief that culture pervades every aspect of our lives, which makes it a dominant fourth force. Pedersen was not arguing that the other psychological perspectives should be dismissed or that they had outlived their purposes; rather, he asserted that it is important for practitioners to understand and interpret human behavior within a cultural context [139].

A similar debate occurs in anthropology, which is highly relevant in psychology, counseling, and social work. The discussion centers on the etic and emic perspectives. The term "etic" is derived from the term phonetic, which refers to sounds assumed to be universal across all languages [20]. Therefore, the etic perspective maintains that, along important dimensions, all humans are basically similar. Helping professionals can employ basic fundamental helping skills in order to work effectively with individuals from all cultures. These basic skills transcend cultural diversity [128]. On the other hand, the emic perspective argues that it is vital for professionals to begin from the paradigm that unique cultural characteristics exist in various cultural groups. This emic orientation acknowledges individual differences within culturally different groups while simultaneously viewing clients/patients within the context of their primary cultural group [110]. Therefore, practitioners would intensely study a specific culture and adapt techniques that work with clients/patients from that group. This debate continues.

Culture is a complex concept, and its common conflation with race and national origin can be confusing [160]. Culture refers to the values and knowledge of groups in a society; it consists of approved behaviors, norms of conduct, and value systems [64,112]. Culture involves attitudes and beliefs that are passed from generation to generation within a group. These patterns are socially learned and include language, religious beliefs, institutions, artistic expressions, ways of thinking, and patterns of social and interpersonal relations [74,440]. Culture can also represent worldviews, encompassing assumptions and perceptions about the world and how it works [158]. Some have defined culture as "the growth, development, and expressions of a client system's worldview through an interaction with its biopsychosocial and spiritual environments" [160]. Culture helps to elucidate why groups of people act and respond to the environment as they do [84]. Culture has been conceptualized as a diversity domain characterized by different value systems, norms, and social and behavioral patterns [277]. Kluckhohn and Strodtbeck proposed five different dimensions that comprise a worldview [97]:

Experts have asserted that culture has two components: the observable and the unobservable [285]. The observable include language, customs, and specific practices, while the unobservable include beliefs, norms, and value systems. The unobservable also includes the symbolic nature of culture and meaning making [440].

Some experts argue it is also necessary to understand epistemological bases of groups' knowledge when defining culture [191]. In other words, it is important to ask: what is knowledge and where is it derived from? For example, some cultural groups' beliefs or knowledge about health and mental health are derived from shamanistic traditions or religious orientations, such as Buddhism or Taoism. This knowledge is therefore rooted in cultural beliefs, which dictate behaviors [191]. Therefore, culture is deeply tied to epistemology.

Current perspectives note that culture is not static; it is not merely inherited nor are groups of people passive recipients of culture. Rather, "culture and people negotiate and interact, thus transforming and developing each other. It is a process of continuous modification" [35].

On the other hand, race has historically been linked to biology. From this perspective, race was partially defined by arbitrary physical markers such as skin or hair color [94,441]. It did not refer to cultural institutions or patterns, but it was generally utilized as a mechanism for classification and the creation of social meanings. Historically, the census in the United States defined race according to ancestry and blood quantum; today, it is based on self-classification [134]. Some have asserted that race is socially constructed, without any biologic component [189].

Today, race is viewed as socially constructed without any biological basis [442]. For example, racial characteristics are also assigned differential power and privilege, lending to different statuses among groups [181]. It has been argued that the use of the term and its definitions have varied over time, as demonstrated by the different definitions offered by the U.S. Census Bureau. Furthermore, different social meanings have been ascribed to the concept to the benefit a particular dominant group [202]. The American Anthropological Association has described race as "an ideology of human differences," which then "became a strategy for dividing, ranking, and controlling colonized people used by colonial powers everywhere" [288].

Acculturation refers to a dynamic process that involves cultural change triggered when two cultural groups come in direct contact [4,9,19]. For example, when immigrants come to the host country, they may adapt to the values, behaviors, and belief systems of the dominant group. According to Berry, ethnic minority immigrants culturally adapt utilizing one of four different strategies: integration, assimilation, separation, or marginalization [19]. An individual can opt to integrate, adopting part of the values, beliefs, and behaviors of the dominant culture while retaining his/her own cultural identity [4]. Assimilation, on the other hand, is defined as an individual choosing to abandon his/her own cultural identity in favor of completely incorporating the value systems of the dominant culture. An individual can select to separate completely from the dominant culture and decide not to adopt any of the cultural values of the dominant culture. This is known as cultural assimilation [251]. Assimilation was highly advocated in the 1960s and was believed to be an essential element to social integration and a means to achieve a society that de-emphasized differences [443]. The other dimension of assimilation is structural, specifically the process by which immigrants become fully integrated and incorporated into the host country's social institutions [251]. Finally, an immigrant can be marginalized, a process by which he/she loses both his/her cultural identity as well as that of the dominant culture. When this is the case, alienation and isolation ensue [4,19].

There is also some research that indicates the acculturation process is not linear but multidimensional [187]. Immigrants may retain elements of both cultures and move back and forth. In one study with Korean American youths and their parents, Korean American youths who spent most of their time in the United States displayed an integrated bicultural strategy [254]. They were integrating well into the United States but still professed a strong allegiance to their Korean heritage. No participants in the study identified as completely assimilated. A study of Filipinos in the Philippines, Filipino immigrants in the United States, and American-born Filipinos compared gender role beliefs among the three groups [192]. If acculturation always occurred in a linear pattern, then one would assume that American-born Filipinos would hold more egalitarian or liberal attitudes toward women. However, immigrant Filipinos in the study indicated more liberal attitudes toward women than native Filipinos in the Philippines but similar attitudes to American-born Filipinos. Interestingly, American-born Filipino men appeared to have returned to more conservative or traditional attitudes, similar to those of Filipinos in the Philippines. The researchers speculated that cultural attitudes are not static; rather, the process is dynamic, and immigrants may feel they have to adapt their attitudes in order to survive. In a study of Chinese immigrant adolescents, researchers found that Chinese immigrant adolescents who had low proficiency in English were concerned with learning to relate to others within their own ethnic group and other racial groups [193]. Adolescents who had more family obligations also expressed more acculturative concerns. It was deduced that adolescents with more family chores and obligations to fulfill are more immersed in the traditional environment and have less time to learn and engage in new situations.

Racism is the "systematic subordination of members of targeted racial groups who have relatively little social power…by members of the agent racial group who have relatively more social power" [178]. Racism is perpetuated and reinforced by social values, norms, and institutions. There is also controversy regarding whether unconscious (implicit) racism exists. Quillian argues that images that are embedded in our unconscious are the result of socializations and personal observations, and negative attributes may be unconsciously applied to racial minority groups [194]. These unconscious attributes affect individuals' thoughts and behaviors without a conscious awareness.

A modernist or positivist perspective maintains that concepts of culture and cultural characteristics of a specific group are stable and can be observed and measured because they endure over time [43]. Therefore, practitioners can learn about the specific sets of beliefs, value systems, behaviors, and norms of particular cultural or ethnic groups and apply them to their clients/patients. Inventories that measure individuals' belief systems and values and instruments or tools that evaluate one's own cultural competence or an organization's level of cultural competence reflect this positivistic philosophy.

The Asian immigrant population is very diverse, and the reasons why immigrants come to the United States reflect these differences. One stereotype is that immigrants come to the United States to escape poverty. Evidence contradicts this prevailing misconception, as there are proportionally more professionals and technicians among immigrants coming into the United States than there are professionals and technicians in the U.S. labor force [141]. Furthermore, the stereotype that many immigrants are uneducated is far from true, as data shows they are well represented in college and graduate levels [141].

The first classification of immigrants is labor migrants [141]. This group comprises both documented and undocumented immigrants. Their primary motivation for coming to the United States is to earn higher wages compared to the wages available in their homeland [141]. When they arrive in the United States, labor migrants find themselves in low-wage jobs. Many eventually return home because the wages they earn in the United States go further in their homelands both in tangible (e.g., purchasing power) and intangible (e.g., social respectability) terms [141]. Again, despite popular notions that manual labor immigration is a one-way flow of immigrants who are motivated primarily to escape poverty, this phenomenon is actually a two-way process involving both employers and laborers who have specific sets of labor expectations [141].

Chinese Americans are the largest Asian American group in the United States. Their immigration history is long and can be distinguished by five different waves. The first wave of Chinese immigration dates back to 1785 [104]. It was only between the period of 1850 and 1919, with the discovery of gold in California, that a large influx of Chinese immigrants to the United States was triggered—primarily Chinese male peasant farmers who left their homelands with dreams of finding a new fortune [104]. In 1864, the building of the transcontinental railroad triggered further recruitment of Chinese immigrants from Canton [104]. The railroad construction promoted an open immigration policy, which gave unrestricted access of Chinese immigrants to the United States, spurred primarily for reasons of cheap labor [104].

As a result of differences among the various immigration waves, Chinese immigrants in the United States are tremendously diverse in terms of a variety of social factors, including educational level, English proficiency, socioeconomic status, and acculturation. For example, there are many Chinese immigrants who originated from rural areas in Canton who came to the United States in the early 20th century, but who remain in Chinese enclaves and speak minimal English [180]. They differ tremendously from more recent Chinese immigrants from Hong Kong or Singapore who are very westernized and highly proficient in English [180].

In 2022, there were 4.5 million Filipinos living in the United States, residing primarily in California [373,374,450]. They, too, are a very diverse group. Approximately half of Filipino Americans and immigrants have at least an undergraduate college degree, which is higher than the rate for all Americans in the United States (38%) and all Asian Americans (31%) [373]. The three main Filipino cultural subgroups are Tagalogs, Ilocanos, and Visayans, and their diversity reflects their immigration patterns [180].

The Japanese have coined terms to describe different generations. Issei were first-generation immigrants, the majority of which having immigrated between 1870 and 1924. Most Issei were not very acculturated or assimilated into the United States, preferring to let their American-born children become more acculturated [94]. Nisei were the American-born children of the Issei, born between 1910 and 1924, making them now senior citizens [94]. This group experienced tremendous discrimination and prejudice growing up in the United States. Sansei are the third generation, or children of the Nisei. With each generation, they become more acculturated, and each generation becomes more assimilated to the norms of the region in which they were raised [94].

Korean immigrants are unique in the sense that they quickly established economic stability in the United States. They are referred to as the "middleman minorities," meaning a group serving as the buffer between a dominant and a subordinate group (e.g., White and Black Americans in the United States) [94]. Upon coming to the United States, Koreans, as middleman minorities, brought with them a high level of education, capital, and skills. They found a niche in small business sectors such as retail shops, serving Korean clientele and other ethnic minority groups [94]. They often rely on family members for labor and financially support new Korean immigrants so they, too, can start small businesses [94]. According to the Pew Research Center, they have the highest rate of self-employment among Asian Americans in the United States. The number of Korean immigrants has not increased in recent years, partially due to the fact that economic conditions in South Korea have improved [290].

Cambodia is a country nestled between Thailand, Laos, and Vietnam. The term "Khmer" refers to the language and the dominant ethnic group in Cambodia [7]. Cambodia was deeply affected by U.S. military assistance to South Vietnam. Covert bombings in the Eastern part of their country with the purpose of destroying communist supply routes and camps resulted in many deaths and left many Cambodians homeless [7]. In 1975, after the fall of Saigon in Vietnam, the Cambodian government fell into the hands of the Khmer Rouge, a communist regime led by Pol Pot [7]. Between 1975 and 1979, Pol Pot led the country by use of force, intimidation, persecution, and torture. Using Maoist principles, Pol Pot placed the Khmers under forced labor [121]. Pol Pot wanted to purge the country of individuals perceived to be enemies (e.g., those who were influenced by Western norms, including former government officials, intellectuals, doctors, professionals, artists, dancers, members of the royal family, and Buddhist monks) [121]. Those who were not instantly killed were sent to forced labor camps, where they experienced hunger, torture, beatings, and indescribable inhumanities [121]. It is estimated that approximately two million Cambodians, mostly from the wealthy and/or educated classes, died during this period [7].

As of 2022, Asian Indians are the second largest Asian American group in the United States, with a population of 4.9 million [450]. The majority (54%) are relatively recent immigrants, having come to the United States between 1990 and 2000. Asian Indians are one of the largest groups to obtain H-1B temporary visas, which allow employers to hire workers from outside the country to enter the United States for highly skilled and specialized jobs [311]. They account for 71.7% of H-1B visas [370]. India is the second most common source country of international higher education students in the United States [452]. In 2019, 75% of Asian Indian Americans and immigrants 25 years of age and older had a Bachelor's degree or higher [382].

Schizophrenia is a debilitating psychiatric disorder that can be difficult to treat. The tremendous stigma associated with this disorder seems to be greater than other psychiatric disorders and can elicit feelings of shame and guilt among family members. This is particularly the case with Asian families, who traditionally believe that private matters should not be shared outside the family and that psychiatric disorders are shameful and reflect on the entire family system. Thus, they often delay seeking psychiatric services until a crisis state has been reached [151].

In general, alcohol consumption rates among Asian Americans are lower than the overall general population. Generally, research indicates that Asian Americans drink less alcohol and are less likely to binge drink [456]. They are also less likely to develop an alcohol use disorder, in part because they carry gene variants that reduce the body's ability to metabolize alcohol, resulting in unpleasant reactions to alcohol consumption and associated lower levels of alcohol consumption [456]. The lifetime prevalence for alcohol use disorders is 15% for Asian American adults, compared with 32.6% for White American adults [386]. This is in part due to Asian cultural beliefs regarding drinking in prescribed social situations. For example, drinking is viewed as a sign of prestige in certain cases, such as business social settings, when refusing a drink would be considered an affront [257].

The lifetime alcohol use rate is 85% among the general U.S. population [115]. When comparing Asian American groups, Japanese Americans have the highest alcohol usage, while Chinese Americans have the lowest [186]. In a study conducted in California in the 1990s, 69% of Japanese Americans, 49% of Korean Americans, 38% of Filipino Americans, 36% of Vietnamese Americans, and 25% of Chinese Americans reported consuming 10 or more drinks in their lifetime [186]. In general, Asian men tend to use alcohol more than women. In a study of Filipino Americans conducted by Lubben, Chi, and Kitano including 145 men and 85 women in Los Angeles, 80% of men were found to be heavy drinkers, while 50% of the women tended to be abstainers [111]. The researchers concluded that these gender differences stemmed from traditional gender roles, which prescribe drinking as more socially acceptable among men.

However, research conducted with college populations differs. In a 2006 study, consisting of 248 Asian American college students attending an Asian American and Pacific Islander leadership conference, lifetime alcohol usage prevalence was 94.5% [205]. For the past 30 days, the prevalence rate was 78.6%. The lifetime prevalence rate for illicit drug use was 37%, with a past 30 day usage rate of 9.5% [205]. In a 2014 study with 258 Asian American college students, 17.7% of men and 8.9% of women were found to have alcohol use disorders [298]. In general, Chinese and Vietnamese male college students were more likely to have alcohol problems than their female counterparts, but this trend was reversed among Korean students (33% of women and 11% of men) [298]. In one study, 37% of Asian American young adults fell in the category of high-risk and monthly binge drinkers [387]. Fraternity or sorority membership was correlated to higher risk drinking. A 2021 study found that the highest rates of binge drinking and alcohol use disorders were among young adults between 18 and 25 years of age [457]. The "model minority" myth and the misperception that Asian immigrants generally have lower rates of alcohol consumption do not negate their risk.

Traditionally, Western Europe and North America have had higher alcohol consumption rates compared to Asia, but alcohol consumption rates in Asian countries are becoming more comparable to Western countries [206]. A telephone survey in Hong Kong with a random sampling of 9,860 Chinese adults found that among adult men, 14.4% were classified as binge drinkers, 5.3% abused alcohol, and 2.3% were alcohol dependent [206]. Among women, the figures were much lower. The survey determined that 3.6% of female participants were binge drinkers, 1.4% abused alcohol, and 0.7% were dependent on alcohol.

Level of acculturation also appears to play a role in alcohol and substance abuse among Asian Americans. In one meta-analysis, level of acculturation predicted alcohol use [316]. It appears that higher levels of acculturation are associated with higher levels of drinking. Some speculate that as immigrants become more acculturated, they are more influenced by norms in the United States that emphasize individualism and self-expression. Enculturation, or the adherence to traditional Asian norms and lifestyle, appears to be protective against problematic alcohol use [316]. The extended family system becomes less of a primary focus [156]. In a study by Hahm, Lahiff, and Guterman using a dataset from the National Longitudinal Study of Adolescent Health including 714 Asian American adolescents, they found that Asian American adolescents who were more acculturated were more likely to binge drink [67]. However, the pathway is not as simple or linear. Their study showed that peer association with drinking mediated this relationship. In other words, if their best friend used alcohol and tobacco, then the relationship between acculturation and drinking no longer existed. Researchers in this study concluded that acculturation did not necessarily lead to or cause drinking as there are some complex social processes regarding group norms [67]. Even this factor may not be uniformly applied to all Asian subgroups. For example, Hendershot, Dillworth, Neighbors, and George found there was a relationship between acculturation and alcohol drinking behavior among Korean young adults but acculturation was negligibly related to Chinese young adults' drinking behaviors [258].

Acculturation may also influence smoking behaviors. Studies have found that higher levels of acculturation are related to greater nicotine and illicit substance use among Asian Americans. Those who are assimilated along several domains (i.e., separated, partial bilingual/bicultural, English dominant/Asian oriented, full bilingual/bicultural, and assimilated) have the highest usage of nicotine and illicit drugs compared with those with lower levels of acculturation [299]. However, in a 2018 study, acculturation level alone did not correlate with substance abuse [390]. Instead, the researchers found that the dimensions of acculturation were essential. For example, having weak ties with one's own ethnic community was associated with an increased likelihood of substance use disorder.

Ja and Yuen advocate for culturally sensitive treatment for Asian substance users [104]. For example, 12-step programs have been tremendously beneficial for many; however, their emphasis on public disclosure and acknowledgment of a substance abuse problem is not culturally congruent with Asian values of emotional inhibition and privacy issues [104]. They argue for a model that incorporates the following factors into the delivery of substance abuse treatment and services: a one-stop service center, involvement of the family, accessibility of nonstigmatized services, and extensive contact with the client's/patient's support network [104].

Typically, many immigrants leave their familiar surroundings and family in hopes of a better life. Yet, on a short-term basis, the immigration and adjustment processes are very stressful and often have ramifications on overall family dynamics and individual well-being. Immigration is associated with numerous life changes and adjustments for the immigrant, including economic changes (e.g., unemployment or underemployment); changes in social supports and networks; adjustment to new customs, the environment, and nutrition differences; and acquiring new language competencies and life skills [18]. Typically, those immigrants coming to a more developed country will experience a more difficult adjustment process [157]. Immigrants with children experience a more pronounced need to navigate between two cultures. Children will often be the first to experience the contrast in norms, values, and behaviors in school settings and with peers. They may acculturate more quickly than their parents, which could produce family stress and feelings of isolation between parents and children [208]. A focus group of 22 Chinese immigrant parents found that differences in Western and Chinese cultural practices at home and at school were predominant stressors [320]. Discrepancies in English language skills among Chinese immigrant parents and children can also promote stress [320]. Parents may also rely on children to help them navigate their new environment and to interpret. This can unwittingly produce challenges in role boundaries.

Another ethnographic study with Vietnamese immigrant families found similar patterns of redefinitions of patriarchal gender relations [89]. In order to ensure economic survival, patchworking was a strategy employed by many Vietnamese families. This strategy involved combining resources from all family members, and the "patchwork" of these collective resources promised a greater likelihood of economic survival in a new country. According to Kibria, the process of immigrating to the United States and the strategy of patchworking resulted in families negotiating new family rules such as gender roles and relations [89]. Because Vietnamese men were periodically or chronically unemployed, women had to step in to contribute to the household's income. This resulted in a shift in power, which challenged traditional authority, an integral characteristic of Asian family structure. Family conflict is often a direct consequence [89]. Any time established family hierarchies are disrupted due to one family member (e.g., child or wife) being perceived to have more power (e.g., access to language or resources), it is inevitable that the boundaries in a family will change. These changes could produce conflict, resulting in mental health and behavioral changes [208]. Acculturative stress often stems from culture conflict [393]. For example, South Asian women who lived in Canada for at least two years often reported acculturative stress due to intergenerational conflict at home [393].

In Western societies such as the United States, alcoholism is viewed primarily as a disease. However, it is not clear how other cultures view alcoholism. It is possible that alcoholism can be viewed as a culturally specific disease, meaning that the concept of "alcoholism" may emerge in different forms in different societies [34]. Even the terms used and their definitions will influence conceptions of illness. In Korean, the term for alcoholism literally means "being poisoned by alcohol" [34]. The word "poison" is obviously biased and will, therefore, influence conceptions of alcoholism among Koreans. In Cho and Faulkner's study, they compared conceptions of alcoholism among Koreans and White Americans [34]. Their findings showed that both samples viewed alcoholism as a disease, although the proportion of Koreans defining alcoholism as a disease was lower than that of White Americans. Using a vignette describing a Korean man with behaviors from the Michigan Alcoholism Screening Test (MAST), nearly all of the Americans stated the man in the vignette was an alcoholic, but only three-quarters of the Korean sample came to the same conclusion. Finally, Americans in the sample were more likely to attribute interpersonal and other social problems (e.g., family problems) as consequences of alcoholism while the Koreans did not. According to Cho and Faulkner, in Korean language there are two terms for "alcoholic" [34]. One means heavy drinker, but these individuals behave well and do not cause any troubles. There is another term for those who drink heavily and engage in negative behaviors.

The communication of information about mental illness and notions about what causes it are also influenced by a cultural framework. It is important for professionals not to dichotomize causal factors into science and superstition. It would be simple to merely assume that Western notions about mental illness are rooted in science and natural or organic causes while other cultures' belief systems about mental illness are rooted in magical beliefs and/or supernatural forces [50]. However, this is simplistic.

Overall, cultural schemas about the mind-body, health/mental health, and religion affect clinical experiences. In Western societies, there is an emphasis on the demarcation or dichotomy between the mind and body. This dichotomy stems from philosophical beliefs about knowledge acquisition. Western societies emphasize the use of rationalism—reason, measurement, and standardization—in order to obtain knowledge. Descartes, for example, focused on distinguishing mind from matter [50]. However, this is in direct opposition to Eastern cultures, in which rationality is viewed as illusory [50]. The yin/yang theory, a common Eastern belief system, captures a holistic systems view that the whole cannot be reduced into parts as the component parts are interrelated to the whole [50]. Similarly, in Asian Indian culture, Ayurveda, a Hindu science about health and longevity, argues that well-being also rests on balance of three major humors: bile, wind, and phlegm [264]. Consequently, in Western societies, feeling "sad," "depressed," "anxious," or "stressed" may be discussed, and a nonphysical cause is linked to these emotional states [9]. However, in other cultures, there is no distinction between the psychological and the physical [9]. Furthermore, psychiatric explanations in Western societies are divorced from religion, spirituality, and ethics. Again, this is not the case in Eastern traditions [50].

The DSM is the most commonly used reference to define and establish psychiatric disorders. However, one of the major questions about the DSM is whether its diagnostic categories are valid across cultures [31]. PTSD as a diagnostic category, for example, has been quite controversial. In part, this stems from measurement issues. In order to accurately capture the amount of stress experienced, it is first necessary to inquire regarding the culturally appropriate traumatic precipitators. Terheggen, Stroebe, and Kleber, for example, noted that in Tibet, the destruction of temples and other religious symbols were regarded as extremely traumatic [165]. It would be necessary to inquire about these events in order to fully capture the traumatic stress experienced. Another aspect of the controversy regarding PTSD as a valid cross-cultural category revolves around how symptoms are displayed within cultures. Guilt, for example, is characteristic of survivors of trauma; yet, in many Asian cultures, shame is expressed rather than guilt. In the Tibetan language, for example, there is no word for guilt. Furthermore, somatic symptoms are also more frequently exhibited in Asian cultures. In Terheggen, Stroebe, and Kleber's study, Tibetans were more likely to endorse the somatically phrased items for depression and anxiety as opposed to psychologically phrased question items for these symptoms [165]. An earlier study conducted by Matkin, Nickles, and Demos found some evidence to suggest that at least some PTSD diagnostic criteria appear to have cross-cultural validity with Cambodians, who tended to manifest more somatic symptoms than some of the other PTSD criteria, such as flashbacks, hypervigilance, and emotional attachment [117]. Similarly, Vietnamese refugees expressed more somatic presentations of PTSD as opposed to the general symptoms typically associated with the disorder [117]. This controversy continues, and it raises questions about the applicability of all DSM-defined entities in all cultural contexts.

It has also been questioned whether psychiatric symptoms expressed in ethnic minority patients or patients from other cultural groups are similar to individuals in Western societies and whether the DSM can detect any cultural variations in the manifestation of symptoms [172]. It is possible that culture-based idioms of distress, or "socially and culturally resonant means of experiencing and expressing distress in local worlds," may not be captured by Western definitions of various psychiatric disorders [265]. In other words, idioms of distress can be mechanisms by which groups express symptoms in a culturally and socially sanctioned manner [397]. Much of this research began in the 1980s in psychological anthropological research related to idioms of distress. It transitioned from asking what are the distressing symptoms to asking why [461]. The emphasis was to view the symptoms in a cultural context and to understand the social function(s) of the symptoms and disorders [461].

Neurasthenia or shenjing shuairuo is a widely used diagnosis in China; the core symptoms include headaches, dizziness, and insomnia [95]. It has been noted that depression is less prevalent in Chinese society compared to Western societies. It is plausible that the diagnostic category of major depression or dysthymia as defined by the DSM is expressed differently in China. Kleinman argues that, in China, the core set of symptoms relating to depression are somatic, unlike in Western societies, where the symptoms of depression are affective, such as sadness or dysphoria [95]. This presentation of somatic symptoms is more culturally congruent to Chinese cultural values, which emphasize organic causation of psychologic problems as well as the cultural focus on inhibition of emotions [162]. Therefore, when the criterion for neurasthenia is utilized, it is possible that it is being diagnosed instead of depression [95]. In Japan, neurasthenia is known as shinkeisui-jaku, which means nervous disposition; patients with this condition are prescribed rest, nutrition therapy, and lifestyle changes, as well as medication [213]. In Vietnam, individuals with symptoms of general anxiety disorder often present with neurasthenia [327]. A diagnosis of neurasthenia gives legitimization to their experience, but the focus on physical symptoms reduces the stigma of mental illness [327]. It is argued that a diagnosis of neurasthenia is less stigmatizing and more acceptable to patients and their family members. However, some Western mental health professionals believe that neurasthenia as a diagnosis could minimize the existence of more serious psychiatric disorders [213].

Another cultural bound syndrome is taijin kyofusho. In Western societies, social phobia as defined by the DSM-5-TR is an anxiety disorder that causes an individual to avoid social or performance situations in which embarrassment might occur [8]. Similar to social phobia, in which an individual develops a persistent fear of social situations, in Korea and Japan taijin kyofusho stems from a fear of giving offense to someone versus fear of embarrassing oneself [9]. There have been some studies that have shown that taijin kyofusho exists outside of Japan and Korea, including in the United States, which then raises the question of whether or not this syndrome is culturally bound (or to what degree) [303]. The individual with taijin kyofusho is concerned that one's appearance and actions during social interactions will offend someone [8,9]. It is believed that there are two subtypes of taijin kyofusho: sensitive type, which falls under the general category of social anxiety disorder, and another offensive type, which is characterized by quasi-delusions [214]. These delusions include the beliefs that the individual has a specific bodily defect, that the individual may harm another person by his/her physical characteristics, or that others are avoiding him/her [215]. A clinical study has found that fluvoxamine, a medication for social anxiety disorders, was effective for this disorder [214].

In several Asian countries, including Japan and Korea, a disorder called hikikomori has emerged. Some regard it as a modern-type of reclusive depression, precipitated by a shift from collectivistic to more individualistic value systems [266]. It generally affects those born after the 1970s and occurs mainly while one is at work. It is unclear whether this is syndrome specific to Asia [266]. In India, dhat is a culture-bound syndrome that refers to severe anxiety or hypochondria-like concerns about excessive discharge of semen or whitish color urine [464]. Dhat has been classified as a culture-bound anxiety state, a symptom of depression, and hypochondriacal neurosis [216]. Other symptoms include physical exhaustion, sleeplessness, and palpitations [9,216]. Many Indians believe the condition is the result of masturbation or sex outside of marriage [216,267]. There is some controversy over whether dhat is truly a culture-bound disorder of depression and whether it occurs in other countries/cultures [304,305].

In Korea, there is a condition called hwa-byung, characterized by symptoms including pain in the upper abdomen, an intense fear of death, exhaustion, depressed affect, indigestion, aches and pains, and palpitations. The Koreans attribute this disorder to anger suppression [9,328,329]. Because Asian values emphasize harmony in interpersonal relationships, it is believed that anger is suppressed, and this condition may be a passive vehicle for exhibiting the anger [217]. It appears to occur more often among Korean women and those from lower socioeconomic and educational backgrounds, and external stressors (e.g., marital conflict, and difficulties with mother-in-law) are risk factors [306,328]. Prevalence rates for hwa-byung range from 4.2% to 13.3% [329].

Understanding individuals' patterns of help-seeking also provides a window to understanding attitudes toward mental health and the role of cultural schemas. Asking for either formal or informal assistance implies different meanings in different cultures. Although Western societies pride themselves on individualism and self-sufficiency, there is also less of a stigma in obtaining psychological or therapeutic help. Particularly in the United States, obtaining counseling or therapy is viewed positively, as it is regarded as a mechanism to promote insight and personal growth. However, in many Asian cultures, emotional and psychological problems are in part attributed to bad luck, misfortunes from displeased ancestors, and/or a lack of personal willpower, self-control, or maturity [167]. Furthermore, personal problems are viewed as private and are not to be expressed to outsiders; these problems should be kept within the family. This ultimately serves to prevent loss of face not only for the individual experiencing the problem, but for the entire family system [104]. Religious beliefs about fate, acceptance, and perseverance can also impede Asian immigrants from seeking formal assistance. Help-seeking is very complicated, as there are a host of variables that can affect the process.

Yet, it is imperative to specifically focus on the health needs of Asian Americans and immigrants. This group is less likely to have a primary care provider compared with White Americans (68% compared with 77%), with level of acculturation a predictor of using a usual care provider [55]. Specifically, lower levels of acculturation (as measured by proficiency of English and length of time in the United States) were predictive of both Asian and White Americans not having a health provider for consistent care and seeking usual care in the emergency department. This was reinforced by a 2019 study that found the likelihood of seeking help decreased twofold in those without a usual place of care and fivefold in those with communication issues in healthcare settings [401].

Over the last few decades, diabetes and the issue of obesity, particularly among children, have been much publicized in educational awareness campaigns. In general, Asian Americans and immigrants tend to have lower body mass index (BMI) [402]. For example, non-Hispanic White Americans are 60% more likely to be obese than their Asian American counterparts [402]. Therefore, one might speculate that this population has lower rates of diabetes, but it is important to consider within-group diversity among Asian Americans. While Asian Americans overall are less likely to be obese, some subpopulations (e.g., Filipinos) are more likely to be obese [402].

In 2019, 9.1% of Asian American adults had diabetes, a rate lower that the general U.S. adult population at 11.6%. Among Asian subgroups, Filipinos had the highest diabetes rate (12.2%), followed by Asian Indians (10.8%) [468]. The prevalence rate of diagnosed diabetes among Asian Americans was 11.2% in 2013–2016; the rate among White Americans was 9.4% [403]. Some subgroups, such as Native Hawaiians and Japanese Americans, are two times more likely to have diabetes compared with their White counterparts [272]. Among Cambodian refugees, the rate of diabetes is more than twice the national average (27.6% vs. 12.4%) [334]. In the Asian Indian population in the United States, type 2 diabetes prevalence rates range from 17.4% to 29% [335].

According to the Racial and Ethnic Approaches to Community Health (REACH) Risk Factor Survey data, the prevalence of diabetes is 19% among Asian Indians, 10.8% among Koreans, and 9.3% among Chinese [41]. In general, Asian Americans have poor diabetes management practices compared to other groups (e.g., less likely to do weekly self-glucose checks). Korean Americans were less likely to have had a physical exam within the last year compared with Chinese and Asian Indian Americans [41].

There also seems to be an intergenerational effect of diabetes. Second- and third-generation Japanese Americans, for example, have higher prevalence of diabetes compared with their counterparts residing in Japan [75]. It is possible that as immigrants become more westernized, they also adopt a more sedentary lifestyle and consume foods higher in fat [75]. This is reflected in the concept of "unhealthy assimilation," which refers to the link between adoption of the host country's lifestyle and dietary habits and poorer health outcomes [469]. However, in another study, acculturation was positively correlated with reaching blood glucose level goals among Asian Americans [404]. In a study using data from the National Health Interview Survey, researchers found that Asian Indians in the United States had lower BMIs than non-Hispanic Whites, but that they were also less physically active [220]. However, Asian Indians have a higher likelihood of becoming diabetic despite their lower rates of obesity compared to their non-Hispanic White counterparts [220].

In 2022, 34.3% of all individuals who were reported to have TB in the United States were Asian American [474]. Although it is on the decline among U.S.-born individuals, it is a highly common disease among foreign-born immigrants, whose rate of TB is 15 times higher than those born in the United States [338]. Foreign-born Asians in the United States have the highest incidence of TB compared with other immigrant groups [338]. In 2014, the TB rate among Asians in the United States was 28.5 times higher than the rate in non-Hispanic Whites [58]. As of 2019, those of Asian descent in the United States have the highest rates of TB [412]. In 2023, in California, 47% of TB cases occurred among Asian residents [413].

In 2010, 80% of TB cases in New York City were among foreign-born individuals [76]. Foreign-born Asians (regardless of birthplace) have the highest rate of latent (asymptomatic) TB in the United States [414]. Among this group, the top 10 countries of origin were all located in South Asia [76]. This is also the case in Los Angeles and Orange Counties, California, where there is a high proportion of Vietnamese population, a recent immigrant group. Consistent with national statistics, TB among foreign-born Vietnamese settled in this area has increased [77]. TB among newly arrived Asians is higher compared to U.S.-born Asians. However, Vietnamese individuals in California had TB at a rate 100 times higher compared to the overall nation and had the highest case rate compared to Koreans, Chinese, and Filipinos [77]. They are at great risk of infecting others and exacerbating their condition, as they are more likely to utilize traditional forms of healing. It is only when traditional healing practices fail that they will resort to Western medical treatment [77].

Cancer is a dreaded disease regardless of an individual's cultural background. However, culture does shape the meaning of the diagnosis, help-seeking patterns, and coping strategies. In general, Asian Americans have the lowest rate of cancers (3.9 per 100,000 population) compared with other racial groups (e.g., 9.9 per 100,000 population among White Americans) [417]. They are also 40% less likely to die from cancer, compared with White Americans [476]. However, it remains the leading cause of death for this group, particularly for Chinese, Filipino, Korean, and Vietnamese Americans, in part due to disparities in seeking preventive care [280,476]. In 2021, there were more than 68,000 diagnosed cases of cancer among Asian Americans and Native Hawaiian and Pacific Islanders [477]. Asian and Pacific Islander men are 50% less likely to have prostate cancer but are twice as likely as their non-Hispanic White counterparts to have stomach cancer [417]. Asian American men are 1.7 times more likely than White men to die from liver cancer [417]. It is the second or third most common cancer for Vietnamese, Hmong, Cambodian, and Laotian men [476]. Liver cancer accounted for 22% of cancer deaths among Vietnamese-American men [345]. Hmong have the highest cancer rates even compared with their Asian American counterparts; specifically, they have the highest incidence of cancers of the liver, stomach, pancreas, and nasopharynx compared to all races [281]. This trend was reproduced in a study that compared adjusted cancer rates for Hmong residents of Minnesota to the general population in Minnesota [347].

Generally, Asian Americans have low cancer screening rates for cancers, ranging from 40.5% to 67.5% [478]. Asian American women are more likely to survive cervical cancer compared with their White counterparts, with the exception of Korean and Japanese American women [348]. However, Asian American women tend to avoid screenings and be diagnosed at an older age. Possible barriers to help seeking include low English proficiency, preference for health providers from the same ethnic group, adherence to a cultural value of modesty, and a general mistrust of Western health systems [281].

Overall, Asian and Pacific Islander women are 30% less likely to have breast cancer than non-Hispanic White women [230]. However, Asian immigrant women who have lived in the United States for more than half of their lives are three times more likely to be diagnosed with breast cancer than those born in the United States [418]. A landmark study of Asian Americans in California found that Asian American women (except Japanese women) had experienced an increase in breast cancer diagnoses, with Korean women experiencing the largest increase [349]. Breast cancer also accounts for about 19.5% of all cancer deaths among Asian Indian women and Filipino women [345].

In a study of 196 Korean American women, 54% had obtained a mammogram in the past two years. Women who reported knowing where to get a mammogram, having a regular doctor, and greater trust in healthcare providers and healthcare system were more likely to adhere to breast cancer screening recommendations [350]. In a study of Asian American college women, women who were sexually active were nine times more likely to have had a clinical breast examination than non-sexually experienced women [232]. The researchers speculate that Asian college women who are sexually active are more likely to visit a gynecologist and therefore will receive such screenings. In addition, culturally appropriate education material about mammograms should be developed and should target Asian women and their spouses and family members, who can be influential in supporting healthy behaviors [107].

Illness is not just an event; it also encompasses the client's/patient's subjective experience, cultural beliefs, and expectations regarding the illness. The term "illness" is different from "disease," as the term "illness" refers to the client's/patient's subjective experience of the disease and its effects on different arenas of his/her life [177]. The biomedical model usually does not focus on the client's/patient's expressions of the illness concept and how culture might impact disease presentation [47]. Level of acculturation, education, and socioeconomic class also influence illness beliefs [47]. Baki-Miri, Gogi, and Baki observe that there are three major categories for health belief systems regarding etiology of illnesses: occult, holistic, and scientific traditions [283].

In holistic traditions, ideas about health and illness are based on the concept of the whole and how interdependent parts (e.g., physical, mental, spiritual, emotional) fit together to play a role in health [283]. "Energies" that work together to either achieve balance or disharmony fall into this holistic domain. The Chinese conceptualization of sickness is rooted in the principles of yin and yang, unlike Western conceptualizations of illness that are rooted in germ theory [164]. From this Chinese perspective, health and day-to-day behavior are interwoven, and if an imbalance occurs, actions are necessary to reinstate the balance [479]. In addition to yin/yang, traditional Chinese medicine is concerned with the concept of qi, the basis of mind/body energy and activity within the body [174]. According to traditional beliefs, a lack of balance in an individual's yin/yang and flow of qi results in illness [174,479]. In Chinese tradition, qigong healing is utilized to establish balance and harmony; this involves techniques with breathing and movement to consciously control the flow of energies [182]. It also involves strengthening the body and eliminating evil. In the case of cancer, strengthening the body entails building the body's cancer-fighting ability, and eliminating evil means inhibiting cancer growth [420]. This, along with herbs and acupuncture, is one of the major components of traditional Chinese medicine [182]. Another factor is the concept of hot and cold elements in the body. Examples of "hot" illnesses include fever and joint pain, and "cold" illnesses include dysmenorrhea and diarrhea [164]. Furthermore, physical health is linked to social relationships [351].

Just as health is not compartmentalized, neither is treatment. Asian Indians see treatment as a daily part of life, integrating holistic and traditional practices [72]. These traditional health practices are called "desi ways," passed down from one generation of women to another [72]. Desi ways are traditional health practices of the country of origin, and they include use of Ayurveda practitioners, various herbs, homeopathy, naturopathy, and spiritual rituals [72]. Desi ways are not employed exclusively, but are often used in conjunction with Western treatment [72].

Scientific tradition focuses on empiricism and objectivity as the basis of health beliefs [283]. The biomedical perspective that dominates much of the health practices of Western medicine falls in this category. It does not take into account diversity and culture and its effect on illness. The biomedical perspective advocates the disease model, which focuses on biologic dysfunction and symptoms [177]. The physician handles the care of the client/patient and legitimizes that the disease is present [177]. This Western biomedical model has been criticized as not being sufficiently patient-centered—it may result in the patient being objectified and reduced to a set of symptoms, and it may not take into account the environmental, social, cultural, and religious factors that influence health [351].

Communicators from high-context cultures generally display the following characteristics [33,132,237,421]:

On the other hand, low-context communicators can typically be described as [33,132,421]:

There are five different conversational traits: formality, intimacy, directness, acknowledgment, and tolerance of conflict [132]. Formality involves the degree of hierarchy acknowledged in the relationship during the communication. For example, are titles employed? Who is addressed first? Most high-context cultures are influenced by the social status and the expertise of the person. The background of the person informs perception of authority and hierarchy [421]. Furthermore, most Asian groups are patriarchal and hierarchal. For example, in Chinese, Korean, Cambodian, and Japanese cultures, men and elders are placed on the top of the authority structure. Therefore, when working with Asian American and immigrant individuals, particularly those who may be less acculturated, practitioners should convey authority, credibility, and legitimacy [104]. For example, when working with Hmong immigrants, practitioners should avoid using overly casual language because Hmong respect professionals and believe they deserve honor and deference [238]. Therefore, any unprofessional behavior on the part of the professional could jeopardize their credibility. Many Asian American or immigrant clients/patients come into counseling believing that the practitioner will quickly identify the problem and provide a solution [104]. When the practitioner does not do so, he/she loses legitimacy in the eyes of the client/patient. Therefore, the practitioner must overtly establish authority. Employing professional titles and displaying diplomas and professional licenses are some examples of overtly establishing legitimacy. Furthermore, by obtaining sufficient information about the client/patient and family, and offering some explanation to the cause of the client's/patient's problems can assist in facilitating credibility. It may also be important to bring in family members, particularly an elder who is considered to be the authority figure, as a sign of respect.

In Western culture, communication is more direct and eye contact is highly valued. When eye contact is not maintained, many Westerners assume that the party is hiding pertinent information. However, in some cultures, including Asian cultures, reducing eye contact is a sign of respect [17]. In Asian culture, the practitioner is viewed as an authority figure, and avoiding eye contact is a symbol of respect, not dishonesty or lack of confidence [36]. Conversely, clients may interpret direct and indirect gazes differently. For example, in one study, Japanese individuals tended to rate faces with a direct gaze as angry and less pleasant compared with Finnish participants [118].

Cross-cultural communication is by no means simple, and there is no set of rules to merely abide by. Instead, promoting culturally sensitive communication is an art that requires practitioners to self-reflect, be self-aware, and be willing to learn. Therefore, as practitioners become skilled in noticing nonverbal behaviors and how they relate to their own behaviors and emotions, they will be more able to understand their own level of discomfort and comprehend behavior from a cultural perspective [132]. It involves the art of calibrating and making "microadjustments" [463]. The illness experience can be viewed as both a shared cultural experience and a unique individual experience. Practitioners should work to adjust their communication and clinical skills in order to capture the shared cultural and individual experience, so patient feel their specific needs are being met [463].

Practitioners may be categorized as either disease-centric or client/patient-centric [31]. Disease-centered practitioners are concerned with sign/symptom observation and, ultimately, diagnosis. On the other hand, client/patient-centered practitioners focus more on the client's/patient's experience of the illness, subjective descriptions, and personal beliefs [31]. Client/patient-centered practice involves culturally sensitive assessment. It allows practitioners to move assessment and practice away from a pathology-oriented model and instead acknowledge the complex transactions of the individual's movement within, among, and between various systems [25].

Autonomy, individualism, and self-determination are values that are highly important in Western societies, especially in the United States. Autonomy may be organized into two categories: first-order autonomy and second-order autonomy [69]. First-order autonomy is what is espoused and valued in Western cultures: self-determination and autonomy in decision-making. Second-order autonomy, however, is prevalent in collectivistic societies where decision-making is group-oriented and takes into account another decision-maker who is accorded authority and respect [69]. In many Asian cultures, particularly if the family system is based on a patriarchal authority system, a male elder or male family head who is regarded as the primary decision-maker is key in this process of informed consent [423]. This notion of relational autonomy is prescribed when working with more collectivistic groups [483]. Therefore, the Western ideal of autonomy will have different connotations in cultures in which paternalism is valued, and a narrow application of autonomy (as defined from a more individualistic perspective) may not be appropriate [240,483]. Kung and Johansson argue that practitioners should acknowledge both having the duty of respect for patients' right to choose and not having the ability to decide if patients delegate decisions to others [483]. All patients have the right to delegate.

As described, the process of informed consent entails the explicit communication of information in order for the individual to make a decision. Again, Western cultures value explicit information, which is centered on American consumerism; believing in having choices and being able to exercise choices in purchases extends to health care. Western values also support the idea that the more information given is better. Therefore, there are underlying dominant norms about the amount and content of information as well as how it is conveyed [241,242]. Some cultures, for example, believe that language and information also shape reality [30]. In other words, explicit information, particularly if it is bad information, will affect the course of reality. The Japanese, for example, believe that it is important not to discuss terminal illnesses and death and dying. The Chinese believe that discussing illnesses will bring about bad fortune and bad luck, and such discussions ensure that illness will inevitably occur [120,185]. For some Asian patients, a direct statement conveying bad news (e.g., a very poor prognosis) may be construed as rude. Instead, a more indirect way using euphemisms is preferred. Yet, for many Americans, this would not be acceptable [241,242].

Another perspective is that the interpreter is an active agent or co-diagnostician, negotiating between two cultures and assisting in promoting culturally competent communication and practice [81,244]. In a study with 27 healthcare interpreters, the participants summarized their work as "a complex mental and social activity that went beyond linguistic transformation and included deciphering body language, establishing trust with multiple stakeholders, and brokering cultural concepts and frameworks" [203]. As co-diagnosticians, interpreters determine what medical information is valuable, seek illness-related information outside of the providers questioning, and participate in the diagnostic process by identifying symptoms the provider may not have directly asked the client/patient about [244]. In this more active role, the interpreter's behavior is also influenced by a host of extralinguistic factors, such as power imbalances, organizational expectations, professional attitudes, and personal biases, as well as cultural variables such as gender, class, religion, educational differences, and power/authority perceptions of the client/patient [81; 485]. In one study, some interpreters reported feeling that speaking out was part of their professional obligation to act as a cultural broker for the client [150]. The downside is that interpreters may overstep their roles [161; 485]. Consequently, an intricate, triangular relationship develops between all three parties.

Another factor affecting the communication process is the fact that many interpreters are not adequately trained in the art of interpretation in mental health and general health settings, as there are many technical and unfamiliar terms. An ideal interpreter goes beyond being merely proficient in the needed language/dialect [33]. Interpreters who are professionally trained have covered aspects of ethics, impartiality, accuracy, and completeness [70]. They are also well-versed in interpreting both the overt and latent content of information without changing any meanings and without interjecting their own biases and opinions [70]. Furthermore, knowledge about cross-cultural communication and all the subtle nuances of the dynamics of communicating in a mental health or general health setting is vital [33; 485].

The approximate-interpreting model refers to the practice of obtaining an individual to serve as an interpreter who happens to be the most conveniently accessible. This may be a person who is currently on staff (e.g., receptionist, file clerk, etc.) in another department, or it may be a relative (adult or child) who accompanies the client/patient. However, it is important to note that in some states, such as California, there are laws that prohibit using a client's/patient's child as an interpreter.

The tele-active and video remote model employs a telephone program or video conferencing platform whereby the client/patient selects from a menu offering different languages/dialect. There is no human interaction, and it is often used after hours, when an interpreter is not on site. Visual cues are not present and the acoustics can be poor, but some argue the convenience factor can perhaps over-ride some of the limitations [484]. There are also national organizations that provide interpreting services via phone to any provider at any geographic location. Handsets are installed in the rooms so a healthcare professional can use one handset and the client/patient can use another. An interpreter is on the line from another location, interpreting in real time [245]. There is now software that can ask initial questions in the client's/patient's language, then connect the provider and client/patient to an interpreter via the telephone [246].

A briefing time between the practitioner and interpreter held prior to the meeting with the client/patient is crucial. The interpreter should understand the goal of the session, issues that will be discussed, specific terminology that may be used to allow for advance preparation, preferred translation formats, and sensitive topics that might arise [33,104,147]. It is important for the client/patient, interpreter, and practitioner to be seated in such a way that the practitioner can see both the interpreter and client/patient. Some experts recommend that the interpreter sit next to the client/patient, both parties facing the practitioner [70].

The practitioner should always address the client/patient directly. For example, the practitioner should query the client/patient, "How do you feel?" versus asking the interpreter, "How does she feel?" [70]. The practitioner should also always refer to the client/patient as "Mr./Mrs. D" rather than "he" or "she" [104]. This avoids objectifying the client/patient. While these behavioral tips are important, the key is to always focus on the interaction, which is always dynamic, complex, and ever-changing [320].

At the start of the session, the practitioner should clearly identify his/her role and the interpreter's role [104]. This will prevent the client/patient from developing a primary relationship or alliance with the interpreter, turning to the interpreter as the one who sets the intervention [33]. Conversely, practitioners should avoid having side conversations with the interpreter when the client/patient is present [225]. Practitioners should also discern any transference and countertransference issues between configurations of the triad [361].

The practitioner should also be attuned to the age, gender, class, and/or ethnic differences between the client/patient and the interpreter [104]. For example, if the client/patient is an older Asian male immigrant and the interpreter is a young, Asian woman, the practitioner must be sensitive to whether the client/patient is uncomfortable given the fact he may be more accustomed to patriarchal authority structures. At the conclusion of the session, it is advisable to have a debriefing time between the practitioner and the interpreter to review the session [33,104,147]. Overall, it is important to remember that clients/patients are an integral component of the active triad [225].

One of the challenges to effective interprofessional collaborations is that professionals are typically socialized to their discipline's professional cultural norms and have not been exposed to other professional value systems [436,437]. When professionals enter the workforce, they often continue to work in silos. Consequently, they are not familiar with the professional goals, language, roles, and tasks of their colleagues from other disciplines. This is particularly true of certain professions that are considered "outside" of traditional healthcare systems, such as practitioners in traditional, complementary, and integrative medicine (TCIM) [438]. However, many Asian immigrants employ TCIM practices. Both cultural competency and interprofessional collaboration require professionals to critically reflect on historical and sociopolitical factors that impact their professional relationships and practices. Cultural competency improves interprofessional collaboration and communication and vice versa [437].