Upskilling in culturally-responsive practice for Asian clients (with Daniela Ho Tan)

[00:00:00] Bronwyn: Hey, mental workers. You're listening to the Mental Work podcast, your companion to early career psychology sponsored by the Australian Association of Psychologists. I'm your host, doctor Bronwyn Milkins, and today, I'm stoked because we are talking about culturally responsive practice for Asian people using a schema therapy framework with Daniela Hotan.

[00:00:26] As I said, I'm really excited for this episode. I always love talking about culturally responsive practice. I think it's one of the key areas that early career psychologists don't get enough guidance and support in, and so I'm really delighted when someone has the passion and wants to come on the podcast and talk about it.

[00:00:42] So as I said, here to help us out is Daniella. Hi, Daniella.

[00:00:47] Daniela: Hi, Bronwyn.

[00:00:48] Bronwyn: Such a pleasure to have you on. Could you please just tell listeners who you are and what your non psychology passion is?

[00:00:54] Daniela: Of course. So I'm Daniela Houghton. I'm a clinical psychologist, advanced accredited schema therapist, and board approved supervisor. outside of my psychology time, I'm a mum of 2 boys. I'm often up to lots of mischiefs with them. We've been playing a lot of hide and seek.

[00:01:13] And in terms of passions, I love travel. I think that's been really something that's been reinvigorated ever since the lockdowns during COVID because we've been itching to travel. So I love travelling.

[00:01:26] I love, um, food. So I love being able to travel and try different foods and, um, I in particular love going snorkeling and just being out at the beach. So I would say that's probably some of the my biggest passions.

[00:01:42] Bronwyn: No. Beautiful. And I love travel as well. It's like through lockdowns, we forgot that. Well, we had to forget that the whole world existed, and now it's like, wow. We can go everywhere, and we can eat all the delicious food.

[00:01:53] Daniela: I know it's just that they all cost quite a bit, doesn't it? So then it's kind of like you're planning for the next holiday and trying to work out, okay, how much do we need to save to make sure we can get there and have a great time?

[00:02:05] Bronwyn: I feel like I've got about 4 or 5 holidays stacked up because I couldn't take them through COVID, and now it's just planning and finances. Right?

[00:02:13] Daniela: Yeah.

[00:02:14] Bronwyn: Well, Daniella, thank you so much for coming on. And I wanted to start off by talking with you about your passion project that you started last year. So listeners, Daniela started a project called Project Horizon in 2023. It's aimed at looking at the intersection of Western psychotherapy principles and Asian cultural values. And I'm wondering, could you share with us your inspiration in starting Project Horizon?

[00:02:39] Daniela: So after I finished my, schema accreditation, I think I waited 1 month before I thought I need a new project. I need something to do.

[00:02:49] And actually, right after my accreditation, I, uh, traveled to Seoul, Korea to attend the World Congress in Cognitive and Behavioral Therapies. And during that time I attended all the cultural trainings. So there was training on cultural adaptations of CBT, adaptations of CBT specific for Chinese populations. I got to talk to some wonderful academics, scholars, psychologists. It was truly just such a enriching environment.

[00:03:21] And I think during my accreditation process, because, um, for people who are going through the process, um, they probably already know. But part of the sessions that you have with your supervisor is examining your own schemas and your own modes. And of course being someone who is, of Asian background, I'm Vietnamese and growing up in Australia, there's been a lot of, I guess, experiences that did shape, uh, the way that my schemas and modes developed, the way that I respond to situations and I found this really important. And so culture became just, you know, a topic of interest that I then shared with a lot of my clients, um, the area where I work.

[00:04:09] So I'm in private practice, um, is a highly Asian populated, um, area. And so I would say about 90 percent of my clients are of Asian background and they're beautiful clients, they've all really inspired and motivated me. They've also helped me realize that things don't just translate from a workshop or workbook into the therapy room all the time. So I've worked alongside my clients to develop ways where we are working in a more culturally responsive way. And, when I finished my accreditation, I thought wouldn't it be great to really sit down and see what other people's experiences are and so I ended up, just just for fun doing a little bit of an exploratory study where I interviewed about 35 different psychologists about their experiences working with Asian clinician Asian clients and it was just really enjoyable to connect with other clinicians. most of them who reached out to me were of Asian background and I just found that there was this whole, uh, population of clinicians who were interested in working with Asian clients and who were also tailoring the work to be culturally responsive, but not having a formal framework to use.

[00:05:29] And I thought, wouldn't it be great if I can, take all the information from the interviews, um, all the experiences and hopefully put it towards some good use and that's, um, how project horizon came to be and this year I'm branching out and running my first workshop. Um, we're looking at, uh, forming some supervision groups. There's been some submissions to conferences. And so I think there will be a lot more work about, um, culturally responsive practice for Asian populations headed everyone's way and hopefully it's something that can be shared with everyone.

[00:06:10] Bronwyn: It's amazing, and it sounds like it's well needed and well wanted by the community as well. Like you said with your interviewees, they want ways to work responsively with their Asian clients, but they don't really have a framework for doing that. So I'm wondering, like, from your interviews or maybe from your own clinical practice, could you tell us maybe a case study or an experience that highlights why culturally responsive therapy is important for Asian clients .

[00:06:39] Daniela: So there have been some really interesting sessions where I've really learned quite a lot. So for instance, I was trying to follow the schema therapy protocol to a tee, uh, with a South Asian older client and things did not go to plan. So it was an imagery rescripting session and as I'm going through so for listeners who um, haven't done that much schema therapy, what we usually do is we ask the client to close their eyes and focus first on a more recent distressing image and then focusing on the feelings. Um, we do what's called a float back um, using an affect bridge to be able to connect to the core schema memory. And usually this is something that happened in their childhood.

[00:07:28] So for this, uh, South Asian older client, the float back was back to a memory when he was young and it was an upsetting situation with uh, mum. And typically what we would do is come in to discuss the needs of the child, the vulnerable child, and then do an empathic confrontation of the parent to give the client a corrective experience.

[00:07:54] So there were a few issues. In terms of thinking about it from, I guess, uh, Asian cultural values and the fact that in Asia a lot of cultures have more of a hierarchical structure and are many concepts that place for instance, you don't speak to elders in, you know, in a way that might be rude and you do have to be sometimes quite submissive and compliant.

[00:08:20] So my client took issue with the fact that I was entering the family image. It felt intrusive to have someone firstly younger than their mother enter the image. Did not want me to address mum by first name and I could just see that he was getting distressed at the idea of having someone a like a stranger come into the image. And so we actually modified the technique and reflected on, uh, from a cultural point of view who would feel like a healthy adult who could enter the image and I could speak through that person and he ended up choosing his grandfather and that actually worked much more beautifully. We were able to achieve a corrective experience and from then on when I do rescripting work with clients where there is a really strong cultural aspect because I don't wanna just assume that just because someone looks of Asian background that they would want me to make all these modifications. Um, so I will often consult with, um, the client and then talk about when I'm doing the rescripting. Okay. Is it okay if I come into the image and give them the choice or would you prefer for me to bring in someone a little bit older and I can speak through them.

[00:09:44] Often I will talk about the process with the client beforehand and they can find it, um, a lot more comforting to know how it will go. So I think that's some of the that's an example of, um, I guess where it's been really helpful to work the cultural element into the technique.

[00:10:05] Bronwyn: Yeah. This sounds really powerful that you can modify schema therapy in this example in this way to get that corrective experience, because I imagine that if you had just persisted in pushing through and being like, nope, I'm going to empathically confront mom. This is how it needs to be. Then like you said, it was already appearing to cause the client distress, but I'm willing to bet you wouldn't have gotten that corrective experience.

[00:10:31] Daniela: That's right. It would have probably been quite a disaster and he probably would not have come back to therapy!

[00:10:37] Bronwyn: Yeah. Yeah. So and it sounds like you were able to do that, like, achieve the corrective experience, one through being flexible, so being able to discuss with the client what it is that they needed. But it sounds like you also drew on your knowledge of Asian values and wondered if that applied to this particular client.

[00:10:57] Daniela: Yes. That's right. And I think that is so important, because we just can't assume that everything from, you know, everything that we read in training manuals and that we are taught which, you know, it most of it does come from the Western world that it's been actually, you know, that there have been trials and studies done with Asian populations. Certainly, there's studies where they look at, okay, there are students included and a percentage of Asian background and it's done in Australia or America where a lot of these, um, people are already acculturated because in order to partake in the study, they need to actually be able to speak English.

[00:11:40] Bronwyn: True.

[00:11:40] Daniela: It's interesting because, um, so with schema therapy, as you know, it's developed to initially it was developed to look at personality disorders. Over the years, um, people use the model more flexibly to work with different presentations like depression, anxiety, OCD, PTSD. And, um, 1 of the areas that I'm really passionate about is working with intergenerational trauma. And I remember watching an interview about trauma with, a psychologist who was researching trauma and she said that it's so interesting that all the studies, all the publications, the trials that look at trauma are with, generally speaking, Western samples, but trauma occurs more within, I guess, what we call minority cultures, but there's no studies being done there. Or because there's so much happening in some of those countries, people don't have the the time to come into the lab to sit for a study!

[00:12:37] Bronwyn: Totally. Yeah. It sounds like there's a huge gap in culturally responsive practice for psychologists working with Asian clients that you've identified just from seeing the research and from what you've gleaned from your own professional development.

[00:12:52] I'm wondering what the intersection is with your own, cultural journey because as you said, you, uh, have a Vietnamese background. And I'm wondering if you could take us through your own cultural journey just as a human and then, like, how they intersect with the psychologist.

[00:13:08] Daniela: So I'm Vietnamese, so both my parents are from Vietnam. But what a lot of people don't know about me is that I was actually born in Germany. So it's a little bit of a random fact about me.

[00:13:20] Bronwyn: Yeah.

[00:13:21] Daniela: Yeah. So, um, my dad, uh, he left Vietnam when he was 18 because he got a scholarship to study engineering in Germany. So he took that pathway. My mum, however, so she left Vietnam during the war and was a boat person. So she went through quite a lot and my parents met in Germany and then I came into the picture and when I was about 4 or 5, my dad's, work transferred him to Australia and it was meant to only be for a year. We have never gone back. So I guess it it was meant to be.

[00:14:03] But it's been an interesting journey because, when I was growing up in Germany, I didn't know what racism was. I just knew that I looked different and there were some experiences that I faced that I never talked about to my parents until I was older where I was being bullied for instance. And it's awful to think about because I would have been about three...

[00:14:26] Bronwyn: Wow.

[00:14:27] Daniela: ...and it happened at daycare and it wasn't just other students who would pull their eyes up to slits and say things like Ching Chong. Um, but it was also the teachers and it was pretty horrific.

[00:14:41] Bronwyn: -is horrific.

[00:14:43] Daniela: Yeah and then my mum actually recently recounted a story where I was singing on the bus and an elderly German lady complained and told my mom that I should be silent and so it was quite a lot of racism that I experienced but didn't know how to comprehend, didn't know how to make sense of and so I attempted to internalise it.

[00:15:05] And then when we moved to Australia, we moved to, um, a part of Sydney, southwest called Bankstown which is very heavily populated by the Vietnamese community. So it was really interesting coming to Australia and then living in a community where a lot of people spoke Vietnamese and that was my first language, so I felt very comfortable there. And it just felt like a sense of acceptance and, um, I grew up during the period of One nation and, um, there was you know, there have been some interesting, um, I guess cultural movements during the time that I was growing up.

[00:15:45] But it just felt nothing like what I had gone through in Germany and so, only when I was older did I start to notice there were little experiences here and there or more like internalized racism and I definitely found it helpful having gone through my own therapy, um, working through my own schema journeys, consulting with my supervisors to get to where I am today where I feel very proud of my heritage and each time I go back to Vietnam, I feel much more connected. I make an effort to speak as much Vietnamese as I can. I'm trying to teach my 2 boys Vietnamese and it just feels a lot nicer now whereas growing up and I'm sure a lot of other um, Asian clinicians or clients or people would have found that there were times where we wish we were blonde and blue eyed. We wish that we had the ham sandwich and we're worried about if I open my lunchbox, are people going to make fun of it? Are they going to comment about the smell of the food? These are, I think, a lot of examples that many migrant children grew up experiencing. And it did feed into some of our schemers in terms of feeling defective or feeling shame or, being quite critical of ourselves because we wanted to fit in.

[00:17:09] Bronwyn: Yeah.

[00:17:09] I was going to ask about how that might translate to schemers. So you mentioned effectiveness. I'd I was wondering whether social isolation could be a big one as well, like feeling different and not accepted.

[00:17:21] Daniela: Definitely. So I was lucky that once we came to Australia, my parents linked up to the Vietnamese community. I was involved in a little Vietnamese dance group. I went to Vietnamese school. And so I felt much more connected to my collective, if you might.

[00:17:41] I didn't actually experience as much of the social isolation, whereas had I stayed in Germany a hundred percent, I would have I would score very high on that schema, but it's interesting because I've noticed and through my interviews of other clinicians, we have mapped out that there are some common schemas that present in Asian culture or Asian clients and that would be so unrelenting standards, the perfectionism, uh, self sacrificing and subjugation, um, enmeshment, uh, emotion inhibition, and for some subcultures even like negativity, pessimism. But the main ones would be that unrelenting standards, self sacrifice, subjugation, um, emotion inhibition. I think what's really interesting though is it's hard to know where does the schema begin and where do cultural, you know, where does the schema end and where do cultural values begin because there is a concept called filial piety that looks at know, you know, the honor and respect that you show to your family and that involves knowing your place in the family and acting in a way that's quite filial so that you respect your elders, um, you take care of your family. Um, it's hard to separate sometimes enmeshment and collectivism or filial piety and it's a topic that I discuss quite a lot with, um, my clients. And then also in terms of okay. Well, over in Asia, most people tend to suppress their emotions if they've been taught that it's, you know, something to it's to do with being very strong.

[00:19:27] Bronwyn: Yeah.

[00:19:29] Daniela: And so it's actually normal then to inhibit feelings and not to show that outwardly and to do that, you know, in the safety of your own home or with your family. And so they may score high on some of these measures, but is it dysfunctional?

[00:19:46] Bronwyn: Yeah. It's the exact question that I was thinking in my head, and it's something that I really struggle with clinically as well because I don't me being a a Western person and um, having, like, an Anglo Saxon background, I don't wanna be a Western clinician being like you're too enmeshed with your family when that might be an important cultural value that that person holds and is important to their survival in that family and their cultural identity.

[00:20:15] Um, likewise, we have self sacrifice or emotional inhibition, I don't wanna be like, okay. Yeah. I wonder if we could be less emotionally inhibited when that's an important part of their cultural identity as well, and that might have consequences, in terms of, like, familial relationships. yes. So it's it's really difficult, and it's good to hear you bring this up that it's it is a difficult topic.

[00:20:36] Daniela: Definitely. And it's it's a work in progress in terms of having a look at, okay, well, how can we use strategies and skills to be able to balance that? And I have to credit one of my clients, um, for this because we actually were working through her enmeshment and it just got to the point where I was trying to understand, okay, well, how enmeshed are you with your family and, you know, how much change do we need? So I ended up getting her to draw it out. Good old Venn diagram.

[00:21:08] Bronwyn: Oh, wow. It's a great idea.

[00:21:10] Daniela: Yeah. It was actually really helpful. So I said, can you just draw for me a circle of your family and a circle for you and show me what how much connectedness there is currently? Shaded in? Yeah. Okay. Great. And show me how much you would like there to be. And look at looking at the difference, I said, okay. What do we need to do to achieve that? And it was really helpful.

[00:21:34] I mean, I love working visually. I think it's a lot easier. And so, that's that was, you know, it's very it's so simple. Right? Like, you know, 2 Venn diagrams. But that was a way to have a look at, okay, well, how can we look at and understand how enmeshed you feel you are and how much independence you actually would like to have and I think that's actually been, yeah, one of the techniques or strategies that I've just come up with my client in this therapy session and we've since I've used it quite a bit with other clients and I just think it's just something that's very small but helpful.

[00:22:11] Bronwyn: Yeah. It's so simple, but it's so genius as well because it immediately dismantles the idea that I, as a therapist, need to come in and be and and be the arbiter of, like, this is too enmeshed versus not enmeshed. Like, I don't need to be that person. We just need to get the client's subjective experience of where they are now and where they would like to be.

[00:22:29] Daniela: Absolutely. And I'm sure that many of the listeners who, have worked with some clients who've had invalidating experiences with clinicians, maybe familiar with having heard the story of I went to the therapist and told them about my my issues with family and they told me to move out.

[00:22:48] Bronwyn: Yeah. I was literally thinking that!

[00:22:50] Daniela: That's not an option. So we need to get more creative around how to balance, um, individualism and collectivism. And I think that's what I love about working in Australia is that experience of working with that kind of Asian diaspora, um, clients and I relate to that so much personally that it's having a look at, okay, well, we need to think outside the box. Let's work creatively and how can we balance that so that we don't actually risk forming a social isolation schema if they actually leave the family and leave their community because we don't want that either because it's such an integral part of who they are that if they leave and they're cut off, then they start to go through things like symptoms of depression around, okay well I'm all alone and perhaps they literally are all alone. How do you thought challenge that? You can't.

[00:23:45] Bronwyn: Yeah. Yeah. It's hard to thought challenge reality.

[00:23:48] Daniela: Yeah. So I think it's really lovely being able to work with clients, come up with strategies, and have them be so collaborative in that process?

[00:24:01] Bronwyn: And coming back to you as a as a human as well, I'm just wondering, like, what prompted you to get into psychology as a psychologist, and maybe you could tell us a bit about if your cultural identity is intersected with your training in psychology. And by that, I mean, like, I've heard from some culturally diverse practitioners that maybe they did feel like a bit of an outsider in this kind of Western psychology training, and I just wanted to get your perspective on that.

[00:24:30] Daniela: (Second sequence begins) So I chose psychology because I had always been drawn to helping people and growing up. Initially, I wanted to be a pediatrician but then I did a placement at Sydney Children's Hospital and saw all the sick babies and thought I'm going to be crying every day. Um, I need to find a new way to help people and children and I decided to turn to psychology because I thought, you know what? If I can help shape the way people think and interact and process, then that's still, you know, being able to give someone a really enriching experience. And there won't be anyone dying on my watch hopefully and I won't be crying over sick babies.

[00:25:19] we do hear as you know, working as a clinician, we do hear a lot and it's very emotionally charged, um, but working in private practice there's no real imminent risks and, um, so I was really drawn to psychology to better understand human behavior. Um, I knew from the beginning I wanted to be a clinical psychologist. I trained at the University of New South Wales which is quite, Asian heavy. So I actually felt like I fit right in especially because, um, it just most of my cohort like a large percentage of my cohort was Asian. UNSW is known for taking in a lot of international students from Asia.

[00:26:02] So I actually felt really comfortable and I had really diverse, um, lecturers and tutors. So I was really lucky in that respect and I actually felt a greater sense of belonging at university than I did high school for instance. So that was actually very interesting for me. I had a beautiful experience at university and especially getting involved with the psychology society. So I had a great time at university. Um, and then for my masters, um, I was accepted to the University of Western Sydney, which is now called Western Sydney University. but they're in Southwest Sydney and capture quite a diverse population of people. So there's a lot of multiculturalism at that university. And so again, I was in that environment where everyone around me actually came from a lot of different backgrounds and that was quite a beautiful experience.

[00:26:59] One thing that I did notice and I've heard, um, from some of the other interviewees on your podcast is that during our clinical training, there just wasn't really a cultural element. I think there was a half day, maybe 3 hour workshop on indigenous mental health and then culture was kind of lumped into that. But I was not taught, okay, how do I formulate this in? Like, it might be part of the background history but it didn't really, uh, filter down to well, how does this, um, impact the way that we practice? How does this impact the way that we interact with our client?

[00:27:39] For instance, what are the questions that we should be asking as part of our diagnostic assessment? There's a bit about family and, um, history, but I just felt there was a bit of a lacking. And I know now that there are a lot of people who, um, are changing this. I know that down at Monash Uni for instance, instance, they actually have, I think, a semester long course around cultural and diversity in their clinical program. And I think that's wonderful. And I heard, um, Doctor Avril Cook on your podcast and she's doing a lot of work around decolonisation

[00:28:15] Bronwyn: Yep.

[00:28:16] Daniela: and psychology. So there's a lot of people out there trying to make these changes and I just want to lend my voice to support that as well. So I'm hoping that in the years to come, we can have a lot more diversity, and cultural responsive practice as part of training for early grads. But in the meantime, that's what really motivated me to put everything into to a workshop to try and promote culturally responsive practice.

[00:28:44] Bronwyn: No. I think it's so cool. And, yeah, I echo what you're saying. I didn't receive much training in cultural responsiveness or all the cultures are lumped into one. And so that's why I really like Project Horizon and what you're doing because it focuses on a specific population, and it really says here's the unique things about this population. I'm sure it includes some generalities as well about how you can be culturally responsive, but I really like how you're using your experiences plus, like, your professional experiences to to give us some insight into this really important area.

[00:29:15] Daniela: Thank you. I really appreciate that and I definitely... when I started forming the workshop, thought okay well I can only speak about what I know and using my lived experience plus the clients that I work with. So it does mean that I can't be as broad as saying, you know, I can this workshop will enable you to work with every culture because that in itself isn't true. And even within Asian, populations, there's subcultures,

[00:29:42] Bronwyn: Yeah.

[00:29:43] Daniela: there's, you know, I would work with adoptees for instance or there's biracial clients or, uh, clients who I work with who are living in Asia. They're not the minority. They're the majority there.

[00:29:54] And so there's so many, I guess, um, factors to consider. So I just hope that my workshop can help people to have a look at, okay, well, we can have a framework for factoring culture into um, the formulation and whether you work from a scheme of point of view, an act point of view, a CBT point of view. I'm hoping that I can provide strategies where people can think, okay well this is how we work culture into the the way that we practice. It's not just about schema therapy. Whilst I am a schema therapist predominantly and I have probably more of a schema therapy lens, I've made sure that the workshop is accessible for everyone so that someone who picks up the Jeffrey Young's, um, schema client guide reads through that. That should be enough to be able to sit through the workshop and the strategies are around, okay, yes. How can we work in a culturally responsive way with Asian clients?

[00:30:50] Bronwyn: Yeah. No. Wonderful. And maybe could you tell us next about some of the challenges that early career psychs might face when working with Asian clients? You mentioned before that there might be different ways of formulating or different things to ask and and what they can do when working with Asian clients?

[00:31:11] Daniela: Absolutely. So I think first and foremost, it's having a look at how you can build rapport with Asian clients. Um, The statistics which I know there aren't many statistics out there and often it's based in Asian American populations, but I think in general it does ring true that, um, Asian clients tend to have one of the highest dropout rates in therapy.

[00:31:35] Bronwyn: Really? Wow. I didn't know that, interesting.

[00:31:37] Daniela: Yeah, yeah. So, um, doing my literature review, I found they have high dropout rates but they also tend to not present to therapy until symptoms are very severe. So they tend to prevent when they're often probably not appropriate for say private practice and needing a higher level of care, but they're also known to drop out much quicker.

[00:32:00] So in client engagement is very important and that starts at the diagnostic assessment and asking the questions that help the client feel that they are being seen and heard as, you know, as they are entirely. Not just specific to, let's say, a medical model of, okay, I just need to know about your symptoms and, quickly dabble on a little bit of your history, but that's not actually important.

[00:32:28] And so I think asking questions around that person's understanding of mental health is important because culture plays into that and then, any of their beliefs that impact the way that they receive treatment or how they would like therapy to go. Um, placard education is so important. Often growing up, they don't have the language and terminology, so it's important to just be careful with how you proceed. I actually didn't know this existed until probably last year, but in the back of the DSM 5, there's a cultural formulation interview.

[00:33:04] Bronwyn: Yep.

[00:33:05] Daniela: I had no idea. It's been sitting in my office for goodness knows how long ever since DSM 5 came but only last year because it's so big as you know. Who really sits through and reads the DSM?

[00:33:15] Bronwyn: No. I literally only found out that this interview existed when I did a whole assignment on culturally responsive assessment tools. And I was like, What? Like, this thing's already in there. It's a really good interview as well.

[00:33:27] Daniela: Yeah. And there's some other resource like in New South Wales, Transcultural Mental Health, they have a mental health checklist in terms of working with, uh, culturally and linguistically diverse population that is great

[00:33:40] I've shared that as a resource on my website and then there's and then there's a few different resource guides they're that are pretty lengthy pdfs but they're wonderful. They're free resources that you can just read through and it's just so well written. Um so I really recommend new career psychologists have a look at those kind of resources just to start to have a look at these are the questions that we could ask. These are the things to consider. How can we bring that into the therapy room? How can we help the client feel that we are considering them as a whole not just, you know, we just wanna know about your symptoms and these are the techniques that you need to do and you should be fine if you do them exactly how I tell you to do.

[00:34:23] Bronwyn: Yeah. Um, this might be a bit of a left field question, and it's putting you on the spot, but when I was a provisional psychologist, I wanted to use the culture the DSM 5 cultural interview to help me ask some, like, adjunct questions with they were actually an Asian client, and I wanted to better understand their cultural perceptions. My supervisor said that I couldn't do that. They didn't want me to use the cultural interview, and they were like, why would you wanna do that? And I was like, because they're a different culture to me, and I wanna understand their culture. And they were like, no. Don't do that.

[00:34:58] Daniela: Oh my goodness. Not surprised.

[00:35:00] Bronwyn: okay. Okay. And then I was like, okay. Um, do you have any tips? Like, why why why is this important? Like, what could I send back to my supervisor?

[00:35:10] Daniela: I actually want to share a story as well because firstly I really appreciate that you were trying really hard that that means a lot and it's my story is actually about something that happened in a workshop. And so I want, I guess, any early career psychs who are sitting in workshops, who have the imposter syndrome, as we all do when we're starting out, That that, um, things like this happen regardless of what level of, um, uh, experience and expertise that you're at.

[00:35:42] But I I was doing an online workshop. It was a schema therapy training and I raised the culture card. And in I was in a breakout room. I was doing a role play with another psychologist who was from a non Asian background. Um, and in the role play, we were going through an imagery scripting and I was role playing one of my clients. And in this, um, rescript, I was saying, look, the client is happy with a compromise where it balances her needs and her parents' needs.

[00:36:23] And the therapist said, no. No. We need to basically win. Like, we need to get the parents to be completely on board. So just to give some context, it was about the client feeling a sense of isolation from friends because she wasn't allowed to go to a sleepover. And growing up from a as someone of an Asian background, I'm very accustomed to that. We don't We're not allowed to go to sleepovers. It was very hard campaigning for that as a child growing up and not wanting to feel like you're missing out as you do. You know, we all wanna fit in.

[00:36:56] Anyway, we ended up somehow in a bit of a heated debate around what would would truly meet the needs of the client. And the other clinician was determined to say, we need to win the exchange. The parents have to allow the client to go on this sleepover. And I said, the client would then get worried because she knows when she comes home, she's going to be met with anger and she's going to get into trouble. So she's not gonna be able to relax at this sleepover. Anyway, we just couldn't agree. Breakout room time ended.

[00:37:26] It went into the bigger room with everyone. I raised it with the workshop facilitator and unfortunately, it was shut down, which I was really really disappointed about. It was an uncomfortable topic and it would have yes, it would have taken some time to talk about and the response we got was, you know, we better stay on track with the workshop so let's just move along. And I was really really disappointed about that.

[00:37:57] Bronwyn: I noticed I feel disappointed as well because I I think it sounds like it was a really important discussion to be had.

[00:38:04] Daniela: Yeah. It was a good learning opportunity. So ever since that workshop I've actually made a conscious effort when I am in a training, to where appropriate raise questions around, okay well if this client is from a different background and these are factors that we should consider, how might we work with that? And, I took the opportunity when I was at the World Congress CBT in Seoul to actually ask that of a lot of the, um, I guess, professors, esteemed, you know, expertise, uh, in CBT...

[00:38:39] Bronwyn: What did they say?

[00:38:39] Daniela: And... that this is an area that is great for further research, which is a very diplomatic response.

[00:38:47] Bronwyn: It totally is.

[00:38:48] Daniela: it just, it just, but, and some, look, some gave some really good, um, answers, which is, I don't know, but I'd be interested to find out more. And I thought, you know what? We you don't have to have all the answers. I certainly do not have all the answers and when clients ask me questions, I let them know that. And I talk about, well, let's work together. Let's figure it out together. I'm happy to do some research.

[00:39:10] And, I guess the good news is there are some international projects that are actually looking at examining, being able to disseminate a lot of the therapies, uh, the questionnaires, the techniques into the you know, across different countries and languages. So that's something that I feel, you know, is something that's changing and I'm really excited about what that means moving forward because there is so much stigma tied to, uh, support seeking or mental health, um, services in Asia. That is slowly changing and some parts of Asia, um, are much more progressive with that. Certainly in Singapore and Hong Kong, um, there's a lot more, psychology workshops, conferences whereas for instance, Vietnam Cambodia or some of the other parts of Asia, it's not as up and coming.

[00:40:07] Bronwyn: There's a there's a few things out of that that I wanna explore with you, if that's okay. firstly, thank you so much for sharing your experience, the disappointing one with the workshop. I think it's important for listeners to hear, like you said, that regardless of your experience, you can have disappointing responses and that it doesn't mean that you're... you raising that was wrong. Um, it means that you needed that space to be able to discuss a very important thing.

[00:40:33] I wanted to ask you... you mentioned that there's some dissemination happening with, uh, with therapies and with schema. I think you mentioned that you've got some work in that area with disseminating some schema therapy resources. Could you just tell listeners about that?

[00:40:50] Daniela: at the moment, there's a big, uh, international project coming out of the University of Amsterdam with, uh, professor Arnold Arntz, and it's a massive project looking at, uh, the schema questionnaire, the mode inventory, and I think one other schema questionnaire that's name escapes me at the moment.

[00:41:11] But we are looking at disseminating across different countries, different languages. I believe it's translated into maybe 9 or 10 languages so far. And we are just at the ethics level at the moment. So, um, in Australia, professor Chris Lee in WA is, um, putting that together and I've just been collaborating with him. And hopefully, if we can get our ethics through, then perhaps sometime, I think in May, we might start the data collection. So what it involves is there's a Qualtrics survey that, uh, we will send the link out to and clinicians can pass it onto clients who may be interested to partake, and they can choose to do that in English or in one of the translated languages if that is, let's say their native language.

[00:42:04] And so I'm really excited about seeing the results of that because I mean, the Zoom meetings are quite full on because there's 40 faces on the the screen because everyone's zooming in from different parts of the country, uh, of the world. Sorry. And I just think that it was really beautiful seeing everyone there up on the screen. There was so much representation. It really made me feel invigorated and excited about the future. And so it's a project that is going to take place for so one year of data collection, then analysis, and then hopefully, uh, publication into a paper that, can be, uh, shared with the wider community.

[00:42:50] So, um, I'm just involved in a little a little way with that, but I'm really excited. And then separately, I'm hopefully going to start some of my own work in, um, disseminating schema therapy for Asian populations. If I can get everything in order for a PhD, then I would love to be able to do that.

[00:43:12] Bronwyn: So cool. And, yeah, please let us know when your survey becomes available because, yes, I would be really happy to share the links. And, yeah, it's so cool to get that dissemination of cross culturally valid, like questionnaires and the translations. Really awesome stuff.

[00:43:28] Another thing that I wanted to bring up with you from what you talked about earlier was that you mentioned that there's some research which shows that, um, um, Asian clients have a really high dropout rate. And I wondered if you knew why that was the case. Because I wanna know how I can help decrease that.

[00:43:46] Daniela: So one of the most common response from one of the papers I read is that the client did not feel that their clinician could actually understand them and could actually work with in a way that was culturally sensitive.

[00:44:02] Now, obviously, that's going to be based on the way that the questions were asked of the clients. So there may be other reasons. But, um, the other thing to consider is also that in for instance, if you're working with clients who have quite conservative views or have a very strong, I guess, Asian upbringing where their view of mental health is more of a medical model version of similar to going to a doctor. You go in, you get a strategy or, you know, you get your prescription and then you're good. You they don't see it as a long term process. And so sometimes the dropout might be that they believe that they're feeling better and that they're okay to be able to move along even though the, uh, therapist might think, oh, well you've only had 3 sessions. That's not a full treatment plan. So that might be one of the reasons.

[00:44:57] Bronwyn: How do you counter that if that is one of the reasons? Like, do you give them more guidance about, um, like, you might be feeling better, but we might need a few more sessions so we can consolidate the strategies and and prevent relapse, that kind of stuff, or do you do something different?

[00:45:13] Daniela: I think this is something that so important at the very start is when we look at, okay, what are the objectives of coming to therapy and understanding and respecting that some of these clients may actually want a shorter term focus, in which case, okay, we may only achieve psychoeducation, maybe some mindfulness, maybe some cognitive challenging and strategies on sleep or behavioral activation and that might be it.

[00:45:39] But I think it's about having that honest conversation around what to expect. And, for some clients they think, well I get 6 sessions from the doctor so then I'm done right. They don't understand, well why do I come back for a review? And I guess this is just for clients who come under a mental health care plan. So I think talking about it is important, having their commitment to therapy. So I tend to try to focus on, okay, this is a process that takes some time, this is what I've got outlined for you.

[00:46:11] So I'm very, um, upfront about my suggested treatment plan. And so they can see how I've mapped out, okay, session by session what uh, strategies and techniques I might use to meet their objectives. And then we will always know that there's a discussion or there's a session around finishing up and what it would mean afterwards. So that definitely helps.

[00:46:33] Um, coming back to your question though, I guess, you know, there are other reasons for high dropout. One of them being the stigma...

[00:46:41] Bronwyn: yeah.

[00:46:42] Daniela: ...of being seen to be receiving treatment. Because I think for a lot of clients, they go through such a battle with the idea of just coming to therapy. There's a lot of anxiety about, uh, sitting in the waiting room and just thinking about talking to someone and a sense of, you know, am I breaking, um, my family's confidentiality by coming and talking about them and is that bringing shame and dishonor to my family?

[00:47:06] Bronwyn: Wow. I hadn't even considered that.

[00:47:08] Daniela: Yeah... And one of the concerns is about even receiving a diagnosis because, um, there's a fear that if other people find out about that, that could so for some cultures they could have concerns that if you have a diagnosed mental health condition, that's going to impact whether or not your children will be able to marry because there's a thought that, oh, well, isn't it hereditary? So if I have mental health issues in the family then people are going to think less of our family because this is such a hierarchical structure... and then this concerns noone will want to marry into this family if they know that there's depression or anxiety even though these are, you know we all have histories that I I would be hard pressed to find anyone who has 0 of depression or anxiety in their family.

[00:47:58] It's, uh, it's just underreported.

[00:48:01] Bronwyn: 100 percent.

[00:48:03] Daniela: Absolutely. And we all respond to stresses. How can you not feel low if something really bad happens? Or, you know, how do we not feel anxious or scared if there's a threatening situation? We are wired as humans to respond and so I think there's there's just so much stigma attached to getting help for mental health disorders. A lot of Asian clients would prefer to think, oh, I've got you know, they'll talk about their somatic symptoms. Oh, it's I've been referred... My doctor said you can help me with my heart issues. I've seen the cardiologist, but they said it's not heart issues. Turns out they're just they're having anxiety or panic attacks. And so I think there's more acceptance of a medical, diagnosis or medical model. There's less so with, I guess, emotional well-being and mental health.

[00:48:52] Bronwyn: And if Asian clients are presenting to you with those somatic symptoms and maybe there is a high level of stigma around, uh, a mental health diagnosis for the reasons that you outlined, do you work with someone going with that medical model, uh, idea, or do you provide them with some education? Like, mental health conditions are very common. They they are recoverable. There's no shame in having a mental health problem. Many people experience them, that kind of stuff.

[00:49:23] Daniela: Yep. So I definitely proceed with caution and I probably at the start take more of a concern conservative view with, um, just gently guiding through using terminology that I feel they'll be more comfortable with and sometimes that might mean, you know, sticking to more of a medical model and then slowly weaving in psycho education, helping them understand, okay, this is, you know, your body's response. It's like, you know, your body responds to viruses and bacteria, your body responses to stresses. These there's different kinds of stresses in the environment and bit by bit I'll see. I'll test the waters I guess. We're trying to let them know.

[00:50:01] One thing that in my research that I found um, was that they in a lot of the guides and manuals around how to work in a culturally responsive way with Asian clinicians Asian clients, sorry, is that they recommended using anecdotal evidence in the sense of, oh, I've seen another client who had similar presentations and they found found X Y Z really beneficial and they were able to overcome it and that actually works quite well with Asian clients because it gives them that sense of okay well there's other people who had similar symptoms and you know what? They they didn't have to stay in therapy forever. They got treated and they're all better and I can be the same.

[00:50:43] So it's interesting, um, I think to know that, okay, well we can use, you know, general stories, you know, definitely not breaking any confidentiality to help clients go, okay. Well, someone else has had these similar symptoms and actually they're they're well, they were able to use strategies and get better and they can be on their merry way

[00:51:06] Bronwyn: That's a really good tip. Thank you for sharing that with us. I really appreciate that because, yeah, I feel like it's important to emphasize the generality. You don't wanna be like, Jane, before you.... like

[00:51:17] Daniela: Yep. That person in the waiting room. No. Exactly.

[00:51:21] Bronwyn: Yeah. It's like many people have been where you are now, and they're experiencing heart difficulties, and they've got something that we call panic attacks. And when they did 5 or 6 sessions with me when we went through this, um, model of how you can understand what's happening in your body and what's happening with your thoughts, and they saw a reduction in their symptoms. That kind of stuff?

[00:51:43] Daniela: That's right. I think that's been something that I found really beneficial and clients will get intrigued and ask, oh, you know, they might say, I tried this and I noticed that, my body started to calm down a bit. Was that what your other client found? And, you know, again, I'll still generalize, not give any specifics, but encourage them, support their that they are reporting back and knowing that they're actually trying because, compliance to therapy homework is something that I'm sure all of us struggle with whether we're early career or later because it is hard.

[00:52:19] And in particular, that's another reason why sometimes Asian clients drop out is that they will feel a sense of shame perhaps from not having done that work and they'd be more likely to cancel and think, okay, well that way I can avoid it. I guess it's a bit of an avoidant protector mode that kicks into because they haven't done their homework and they feel embarrassed or ashamed about that. So then they just cancel and they're too anxious to book back in and have to explain why.

[00:52:49] Bronwyn: How do you deal with that? Because something that I would say around that with clients who I think might skimp out on the homework is like, I'm interested in whatever happens. If you do this homework, I'm interested in what happens with it. If you don't, I'm still interested in hearing about it, and I'd really appreciate it if you came back and told me about that so we could work out maybe it wasn't as relevant or as helpful, or maybe there was another barrier that we didn't talk about today that could have gotten in the way of that. That's that's kind of something that I would say. Uh, is that is that your approach? Please say yes.

[00:53:23] Daniela: It is. Absolutely. But I also encourage clients and this is our clients of whatever back around, to be very creative. They can do it as a voice memo. They can do it as a dot points. They can do it 10 minutes sitting in the car before their session and I won't know. And that's fine. They can email dot points to me that I like, as it comes to them and then I'll just copy into their file and pull it up.

[00:53:48] And for the clients at the very start who I feel like, okay, it's a lot of effort to get them to put anything down on paper, I might actually, for their homework, give them like a recording to listen to where it might be a safe place imagery or a safety bubble or something that's a little bit more passive for them to do. It makes it a little bit easier for them to engage with.

[00:54:10] And they may have listened to it once or twice. It might be at the start a very short recording that goes for a minute or 2. Most of them find that that's manageable enough or they might only listen to 30 seconds, but they still listen to it. And so I'll build from there and if it's a lot of, um, challenge to actually do the work, then sometimes that's actually very useful, um, for an imagery session in looking at what's coming up for them.

[00:54:40] Bronwyn: Yes. So useful. Daniela, I think we're coming towards the end of our conversation, and I wanted to ask you, is there anything that we haven't touched on which you feel would be really helpful for the early career listeners listening to know about?

[00:54:55] Daniela: What I would really like early career listeners to really reflect on is even having a look at their own culture and think about, okay, based on your own cultural experience, how might you like that to be worked into therapy if you were going to therapy? How might your own experiences inform the way that you think, the way that you behave, and knowing that the person sitting across from you in the therapy room, they're just another human who has had, you know, it might be a similar cultural experience, it might be a dissimilar, but all we have to do is just ask them and understand.

[00:55:35] And I would really encourage, uh, early career psychs to pick up a journal article, a book, watch a YouTube clip, anything that helps them just start to think a little bit more broadly around how does culture impact us. And I think just from starting that thought process, it can really, really change the way that we work.

[00:55:59] And so, you know, and and don't hesitate to ask and to get support. There are some amazing clinicians and supervisors out there who would be more than happy to help support you and, like, I'm definitely always happy to have a chat to anyone if I can be of any help. It doesn't hurt to us and I think it's so important.

[00:56:22] Bronwyn: Wonderful. Thank you so much, Daniella, for coming on and sharing not only your professional insights and expertise, but your personal journey in your cultural identity and growing up has been really valuable, and I'm so glad that we're able to have this discussion.

[00:56:40] Daniela: Oh, thanks, Bron, I really appreciate it.

[00:56:42] Bronwyn: Danielle, Daniela, if listeners wanna learn more about you and your offerings and get in touch with you, where can they find you?

[00:56:48] Daniela: So what I would recommend is they head over to my website which is w w w dot project horizon, that's h o r I z e n dot com. Just a little bit of a play on words there. And because I've got a Sydney workshop in March and a Melbourne one in June. Um, I know that when you're first starting out, what the pay is like and the cost of living in Australia. So if anyone is keen to do the workshop and is currently studying or is within 2 years of gradual of 2 years since graduating, so essentially registers, I'm happy to provide a discount to make it an accessible workshop because I know workshops really rack up in terms of the finances. So all you have to do is just, um, shoot me through an email at contact at project horizon dot com and I'm more than happy to support your growth and have you partake in my workshop. So, yeah. That's how they can reach me and if anyone has any questions then feel free to ask away.

[00:57:55] Bronwyn: Wonderful. I will make sure that all of those links are in the show notes. And listeners, look, if you want I mean, the culture is gonna come in the room for all of us. Like, we all need to be competent and be culturally responsive. Right?

[00:58:08] Daniela: Absolutely.

[00:58:09] Bronwyn: Yep. So listeners, get in touch with Daniella. It sounds like she is a wonderful offering, and it sounds like it would be really valuable.

[00:58:17] And listeners, thank you so much for listening. Again, this episode was sponsored by the Australian Association of Psychologists.

[00:58:24] I hope you have a good one. Catch you next time. Bye.