Cultural Considerations for Chinese New Zealanders in Psychological Interventions

Introduction

Despite being Aotearoa New Zealand’s fourth-largest ethnic group, the experiences of Chinese patients in accessing mental health services remain poorly understood. The Chinese population in New Zealand is diverse, and was shaped by various migration waves over the past 150 years; around three-quarters were born overseas and nearly half arrived within the last decade (Chung et al., 2022; Statistics New Zealand, 2021). Evidence suggests that Chinese individuals under-use mental health services compared with non-Chinese, with this disparity exacerbated by the COVID-19 pandemic and subsequent discrimination towards the Chinese population (Chung et al., 2022; W. W. Li et al., 2021). As the New Zealand Government undertakes significant healthcare reforms, it is crucial to develop cultural competence and gain deeper insights into the experiences of Chinese patients and their whānau. However, the New Zealand Government has lagged in addressing Chinese mental health. The last comprehensive review was conducted nearly 20 years ago and academic institutions place little emphasis on this area (Chung et al., 2022). Current literature suggests that enhancing cultural understanding and competence among clinicians can significantly improve engagement and outcomes for minority groups, such as Chinese New Zealanders (Sue et al., 2009). Integrating elements of Chinese culture, such as Confucian beliefs, the concept of ‘face’ and values surrounding education in mental health interventions can provide more effective support, which will ultimately optimise mental health outcomes for this population (Chen & Davenport, 2005; Guo & Hanley, 2014; X. Xu et al., 2017).

Confucianism

Societal philosophies profoundly influence our worldview and the way we engage meaningfully with others. Confucianism is a philosophy deeply ingrained in the Chinese psyche, and emphasises familial values, social hierarchy, community orientation, achievement and respect for authority. In the context of therapy, Confucianism shapes the therapeutic relationship by reinforcing the notion of respect for authority, whereby the clinician is positioned as a figure of power (Meng et al., 2024). From a Confucian perspective, the clinician is viewed as an expert or teacher who directs the session, whereas the client often assumes a more passive role (Chen & Davenport, 2005; Meng et al., 2024). Techniques that allow clinicians to adopt a passive stance, such as reflective questioning, may inadvertently place the client in the position of the expert. These approaches should be used cautiously as they can disrupt the expected Confucian dynamic and may lead to perceptions of therapeutic incompetence if the clinician does not embody the expert role (Guo & Hanley, 2014; W. Li et al., 2017). Research has shown that clinicians who maintain a more authoritative position with Chinese clients tend to establish better rapport and achieve more favourable outcomes compared with those that do not adopt such a position (Chen & Davenport, 2005; Guo & Hanley, 2014).

Face

Another critical aspect of Chinese culture to consider in therapeutic relationships is the stigma associated with mental health. Research indicates that up to half of Chinese individuals experiencing mental illness internalise negative stereotypes, which leads to self-stigma and fear of judgement by society and family. This often results in individuals choosing to conceal their mental health struggles and preferring to confide within their family circle rather than seek professional help. To understand this stigma, it is essential to consider the Chinese concept of ‘face’ (面子; Ma et al., 2021; X. Xu et al., 2017).

Face reflects a person’s social standing, esteem, accomplishments and values. Maintaining face is crucial for fostering good relationships in a collectivistic society, which aligns with Confucian beliefs. Conversely, losing or lacking face can be devastating, and lead to consequences that range from embarrassment to social ostracism (X. Xu et al., 2017). In Chinese culture, mental health issues are often linked to the loss of face, which can be perpetuated by prejudices such as the belief that mental illness indicates poor upbringing or the Buddhist view that those suffering are paying for sins from a previous life. As a result, Chinese clients may hesitate to initiate or engage in therapy because of the fear of losing face in their communities or grappling with their own stigma-related beliefs (Z. Xu et al., 2017). For clinicians, addressing mental health-related stigma in Chinese clients can be beneficial. By doing so in a culturally responsive manner, clinicians can help reduce barriers to engagement and foster a sense of validation for their clients. This approach promotes trust in the therapeutic relationship and enhances the likelihood of positive mental health outcomes (Cheng et al., 2018; Sue et al., 2009).

Values Around Education

A third concept that can enhance cultural responsiveness in therapy is education. Historically, Chinese culture has regarded education as a pathway to a better life and social mobility. This was exemplified by the Imperial examination system during the Tang dynasty, which laid the groundwork for the contemporary Gaokao high school exam. This cultural emphasis on education suggests that Chinese clients may respond positively to psychoeducational interventions about mental health (Guo & Hanley, 2014). Providing psychoeducation about mental health disorders can strengthen the therapeutic relationship by fostering a holistic understanding of these conditions and allow the client to have a tangible outcome from the session. It allows clinicians to assume the role of an expert, thereby aligning with Confucian values that emphasise respect for authority (Guo & Hanley, 2014; Wong et al., 2016).

For example, in the case of depression, Chinese individuals often express their distress through physical discomfort, which leads them to believe they have a somatic illness during depressive episodes. This tendency may be partly attributed to the Mandarin term for depression, 忧郁 (youyu), which conveys a sense of melancholy but does not encapsulate the physical symptoms frequently reported by Chinese clients (Zhao et al., 2018). This phenomenon results in many Chinese individuals that suffer from depression first seeking medical attention for bodily pain before being referred to mental health services. Psychoeducation around mental illness can help improve awareness of differing presentation styles and allow clients to seek appropriate help and interventions. This underscores the importance of emphasising education in therapeutic settings, as it aligns with Chinese cultural values and helps build trust in the clinician by allowing them to fulfil the role of an expert consistent with Confucian principles (Chen & Davenport, 2005; Guo & Hanley, 2014). By effectively communicating with and educating clients about mental health, clinicians can enhance engagement and improve treatment outcomes.

Conclusion

Being a client in therapy is an inherently vulnerable experience, and establishing a strong therapeutic relationship with the clinician is crucial for achieving positive outcomes (Stubbe, 2018). The New Zealand Chinese community has faced significant challenges since the COVID-19 pandemic, yet the New Zealand Government’s response has been inadequate. It is essential to recognise that the Chinese population is not monolithic; rather, Chinese New Zealanders share a unique cultural history that influences their worldview, and each individual does so to a different extent (Chung et al., 2022). Concepts such as Confucianism, the notion of ‘face’ and the emphasis on education merely scratch the surface of this cultural complexity (Chen & Davenport, 2005; Guo & Hanley, 2014; X. Xu et al., 2017). For psychologists, integrating these elements (as appropriate) in therapeutic practices is vital for improving mental health outcomes. Doing so allows practitioners to create a more culturally responsive environment, fostering trust and engagement with clients.

Implications for Practice

Understanding Confucian values can guide clinicians in navigating the dynamics of authority in the therapeutic relationship for Chinese New Zealanders, thereby enhancing the sense of safety and respect that clients may seek (Chen & Davenport, 2005). In addition, recognising the significance of ‘face’ can inform how clinicians approach discussions around mental health, and reduce the stigma that clients may feel (X. Xu et al., 2017). An emphasis on education is also critical; by providing clients with knowledge about mental health conditions, clinicians can empower them and validate their experiences, thereby aligning with cultural expectations (Guo & Hanley, 2014). Ethically, prioritising clients’ cultural context is a clear imperative for their well-being, as it demonstrates a commitment to understanding their unique backgrounds and experiences (Sue et al., 2009).

Declaration of Conflicting Interests

The author has declared no potential conflicts of interest with respect to the research, authorship and publication of this article.

Funding

The author received no financial support for the research, authorship or publication of this article.