An Asian American Student’s Reticence

Ms. C was a 24-year-old single Asian American female medical student who was born in the Philippines and who immigrated with her family to the United States when she was 6 years old.

Throughout high school and college, Ms. C had coped with her public speaking anxiety by avoiding it. Knowing that avoidance would no longer be possible when she would be required to give presentations on hospital rounds, she knew that it was time to seek help.

Ms. C stated that her anxiety about speaking in class was so severe that, to the best of her recollection, she had never done it. She feared that professors and peers would call her stupid and that they would humiliate her, make her an outcast, and eventually ostracize her from school. Sometimes she would become so anxious she would feel dizzy.

She had known since her early college years that she had a problem. However, she postponed seeking help in order to focus on getting good grades so that she could be admitted to medical school. She reached her objective, but during her first semester there she became so disturbed about her public-speaking anxiety that she stopped attending classes. She felt extremely depressed and hated herself. She felt lethargic, slept too much, and had frequent crying spells. At one point she did not leave her home for 2 weeks. There were no thoughts of suicide, but this was the first time Ms. C had been so depressed that it interfered in a significant manner with her functioning. These symptoms resolved spontaneously within 8 weeks while Ms. C was on a Christmas vacation.

During the second semester Ms. C decided to seek help, realizing that in order to complete medical school she would need to speak in front of others. She was especially concerned that during her third year she would need to make presentations regularly in different settings and practically all the time. She went to the Student Counseling Center and requested help, stating that she preferred to be seen by a female Asian American clinician. She felt that an Asian American might have an understanding of the aspects of her personality and values that she attributed to her Asian cultural upbringing. She also felt that an Asian American therapist would be less likely to see her problems as weird.

At the time of the evaluation, her depressive symptoms and crying spells had resolved and her energy and sleep patterns had returned to normal. However, her anxiety about speaking in class and her low self-esteem related to this matter remained unchanged. In addition, Ms. C complained of other related problems, such as difficulty in asserting herself in laboratory groups, especially when it would involve contradicting classmates. For example, during one laboratory assignment, Ms. C’s group had decided to proceed in a manner that she knew would fail. However, she could not bring herself to tell them. After her group had gone through multiple failures, Ms. C finally expressed her ideas on how to handle the project. They followed her suggestions, and their next attempt was successful. According to Ms. C, she would never want to assume a leadership position from the start. However, if for some reason it was necessary for her to do so, then she would do it for the good of the group.

Ms. C also experienced anxiety in a variety of other social situations. She envied the way some of her classmates would have casual conversations with her professors. Whenever she would see a professor by chance at school, she would either go to great lengths to avoid him or her, or she would make a quick greeting and then scurry away. Ms. C realized that she felt especially uncomfortable in small groups led by a male professor, and she wished she could “chum” with her professors the way her classmates did. At lunchtime, she usually ate with one of her classmates, another Asian American woman. When this classmate was unavailable, she ate alone, all the while feeling anxious about others observing her doing so. Ms. C would join others only if asked, since she would not want to intrude upon them otherwise. A similar anxiety would occur at parties, when she would be very anxious about socializing. She would sit with her boyfriend and join others only when asked. Often she would go home wondering why she bothered to go to parties.

This was Ms. C’s first contact with a mental health care professional. Actually, it can be said that her past psychiatric history weaves into the history of her present illness.

Ms. C had no significant medical history, was taking no medications, and had no known drug allergies.

Ms. C used alcohol rarely, and she had never tried any illegal substances.

Ms. C was born in the Philippines and moved with her family to the United States when she was 6 years old. She was the youngest of four children. Her father, a man in his late fifties, worked as a supervisor in a local government agency. Her mother, a woman in her early fifties, worked in a factory. Ms. C had three older siblings: two sisters and a brother. All were within 6 years of her age, were college graduates with some graduate education, and had successful professional careers. Their father had decided that the family should emigrate to the United States, as he thought opportunities for his children would be greater. The family had moved to a suburban community in California and had lived there ever since.

Adjusting to life in the United States was difficult for Ms. C’s father, who started drinking heavily and became irritable at home. Ms. C recalls once asking at the dinner table how to say a certain word in Tagalog. Her father became angry that his children had forgotten how to speak Tagalog and raged that from then on, only Tagalog could be spoken in the house. After he left the dinner table, her siblings criticized her for having asked this question. At another time she asked her father to help with her homework. He became angry and called her stupid. She never asked him for help again. In retrospect, she realized that he had probably felt inadequate to help her and that he was being defensive. She suspected that her relationship with her father might be related to her anxiety about speaking in class.

Her mother was a nurturing and consistent figure in the family’s life. She would often dissipate her husband’s anger and smooth over potential or actual conflicts. Her devotion to her family was illustrated in one of Ms. C’s recurring dreams. In this dream, Ms. C and her mother would hide behind the living room sofa, dodging enemy gunfire. Sometimes her mother would leave their sofa foxhole to walk toward the kitchen. She would get shot, and Ms. C would run out and hold her bleeding mother in her arms. Then her mother would get up and continue toward the kitchen to prepare dinner for her family. This scenario would repeat itself continuously.

Ms. C states that her parents put pressure on her oldest sister to go to medical school and become a doctor. However, she did not excel enough academically and became a pharmacist instead. Ms. C stated that she did not believe the other children underwent the same parental pressures as her oldest sister did. All, however, were far better educated than their parents.

Ms. C lived at home during her first 2 years of college, then transferred to a more prestigious university away from home for the remainder of her studies. As another sister lived near the university, Ms. C moved in with her. They shared cooking and cleaning chores. At the time of presentation, Ms. C had never lived independently.

Ms. C had met her boyfriend when they were both age 16. He was Caucasian American, and they attended the same high school. Following high school, he worked in the computer field; he had never attended college. According to Ms. C, this discrepancy in their educational levels was disturbing to him but not to her. They had a supportive relationship, and Ms. C found him comforting when she felt distressed about her difficulties at school.

Ms. C felt guilty about having moved away from home even though she recognized the necessity for it. She worried that her parents were lonely and sad without their children at home, particularly as she was the last child to leave. She and her sister had frequent contact with their parents by phone and visited them almost every weekend. Often these visits would occur when their mother asked them to come home and do domestic chores. Ms. C believed her mother used the chores as a way of asking her children to visit and that the chores themselves were not important. This was a source of conflicting feelings for Ms. C: as she became busier with medical school, she felt increasingly burdened by visiting her parents so regularly. When she began her clinical rotations, she would have few free weekends, and she did not want to spend them working at her parents’ home.

During the first summer of medical school, Ms. C did research as part of a fellowship she had earned. Other than this, she had never been employed and was financially supported by her parents.

Ms. C’s parents had met and married in the Philippines, where her father belonged to a large family working mostly in manual and field labor. His family considered him unusual because he felt education was important, and when he earned his bachelor’s degree, his family failed to attend his graduation. According to Ms. C, the desire for his children to be educated was a main factor in her father’s decision to emigrate.

When Ms. C’s family came to the United States, her father became separated from relatives and lifelong friends. According to Ms. C, her father was popular and well connected in the Philippines. Whenever he returned to visit, there would be many parties welcoming him. Through his government connections he was able to help relatives get jobs in the Philippines, even though he lived in the United States. In the Philippines, her father often drank socially with groups of male friends, but in the United States he no longer had this group of friends, so he drank alone. Ms. C recalls him drinking shots of hard liquor in the morning, before afternoon naps, and after dinner. She believed that all the men she knew in the Philippines drank but that the stresses of dislocation probably caused her father to drink more heavily and even excessively. He had no history of treatment for this drinking problem.

While her family lived in the Philippines, her older brother was treated by a “witch doctor.” He was about 10 years old, and it was believed that he was possessed. Ms. C remembered her mother burying items beneath a mango tree as part of his treatment. In adulthood, her brother underwent psychotherapy in the United States. However, Ms. C did not believe that he was treated with medication. She did not know the nature of the symptoms for which he sought treatment.

A review of systems revealed only the dizziness that often accompanied her anxiety episodes.

The physical examination was deferred, because Ms. C was seen as an outpatient and because she had no significant medical history or physical complaints.

Ms. C was a petite woman who looked younger than her age. She was always neatly groomed and wore casual, inconspicuous clothing, such as jeans and shirts in shades of brown and tan. She wore glasses with large plastic frames that hid her face. She wore no makeup. She appeared anxious in the first interview, but in subsequent sessions she showed a more relaxed demeanor. Her speech was of normal rhythm, rate, and volume. She was articulate and quite verbally expressive.

Ms. C described herself as usually being a happy-go-lucky person and denied any chronic mood symptoms. Indeed, she was usually bright, cheerful, and congenial, but she expressed self-deprecating feelings in regard to her inability to speak in class. Her thoughts were coherent and of normal form and content. There was no history of psychotic symptoms and no history of suicidal ideation. She was alert, with a clear sensorium, and seemed to function at a high intellectual level with good cognitive abilities. Memory and ability to abstract were excellent. She had a good fund of knowledge and appeared to have excellent judgment. She also appeared to have a good amount of psychological insight.

At the time of evaluation, there were no vegetative symptoms of depression such as sleep or appetite disturbance, nor were there symptoms consistent with a history of mania, such as periods of increased energy or decreased need for sleep.

Ms. C functioned at a high level and had earned good grades and a fellowship in medical school. Socially, she also functioned well, having supportive relationships with her family and her long-term boyfriend. Her social anxiety, however, interfered with her performance at school as well as with relationships with peers. In the context of medical school, there was a significant impairment whenever she was required to speak in front of others.

Routine laboratory values were within normal limits. They included thyroid function tests, complete blood count, electrolytes, liver function tests, and urinalysis.

Under the conventional DSM-IV-TR diagnostic system, Ms. C met full criteria for the diagnosis of social phobia: her anxiety about speaking in front of others, her fear of negative evaluation, her own recognition that her fear was excessive, the anxiety interfering with her performance in medical school, the persistence of this anxiety for all of her years of schooling, and her avoidance of anxiety-provoking social situations such as speaking in class.

Other anxiety disorders were considered and excluded, as her anxiety was limited to social performance situations. She experienced dizziness but no other physical symptoms of anxiety. Therefore, she did not meet criteria for panic attacks or panic disorder. There was no clear history of trauma, which would be essential for the diagnosis of post-traumatic stress disorder. In fact, she seemed to have managed appropriately her father’s unpredictable behavior, even though she attributed at least part of her anxiety symptoms to such factor.

The diagnosis of adjustment disorder with anxious and depressed mood was excluded because of the long-standing nature of Ms. C’s problem. Before the evaluation, Ms. C had undergone an episode of depression, which lasted less than 8 weeks and which prevented her from attending class or even leaving her home for 2 weeks. This episode had apparently resolved spontaneously.

Other mood disorders were considered. Ms. C had never experienced symptoms consistent with mania. The possibility of chronic dysthymia was also dismissed, since her discontent was limited to school-related performance situations. On weekends, she enjoyed herself with her boyfriend, friends, and siblings.

There was no evidence of a personality disorder. Her avoidance was limited to social performance situations, and she never avoided school or family responsibilities. She had a stable relationship with her boyfriend of 8 years.

Treatment consisted of weekly psychotherapy, which addressed issues of adjustment and focused most prominently on Ms. C’s social phobia symptoms as the most pressing issue. Cognitive-behavioral techniques targeting social phobia symptoms as well as psychodynamic approaches to exploring adjustment issues were employed. Through the course of cognitive-behavioral therapy, Ms. C realized that her automatic thoughts consisted of cognitive distortions, such as jumping to conclusions that she would be criticized, seeing things through a mental filter portraying everything in a negative light, and catastrophizing: thinking that small errors would result in far-reaching consequences, such as failing school and being ostracized by her peers. Ms. C began to recognize her cognitive distortions; she began to make brief comments in class and to be able to participate in small-group discussions. However, she still had significant anxiety about speaking up in front of larger groups.

Ms. C’s treatment became urgent when she was asked to present her summer research project at a national conference. She realized that this was an honor, since most presenters would be faculty, and few students were invited. However, the prospect of standing next to her poster and answering questions for several hours seemed insurmountable. In addition, she was anxious about traveling alone to an unfamiliar city. In the past when had she traveled alone, she had avoided contact with people and isolated herself in her hotel room. She strongly considered refusing the invitation.

At this point, antianxiety medications were discussed. Ms. C agreed to a trial of propranolol, 10 mg po before social performance situations. Her first use was during a lecture in a large classroom. To her surprise, when she thought of a question, she quickly raised her hand and asked it. Her question was well received, and classmates complimented her afterward.

She attended the conference. With the use of propranolol, she presented her poster without difficulty. She also enjoyed a party without her usual anxiety and reticence. She went to a restaurant and enjoyed eating lunch alone. At another point, she telephoned student presenters from other medical schools and organized an outing. Toward the end of the conference, she volunteered to participate in a panel discussion and did so without the use of propranolol. Ms. C returned home satisfied that not only had she successfully presented her research, but that she had made new friends.

When she returned to school, she continued to participate regularly in classes without the use of the medication. When clinical rotations began, Ms. C started with 8 weeks of surgery. She completed the clerkship, regularly made presentations, and tolerated critical remarks from surgery attendings and house staff.

From the cultural perspective, Ms. C also resolved many issues with her family during the course of treatment. She realized that her inner turmoil about how much time she should spend with her family constituted retaining Filipino cultural ideals, but living in the reality of American culture. She realized that in the Philippines village where her family had lived, children would usually grow up and build homes in the same neighborhood as their parents. This would result in large extended family networks that had frequent contact. She realized that in the United States, most families lived differently, and children usually moved away from their parents. Moreover, given her situation, it would not have been possible for her to meet the same family expectations as she would if her family still lived in the village. She informed her mother of this insight and her mother received it well, pleased that Ms. C had been so concerned for the happiness of her parents.

At times the therapist tried to bring up other issues of culture with Ms. C. However, she usually seemed reluctant to discuss them. This was interpreted not as denial or avoidance but as her reticence about engaging in a discussion that seemed artificial. Just as a therapeutic dyad of Caucasian American therapist and patient would not need to dwell on issues of American culture, this therapeutic dyad did not need to overemphasize culture: cultural understanding was implicit during the sessions. However, the therapeutic relationship benefited from common understandings. For example, as an Asian American, the therapist was able to empathize with Ms. C’s predicament about her loyalty to her parents, as well as her ambivalence in social situations.

When the decision to terminate therapy was made because Ms. C was beginning her busy clerkship year and because the therapist was planning on relocating to another state, the therapist asked Ms. C if she would like the therapist’s new phone number should Ms. C need help. She declined. Instead, she requested a prescription for a small quantity of propranolol, which she had not used in approximately a year. Asking for the medicine was symbolic of Ms. C’s desire to seek support only if she needed it. The therapist gave her the prescription and also the new phone number, understanding that Ms. C had originally refused it out of pakakisama, and perhaps even out of respect for the therapist as an elder, as well as her desire to not impose herself. Perhaps Ms. C thought that the therapist had originally offered the phone number also out of pakakisama and politeness. Later, however, she understood that the therapist’s offer was heartfelt, and she took the phone number eagerly and appeared relieved. This type of exchange is typical among Asians and Asian Americans: one person may make an offer; the other refuses out of politeness. A round (or often several rounds) of offers and polite refusals will ensue as the two parties feel each other out. Each round allows the parties involved to discover empathetically what would be in the best interest of both involved. Each offer and refusal is highly symbolic, and more is at stake than simply goods or services. Each offer and refusal is an expression of one’s desire to think of the other’s welfare and to anticipate the other’s needs. The good of the group is valued over an individual’s wants. The wants of one person are not separable from the wants of others. A quite typical Asian and Asian American view is that what is best for the group is ultimately what is best for the individual as well.

The following is a discussion of three values (face, respect for elders, and group-oriented thinking) common to many Asian and Asian American cultures. These values should be taken into account whenever the diagnosis of social phobia is considered in an Asian American patient. An assessment of other clinical and cultural issues of the case will follow.