Coping as a Mediator Between Losing Face and Depressive and Social Anxiety Symptoms Among Asian Americans

Abstract

Applying the proximal–distal framework, we were interested in whether the relationship between loss of face (LOF) concerns to depression and social anxiety were mediated by coping among 154 Asian Americans (AA). Utilizing a convenience sample from an online survey of AA, we ran ordinary least squares (OLS) regressions to examine whether direct and indirect coping explained the relationship between LOF concerns, depression, and social anxiety. LOF was positively associated with both direct and indirect coping. LOF also was positively associated with depression and social anxiety. The relationship between LOF and depression was significantly mediated by indirect coping but not direct coping. Higher levels of indirect coping explained the relationship between LOF and depression. In addition, the relationship between LOF and social anxiety was significantly mediated by indirect coping and direct coping. The relationship between LOF and social anxiety was partially explained by lower levels of direct coping and higher levels of indirect coping. LOF, however, continued to significantly predict social anxiety even after accounting for coping strategies. These results suggest that the LOF has a distal relationship to depression and social anxiety. Coping has a more proximal relationship to depression and social anxiety. By identifying proximal factors to depression and social anxiety, it is possible to reduce symptoms of depression and social anxiety among AA without mitigating the endorsement of traditional cultural values.

Keywords

coping face concerns depression social anxiety Asian Americans

Introduction

By promoting behaviors that maintain in-group harmony, Asian cultural values serve an important function in collectivistic cultures. In particular, concern for losing face or the Asian value of loss of face (LOF), is an important protective factor against antisocial behaviors (Hall, DeGarmo, Eap, Teten, & Sue, 2006; Hall, Teten, DeGarmo, Sue, & Stephens, 2005). Despite the importance of LOF to Asian cultures, LOF is associated with depression and social anxiety among Asian Americans (AA; Lau, Fung, Wang, & Kang, 2009; Zane & Yeh, 2002). LOF fosters a greater concern for the needs of others over the needs of the individual. In an individualistic context, AA may experience higher levels of distress because LOF is inconsistent with the broader milieu. In spite of this inconsistency, LOF can be an important cultural strength among AA. As such, it is important to maintain LOF’s protective mechanisms while mitigating its negative psychological effects.

Using Sue and Zane’s (1987) proximal–distal model, which explains that culture’s influence can be understood according to a hierarchy of predictors, it is possible to alter the relationship between LOF and psychological distress by targeting coping. There is currently little research on how LOF is related to coping. Although there is some evidence that LOF is associated with a lack of social support seeking (Taylor, Welch, Kim, & Sherman, 2007) and treatment seeking (David, 2010), this conceptualization narrowly examines how LOF is associated with coping. The current study is interested in applying the proximal–distal model to (a) identifying the relationship between LOF with indirect and direct coping. Indirect coping is a coping behavior where individuals attempt to manage their distress by changing the self rather than changing or acknowledging the stressor (W. M. Liu & Iwamoto, 2007). For instance, indirect coping behaviors include behavioral disengagement or substance use. The opposite is true in direct coping. Individuals manage their distress by actively changing or acknowledging the stressor. For instance, direct coping behaviors include problem solving or seeking social support. The study is also interested in (b) examining whether coping responses may explain the relationship between LOF, depression, and social anxiety.

Proximal–Distal Model of Understanding Culture

Sue and Zane (1987) proposed a proximal–distal model to understanding the effects of culture on psychotherapeutic processes. A proximal–distal framework posits that culture’s influence on outcomes can be organized according to the distance between the explanation and the outcome. Cultural values and knowledge are considered distal factors, or factors that are further away from the goal or outcome. Cultural values often are explained in a way that is disconnected from specific processes. Sue and Zane (1987) pointed out, for example, that in psychotherapy recommendations there tends to be emphasis on applying cultural knowledge to the psychotherapeutic process with the assumption that such an application leads to a greater understanding of the client’s internal experience. This explanation, however, neglects concrete ways in which cultural knowledge is tangibly related to outcomes.

Although the proximal–distal model has mainly been applied to understanding the effects of psychotherapy, the framework can be generalized to a broader range of psychological processes. Applied to the current study, LOF may be related to depression and social anxiety, but the relationship is explained by how AA manage their distress. LOF does not automatically lead to depression or social anxiety. If this were the case, LOF may not have persisted as an important cultural motivator. LOF’s influence is manifested through a particular process or behavior, such as coping. LOF may be considered a distal explanation to depression and social anxiety while coping may be a more proximal explanation. Concern for LOF is considered to be more distal because the model predicts that it is further from predicting the outcome than coping, which is considered to be closer to the outcome of interest. Previous studies have identified coping as a possible proximal variable that explains treatment response among AA (J. E. Kim, Zane, & Blozis, 2012). Variables that are more proximal to the outcome are also more malleable, suggesting that AA may be able to negotiate their cultural values within a different cultural context without compromising their psychological health.

Losing Face

Face concerns haves roots in Chinese culture, even though its fundamental tenets may describe universal concerns (Ho, 1976). LOF describes the failure of an individual to meet obligations placed upon him or her by members of his or her in-group (Zane & Yeh, 2002). Losing face implies that one has shamed members of his or her family through one’s actions. Face concerns differ from Western concepts of shame or embarrassment because it extends beyond the individual and affects members of one’s in-group. The shame associated with one’s actions is due primarily to how one’s behavior reflects upon his or her family and extended family, not necessarily due to how the behavior reflects upon the individual. The idea of face is to maintain social harmony. The members of one’s in-group may discourage any behavior that does not contribute to social harmony and may apply implicit pressure for in-group members to conform.

There are individual variations in the degree that AA endorse LOF. Research suggests that LOF influences a range of psychological constructs, such as personality and behavior. Eap et al. (2008) found that LOF is negatively associated with extraversion, openness, and conscientiousness and positively associated with neuroticism. The Chinese Personality Assessment Inventory (CPAI) has conceptualized face concerns as a dimension of personality (Cheung et al., 1996). Face concerns also are included in measures of Asian values (B. S. Kim & Hong, 2004). Given the importance of face concerns to people of Asian descent, researchers should seek to understand its role in affecting a range of psychological experiences.

Face Concerns and Psychological Distress

Although some epidemiological studies using interview methods suggest that AA function better psychologically relative to other ethnic groups (Alegria et al., 2004; Takeuchi, Hong, Gile, & Alegría, 2007), self-report studies suggest that AA report higher levels of social anxiety (Okazaki, Liu, Longworth, & Minn, 2002) and depression (C. Y. Lam, Pepper, & Ryabchenko, 2004; Okazaki, 2000) relative to other ethnic minority groups in the United States. The elevated levels of social anxiety and depression reported by AA may be influenced by cultural variables. LOF, for instance, is positively associated with greater levels of psychological distress among AA (Mak & Chen, 2006; Mak, Chen, Lam, & Yiu, 2009; Zane & Yeh, 2002). Okazaki (1997) pointed out that people with an interdependent self-construal, which is characteristic of people from Asian cultures, base their self-worth on social acceptance by others. As such, one is more likely to be sensitive to social cues that may indicate social rejection. In addition, LOF may lead to higher levels of reported social anxiety because LOF causes heightened sensitivity to other people’s emotional responses. On the other hand, social anxiety experienced by Asians living in North America may not necessarily be directly due to cultural values but rather is the result of the cultural discrepancy between Asian and American cultures (Hsu et al., 2012). Even in cross-cultural studies that compare Asians living in Asia with AA, however, Asians tend to report higher levels of social anxiety than other cultural groups (Hong & Woody, 2007; Okazaki, 2000), suggesting that cultural discrepancies do not entirely explain the higher levels of social anxiety among AA. Lau et al. (2009) found that ethnic differences between AA and European Americans on social anxiety were explained primarily by greater concern with LOF. They also found that, despite the greater emotional attunement concerns found in Asian culture relative to mainstream culture, AA were less accurate at detecting the emotional experiences of others. AA, then, might be able to reduce their social anxiety by utilizing cognitive restructuring—a form of direct coping—in social situations rather than changing their cultural tendency to be emotionally attuned (Lau et al., 2009). This suggests that coping may be an effective strategy for AA to negotiate their cultural values with that of mainstream culture.

Although LOF may put one at increased risk for depression and social anxiety, it can also function as a protective factor against antisocial behaviors, such as sexual aggression (Hall et al., 2006; Hall et al., 2005). Asian values, which include face concerns, may lead to positive psychological outcomes such as collective self-esteem (B. S. Kim & Omizo, 2005), decreased risk-taking, and alcohol use (Liu & Iwamoto, 2006). Given the cultural strengths afforded by concern for LOF, understanding how LOF relates to coping provides a possible mechanism for mitigating psychological distress without reducing cultural strengths.

AA and Coping

Coping can be categorized in a number of different ways. The tendency to confront a problem by actively attempting to change the problem and/or acknowledging it has been described as a form of direct coping (e.g., W. M. Liu & Iwamoto, 2007), engagement coping (e.g., Wong, Kim, & Tran, 2010), reflective coping (e.g., Wei, Ku, Russell, Mallinckrodt, & Liao, 2008), primary coping (e.g., A. G. Lam & Zane, 2004), and approach coping (e.g., Yoo & Lee, 2005). The tendency to cope by changing oneself or by not directly addressing the problem has been described as indirect coping (e.g., W. M. Liu & Iwamoto, 2007), suppressive coping (Wei et al., 2008), disengaged coping (e.g., Wong et al., 2010), secondary coping (e.g., A. G. Lam & Zane, 2004), and avoidant coping (e.g., Yoo & Lee, 2005).

The predominant coping utilized by AA is unclear. Some studies suggest that AA underutilize direct coping relative to European Americans (Chang, 1996; Taylor et al., 2004), while others found AA to engage direct coping as frequently as other ethnic groups (Lee & Liu, 2001). These inconsistencies may be a function of within-group differences. Coping responses may be influenced by cultural value systems that may vary among AA.

LOF and Coping

Previous studies have found differences between AA and European Americans on coping (e.g., H. S. Kim, Sherman, & Taylor, 2008). Although research on culture and coping is growing, less research is available on how culture is related to coping (Heppner, Wei, Neville, & Kanagui-Muñoz, 2014; Kuo, 2011). Face concerns may lead AA to utilize some coping behaviors over others. A. G. Lam and Zane (2004) suggested that AA are less likely to rely on primary coping (e.g., altering their environment) and are more likely to engage in secondary coping (e.g., changing themselves) because of the cultural importance placed on accommodating to one’s environment. Wong et al. (2010), for example, found that a high level of endorsement of Asian values was associated with higher levels of disengaged coping and lower levels of engaged coping.

LOF may explain the relative underutilization of explicit social support among AA (Taylor et al., 2004; Taylor et al., 2007). LOF affects other coping behaviors but the direction of the effect is mixed. Zane, Umemoto, and Park (1998) noted that AA with a high degree of face concerns were less likely to self-disclose (as cited in Mak et al., 2009) and David (2010) found that Filipino Americans with higher levels of LOF had more negative attitudes toward seeking psychological help. On the other hand, there is also research to suggest that a high degree of concern with losing face was related to a more positive attitude toward seeking mental health treatment among AA college students (Leong, Kim, & Gupta, 2011).

Given the discrepant relationship between LOF and help-seeking behaviors, it is important to clarify how LOF affects the different forms of coping behaviors. There can be a broad range of coping behaviors in one’s repertoire. Failing to engage in one type of coping does not preclude one from effectively managing one’s psychological distress. Many studies also did not examine the relationship between coping and distress, making it difficult to discern whether AA were able to effectively cope without seeking out social support or seeking treatment. It is possible that LOF concerns motivate AA to actively seek out solutions to their problems without burdening members of their in-group. Although the research assumes that AA high in LOF are less able to cope with emotional distress, no studies have examined LOF’s relationship to other forms of coping.

The Current Study

AA must navigate multiple cultural worlds. A variety of research has demonstrated a relationship between LOF, social anxiety, and depression. There also is evidence that AA are more likely to utilize ineffective coping behaviors, such as avoidance or denial, relative to other ethnic groups, potentially making them more vulnerable to the effects of psychological stress. Lau et al. (2009) also found that LOF could explain ethnic differences between AA and European Americans on social anxiety. Given the evidence that there are ethnic differences between AA and European Americans on coping, LOF, social anxiety, and depression, we chose to focus on AA for the current study. Because AA are examined as a group, it is also important to explore whether there are within-group differences among AA on the research constructs. AA constitute a diverse group who may share cultural similarities but also may exhibit within-group variability. The process of acculturation for AA may reduce some of the cultural discrepancy that lends itself to greater distress, but there is also a potential loss in cultural protective factors. Coping may potentially play a mediating role between LOF and distress. If coping did function as a mediator, it would suggest that coping can be a potential target for treatment rather than modifying the degree to which individual’s prescribe to traditional cultural values, which may have iatrogenic effects for other aspects of psychological functioning. Applying the proximal–distal model, our study predicts that the association of LOF with social anxiety and depression can be explained by direct and indirect coping.

Method

Procedures

The study’s procedures were approved by the University Institutional Review Board (IRB). The data for the current study were collected from a separate study comparing European Americans and AA on trauma disclosure (Foynes, Platt, Hall, & Freyd, 2014). Participants were recruited through ads posted on Craiglist in major metropolitan cities (e.g., New York City, Los Angeles, San Francisco, San Diego, Honolulu, Chicago, Houston, and Seattle) with large AA populations. The first 100 participants were compensated with a $10 gift certificate to an online bookstore, and the rest of the participants were entered into the lottery to receive a $25 gift. People were directed to fill out the measures online through a website. For further study details on the recruitment of study participants, please refer to Foynes et al. (2014).

Participants

For the purposes of this study, we included only those participants who indicated they were AA (N = 154). No measure used in the current study was previously reported. Self-identified AA included Chinese (n = 68), Filipino (n = 14), Indian (n = 13), Japanese (n = 15), Korean (n = 15), Vietnamese (n = 9), “Other” AA (n = 8), and mixed AA (n = 7). Three participants did not report their specific Asian identity. Although AA from other regions of Asia may endorse many of the same values as those measured in East Asian cultures, there are also within-group AA cultural differences (B. S. Kim, Yang, Atkinson, Wolfe, & Hong, 2001). These differences are even observed between cultures that share a strong Buddhist and Confucian tradition (B. S. Kim et al., 2001). For this reason, a between-group analysis was conducted to assess for differences between AA subgroups. Due to the small sample size of the other AA subgroups, a preliminary analysis was conducted assessing for differences between Chinese American subgroups and other AA subgroups. Informed consent was obtained from all participants under an IRB-approved protocol.

The mean age of the sample was 27.6 (SD = 7.67). Seventy percent identified as female (n = 112). The participants were highly educated with 114 participants of the sample having at least a college degree (74%). Participants were specifically asked to specify the person who was the first in the family to immigrate to the United States. One hundred ten people identified as being first generation or second generation by reporting that either they (n = 10; 6.5%) or their parents (n = 101; 65.6%) were the first to immigrate to the United States. Twenty-eight identified as third generation by identifying that their grandparents were the first to immigrate to the United States (18.2%), 10 identified as fourth generation or above by identifying that their great-grandparents were the first to immigrate to the United States (6.5%), and five participants are of an unknown generational status because they identified someone other than the specified categories as being the first to immigrate to the United States (3.2%). People in this category may have had a sibling or a distant relative immigrate to the United States. Thirty-nine (25%) reported being born outside the United States.

Measures

Direct and indirect coping

Coping was assessed using Cope Inventory–Short Form (Carver, 1997). Direct coping was operationalized as coping that directly acknowledges and addresses the problem. Direct coping was comprised of the mean of seven subscales: Positive Reframe, Active Coping, Planning, Acceptance, Emotional Support, Religious Coping, and Instrumental Support. Indirect coping was operationalized as coping that is avoidant in nature and is not considered proactive. Indirect coping was comprised of the subscales Self-Distraction, Denial, Substance Use, Behavioral Disengagement, Venting, and Self-Blame. The internal consistency for indirect coping was α = .86 and α = .90 for direct coping. People were asked to rate on a 4-point Likert-type scale ranging from 1 (I haven’t been doing this at all) to 4 (I’ve been doing this a lot) to statements such as “I’ve been trying to get advice or help from other people about what to do,” “I’ve been trying to come up with a strategy about what to do,” and “I’ve been saying to myself ‘this isn’t real.’” Previous studies have demonstrated adequate validity for each subscale of the Brief Cope. For example, Yusoff, Low, and Yip (2010) found evidence of discriminant validity for active coping, planning, and acceptance coping in distinguishing between female breast cancer patients who received a mastectomy versus a lumpectomy. Meyer (2001) found evidence of concurrent validity for adaptive coping among a sample that included patients with severe mental illness. Adaptive coping was significantly positively correlated with psychological well-being and positive social functioning.

To establish content validity, this study replicated the two factor model of coping suggested by Lee and Liu (2001) and W. M. Liu and Iwamoto (2007). However, the factor analyses were conducted using the subscale mean scores instead of the individual items for the sake of parsimony and to reduce the amount of possible shared variance between items. A principal component extraction with varimax rotation was conducted on all 14 subscales (Emotional Support, Self-Distraction, Acceptance, Denial, Substance Use, Instrumental Support, Behavioral Disengagement, Venting, Positive Reframe, Planning, Humor, Religious, Self-Blame, and Active Coping) to see whether an a priori two factor solution fit the data. Factor 1 (direct coping) accounted for 39.6% of the variance. Factor 2 (indirect coping) accounted for 13.9% of the variance. The factors loaded similarly to Liu and Iwamoto with a few exceptions. Humor did not clearly load onto any factor and was removed from the final calculation. Direct coping consisted of the mean of six subscales. Indirect coping consisted of the mean of seven subscales (see Table 1).

Table 1.

Principle Component Analysis With Varimax Rotation for the Brief Cope (N = 154).

Subscales	Factor 1	Factor 2	M (SD)	Range
Indirect Coping			4.03 (1.17)	2-8
Self-Distraction	.729		5.27 (1.83)	2-8
Denial	.801		3.35 (1.60)	2-8
Substance Use	.729		5.27 (1.83)	2-8
Behavioral Disengagement	.676		3.53 (1.68)	2-8
Venting	.660		4.58 (1.52)	2-8
Self-Blame	.612		4.28 (1.61)	2-8
Direct Coping			5.10 (1.24)	2-8
Emotional Support		.701	4.82 (1.65)	2-8
Acceptance		.741	5.34 (1.66)	2-8
Positive Reframe		.703	5.27 (1.65)	2-8
Planning		.786	5.67 (1.71)	2-8
Active Coping		.728	5.79 (1.73)	2-8
Religious Coping		.503	4.12 (1.90)	2-8
Instrumental Support		.703	4.70 (1.68)	2-8
Other
Humor	.364	.349	3.96 (1.62)	2-8

Note. Bolded numbers indicate the strongest factor loadings for each sub-scale.

LOF

The LOF scale assesses the degree to which respondents are sensitive to preventing a threat or loss to one’s social integrity, which is a dominant construct describing social relationships in Asian cultures (Zane & Yeh, 2002). Participants respond on a 7-point Likert-type scale ranging from 1 = strongly disagree to 7 = strongly agree to 21 items, such as “I am more affected when someone criticizes me in public than when someone criticizes me in private,” “I try to act like others to be consistent with social norms,” “I downplay my abilities and achievements so that others do not have unrealistically high expectations of me,” and “I try not to do things which call attention to myself.” In the current study, Cronbach’s alpha was .92. Participant scores can range between 21 and 147, with higher scores indicating a greater concern for LOF. Scores for the current AA sample are comparable to other studies using AA college samples that have found that scores range between 91.8 and 93.6 when utilizing the measure with a 7-point Likert-type scale (Lau et al., 2009; Zane & Yeh, 2002). Zane and Yeh (2002) found evidence for concurrent validity due to significant positive correlation between LOF and private self-consciousness, public self-consciousness, other directedness,and negative relations with White cultural identity. They found evidence for discriminant validity due to moderate significant correlations between LOF and social anxiety and also LOF and social desirable responding. Incremental validity was evidenced by LOF’s ability to explain differences between European Americans and AA above and beyond personality differences. In a factor analysis of the LOF measure, Zane and Yeh found a one-factor solution for the measure.

Depression

The Center for Epidemiologic Studies Depression Scale (CES-D) is a 20-item screen for depression in the general population (Radloff, 1977). Participants respond on a 4-point scale ranging from 1 = rarely or none of the time to 4 = most or all of the time to items such as “I felt that I could not shake off the blues even with the help of my family or friends.” This measure has demonstrated high internal reliability with a Cronbach’s alpha of .80 and test–retest reliability over 2 weeks of .51. Cronbach’s alpha in this study was .88. Higher scores indicate higher levels of depressive symptoms.

Social anxiety

The Social Interaction Anxiety Scale (SIAS; Mattick & Clarke, 1998) is a 19-item scale assessing for symptoms of social anxiety. Participants respond on a 5-point Likert-type scale that ranges from 0 = not at all to 4 = extremely to items such as “when mixing socially, I feel uncomfortable.” Internal consistency for the current sample was α = .95. Higher scores indicate higher levels of social anxiety.

Results

Preliminary Analyses

No significant differences were found between foreign and U.S. born, or among different generations, on research variables. An independent samples t test was run comparing Chinese and non-Chinese Americans on the research variables. A statistically significant difference between Chinese AA and other AA groups was found on endorsement of indirect coping, t(149) = 4.10, p < .05, LOF, t(149) = 2.80, p < .05, and depression, t(149) = 2.88, p < .05. This suggests that Chinese Americans endorse higher levels of LOF (M = 96, SD = 20.5), indirect coping (M = 4.43, SD = 1.18), and depression (M = 21.76, SD = 11.92) than other AA groups (LOF, M = 85.98, SD = 22.93; indirect coping, M = 3.68, SD = 1.07; depression, M = 16.28, SD = 11.45). This difference was not due to differences in average age or generational status as age and generational status were comparable between Chinese Americans and other AA groups. There were no significant differences between males and females on any of the research variables. Bivariate correlations were run on the research variables to examine significant associations (see Table 2). Preliminary analysis suggests a possible mediating role of indirect and direct coping. Interestingly, LOF was positively correlated with direct and indirect coping.

Table 2.

Means, Standard Deviations, and Intercorrelations Among Research Variables (N = 154).

Variable	1	2	3	4	5	6	7	8	M	SD
1. Gender	—	.06	.00	−.32	−.01	−.14^†	.09	−.04	—	—
2. Education			.20*	.24**	.16	.06	.03	−.05	—	—
3. Age				.03	.12	−.15^†	.11	−.13	29.63	9.79
4. Ind-Cop					.47***	.46**	.57***	.43***	4.18	1.21
5. Dir-Cop						.27**	.16	.00	5.27	1.30
6. LOF							.32**	.40***	90.53	22.18
7. CES-D								.47***	18.95	11.93
8. SIAS									27.68	16.32

Note. Male = −1; Female = 1; Ind-Cop = indirect coping; Dir-Cop = direct coping; LOF = Loss of Face; CES-D = Center for Epidemiologic Studies Depression; SIAS = Social Interaction Anxiety Scale.

†

p < .10. *p < .05. **p < .01. ***p < .001.

Main Analyses

SPSS Process macro was used to test a parallel multiple mediation model (Hayes, 2013). A parallel multiple mediation analysis tests the contributions of each mediator independently. Five thousand boot strapped samples were generated to calculate 95% bias-corrected confidence intervals (CIs) of the indirect effects. This method does not make any assumptions regarding the shape of the sampling distribution because estimates are based on repeated bootstrap sampling. It was hypothesized that the relationship between LOF with depression and with social anxiety would be mediated by both direct and indirect coping. CIs that do not include 0 are considered to be statistically significant.

An ordinary least squares (OLS) regression was run through PROCESS. The results showed that higher levels of face concerns (LOF) led to a greater frequency of direct coping, β = .02, SE = .004, t(152) = 3.04, p < .05, increased frequency of indirect coping, β = .03, SE = .004, t(152) = 6.61, p < .05, and increased depression symptoms β = .17, SE = .04, t(152) = 4.194, p < .05. After accounting for coping strategies, LOF was no longer significantly associated with depression β = .05, SE = .04, t(152) = 1.13, p > .05. The results suggest that indirect coping significantly explained the relationship between LOF and depression (β = .15, CI: [.09, .23]) but direct coping did not (β = −.02, CI: [−.05, .00]). A comparison of both mediators in explaining the relationship between LOF and depression provides further evidence that the function of indirect coping in explaining the relationship between LOF and depression is significantly different than the function of direct coping on depression (β = −.16, p < .05, CI: [−.26, −.10]). More indirect coping leads to higher levels of depression whereas more direct coping leads to lower levels of depression. The positive relationship between depression and face concerns was explained by high levels of indirect coping rather than low levels of direct coping. The multiple mediator model accounted for 32% of the variance in depression (p < .05; see Figure 1).

Figure 1.

Mediation model of coping behaviors on LOF and depression.

Results also indicate that the total indirect effects of LOF on social anxiety through the two mediators, direct and indirect coping, were statistically significant. Higher levels of face concerns were associated with higher levels of social anxiety, β = .30, SE = .055, t(152) = 5.43, p < .05. LOF’s influence on social anxiety was reduced after accounting for direct and indirect coping, but LOF’s relationship with social anxiety was still statistically significant, β = .21, SE = .06, t(152) = 3.60, p < .05. An examination of the mediational effect of direct and indirect coping suggests that the indirect effect of LOF on social anxiety through indirect coping was statistically significant (β = .14, CI: [.08, .24]) and the indirect effects of LOF and social anxiety through direct coping was also statistically significant (β = −.05, CI: [−.11, −.02]). A comparison of each mediator in explaining the relationship between LOF and social anxiety showed that the function of direct coping and indirect coping in mediating the relationship between LOF and social anxiety was statistically different (β = −.19, CI: [−.31, −.11]). More indirect coping leads to higher levels of social anxiety whereas more direct coping leads to lower levels of social anxiety. The multiple mediator model accounted for 28% of the variance in social anxiety (p < .05; see Figure 2).

Figure 2.

Mediation model of coping behaviors on LOF and social anxiety.

Discussion

Our study found support for the proximal–distal model of understanding LOF’s relationship to depression and social anxiety through coping responses. The proximal–distal model posits that the influence of culture can be understood according to a hierarchy of predictors. In our model, LOF is considered to be a distal factor and coping responses a proximal factor in predicting depression and social anxiety. As such, we expected that the relationship between LOF to depression and LOF to social anxiety would be explained by coping. Consistent with this model, indirect coping mediated the relationship between LOF and depression and partially mediated the relationship between LOF and social anxiety.

Consistent with previous studies, LOF was positively associated with indirect coping (David, 2010; Taylor et al., 2004; Zane et al., 1998). AA who endorse high levels of LOF report using indirect coping more frequently than AA with low levels of LOF. Contrary to what was expected, LOF was also significantly positively associated with direct coping. Because indirect and direct coping were significantly positively correlated, our findings support theories that people from Asian cultures may have more coping flexibility relative to people from other cultures (Cheng, 2009; Kato, 2012). People of Asian descent may utilize both strategies but may rely on one more than the other. This is consistent with previous studies that found two seemingly diametrically opposed constructs, such as positive and negative affect, are positively related among East Asian samples but negatively related among Western samples (Schimmack, Oishi, & Diener, 2005; Spencer-Rodgers, Peng, Wang, & Hou, 2004). Coping flexibility is associated with the East Asian philosophy of dialecticism, which describes the cognitive ability to view contradictions as coexisting in harmony (Cheng, 2009). These results also speak to the multi-dimensional nature of LOF. In an effort to save face, AA may utilize multiple coping strategies due to the strong motivation to avoid bringing shame to one’s family. The tendency to self-blame, vent, or deny does not preclude AA from engaging in more direct coping such as planning or seeking support.

Consistent with previous research, there also was evidence that LOF may put AA at increased risk for depression and social anxiety (Lau et al., 2009; Mak & Chen, 2006; Mak et al., 2009; Zane & Yeh, 2002). AA who endorse high levels of LOF have higher levels of depression and social anxiety. There may be multiple explanations for these relationships. LOF may make individuals vulnerable to internalizing symptoms because it increases the awareness of perceived failures in meeting social obligations. Another reason may be that LOF may be inconsistent with the values of the mainstream. As such, LOF is only a risk factor in an individualistic cultural context, but may not be associated with depression or anxiety in a collectivistic context.

Despite the increased risk for depression, traditional Asian LOF may be a protective factor against externalizing symptoms such as sexual aggression, risk-taking, and substance use (Hall et al., 2006; Hall et al., 2005; W. M. Liu & Iwamoto, 2007). Given these benefits, it is important to explore the factors that are more proximal to explaining depression and social anxiety than LOF. The significance of LOF is its role in affecting specific behaviors that may be more directly related to psychological functioning. The results suggest that LOF is a distal factor and coping a proximal factor in explaining depression. The relationship between LOF and depression was entirely accounted for by indirect coping. LOF may lead to ways of coping with stress that puts AA at increased risk of depressive symptoms. Given that LOF was significantly correlated with direct coping as well as indirect coping, this suggests that having AA utilize more direct coping strategies and less indirect coping is a culturally congruent strategy for managing psychological distress. Individuals are more likely to work harder to reach a goal when their actions have a prosocial benefit (Grant, 2007). This may be particularly true for AA who often cite family obligations as an explanation for their academic hard work (Fuligni, 1997). The utilization of one set of coping responses over another may be influenced by concern and protection of one’s in-group. Although strategies such as self-blaming is consistent with the Asian value of taking responsibility, it can also result in other coping strategies that may have a more direct effect on the stressor. Because of this tendency to take responsibility, indirect coping may increase the likelihood of more direct forms of coping.

One positive aspect of LOF is that people may be more likely to address problems directly if they feel implicit social pressure to resolve issues. Because LOF is more distal to psychological distress, coping responses may offer a pathway for addressing the association between LOF and depression without decreasing endorsement of a cultural value that serves an important function in collectivistic cultures.

A different pattern was observed for social anxiety. LOF, indirect coping, and direct coping all uniquely predicted social anxiety. AA reporting high levels of LOF, high levels of indirect coping, and low levels of direct coping reported more symptoms of social anxiety. Although LOF seemed to be proximal to explaining social anxiety, direct and indirect coping were also proximal factors. These results support previous studies that observed differences in social anxiety between AA and European Americans due to the importance of saving face in Asian culture (Lau et al., 2009). Because the construct of LOF elicits a high degree of concern for one’s social reputation, it may lead to heightened social vigilance. This suggests that a certain degree of social anxiety may be normative in Asian cultures; however, social anxiety might be mitigated among AA with different patterns of coping. Because both indirect and direct coping were associated with social anxiety, it may be possible to reduce social anxiety concerns with higher engagement in direct coping. It is also possible that the heightened levels of social anxiety among AA may be less concerning among AA than it would be among people in mainstream culture. The high level of sensitivity to other’s reactions is consistent with cultural expectations and may not be indicative of a problem.

The differential function of coping in explaining the relationship between LOF to depression compared with LOF and social anxiety suggests that there may be an aspect of LOF that may resemble Western definitions of social anxiety. Although altering coping behaviors may reduce the relationship between LOF and depression, the same is not true for LOF and social anxiety. People working with AA in a therapeutic setting may need to distinguish between social anxiety that is problematic and social anxiety that is adaptive in an Asian cultural context. The inability of coping to completely explain the relationship between LOF and social anxiety is perhaps due to LOF’s underlying concern for one’s social reputation.

Although there have been many studies examining the prevalence of direct and indirect coping among AA, ours is the first to examine coping strategies as a mediator between LOF and depression and social anxiety. Because traditional cultural values have protective qualities, inadvertently reducing adherence to traditional values may lead to externalizing symptoms. Our study offers a strategy for AA to reduce internalizing symptoms without completely mitigating cultural values and beliefs.

Unexpectedly, our study also found within-group differences between AA subgroups. Chinese Americans scored higher than other AA subgroups on LOF, depression, and indirect coping. Previous research has found no differences between AA subgroups (i.e., Zane & Yeh, 2002), focused on one ethnic group (i.e., Gong, Gage, & Tacata, 2003), and did not report or did not analyze within-group differences (i.e., Eap et al., 2008; Lau et al., 2009). Leong et al. (2011) found evidence of significant intragroup differences on LOF. That difference, however, was primarily between Korean Americans and Japanese Americans, Chinese Americans, and Southeast Asian Americans. Abe-Kim, Okazaki, and Goto (2001) found a significant difference between foreign and U.S born AA but did not conduct an analysis between AA subgroups.

Limitations

As with any research study, our findings have several limitations that are important to acknowledge. First, our study included a mostly female sample. Some studies identified gender differences in coping among AA (H. S. Kim, Sherman, Ko, & Taylor, 2006), but others have not (i.e., Wei, Ku, Mallinkrodt, & Liao, 2008; Wong et al., 2010). The consideration of the gender ratio of the sample is important to consider in light of previous studies. Past research did not find a relationship between traditional Asian values and psychological symptoms among men (W. M. Liu & Iwamoto, 2006). As such, results may differ if there was a larger male sample.

In addition, our study was composed of primarily educated individuals from an East Asian background. Different Asian subgroups have vastly different experiences living in the United States. Although Japanese and Chinese Americans are relatively educated and affluent, Southeast Asian immigrants have one of the highest poverty rates and lowest levels of educational attainment compared with other Asian ethnic groups (C. H. Liu, Murakami, Eap, & Hall, 2009) and may experience heightened levels of stress. Our study provides further support for the heterogeneity between AA groups. Chinese Americans scored higher than other AA groups on LOF, indirect coping, and depression. Previous studies that have not found within AA differences may not have sufficient power to detect these differences (Zane & Yeh, 2002) or did not examine for possible within-group differences. Our results suggest that LOF may be more salient for Chinese Americans relative to other Asian subgroups. Ho (1976) suggests that LOF is a universal construct that can be experienced by people from different cultures. Consistent with this, Zane and Yeh found evidence that LOF is a valid measure even among European Americans. As such, the mediational model proposed by this study may be a universal phenomenon rather than a culturally specific one. Although LOF may be a universal and equally valid phenomena among different cultural groups, AA have consistently been found to score higher on this construct than European Americans. Furthermore, endorsement of LOF may even vary along AA subgroups, acculturation levels, and generation status (Abe-Kim et al., 2001; Leong et al., 2011).

The level of discrimination and marginalization that individual AA experience may operate with cultural variables and potentially compound psychological symptoms. Lopez and Guarnaccia (2000) caution against examining culture in isolation of social variables such as marginality, class, and poverty. These findings may be less accurate at describing the experiences of AA subgroups who are more likely to struggle against economic hardship or daily disempowerment.

Future Directions

Because of the correlational nature of our study, the directionality of the effects cannot be determined. Future studies should consider experimentally testing these relationships by priming LOF concerns. Cultural priming studies yield larger effect sizes than self-report studies (Oyserman & Lee, 2008) and researchers are better able to determine the direction of the effects of culture. Because AA often must navigate conflicting cultural systems, priming culture can provide insight into how they view themselves and behave in specific cultural contexts. Mok and Morris (2009), for instance, demonstrated that participants had significantly different scores on the Big Five Personality Inventory depending on whether they were primed with Asian or American culture.

Current coping measures are rooted in individualistic perspectives on coping (Heppner et al., 2014). Future studies might compare more mainstream measures of coping with culturally specific ways of coping, such as Collectivistic Coping Style (Heppner et al., 2006) or the Collectivistic Coping Style Measure (Moore & Constantine, 2005), to see if those who endorse more traditional LOF have better psychological adjustment when utilizing more culturally syntonic coping strategies (Hall, Hong, Zane, & Meyer, 2011).

Heppner et al. (2014) also points to a lack of research on the influence of cultural values in shaping appropriate coping responses. Their cultural and contextual model of coping (CCMC) attempts to connect individual coping responses to the larger social and cultural context. Our study is an initial step toward viewing coping responses in the context of cultural values. However, further research, which examines the multiple individual, environmental, and categories of stressors that affect coping and stress responses, is necessary for establishing culturally valid coping models.

Future studies may compare whether the mediational model applies to different AA subgroups. The current study was predominantly composed of Chinese Americans. As such, the results of the mediational model are influenced mostly by Chinese Americans.

Given the significant relationship between direct and indirect coping, it may be informative to discern the context in which AA utilize one strategy or another. Both types of coping strategies seem to be culturally congruent to Asian culture (Hall et al., 2011), but in order for clinicians to help AA utilize more direct coping and less indirect coping, studies need to explore how these disparate coping strategies are integrated. For instance, does direct coping follow indirect coping after a period of emotional vulnerability? Or does indirect coping follow direct coping when AA experience failure at being able to change the nature of their stressor? Having a flexible approach to coping may be the best strategy for bicultural individuals who must constantly engage in frame switching when adapting to different environments (Cheng, 2009).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Abe-Kim

Okazaki

Goto

S. G.

(2001). Unidimensional versus multidimensional approaches to the assessment of acculturation for Asian American populations. Cultural Diversity & Ethnic Minority Psychology, 7, 232-246. doi:10.1037/1099-9809.7.3.232

Alegria

Takeuchi

Canino

Duan

Shrout

Meng

X. L.

. . . Gong

(2004). Considering context, place and culture: The National Latino and Asian American Study. International Journal of Methods in Psychiatric Research, 13, 208-220. doi:10.1002/mpr.178

Carver

C. S.

(1997). You want to measure coping but your protocol is too long: Consider the brief cope. International Journal of Behavioral Medicine, 4, 92-100.

Chang

E. C.

(1996). Cultural differences in optimism, pessimism, and coping: Predictors of subsequent adjustment in Asian American and Caucasian American college students. Journal of Counseling Psychology, 43, 113-123.

Cheng

(2009). Dialectical thinking and coping flexibility: A multimethod approach. Journal of Personality, 77, 471-494. doi:10.1111/j.1467-6494.2008.00555.x

Cheung

F. M.

Leung

Fan

R. M.

Song

W. Z.

Zhang

J. X.

Zhang

J. P.

(1996). Development of the Chinese Personality Assessment Inventory. Journal of Cross-Cultural Psychology, 27, 181-199. doi:10.1177/0022022196272003

David

E. J. R.

(2010). Cultural mistrust and mental health help-seeking attitudes among Filipino Americans. Asian American Journal of Psychology, 1, 57-66. doi:10.1037/a0018814

Eap

DeGarmo

D. S.

Kawakami

Hara

S. N.

Hall

G. C.

Teten

A. L.

(2008). Culture and personality among European American and Asian American men. Journal of Cross-Cultural Psychology, 39, 630-643. doi:10.1177/0022022108321310

Foynes

M. M.

Platt

Hall

G. C.

Freyd

J. J.

(2014). The impact of Asian values and victim–perpetrator closeness on the disclosure of emotional, physical, and sexual abuse. Psychological Trauma: Theory, Research, Practice, and Policy, 6, 134-141. doi:10.1037/a0032098

10.

Fuligni

A. J.

(1997). The academic achievement of adolescents from immigrant families: The role of family background, attitudes, and behavior. Child Development, 68, 351-363. doi:10.1111/j.1467-8624.1997.tb01944.x

11.

Gong

Gage

S. J. L.

Tacata

L. A.

(2003). Helpseeking behavior among Filipino Americans: A cultural analysis of face and language. Journal of Community Psychology, 31, 469-488. doi:10.1002/jcop.10063

12.

Grant

A. M.

(2007). Relational job design and the motivation to make a prosocial difference. Academy of Management Review, 32, 393-417. doi:10.5465/AMR.2007.24351328

13.

Hall

G. C. N.

DeGarmo

D. S.

Eap

Teten

A. L.

Sue

(2006). Initiation, desistance, and persistence of men’s sexual coercion. Journal of Consulting and Clinical Psychology, 74, 732-742. doi:10.1037/0022-006X.74.4.732

14.

Hall

G. C. N.

Hong

J. J.

Zane

N. W.

Meyer

O. L.

(2011). Culturally-competent treatments for Asian Americans: The relevance of mindfulness and acceptance-based psychotherapies. Clinical Psychology: Science and Practice, 18, 215-231. doi:10.1111/j.1468-2850.2011.01253.x

15.

Hall

G. C. N.

Teten

A. L.

DeGarmo

D. S.

Sue

Stephens

K. A.

(2005). Ethnicity, culture, and sexual aggression: Risk and protective factors. Journal of Consulting and Clinical Psychology, 73, 830-840. doi:10.1037/0022-006X.73.5.830

16.

Hayes

A. F.

(2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York: Guilford Press.

17.

Heppner

P. P.

Heppner

M. J.

Lee

D. G.

Wang

Y. W.

Park

H. J.

Wang

L. F.

(2006). Development and validation of a Collectivist Coping Styles Inventory. Journal of Counseling Psychology, 53, 107-125. doi:10.1037/0022-0167.53.1.107

18.

Heppner

P. P.

Wei

Neville

H. A.

Kanagui-Muñoz

(2014). A cultural and contextual model of coping. In Leong

Comas-Diaz

Hall

G. C. N.

McLoyd

V. C.

Trimble

J. E.

(Eds.), APA handbook of multicultural psychology: Applications and training (Vol. 2, pp. 83-106). Washington, DC: American Psychological Association.

19.

D. Y. F.

(1976). On the concept of face. American Journal of Sociology, 18, 867-884.

20.

Hong

J. J.

Woody

S. R.

(2007). Cultural mediators of self-reported social anxiety. Behaviour Research and Therapy, 45, 1779-1789. doi:10.1016/j.brat.2007.01.011

21.

Hsu

Woody

S. R.

Lee

H. J.

Peng

Zhou

Ryder

A. G.

(2012). Social anxiety among East Asians in North America: East Asian socialization or the challenge of acculturation? Cultural Diversity & Ethnic Minority Psychology, 18, 181-191. doi:10.1037/a0027690

22.

Kato

(2012). Development of the Coping Flexibility Scale: Evidence for the coping flexibility hypothesis. Journal of Counseling Psychology, 59, 262-273. doi:10.1037/a0027770

23.

Kim

B. S.

Hong

(2004). A psychometric revision of the Asian Values Scale using the Rasch model. Measurement and Evaluation in Counseling and Development, 37, 15-27. doi:10.1037/t03648-000

24.

Kim

B. S.

Omizo

M. M.

(2005). Asian and European American cultural values, collective self-esteem, acculturative stress, cognitive flexibility, and general self-efficacy among Asian American college students. Journal of Counseling Psychology, 52, 412-419. doi:10.1037/0022-0167.52.3.412

25.

Kim

B. S.

Yang

P. H.

Atkinson

D. R.

Wolfe

M. M.

Hong

(2001). Cultural value similarities and differences among Asian American ethnic groups. Cultural Diversity & Ethnic Minority Psychology, 7, 343-361. doi:10.1037/1099-9809.7.4.343

26.

Kim

H. S.

Sherman

D. K.

Taylor

S. E.

(2006). Pursuit of comfort and pursuit of harmony: Culture, relationships, and social support seeking. Personality and Social Psychology Bulletin, 32, 1595-1607. doi:10.1177/0146167206291991

27.

Kim

H. S.

Sherman

D. K.

Taylor

S. E.

(2008). Culture and social support. American Psychologist, 63, 518-526. doi:10.1037/0003-066X

28.

Kim

J. E.

Zane

N. W.

Blozis

S. A.

(2012). Client predictors of short-term psychotherapy outcomes among Asian and White American outpatients. Journal of Clinical Psychology, 68, 1287-1302. doi:10.1002/jclp.21905

29.

Kuo

B. C.

(2011). Culture’s consequences on coping theories, evidences, and dimensionalities. Journal of Cross-Cultural Psychology, 42, 1084-1100. doi:10.1177/0022022110381126

30.

Lam

A. G.

Zane

N. W.

(2004). Ethnic differences in coping with interpersonal stressors: A test of self-construals as cultural mediators. Journal of Cross-Cultural Psychology, 35, 446-459. doi:10.1177/0022022104266108

31.

Lam

C. Y.

Pepper

C. M.

Ryabchenko

K. A.

(2004). Case identification of mood disorders in Asian American and Caucasian American college students. Psychiatric Quarterly, 75, 361-373. doi:10.1023/B:PSAQ.0000043511.13623.1b

32.

Lau

A. S.

Fung

Wang

S. W.

Kang

S. M.

(2009). Explaining elevated social anxiety among Asian Americans: Emotional attunement and a cultural double bind. Cultural Diversity & Ethnic Minority Psychology, 15, 77-85. doi:10.1037/a0012819

33.

Lee

R. M.

Liu

H.-T.

(2001). Coping with intergenerational family conflict: Comparison of Asian American, Hispanic, and European American college students. Journal of Counseling Psychology, 47, 211-222.

34.

Leong

F. T.

Kim

H. H.

Gupta

(2011). Attitudes toward professional counseling among Asian-American college students: Acculturation, conceptions of mental illness, and loss of face. Asian American Journal of Psychology, 2, 140-153. doi:10.1037/a0024172

35.

Liu

C. H.

Murakami

Eap

Hall

G. C. N.

(2009). Who are Asian Americans? An overview of history, immigration, and communities. In Tewari

Alvarez

(Eds.), Asian American psychology: Current perspectives (pp. 1-29). New York, NY: Lawrence Erlbaum.

36.

Liu

W. M.

Iwamoto

D. K.

(2006). Asian American men’s gender role conflict, distress, self-esteem, and Asian values. Psychology of Men & Masculinity, 7, 153-164. doi:10.1037/1524-9220.7.3.153

37.

Liu

W. M.

Iwamoto

D. K.

(2007). Conformity to masculine norms, Asian values, coping strategies, peer group influences and substance use among Asian American men. Psychology of Men & Masculinity, 8, 25-39.

38.

Lopez

S. R.

Guarnaccia

P. J.

(2000). Cultural psychopathology: Uncovering the social world of mental illness. Annual Review of Psychology, 51, 571-598. doi:10.1146/annurev.psych.51.1.571

39.

Mak

W. W.

Chen

S. X.

(2006). Face concern: Its role on stress–distress relationships among Chinese Americans. Personality and Individual Differences, 41, 143-153. doi:10.1016/j.paid.2005.12.016

40.

Mak

W. W.

Chen

S. X.

Lam

A. G.

Yiu

V. F.

(2009). Understanding distress: The role of face concern among Chinese Americans, European Americans, Hong Kong Chinese, and Mainland Chinese. The Counseling Psychologist, 37, 219-248. doi:10.1177/0011000008316378

41.

Mattick

R. P.

Clarke

J. C.

(1998). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behaviour Research and Therapy, 36, 455-470. doi:10.1016/S0005-7967(97)10031-6

42.

Meyer

(2001). Coping with severe mental illness: Relations of the Brief COPE with symptoms, functioning, and well-being. Journal of Psychopathology and Behavioral Assessment, 23, 265-277.

43.

Mok

Morris

M. W.

(2009). Cultural chameleons and iconoclasts: Assimilation and reactance to cultural cues in biculturals’ expressed personalities as a function of identity conflict. Journal of Experimental Social Psychology, 45, 884-889. doi:10.1016/j.jesp.2009.04.004

44.

Moore

J. L.

Constantine

M. G.

(2005). Development and initial validation of the collectivistic coping styles measure with African, Asian, and Latin American international students. Journal of Mental Health Counseling, 27, 329-347.

45.

Okazaki

(1997). Sources of ethnic differences between Asian American and White American college students on measures of depression and social anxiety. Journal of Abnormal Psychology, 106, 52-60. doi:10.1037/0021-843X.106.1.52

46.

Okazaki

(2000). Asian Americans and White differences on affective distress symptoms: Do symptom reports differ across reporting methods? Journal of Cross-Cultural Psychology, 31, 603-624. doi:10.1177/0022022100031005004

47.

Okazaki

Liu

J. F.

Longworth

S. L.

Minn

J. Y.

(2002). Asian American-White American differences in expressions of social anxiety: A replication and extension. Cultural Diversity & Ethnic Minority Psychology, 8, 234-247. doi:10.1037/1099-9809.8.3.234

48.

Oyserman

Lee

S. W.

(2008). Does culture influence what and how we think? Effects of priming individualism and collectivism. Psychological Bulletin, 134, 311-342. doi:10.1037/0033-2909.134.2.311

49.

Radloff

L. S.

(1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401.

50.

Schimmack

Oishi

Diener

(2005). Individualism: A valid and important dimension of cultural differences between nations. Personality and Social Psychology Review, 9, 17-31. doi:10.1207/s15327957pspr0901_2

51.

Spencer-Rodgers

Peng

Wang

Hou

(2004). Dialectical self-esteem and East-West differences in psychological well-being. Personality and Social Psychology Bulletin, 30, 1416-1432. doi:10.1177/0146167208325772

52.

Sue

Zane

(1987). The role of culture and cultural techniques in psychotherapy: A critique and reformulation. American Psychologist, 42, 37-45.

53.

Takeuchi

D. T.

Hong

Gile

Alegría

(2007). Developmental contexts and mental disorders among Asian Americans. Research in Human Development, 4, 49-69. doi:10.1080/15427600701480998

54.

Taylor

S. E.

Sherman

D. K.

Kim

H. S.

Jarcho

Takagi

Dunagan

M. S.

(2004). Culture and social support: Who seeks it and why? Journal of Personality and Social Psychology, 87, 354-362. doi:10.2105/AJPH.2006.088401

55.

Taylor

S. E.

Welch

W. T.

Kim

H. S.

Sherman

D. K.

(2007). Cultural differences in the impact of social support on psychological and biological stress responses. Psychological Science, 18, 831-837. doi:10.1037/0003-066X

56.

Wei

T. Y.

Russell

D. W.

Mallinckrodt

Liao

K. Y. H.

(2008). Moderating effects of three coping strategies and self-esteem on perceived discrimination and depressive symptoms: A minority stress model for Asian international students. Journal of Counseling Psychology, 55, 451-462. doi:10.1037/a0012511

57.

Wong

Y. J.

Kim

S. H.

Tran

K. K.

(2010). Asian Americans’ adherence to Asian values, attributions about depression, and coping strategies. Cultural Diversity & Ethnic Minority Psychology, 16, 1-8.

58.

Yoo

H. C.

Lee

R. M.

(2005). Ethnic identity and approach-type coping as moderators of the racial discrimination/well-being relation in Asian Americans. Journal of Counseling Psychology, 52, 497-506. doi:10.1037/0022-0167.52.4.497

59.

Yusoff

Low

W. Y.

Yip

C. H.

(2010). Reliability and validity of the Brief COPE Scale (English version) among women with breast cancer undergoing treatment of adjuvant chemotherapy: A Malaysian study. Medical Journal of Malaysia, 65, 41-44.

60.

Zane

Umemoto

Park

(1998). The effects of ethnic and gender match and face concerns on self-disclosure in counseling for Asian American clients. Unpublished manuscript.

61.

Zane

Yeh

(2002). The use of culturally-based variables in assessment: Studies on loss of face. In Asian American mental health (pp. 123-138). New York, NY: Kluwer Academic/Plenum Press.