Substance abuse has adverse health, economic, and social consequences on not just individuals, but also families and communities. As a critical public health issue with a high disease burden and impact on quality of life in the United States, an estimated $428 billion in economic costs are because of substance abuse, and it accounts for 590,000 deaths and 40 million injuries and illnesses annually.1 Yet the issues regarding Asian Americans and substance abuse are relatively obscure and difficult to discern both nationally and even locally. Historically, Asians in America were commonly excluded in governmental data collection samples because of a belief that substance abuse was not a significant problem in Asian American communities. To compound the problem, many people within these communities view substance abuse as a highly stigmatized condition that shames families and communities alike.
Typically when one thinks of someone abusing drugs and alcohol, a series of problems come to mind. For youth, such problems might be poor school performance, strained relationships with peers and family members, and involvement with the juvenile justice system. For adults, involvement with the criminal justice system, a history of unemployment/underemployment, strained marital and family relationships, financial problems, and poor health are just a few of the symptoms of substance abuse. For Asian Americans, it is believed that many of the “problems” associated with substance abuse are often hidden by both the individual, but also by family and close friends because of the painful stigma associated with drugs.
National survey results show that Asian Americans are reporting the lowest rates of substance abuse, yet when disaggregated, data reveals a range of prevalence rates for Asian Americans.2 With illicit drug use, Asian Americans as a whole report less use (2.7%) in comparison to other racial/ethnic groups, yet the rates for Korean Americans (6.9%) are on a par with whites and African Americans. In addition, a growing demographic category of mixed-race Americans is showing the second or third highest illegal substance use rates. Asian Americans tend to use alcohol, tobacco, and methamphetamines.
The risk of starting alcohol, cigarette smoking, and illegal drug use is highest during the adolescent and young adult years. Multiple risk and protective factors influence substance use behaviors. Personality traits such as aggressiveness, antisocial behavior, and low levels of community participation may also make one more prone to abusing drugs and alcohol.3 Among youth, for instance, favorable parental attitudes toward drugs and alcohol, low family bonding, and high family conflict would predispose the youth toward substance use. For Asian American youth, sources of family conflict often involve the intergenerational cultural gap they face with their parents, and in some cases, grandparents as well. Asian American youth from families in which parents speak little or no English may experience substantial burden from being their parents’ interpreters and social navigators for the family. Such difficulties can lead to emotional distress in the forms of anxiety, loss, grief, and depression. Furthermore, these second-generation Asian American youth, in comparison to other racial and ethnic groups, possess less knowledge of their parents’ languages and homeland cultures, implying greater cultural dissonance, greater risk of low self-worth and a lack of well being.4 These stressors may place Asian Americans at greater risk for substance abuse and mental health problems.
At the same time, traits such as high self-esteem, socialization, relationship with peers and family, and low depression are protective factors. For Asian American children and adolescents, the family environment, as well as a student’s level of connectedness to school, can sometimes reduce the impact of peer risk factors.5 Additionally, participation in church or spiritual activities and athletics can offer healthy alternatives to substance use. Policies and social norms have the power to reinforce positive attitudes toward substance use or limit its acceptability and accessibility, as with age restrictions and taxation on alcohol and tobacco.
Many studies show that the most powerful and consistent predictor of substance use among mainstream youth is peer influence.6 A 2004 study found peer influence to be significantly associated with substance use for Asian American adolescents though more empirical studies are needed.7 There has been more interest in examining the role of acculturation in influencing health behaviors in Asian Americans. Some findings have determined acculturation to be a key predictor of adolescent alcohol use, while others have pointed to more complex social, economic, and cultural factors, beyond acculturation that determine use.8
Cultural norms, immigration status, and different levels of acculturation within families not only aggravate Asian Americans’ substance abuse and mental health problems, but they powerfully (and usually negatively) affect the degree to which they access services. Denial has been the primary barrier of Asian Americans to seeking treatment. Stigma and shame make it difficult to identify clients as well. Similarly, because of such powerful stigma, Asian Americans often underreport their use of alcohol, tobacco, and other drugs so that problems seem unapparent. Especially strong individual, family, and com-munity denial of the problem are all obstacles to seeking out treatment. The powerful role that such cultural considerations play in preventing or delaying an individual and his or her family from seeking help, often means that a family must be enlisted for treatment to begin and be successful.
Acculturation differences within families, moreover, usually yield no benefits in willingness to access services; the least acculturated generation (parents) needs to assent to services that their children, the more acculturated generation, may desperately need, but parents may be reluctant to access culturally unfamiliar services.
Co-occurring disorders refers to the diagnosis of both a mental health and substance abuse disorder. About 50–70 percent of substance abusers also have a mental disorder, and about one-third of adults with mental illness have a co-occurring substance abuse disorder, often to self-medicate.9 Although the incidence of co-occurring disorders is on the rise, there is, at the same time, a decline in the number of inpatient mental health services available.10 Recent efforts to address co-occurring disorders aim to integrate treatment from both fields.
According to the American Psychiatric Association, Asian Americans are, among all ethnicities, the least likely to seek help for mental health issues. Several studies show that Asian Americans delay seeking treatment, and once they do present for services, show acute symptoms. For many Asian Americans, somatic expressions of emotional distress are the norm. Thus for treatment, they tend to seek primary care physicians rather than mental health professionals. Particularly for Asian Americans with co-occurring disorders, substance abuse treatment programs are the entry point for diagnosing and entering mental health treatment, which otherwise would remain undetected and untreated.
Asian Americans are three times less likely than Caucasians to use mental health services despite high suicide and depression rates among some sectors of the Asian Americans population.11 A statewide study of California’s mental health service usage found that Asian American children received psychiatric emergency care from California’s county public mental health systems only when they experienced acute crises.12 These treatment-seeking trends for serious mental health issues are consistent with national observations of Asian American adult behaviors.13 The use of emergency services by Asian American youth and their caretakers may indicate that families are postponing treatment until they are absolutely overwhelmed or until outside authorities (such as law enforcement or school staff) intervene and force the issue. Factors related to such delay in seeking treatment among Asian Americans may be reflective of cultural barriers in presenting for mental health services, including stigma, mis-trust, and perceived racism of the mental health system.14 Additionally, among immigrant and refugee families, the tendency to avoid mental health treatment until reaching an extreme crisis has been directly linked to their limited profi-ciency in English.15
Traditionally, substance abuse services have targeted behavior change only in the individual drug abuser, but recently the focus has been on community and population-level change. In the Asian American community, media campaigns and policy initiatives have been used to affect community norms on substance use. In San Mateo County in California, the Stay Safe Youth Coalition has been working collaboratively with youth and community-based organizations to create change and mobilize around local issues regarding alcohol, tobacco, and other drugs. For example, the coalition’s Tobacco Retail Licensing Campaign aims to adopt a policy that would require and enforce all tobacco retailers in Daly City to obtain a license for selling tobacco products. Traditionally, sub-stance abuse addiction has been handled through treatment; common examples are counseling services and medical detoxification treatment such as methadone clinics. For Asian Americans, these methods might be problematic because these approaches are modeled after mainstream systems of care, with little emphasis on culturally relevant services. Effective strategies for working with Asian American individuals and communities are being developed in community-based organizations across the United States to tailor models that have particular relevance to Asian Americans. Evidence-based treatment models that seem to have some success in working with Asian American populations include Motivational Interviewing, Strategic Family Therapy and Cognitive Behavioral Therapy. Motivational interviewing (MI) is a counseling style that draws motivation to change by having the client examine and resolve his or her ambivalence toward challenges and problems. Cognitive Behavioral Therapy (CBT) aims to identify the client’s thoughts, feelings, and behaviors related to his or her debilitating negative emotions and restructure them into more adaptive patterns. Family-based services, such as Strategic Family Therapy and parenting classes, are effective not only because family dynamics play a significant role in an individual’s susceptibility to addictive behaviors, but also because the family, rather than the individual, serves as a focal point in the lives of many Asian Americans. Therefore, families are also significant during the recovery process for Asian clients in particular. Asian American Recovery Services Inc. of the San Francisco Bay Area incorporates the family in many of its substance abuse prevention and treatment programs and more recently has adapted Strategic Family Therapy for Asian American clients.16
Access and availability to culturally appropriate services remain a consider-able challenge to the field of substance abuse, calling upon the imminent need for culturally based interventions. Undoubtedly, with a focus on understanding the disparities in accessing care and a stronger culturally based approach, more minorities–including Asian Americans–facing linguistic and cultural barriers, would find support for substance abuse and its related conditions.
D. P. Rice, “Economic Costs of Substance Abuse, 1995,” Proceedings of the Association of the American Physicians 111 (1999): 119–125; J. M. McGinnis and W. H. Foege, “Mortality and Morbidity Attributable to use of Addictive Substances in the United States,” Proceedings of the Association of the American Physicians 111 (1999): 109–118.
National Institute on Drug Abuse, Drug Use among Racial/Ethnic Minorities (US Department of Health and Human Services, 2003), http://www.drugabuse.gov/pdf/minorities03.pdf (accessed July 10, 2008).
D. J. DeWit, G. Silverman, M. Goodstadt, and G. Stoduto, “The Construction of Risk and Protective Factor Indices for Adolescent Alcohol and Other Drug Use,” The Journal of Drug Issues 25 (1995): 837–863.
A. Portes and R. G. Rumbaut, Legacies: The Stories of the Immigrant Second Generation (Berkeley: University of California Press, 2001).
J. S. Brook et al., “Onset of Adolescent Drinking: A Longitudinal Study of Intrapersonal and Interpersonal Antecedents,” Advances in Alcohol and Substance Abuse 5 (1986): 91–110; J. D. Hawkins, R. F. Catalano, and J. Y. Miller, “Risk and Protective Factors for Alcohol and Other Drug Problems in Adolescence and Early Adulthood: Implications for Substance Abuse Prevention,” Psychological Bulletin 112 (1992): 64–105.
I. J. Kim, N. W. S. Zane and S. Hong, “Protective Factors against Substance Use Among Asian American Youth: A Test of the Peer Cluster Theory,” Journal of Community Psychology 30, no. 5 (2002): 565–584.
H. C. Hahm, M. Lahiff and N. B. Guterman, “Asian American Adolescents’ Acculturation, Binge Drinking, and Alcohol- and Tobacco-Using Peers,” Journal of Community Psychology 32 (2004) 295–308.
H. C. Hahm, M. Lahiff, and N. B. Guterman, “Acculturation and Parental Attach-ment in Asian-American Adolescents’ Alcohol Use,” Journal of Adolescent Health 33 (2003): 119–129; W. K. Cook et al., “Rethinking Acculturation: A Study of Alcohol Use of Korean American Adolescents in Southern California,” Contemporary Drug Problems, in press.
D. Inaba and W. Cohen, Uppers, Downers, All-Arounders: Physical and Mental Effects of Psychoactive Drugs 5th ed. (CNS Publications, Medford, OR, 2004).
J. Matsuoka, C. Breaux, and D. Ryujin, “National Utilization of Mental Health Services of Asian Americans/Pacific Islanders,” Journal of Community Psychology 25, no. 2 (1997): 141–145.
M. C. Snowden et al., “Racial/Ethnic Minority Children’s Use of Psychiatric Emergency Care in California’s Public Mental Health System,” American Journal of Public Health 98 (2008): 118–124.
Office of the Surgeon General. “Mental Health: Culture, Race, and Ethnicity. A Supplement to Mental Health: A Report of the Surgeon General.” Rockville, MD: U.S. Dept of Health and Human Services, 2001. HHS publication SMA-01-3613.
R. Benkert et al., “Effects of Perceived Racism, Cultural Mistrust, and Trust in Providers on Satisfaction with care,” Journal of the National Medical Association 98 (2006): 1532–1540.
R. J. Lamarine, “Alcohol Abuse among Native Americans,” Journal of Community Health 13 (1988): 143–155; L. R. Snowden, M. Masland, and R. Guerrero, “Federal Civil Rights Policy and Mental Health Treatment Access for Persons with Limited English Proficiency,” American Psychologist 62 (2007): 109–117.
For other programs offering substance abuse services for Asian Americans throughout the United States see the National Asian Pacific American Families Against Substance Abuse’s 2008 Asian American and Pacific Islander Treatment Providers Directory, http://www.napafasa.org/resources/publications.htm#tps.
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