Substance use disorders (SUDs) are a complex and intricate phenomena. While there are similarities among individuals struggling with these disorders, diversity factors influence the experience of these disorders for the individual, family, and community, as well as the influence on treatment and clinical considerations when collaborating with professionals. This article explores cultural considerations relating to Asians who struggle with SUDs and includes treatment considerations to address. While there are many diversity factors to be explored related to Asian cultures, that is beyond the scope of this article; what is presented here is a synopsis of considerations in treating SUDs with individuals who identify themselves as of Asian descent.
Asians make up a little over 5 percent of the total population in the United States. According to the most recent Pew Research Center report, Asians—the six largest in the US to be Chinese Americans, Filipino Americans, Indian Americans, Vietnamese Americans, Korean Americans, and Japanese Americans—make up about 83 percent of the total Asian population in the US (2013). Asians are a growing population in the United States and are not immune to the tragedies afflicting other groups of individuals. As substance use in the United States is common for a variety of reasons, it is not specific to individuals who are “Westerners.” Statistically, while substance use among Asians has been the lowest in national studies (e.g., Sue, Yan Cheng, Saad, & Chu, 2012), because of the mix of culture, ethnicity, religion, acculturation status, and escape from one’s own country, SUDs are becoming more prevalent among the Asian population and individuals are finding themselves in the grips of this disorder. As a substance abuse counselor, there are several dynamics to consider when assessing individuals for SUDs, who identify themselves as having an Asian background. There are also several features to consider in the recommendations for treatment.
Asian cultures have a variety of protective factors, often factors that both protect and prevent the abuse of substances. However, when clients enter the counselor’s door, these are also factors to explore in terms of the level of presence of these protective factors, both prior to the onset of the problematic use of substances, as well as to the current status at the time of assessment and/or treatment.
For example, Asian cultures in general tend to have strong family ties. It is not uncommon to have several generations of a family and extended family residing in one home, which allows for the constant relationships central to many Asian cultures to be present and cultivated. It also allows for the dependency upon one another for a variety of things—domestic, economic, and support to name a few. Doing “good” for the family as a whole is considered more a virtue than doing what one wants for oneself. Additionally, because of these strong family ties, extensive family support, and family values, there may also generally be less modeling of the use of substances as a coping mechanism (Luk, Emery, Karyadi, Patock-Peckham, & King, 2013). Thus, if there are individuals who struggle with SUDs, either not everyone may know about this or it may be that these individuals simply don’t exist within the household. The image of the family is important, so when clients come in to treatment for a SUD it is important to first inquire if they live alone or with others. If they live with others, it is essential to ask who they are and what role they play in the client’s life. Other questions to explore include if other family members are aware of what is happening with clients’ use, what is the significance of the issue to the clients, and if the family members are aware of the issue, how clients understand and internalize this. Family ties provide support and understanding and how individuals utilize this will be helpful. For example, can they turn to their family members about the SUD? Do they feel comfortable discussing and/or involving family members with treatment and education of the present issues? Some clients may not want to do this and some may. Later, we explore the concept of acculturation and generational status, as these factors may also influence clients’ consent for family involvement.
Another protective factor is education. Most Asians tend to have some college education and beyond, protecting them from the seductions of substances. For example, in the Pew Research Study published in 2012, approximately 65 percent of recently immigrated Asians were either in college or had college or advanced degrees. According to the Pew Research Center report, this is almost twice as many individuals with degrees than for other immigrants (2013).
While there are a variety of other protective factors, as well as risk factors, that may expose Asians to the seductions of using substances and continuing the progression of use, the two specific factors previously mentioned were discussed here as they contribute to considerations in the treatment of individuals who identify as Asian and are struggling with a SUD.
Research demonstrates that immigration/acculturation status plays a role in substance use (Savage & Mezuk, 2014). For example, immigrants tend to continue traditions and cultural rituals when they arrive in the United States. For some Asians living in America and wanting to be similar to their colleague and peer counterparts, the continued traditions may be interpreted as another “difference” that they may want to avoid. For example, alcohol and other substances may not have been as accessible or accepted back home. If one looks at some of the traditional rituals in Asian culture, tea and food seem to be the staple of social gatherings, as opposed to alcohol or other substances. Researchers discuss how acculturation factors increase the possibility of the use of substances, since there is more access to substances within host cultures; acculturation modifies the meaning of family and ties to family; and there is increased intergenerational conflict, as values between more traditional culture immigrants are different from acculturated or second- and third-generation individuals (Savage & Mezuk, 2014; Sandhu, 2009).
Additionally, the desire to fit in with colleagues and peers may motivate some individuals to pursue after-work substance use activities such as happy hour. However, while the use of certain substances may be seen as taboo and stigmatizing for traditional individuals, individuals who have acculturated or see themselves as being more “American” may consider this to be no big deal. This can create conflict between these two very different sets of beliefs and values, so it is therefore helpful to explore what generation clients are from and what this means. Many Asians may consider themselves more Asian than American, more American than Asian, bicultural or none of the above. These identifiers include their own struggles as an ethnic, cultural, individualistic, and collective individual, which can be conflictual or not, yet all of which can contribute to the use of substances.
Another aspect is related to gender. Depending on the culture individuals are from, there are traditional roles ascribed to males and females. Unfortunately diverse gender identities and sexual orientations are not within the scope of this article, though they are aspects that may contribute to substance use (Cochran, Mays, Alegria, Ortegra, & Takeuchi, 2007). Females typically are dependent on others within the family context in traditional families and often at the sacrifice of their own wishes and dreams. Exposure to the freedoms women have in Western culture can add additional conflict and stress to an individual trying to understand her own identity, and sometimes may contribute to substance use. Exploring appropriate ways to assert themselves, within the context of what clients want, can be helpful.
Another factor to explore is the concept of arranged marriages. In many Asian cultures, spouses are usually chosen for individuals by family members. While some research indicates individuals in an arranged marriage are more satisfied with the relationship than couples who marry for love or companionship (Myers, Madathil, & Tingle, 2005), domestic violence and tension among in-laws tend to be contributing factors to substance use among women (Yaman & Taskin, 2015). While traditional values prohibit divorce in some Asian cultures, despite the justifications for this, exploring alternative options to divorce and the use of substances as a coping mechanism to deal with an unsatisfying marriage, or as a means of coping with abuse, is a clinical consideration. In this respect, it may also be a challenge for clinicians to put their own values aside to respect the decision of clients who choose to stay in a marriage that while abusive, is less stigmatizing than divorce. Not all Asians subscribe to this belief, however, so it will be beneficial to explore these beliefs as well.
Exploring spiritual and religious factors within the context of substance use and abuse is also a clinical consideration. Some research explores the use of substances in the context of seeking an altered state of mind (Sandhu, 2009) of finding answers or as a means of expanding spiritual and religious ties. Research also exists exploring the use of religious and spiritual rituals and meaning within the context of therapy and counseling (Wali, 2001).
Asian cultures value image and status. Some of this is historically demonstrated through the sacrifice of one’s life when shame is brought upon others by that individual. Other ways this is demonstrated is in the use and sharing of substances, as having certain substances to offer and share may indicate a status symbol, particularly depending upon the social economic class of the individuals initially offering the substance (Sandhu, 2009). Exploring the social status of clients, as well as what it means to be able to use substances and offer them, may provide important information in the design of a treatment plan.
While substance use disorders may be a problem in some Asian cultures, accepting this and seeking help may be viewed as a weakness, particularly if there is the belief individuals can take care of their own problems without involving outside help. There is an illusion that one can “solve” the problem of a substance use disorder without having the information about what drugs do and can do to a body, brain, mind, and psyche. There may be beliefs viewing the use of alcohol and other substances as “medicine” to heal a hard day’s work (Sandhu, 2009). Exploring the function use serves for the individual can be helpful in the collaborating of appropriate treatment goals. Saving face is an important value within many Asian cultures. It can be seen as a stigma to share problems with individuals outside the family. Thus, many Asians may not discuss concerns with professionals or acknowledge the intensity of existing problems. The flip side of this is that individuals may not even want to share this with family members, as it may bring shame and embarrassment to the family (Hwang, 2006). Thus, some individuals coming in for treatment may not want to involve family members or other individuals in their treatment. It’s necessary to explore their beliefs around family involvement and respect decisions made regarding family involvement.
It is also not uncommon for some Asians to inquire about their counselor’s credentials and experience. This is not meant to be a challenge; rather, it is to determine if counselors have expertise within the subject. Additionally, individuals from some Asian cultures may inquire about the counselor’s social networking and community ties. Within some Asian cultures, gossip may be a pastime and there may be concern the counselor will know others within clients’ social circles. Reassuring confidentiality and explaining HIPPA compliance is an important component to developing rapport and establishing trust.
As previously mentioned, some Asians may not understand or know the effects of substance abuse. They may not see a need to seek help because they have not experienced the physical consequences of their use or they have not recognized any connections between the use of substances and other consequences in their life. Additionally, many individuals may not know even where to receive help or services for the kinds of issues that may be present. There may be more of a focus on the physical symptoms, thus visits or calls to a primary care doctor go unquestioned. There’s an existing, then, when services are challenging to find; so individuals do not utilize them; thus, funding and research for Asians and substance use remain limited (Matsuyoshi, 2001).
While it is well known that the use of support groups can be effective in substance use treatment, when it comes to Asian individuals this may not be the most effective, depending on the acculturation level and beliefs they hold. Since discussing their problems to individuals outside of the family has its own stigma attached to it, many Asian individuals may not share information or current status. This may be construed as being resistant or being in denial, where in fact, the behavior may be more aligned with cultural and traditional beliefs (Amodeo, Robb, Peou, & Tran, 1996). Additionally, some Asian individuals are refugees and may not trust a group setting. Individuals with this history bring additional factors to be considered within a treatment setting, as oppression, trauma, and political ties increases layers that may contribute to the use of substances and the lack of seeking treatment. However, some research demonstrates the success of Twelve Step groups that are culturally, religiously, and politically sensitive (Amodeo et al., 1996).
Another consideration is the view individuals have about their disorder. Many Asian cultures do not embrace the same philosophy as Western medicine. Thus, exploring clients’ understanding of what is happening to them assists in the development of treatment. For example, Amodeo et al. (1996) discuss how Eastern medicine understands illness within the contexts of a natural, supernatural or metaphysical cause. Exploring this with clients and understand healing systems from a cultural perspective and what clients may want to include—things such as traditional Chinese medicine or Ayuveda—can open the dialogue of healing and illness and what it means to the individual struggling with this disorder.
Asking direct questions relating to the aforementioned considerations may be effective for many Asian clients.
Evidence-Based Treatment Approaches
Much of the treatment approaches utilized with Asians focus on the use of Western approaches and the limited research on the effectiveness of these approaches with Asians. Within the field of substance use, there is a paucity of research on effective treatment approaches. Hwang (2006) explores the need for research with treatment approaches that include modifications and adaptations to Asian culture. He discusses how a few cultural approaches exist—for example, Chinese Taoist cognitive psychotherapy—to incorporate cultural and spiritual elements of the East. Wu and Blazer (2015) discuss how factors like karma, family-related stigma, and lack of knowledge of SUDs and of treatment options in general are missing elements in treatment approaches. Juthani (2001) explores how treating Hindu clients requires a more directive approach from clinicians and symptom relief is a goal, while Hwang (2006) explores a similar concept with Asians in general.
Additionally, mindfulness is gaining attention in the current literature, particularly as a supplement to addiction treatment (Marlatt, 2002). Current literature explores mindfulness as a tool to addiction treatment and an element that does find origins in Asian cultures and religions. Other substance use treatment approaches developed include Moita therapy, Naikan therapy, and Daoistic cognitive therapy.
Asian American adolescents abuse drugs at different rates in comparison to their European counterparts. There are many factors that contribute to lower rates of substance abuse in the Asian American adolescent community, one of them being social factors. Close ties with family and lots of family interaction are significant parts of socialization amongst Asian Americans. In a study conducted by Fang, Barnes-Ceeney, and Schinke (2011), Asian American girls had lower levels of alcohol use, nonprescription drug use, and other substance abuse when families intervened and communicated more. From this study, adolescent girls who interact with their families more have a lower substance abuse rate. In Asian American societies, families play a large role in the development and socialization of children.
Au and Donaldson (2000) looked at the differences in substance use between Asian American and European American adolescents. This study focused on social factors and familial interactions to determine rates of substance abuse. European American adolescents experienced 2.75 times more peer pressure into using substances than Asian American adolescents. European American adolescents had broken families and therefore spent more time with friends, while Asian American adolescents spent less time with friends and had fewer close friends. In the Asian American community it is more important to spend time with family. Data also shows that when Asian American adolescents do have close friends, they tend to have higher rates of abusing substances. One can conclude from this data that familial influences reduce the use of substances and the likelihood of falling into peer pressure.
Kim, Zane, and Hong (2002) looked at social factors that put Asian American adolescents at risk of substance abuse and protect from substance abuse. Social factors such as peer pressure, family, and school play a direct role in using substances. Substance use is deterred when family factors come into play. The family variable negates peer and school variables that influence substance use. On the other hand, the school variable negates family and peer factors from influencing the use of substances. The more exposed Asian American adolescents were to peer pressure, the higher likelihood of them using cigarettes and alcohol. When Asian American adolescents had closer family relationships, the less likely they were to be influenced by peer pressure. In conclusion, social factors such as school, peers, and family play a significant role in the use of substances in the Asian American community. Interaction with family is negatively associated with abusing substances, while interaction with friends is positively associated with abusing substances. Family socialization is a key part in substance abuse.
Note that this is a hypothetical case illustration based on integrated factors from many clients and does not represent a real client. The following case will demonstrate an initial assessment and the factors that should be explored with a client of Asian descent.
Dave is a twenty-four-year-old Indian American client. When he initially arrived at his assessment for substance abuse, he was calm. When asked about why he was here, he reported his parents (specifically his father) caught him smoking marijuana at home and demanded he get an assessment. During the initial assessment, Dave responded to the questions, speaking English well and maintaining eye contact. He was well groomed, laid back, and did not present with agitation or symptoms of anxiety. In response to a question about whether he thinks he has a problem, he said that he is unsure, as many of his friends use. He reported living with his parents, older sister, brother-in-law, and aunt and uncle. He works and is studying towards his advanced degree.
In the initial assessment, I asked him about his use, how he supports it, and how often he uses. He reported he’s able to buy marijuana from his friends when he wants to, as he is financially stable. He indicated using more with his friends on the weekends, and sometimes during the week to “ease the stress from work and school.” I asked about other coping mechanism for stress and he reported he doesn’t really utilize other resources, as sometimes it’s challenging within his living situation—he can’t go as he pleases due to family obligations, watching his niece and nephew, and helping to take care of his parents and extended relatives. When asked where he was born, he replied he was born in Canada and this didn’t have any significance on how he identified himself. Dave reported that he doesn’t really think about his identity when he’s outside the home; however, when he is at home, because his parents speak in the traditional native tongue and follow traditional rituals, he recognizes how this sometimes leads him to feel conflicted in his own identity and retreating to his room to reduce the tension becomes a routine. He was surprised to discover this contributed sometimes to his use. I asked him if this is something he felt open to explore and he replied “maybe.”
Upon learning he is first generation, I asked what that was like for him, to be caught between two worlds. He related stressors to having traditional parents and trying to fit in with his peers and work culture. He said he felt sometimes his parents didn’t understand some of the things he wanted to do and focused more on the pressure of finishing school and getting married. He reported he wasn’t ready to get married and wanted some time to finish school, explore new opportunities, and had other aspirations before settling down. I asked him his thoughts on having his parents come in for a session to talk about substances and some of his concerns and he reported he wanted to wait on that, as he felt his use wasn’t necessarily a problem, yet recognized he wanted to identify some other outlets for stress relief. I asked if working on stress management tools is of interest, given his reports and he replied that this is something he is okay with.
I asked about conflicts with his extended family members, what it is like for him with additional family in the household and he replied it wasn’t an issue for the most part. When asked about cultural conflicts—as he mentioned his traditional parents don’t seem to understand his efforts with “fitting into the work and social dimensions”—he related that the cultural differences did make it frustrating sometimes. Since these questions took up most of the first session, I asked if Dave was willing to return for a second session to complete the assessment and discuss next steps. He reported he was okay with this and asked if we can do so in two weeks. I did ask about this and he reported he had to travel for work. We scheduled the appointment for the following week.
As a whole, substance use among Asians has not received as much research and attention as other racial and ethnic groups. Most treatment facilities focus on promoting Western cultural values and beliefs, which may not align with many Asians who seek treatment. Thus, this contributes to higher rates of premature dropouts from treatment as well as inconsistences between the ethics of service and the delivery of services. When working with Asian clients, substance abuse counselors can explore and acknowledge this limitation, as a means of promoting cultural competency and involving these clients as collaborators within treatment. Inquiring about best practices, cultural rituals, and cultural and religious texts to promote recovery goals can be helpful. Some subcultures of the Asian population may need reminders about confidentiality and HIPPA compliance, as stigma about “who you may know” can interfere with effective treatment. Exploring acculturation levels and immigration status will provide some knowledge about additional stressors to address in treatment, as well as effective coping mechanisms to replace substance use. Some Asians may not consider abstinence as a goal, so harm reduction pathways may be effective. Consideration can be given to some of the existing approaches in working with Asians, as relating to substance abuse treatment and cultural considerations. While there are many factors that are also outside the scope of this article to consider and explore with Asians seeking treatment for SUDs, this overview provides a foundation of where and possibly how to start.
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