substance abuse among southeast asians in the u.s
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SubstanceAbuse
AmongSoutheastAsians inthe U.S.Thomas O'HarePhD, ACSW a &Thanh Van TranPhD aa Boston College,Graduate Schoolof Social Work ,Chestnut Hill,MA, 02167-3807,USAPublished online:12 Oct 2008.
To cite this article: Thomas O'Hare PhD, ACSW& Thanh Van Tran PhD (1998) Substance AbuseAmong Southeast Asians in the U.S., Social Workin Health Care, 26:3, 69-80, DOI: 10.1300/J010v26n03_05
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To link to this article: http://dx.doi.org/10.1300/J010v26n03_05
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Substance Abuse Among Southeast Asians
in the U.S.: Implications for Practice
and Research
Thomas O'Hare, PhD, ACSW Thanh Van Tran, PhD
ABSTRACT. The literature on Asian-American substance use has shown a general increase in consumption and related problems due, in part, to the effects of acculturation toward U.S. drinking norms. Southeast Asians arc the most recent of Asian groups to come to the U.S., and have done so following an immigration and refugee expe- rience that was among the most traumatic in recent memory resulting in significant levels of psychosocial distress. The combined in- fluences of mental health disorders, which frequently co-occur with substance abuse, and acculturation pressures suggest that a signifi- cant increase in substance abuse problems may be in progress for Southeast Asian immigrants. Preliminary evidence appears to bear out this hypothesis. The current article outlines the literature on substance abuse among Vietnamese, Cambodians and Laotians in the U.S., and makes tentative recommendations for assessment, treat- ment and future research. [Arficle copies available for u fee from The Huworlh Doctm?errt Delivery Service: 1-800-342-9678. E-rrrail address: [email protected]?J
Prcliminary evidence suggests that Southeast Asian immigrants, ref- ugees and their children in the U.S. are at increascd risk for abusing
Thomas O'Hare and Thanh Van Tran are affiliated with Boston Collcgc, Grad- uate School of Social Work, Chestnut Hill, MA 02167-3807.
Social Work in Health Care, Vol. 26(3) 1998 O 1998 by The Haworth Press, Inc. All rights resewed. 69
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70 SOCIAL WORK INHEALTH CARE
alcohol and other drugs. The consequences of war trauma, leaving one's homeland and loved ones, and acculturation to American society may be contributing to stress-related mental disorders with co-occurring increases in substance abuse. Bemier (1992) has suggested four stress-related theories as a framework to account for problems among Southeast Asian refugees: stress related to acculturalion in the new host country (e.g., struggling to learn a ncw language, encountering a new culture), bereavement (e.g., loss of status, physical possessions, loved ones), change (e.g., a new social environment, financial status), and trauma (e.g., war, famine, persecution, torture), the effects of which may endure for years. Given the growing evidence that mental health and substance use problems frequently co-oc- cur in both general population (Helzer and Pryzbeck, 1988) and clinical samples (O'Hare, 1995), the literature on psychological disturbances among Southeast Asians provides a cogent backdrop to a discussion of substance abuse disorders. In addition, the acculturation experiences of other Asian- American groups has apparently contributed to increases in substance abuse. The purpose of this article is to critically examine research findings relevant to Southeast Asian mental health and substance abuse problems in order to provide an empirical framework for preliminary practice guide- lines and future research.
Having increased in numbers from 133,438 in 1975 to 1,204,900 in 1992 (US. Ofice of Refugee Resettlement), immigrants from Vietnam, Cambodia and Laos are a rapidly growing part of the Asian-American population in the United States. The vast majority of immigrants from these groups arrived as political refugees, and all have shown dispropor- tionate signs of psychological strain when comparcd to US. population norms. Much of the distress found among Vietnamese immigrants and refugees has been associated with lower socio-economic status, poor En- glish language proficiency, less confidence in interacting with Americans, lack of other social supports (Nicassio, 1983; Tran and Wright, 1986), greater pre-migration stresses (Matsuoka, 1990), lower personal self-effi- cacy with subsequent depression (Tran, 1993), and a lack of adequate health care (Tran and Nguyen, 1994). A recent study of a clinical sample of Southeast Asians in the mid-west showed that more than half had serious, often chronic, physical disorders which caused or exacerbated a mental health disturbance. Somc of these conditions apparently were caused by pre-immigration trauma, including torture (Ta, Westermeyer and Ncider, 1996). Suggesting that Cambodians experienced thc worst trauma in recent Southeast Asian history, Carlson et al. (1991) conducted structured interviews with a small random community sample, and discov- ered that 86% of Cambodians met Post Traumatic Stress Disorder criteria
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Thomas O'Hare and Thailh Varl Tran 71
(based on DSM-111-R criteria, r = .85), 96% had high dissociative symp- toms (Dissociative Experiences Scale, r = .84), and 80% appeared to be clinically depressed (Hopkins Symptom Checklist-25, r = 39). Almost all respondents reported a variety of traumatic experiences. Mollica et al. (1993), based on a refugee camp sample of 993, and Sack et al. (1994), surveying adolescents (n = 209) and their parents (n = 95), uncovered similar evidence in a sample of Cambodians who had survived the refugee experience, although the latter study may have suffered from a sample selection bias between the two sites. Even after ten years in the U.S., the Hmong community of Laos also showed higher rates of mental distur- banccs compared to American norms based on the analysis of 102 ref- ugees who participated in structured interviews over 7-9 years (Wester- meyer, 1988). Lastly, Ying and Hu (1994) showed that over 1,700 Southeast Asian outpatient mental health clients experienced more anxiety disorders, had higher service utilization rates, and poorer outcomes overall perhaps due to their relatively recent and more traumatic migration to the U.S.
SOUTHEAST ASIAN SUBSTANCE USE PATTERNS AND ASSOCIATED PROBLEMS IN THE US.
Although substance abuse data on Southeast Asians in the U.S. are only beginning to emerge, robust findings which include other Asian-American groups show changes in substance use patterns and consumption increases over recent generations apparently resulting from acculturation to Ameri- can norms (Kitano, 1989; Sue, Zane and Ito, 1979). Data from the 1992 National Health Interview Survey (NHIS) found that 24.4% of Asian- American youth (12-21 years of age) consumed alcohol at least once within the past 30 days (vs. 43.8% whites). Regarding illicit substances, 15% of Asian-American youth used marijuana and 3.7% tried cocaine at least once in their life (vs. 28.5% and 6.4% for whites, respectively) (National Center for Health Statistics, 1995). Although there are no specific substance use data on "bi-cultural" Asian-Americans, one might suspect that they are at greater risk to drink excessively since they are more acculturated in general to American norms (Uba, 1994). One study dcm- onstrated that a small proportion of Asian high school students who drank heavily actually consumed more than their heavy drinking non-Asian counterparts (Barnes and Welte, 1986). A survey at a large eastcm univer- sity, a setting in which many Asian students are initiated to "American- style" drinking (Kitano et al., 1985), showed almost 15% of Asian students to be hcavy-moderate to heavy drinkers (O'Hare, 1990). Indeed, heavy drinking for Chinese men (who often develop drinking problems after
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72 SOCIAL WORK IN HEALTH CARE
immigration as a result of easier accessibility of alcohol) seems related to drinking with friends and going to bars (Chi, Kitano and Lubben, 1988), increased family problems and social isolation (Chin, Lai and Rouse, 1991). Heavy drinking among Japanese-American men and women is not uncommon (Kitano, Lubben and Chi, 1988), and Japanese-American women appear to have a higher percentage of heavy drinkers than Chinese, Korean, and Filipino Asian-American females (IOtano and Chi, l986Il987).
Although some have suggested that moderation in Asian-American drinking practices is, to some degree, physiologically mediated (Akutsu et al., 1989), the prepondcrance of evidence suggests that cultural factors have had a more uowerful influence on substance use wattems (Li and Rosenblood, 3994, Sue, 1987). Kitano (1989) has asserted that when the immigrant's traditional behavior comes in contact with the dominant cul- ture, the traditional behavior will be modified over time. Variables which mediate this process may include length of time in the country, availability and cost of alcoholic beverages, and the amount and quality of interaction with the dominant culture. Acculturated Japanese and Chinese students, for example, drink more than do less acculturated counterparts (Sue et al., 1979). Although this process does not always occur uniformly among Asian-Americans (Kitano, Chi, Rhee et al., 1992), alcohol abuse has in- creased overall, and the meaning, context and consequences of alcohol abuse have become more problematic.
Although no well-controlled longitudinal data are currently available, preliminary evidence suggests that pockets of trouble are beginning to emerge in Southeast Asian communities, and they appear to be directly related to a host of psychosocial stressors. Yee and Thu (1987) found in a study of Vietnamese immigrants that almost 14% had trouble with other drugs "some of the time," over 40% reported using alcohol as a means of "coping with sorrows," and almost 12% reported using drugs for the same purpose. Structured interviews with a snowball sample of 120 Cambodian women on the East and West Coasts of the U.S. (D'Avanzo, Frye and Froman, 1994) revealed that almost seven percent reported a family mem- ber to have a drinking problem, about 15% of the East Coast group re- ported that a family member (usually an adolescent) was using street drugs, and 17% of the women reported using prescription drugs, in part, for their "street drug" effects. Over 58% of the West Coast sample re- ported using medications for sclf-treatment of conditions other than that for which the drug was prescribed: coping with stress, forgetting troubles, and dealing with physical discomforts, including those associated with pregnancy. Based on longitudinal qualitative field research with non-ran- dom samples, Westermcyer (1985) reported Laotian alcohol consumption
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Tliomas 0 'Have and Thar~h Van Trait 73
levels in the US . to be lower than pre-migration levels. However, drinking patterns appeared to be more problem-prone (particularly for young males) than the more narrowly prescribed ceremonial drinking which occurred in rural Southeast Asia. Although drinking has replaced opium for some in the U.S., opium use overall appears to be on the increase (Westermeyer, Lyfoung, Westemeyer and Neider, 1991). The same study which ex- amined Hmong seeking treatment for opium addiction found that more than half experienced a range of co-occurring symptoms including: toler- ance and withdrawals, occasional loss of control, guilt over opium use, . - nightmares, anxiety, suicidal ideation, interpersonal and &mily dis- tress, school and work-related problems, financial and legal difficulties. Rather than the oleasurable ceremonial or recreational activitv it was eener- ., ally regarded in their homeland where rates of opium use have been estimated at 8-12% among farmers (Westemeyer et al., 1991), the use of alcohol or opiates has come to have very negative associations, and con- cerns about an expanding substance abuse problem are growing (Wester- meyer, 1985).
Although most of the data are based on non-representative samples, indications are that substance abuse is a growing concern for many South- east Asian immigrants, once again challenging the myth of Asian-Ameri- cans as the "model minority" (Uba, 1994). Given these reports combined with evidence of disproportionate psychosocial stressors and the docu- mented increases in substance abuse among other traditionally abstemious Asian-American groups, social workers should be vigilant to signs of substance abuse within the Southeast Asian community.
Zntplicatiorts for Practice and Research
Clinical Assessment
Diagnosis of both substance abuse and mental health concerns should be conducted warily for Southeast Asian clients. In particular, practitio- ners might considerkmploying a more heterogenous p&pective~(~reeman, 1991) when making substance abuse assessments with thcse groups. A multivariate view emphasizes a continuum of abuse along which the causes, course and consequences are often intcrtwined with co-occurring health, mental health and other psychosocial problems. Such an assess- ment model may comport well with the problems of Southeast Asian clients who, for example, may not consume alcohol at levels of other Arncrican groups, but, nevertheless, suffer from a range of co-occurring psychosocial difficulties aggravated by the use of alcohol or other drugs. Practitioners also need to bring cultural context and meaning to the client's
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74 SOCIAL WORK IN HEALTH CARE
problems which often include grieving multiple losses and struggling with the stresses of acculturation and adaptation (Eisenbruch, 1991). There is also a growing availability of assessment tools which can be employed in culturally sensitive practice research with Southeast Asian clients, or could be used to complement clinical interviewing. These include an ac- culturation scale which emphasizes language proficiency (Anderson et al., 1993), the Hopkins Symptom Checklist (HSCL-25) for measuring anxiety and depression among Vietnamese, Cambodians and Laotians (Mollica, 1987), and the Vietnamese Depression Scale (Kinzie et al., 1987), which measures various dimensions of this disorder.
Intervention
General guidelines recommended for social work practice with South- east Asian clients include a focus on multiple losses, stress-related somatic concerns, and daily problems of adaptation. Recommended interventions include the use of psychoeducation, role modeling, coping skills to bolster self-efficacy and to deal with stressful environmental challenges, and to strengthen support networks within the family and community (Timber- lake and Cook, 1984; Montero and Dieppa, 1982; Land, Nishimoto and Chau, 1988; McQuaid, 1989). Psychoeducation is a direct way to impart knowledge about American culture (informal interpersonal styles, slang meanings, government bureaucracies, available goods and services). Role playing new communication and coping skills can reduce anxiety and improve the client's confidence and effectiveness in obtaining resources and problem solving in a new and different culture.
With respect to problems related to substance abuse, practitioners are admonished to avoid insight-oriented therapies (Timberlake and Cook, 1988; McQuaid, 1989; Beohnlein et al., 1985) as well as approaches which pressure clients to admit "alcoholism," and engage in a recovery process based on Western views of spiritual redemption. This strategy may be particularly incongruent with Southeast Asian culture given the hcavy emphasis on extensive self-examination and public confession. Evidence suggests, however, that cognitive-behavioral therapies (CBT) have been positively received by Asian-American clients and their practitioners (Mo- kuaua-Matsushima, Tashima and Murase, 1982), and offer much promise for work with substance abusing clients. Effective interventions for sub- stance abuse (Miller, 1992) typically emphasize learning new skills to reduce or eliminate consumption, prevent relapse, and reduce negative consequences in the community. CBT for persons who abuse substances typically include some combination of the following: ( I ) self-monitoring thoughts, feelings and situations which are likely to "trigger" an impulse
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771oma.s O'Hare and Tlzanh Van Tran 75
to abuse alcohol or drugs; (2) teaching more effective social skills to deal with situations in which the client may be pressured to use drugs; and (3) teaching stress management skills to lower anxiety, deal with somatic complaints, and covertly rehearse new behavioral skills. These methods have been incorporated into individual, couples, family and community- based interventions (McCrady, 1991) and have a record of demonstrated effectiveness for a broad range of clients. When adapting CBT approaches for Southeast Asian families, clinicians must be especially sensitive to the degree of guilt and shame, and skillfully enhance family communication skills while, at the same time, emphasizing respect for tradition, family hierarchy and the importance of indigenous community supports which may enhance the reduction or elimination of substance abuse (Ja and Aoki, 1993; Perez-Arce, Cam and Sorensen, 1993). CBT skills are also applica- ble to a range of problems such as depression and anxiety disorders which frequently co-occur with substance abuse. Future research efforts should examine the effectiveness of family-based CBT approaches with South- east Asians who suffer from combined mental health and substance use disorders.
The evidence for the acceptability of CBT by Southeast Asian clients may be due, in part, to the complementarity between CBT principles and Asian cultural values including: ( I ) respect for the teaching modality inherent in psychoeducation and skill-based approaches; (2) the relative structure and emphasis on personal initiative and responsibility in treat- ment; (3) the ability to examine cognitive schemas relevant to the problem without being unnecessarily intrusive; (4) the use of stress management techniques based on Asian philosophies which clients may find familiar; and, (5) the ease of incorporating CBT methods into family and communi- ty-based interventions. Employing CBT interventions can also accornrno- date two ingredients crucial to engaging Asian-American clients: first, credibiliq (i.e., a client's perception that the clinician is both effective and trustworthy), and, secondly, a phenomenon known as giving, that is, the client's experience that something of significant value has been received from the therapeutic encounter (Sue and Zane, 1987).
DIRECTIONS FOR FUTURE RESEARCH
Emphasis has recently been given in the addictions literature to avoid- ing broad ethnic and racial glosses to describe culturally disparate peoples (Heath, 1991; Cheung, 1991; Trimble, 1990191). The same suggestions have been made specifically for Southeast Asian studies as well (Bromley, 1987; Fong and Mokuau, 1994). More specifically, Cheung (1991) has
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76 SOCIAL WORK IN HEALTH CARE
suggested that future research emphasize more accurate measures of eth- nicity which address both the objective component of culture retention and the more subjective notion of ethnic identification. Other specific im- provements to measuring ethnicity summarized by Trimble (1990/1991) might include employing natal measures (i.e., birthplace of self, siblings, natural parents, grandparents and relatives), measuring behavior (i.e., lan- guage use, affiliative patterns with friends and acquaintances, media usage, participation in ethnic-specific activities such as cultural and religious events, music and food preferences, club membership); subjective assess- ments of ethnicity (e.g., self-identified ethnicity, assessment of accultura- tive status, real and aspired self-image, value preferences, role models and preferred reference groups, ego involvement in group, attitudes toward "out" groups), hierarchical nestingprocedures (i.e., "layering" questions about place of birth, nation, ethnic composition of current neighborhood, preferences for acquaintances, colleagues, spouses, etc.), and accounting for the variability in ethnic identity as a function of social context.
Given the acculturation experiences of other Asian-Americans, co-oc- curring psychosocial risk factors and preliminary evidence of substance abuse problems among Southeast Asian-Americans, research is urgently needed to more completely measure the incidence and prevalence of sub- stance use and abuse among these ethnic groups, and to examine the causes and extent of associated psychosocial dysfunction. Within the con- text of Bemier's (1992) framework, a multivariate model should, at a minimum, include: a thorough examination of ethnic identity, history of trauma and losses experienced by the respondent and their parents, mea- sures of assimilation and acculfuration stresses, psychosocial and menial health problem ratings, several substance use ratings (including pre- migration retrospective measures) to gauge consumption level and prob- lem severity, and alcohol and drug expectancies (to measure social learn- ing influences with respect to substance use). These measures can also be incorporated into research on culturally congruent treatment processes and outcomes, the need for which is clearly evident (Sue and Zane, 1987; Spencer, Heggenhougen and Navaratnam, 1980).
Accepted for Publication: 07/11/96
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