9.4: Counseling for Asian Americans, Native Hawaiians, and Other Pacific Islanders

Asian Americans, per the U.S. Census Bureau definition, are people whose origins are in the Far East, Southeast Asia, or the Indian subcontinent (Humes et al. 2011). The term includes East Asians (e.g., Chinese, Japanese, and Korean Americans), Southeast Asians (e.g., Cambodian, Laotian, and Vietnamese Americans), Filipinos, Asian Indians, and Central Asians (e.g., Mongolian and Uzbek Americans). In the 2010 Census, people who identified solely as Asian American made up 4.8 percent of the population, and those who identified as Asian American along with one or more other races made up an additional 0.9 percent. Census data includes specific information on people who identify as Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and “other Asians.” The largest Asian populations in the United States are Chinese Americans, Filipino Americans, Asian Indian Americans, Korean Americans, and Vietnamese Americans. Asian Americans overwhelmingly live in urban areas, and more than half (51 percent) live in just three states New York, California and Hawaii. (Hoeffel et al. 2012).

Not all people with origins in Asia belong to what is commonly conceived of as the Asian race. Some Asian Indians, for example, self- identify as White American. For this reason, among others, correctional professionals should be careful to learn from their Asian American offenders how they identify themselves and which national heritages they claim. Correctional professionals should recognize that offenders who appear to be Asian may not necessarily think of themselves primarily as persons of Asian ancestry or have a deep awareness of the traditions and values of their countries of origin. For example, Asian orphans who have been adopted in the United States and raised as Americans in White American families may have very little connection with the cultural groups of their biological parents (St. Martin 2005). Correctional professionals should not make generalizations across Asian cultures; each culture is quite distinct.

Little literature on substance use and mental disorders, rates of co-occurrence, and treatment among Asian Americans focuses on behavioral health treatment for Native Hawaiians and Pacific Islanders; thus, a text box at the end of this section summarizes available information.

Beliefs About and Traditions Involving Substance Use

Within many Asian societies, the use of intoxicants is tolerated within specific contexts. For example, in some Asian cultural groups, alcohol is believed to have curative, ceremonial, or beneficial value. Among pregnant Cambodian women, small amounts of herbal medicines with an alcohol base are sometimes used to ensure an easier delivery. Following childbirth, similar medicines are generally used to increase blood circulation (Amodeo et al. 1997). Some Chinese people believe that alcohol restores the flow of qi (i.e., the life force). The written Chinese character for “doctor” contains the character for alcohol, which implies the use of alcohol for medicinal purposes.

Some Asian American cultural groups make allowances for the use of other substances. Marijuana, for instance, has been used medicinally in parts of Southeast Asia for many years (Iversen 2000; Martin 1975). However, some Asian Americans tend to view illicit substance use and abuse as a serious breach of acceptable behavior that cannot readily be discussed. Nonetheless, there are broad differences in Asian cultures’ perspectives on substance use, thus requiring correctional professionals to obtain more specific information during intake and subsequent encounters.

Acknowledging a substance abuse problem often leads to shame for Asian American offenders and their families. Families may deny the problem and inadvertently, or even intentionally, isolate members who abuse substances (Chang 2000). For example, some Cambodian and Korean Americans perceive alcohol abuse and dependence as the result of moral weakness, which brings shame to the family (Amodeo et al. 2004; Kwon-Ahn 2001).

Substance Use and Substance Use Disorders

According to the 2012 NSDUH, Asian Americans use alcohol, cigarettes, and illicit substances less frequently and less heavily than members of any other major racial/ethnic group (SAMHSA 2013d). However, large surveys may undercount Asian American substance use and abuse, as they are typically conducted in English and Spanish only (Wong et al. 2007b). Despite the limitations of research, data suggest that although Asian Americans use illicit substances and alcohol less frequently than other Americans, substance abuse problems have been increasing among Asian Americans. The longer Asian Americans reside in the United States, the more their substance use resembles that of other Americans. Excessive alcohol use, intoxication, and substance use disorders are more prevalent among Asians born in the United States than among foreign-born Asians living in the United States (Szaflarski et al. 2011). Among Asian Americans who entered substance abuse treatment between 2000 and 2010, methamphetamine and marijuana were the most commonly reported illicit drugs (SAMHSA, CBHSQ 2012). Methamphetamine abuse among Asian Americans is particularly high in Hawaii and on the West Coast (OAS 2005a). As with other racial and ethnic groups, numerous factors—such as age, birth country, immigration history, acculturation, employment, geographic location, and in- come—add complexity to any conclusions about prevalence among specific Asian cultural groups. Asian Americans who are recent immigrants, highly acculturated, unemployed, or living in Western states are generally more likely than other Asian Americans to abuse drugs or alcohol (Makimoto 1998). For example, according to the National Latino and Asian American Study (NLAAS), Asians who are more acculturated are at greater risk for prescription drug abuse (Watkins and Ford 2011).

Despite rates of substance use disorders among Asian Americans having increased over time, research has regularly found that, of all major racial/ethnic groups in United States, Asian Americans have the lowest rates of alcohol use disorders (Grant et al. 2004; SAMHSA 2012b). This phenomenon has typically been explained in part by the fact that some Asians lack the enzyme aldehyde dehydrogenase, which chemically breaks down alcohol (McKim 2003). Thus, high levels of acetaldehyde, a byproduct of alcohol metabolism, accumulate and cause an unpleasant flushing response (Yang 2002). The alcohol flushing response primarily manifests as flushing of the neck and face but can also include nausea, headaches, dizziness, and other symptoms.

Mental and Co-Occurring Disorders

Overall, health and mental health are not seen as two distinct entities by Asian American cultural groups. Most Asian American views focus on the importance of virtue, maturity, and self-control and find full emotional expression indicative of a lack of maturity and self-discipline (Cheung 2009). Given the potential shame they often associate with mental disorders and their typically holistic worldview of health and illness, Asian Americans are more likely to present with somatic complaints and less likely to present with symptoms of psychological distress and impairment (Hsu and Folstein 1997; Kim et al. 2004; Room et al. 2001; U.S. Department of Health and Human Services [HHS] 2001; Zhang et al. 1998), even though mental illness appears to be nearly as common among Asian Americans as it is in other ethnic/racial groups. In 2009, approximately 15.5 percent of Asians reported a mental illness in the past year, but only 2 percent reported past-year occurrence of serious mental illness (SAMHSA 2012a). Asian Americans have a lower incidence of CODs than other racial/ethnic groups because the prevalence of substance use disorders in this population is lower. In the 2012 NSDUH, 0.3 percent of Asian Americans indicated co-occurring serious psychological distress and substance use disorders, and 1.1 percent had some symptoms of mental distress along with a substance use disorder—the lowest rates of any major racial/ethnic group in the survey (SAMHSA 2013c).

Considerable variation in the types of mental disorders diagnosed among diverse Asian American communities is evident, although it is unclear to what extent this reflects diagnostic and/or self-selection biases. For example, Barreto and Segal (2005) found that Southeast Asians were more likely to be treated for major depression than other Asians or members of other ethnic/racial groups; East Asians were the most likely of all Asian American groups to be treated for schizophrenia (nearly twice as likely as White Americans). Traumatic experiences and PTSD can be particularly difficult to uncover in some Asian American offenders. Although Asian Americans are as likely to experience traumatic events (e.g., wars experienced by first-generation immigrants from countries such as Vietnam and Cambodia) in their lives, their cultural responses to trauma can conceal its psychological effects. For instance, some Asian cultural groups believe that stoic acceptance is the most appropriate response to adversity (Lee and Mock 2005a,b).

Treatment Patterns

Treatment-seeking rates for mental illness are low among most Asian populations, with rates varying by specific ethnic/cultural heritage and, possibly, level of acculturation (Abe-Kim et al. 2007; Barreto and Segal 2005; Lee and Mock 2005a,b). Asian Americans who seek help for psychological problems will most likely consult family members, clergy, or traditional healers before mental health professionals, in part because of a lack of culturally and linguistically appropriate mental health services available to them (HHS 2001; Spencer and Chen 2004). However, among those Asian Americans who seek behavioral health treatment, the amount of services used is relatively high (Barreto and Segal 2005).

Beliefs and Attitudes About Treatment

Compared with the general population, Asian Americans are less likely to have confidence in their medical practitioners, feel respected by their doctors, or believe that they are involved in healthcare decisions. Many also believe that their doctors do not have a sufficient under- standing of their backgrounds and values; this is particularly true for Korean Americans (Hughes 2002). Even so, Asian Americans, especially more recent immigrants, seem more likely to seek help for mental and substance use disorders from general medical providers than from specialized treatment providers (Abe-Kim et al. 2007). Many Asian American immigrants underuse healthcare services due to confusion about eligibility and fears of jeopardizing their residency status (HHS 2001).

As with other groups, discrimination, acculturation stress, and immigration and generational status, along with language needs, have a large influence on behavioral health and treatment-seeking for Asian Americans (Meyer et al. 2012; Miller et al. 2011). The NLAAS found that although rates of behavioral health service use were lower for Asian Americans who immigrated recently than for the general population, those rates increased significantly for U.S.-born Asian Americans; third- generation U.S.-born individuals’ rates of service use also were relatively high (Abe-Kim et al. 2007). Of those Asian Americans who had any mental disorder diagnosis in the prior year, 62.6 percent of third-generation Americans sought help for it in the prior year compared with 30.4 percent of first-generation Americans.

Overall, Asian Americans place less value on substance abuse treatment than other population groups and are less likely to use such services (Yu and Warner 2012). Niv et al. (2007) found that Asian and Pacific Islanders entering substance abuse treatment programs in California expressed significantly more negative attitudes toward treatment and rated it as significantly less important than did others entering treatment. Seeking help for substance abuse can be seen, in some Asian American cultural groups, as an admission of weakness that is shameful in itself or as an interference with family obligations (Masson et al. 2013). Among 2010 NSDUH respondents who stated a need for substance abuse treatment in the prior year but did not receive it, Asian Americans were more likely than members of all other major racial/ethnic groups to say that they could handle the problem without treatment or that they did not believe treatment would help (SAMHSA 2011c). Combining NSDUH data from 2003 to 2011 NSDUH, Asian Americans who needed but did not receive treatment in the past year were the least likely of all major ethnic/racial groups to express a need for such treatment (SAMHSA, CBHSQ 2013c).

Treatment Issues and Considerations

It is important for correctional professionals to approach presenting problems through offenders’ culturally based explanations of their own issues rather than imposing views that could alter their acceptance of treatment. In Asian cultural groups, the physical and emotional aspects of an individual’s life are undifferentiated (e.g., the physical rather than emotional or psychological aspect of a problem can be the focus for many Asian Americans); thus, problems as well as remedies are typically handled holistically. Some Asian Americans with traditional backgrounds do not readily accept Western biopsychosocial explanations for substance use and mental disorders. Correctional professionals should promote discussions focused on offenders’ understanding of their presenting problems as well as any approaches the offenders have used to address them. Subsequently, presenting problems need to be reconceptualized in language that embraces the offenders’ perspectives (e.g., an imbalance in yin and yang, a disruption in chi (Lee and Mock 2005a,b). It is advisable to educate Asian American offenders on the role of the counselor/therapist, the purpose of therapeutic interventions, and how particular aspects of the treatment process (e.g., assessment) can help offenders with their presenting problems (Lee and Mock 2005a,b; Sue 2001). Asian American offenders who receive such education participate in treatment longer and express greater satisfaction with it (Wong et al. 2007a).

As with other racial/ethnic groups, Asian American offenders are responsive to a warm and empathic approach. Correctional professionals should realize, though, that building a strong, trusting relationship takes time. Among Asian American offenders, humiliation and shame can permeate the treatment process and derail engagement with services. Thus, it is essential to assess and discuss offender beliefs about shame (see the “Assessing Shame in Asian American Offenders” advice box on the next page). In some cases, self-disclosure can be helpful, but the counselor should be careful not to self-disclose in a way that will threaten his or her position of respect with Asian American offenders.

Theoretical Approaches and Treatment Interventions

Some Asian cultural groups emphasize cognitions. For instance, Asian cultural groups that have a Buddhist tradition, such as the Chinese, view behavior as controlled by thought. Thus, they accept that addressing cognitive patterns will affect behaviors (Chen 1995). Some Asian cultural groups encourage a stoic attitude toward problems, teaching emotional suppression as a coping response to strong feelings (Amodeo et al. 2004; Castro et al. 1999b; Lee and Mock 2005a,b; Sue 2001). Treatment can be more effective if providers avoid approaches that target emotional responses and instead use strategies that are more indirect in discussing feelings (e.g., saying “that might make some people feel angry” rather than asking directly what the offender is feeling; Sue 2001).

Asian Americans often prefer a solution-focused approach to treatment that provides them with concrete strategies for addressing specific problems (Sue 2001). Even though little research is available in evaluating specific interventions with Asian Americans, clinicians tend to recommend cognitive–behavioral, solution-focused, family, and acceptance commitment therapies (Chang 2000; Hall et al. 2011; Iwamasa et al. 2006; Rastogi and Wadhwa 2006; Sue 2001). Asian American offenders are likely to expect that their correctional professionals take an active role in structuring the therapy session and provide clear guidelines about what they expect from offenders. CBT has the advantages of being problem focused and time limited, which will likely increase its appeal for many Asian Americans who might see other types of therapy as failing to achieve real goals (Iwamasa et al. 2006). Although specific data on the effectiveness of CBT among Asian Americans is not available, there is some research indicating that CBT is effective for treating depressive symptoms in Asians (Dai et al. 1999; Fujisawa et al. 2010). In China, a Chinese Taoist version of CBT has been developed to treat anxiety disorders and was found to be effective, especially in conjunction with medication (Zhang et al. 2002).

Family Therapy

Some Asian Americans, particularly those who are less acculturated, prefer individual therapy to group or family interventions because it better enables them to save face and keep their privacy (Kuramoto 1994). Some offenders may wish to enter treatment secretly so that they can keep their families and friends from knowing about their problems. Once treatment is initiated, correctional professionals should strongly reinforce the wisdom of seeking help through statements such as “you show concern for your husband by seeking help” or “you are obviously a caring father to seek this help.”

The norm in Asian families is that “all problems (including physical and mental problems) must be shared only among family members”; sharing with others can cause shame and guilt, exacerbating problems (Paniagua 1998, pp. 59–60). Correctional professionals should expect to take more time than usual to learn about offenders’ situations, anticipate offender needs for reassurance in divulging sensitive information, and frame discussions in a culturally competent way. For example, correctional professionals can assure offenders that discussing problems is a step toward resuming their full share of responsibility in their families and removing some of the stress their families have been feeling.

Group Therapy

Group therapy may not be a good choice for Asian Americans, as many prefer individual therapy (Lai 2001; Sandhu and Malik 2001). Paniagua (1998, p. 73) suggests that “group therapy...would be appropriate in those cases in which the offender’s support system (relatives and close friends) is not available and an alternative support system is quickly needed.” Some Asian Americans participating in group therapy will find it difficult to be assertive in a group setting, preferring to let others talk. They can also abide by more traditional roles in this context; men might not want to divulge their problems in front of women, women can feel uncomfortable speaking in front of men, and both men and women might avoid contradicting another person in group (especially an older person). It may not make sense to Asian American offenders to hear about the problems of strangers who are not part of their community.

Asian Americans are likely to be motivated to work for the good of the group; presenting group goals in this framework can garner active participation. Still, in group settings and in other instances, Asian American offenders may expect a fair amount of direction from the group leader. Chen (1995) described leader- ship of a culturally specific therapy group for Chinese Americans, noting that offenders expect a group leader to act with authority and give more credence to his or her expertise than to other group members. If members of the group belong to the same Asian American community, the issue of confidentiality will loom large, because the community is often small. Asian cultural groups generally appreciate education in more formal settings, so psychoeducation groups can work well for Asian Americans. It is possible for a psychoeducational group with Asian American participants to evolve comfortably into group therapy.

Mutual-help Groups

According to 2012 NSDUH data, Asian Americans were less likely than other racial and ethnic groups to report the use of mutual-help groups in the past year (SAMHSA 2013d). Mutual-help groups can be challenging for Asian Americans who find it difficult and shaming to self-disclose publicly. The degree of emotion and candor within these groups can further alienate traditional Asian American offenders. Furthermore, linguistically appropriate mutual-help groups are not always available for people who do not speak English. Highly acculturated Asian Americans may perceive participation in mutual-help groups as less of a problem, but nevertheless, Asian Americans can benefit from culture-specific mutual-help groups where norms of interpersonal interaction are shared. Asian American 12-Step groups are available in some locales. It is important for correctional professionals to assess offender attitudes toward mutual-help participation and find alternative strategies and resources, including encouragement to attend without sharing (Sandhu and Malik 2001).

Although they are not mutual-help groups in the traditional sense, mutual aid societies and associations are important in some Asian American communities. Some mutual aid societies have long histories and have provided assistance ranging from financial loans to help with childcare and funerals. The Chinese have family associations for people with the same last name who share celebrations and offer each other help. Japanese, Chinese, and South Asians have specific associations for people from the same province or village. For some Asian American groups, such as Koreans, churches are the primary organizational vehicles for assistance. These social support groups can be important resources for Asian American offenders, their families, and the behavioral health agencies that provide services to them.

Relapse Prevention and Recovery

Little research has evaluated relapse prevention and recovery promotion strategies specifically for Asian Americans. However, issues involving shame can make the adjustment to abstinence difficult for Asian offenders. Correctional professionals should take this into account and address difficulties that can arise for offenders with families who have shame about mental illness or substance use disorders. To date, there are no indications that standard approaches are unsuitable for Asian American offenders.