Can Western Treatment Serve an Eastern Mind-set?

Asked about the factors that might make addiction treatment services for the Asian-American/Pacific Islander (AAPI) population different from those for other groups, Alan Shinn, MSW, executive director of the Coalition for a Drug-Free Hawaii in Honolulu, replied, “Which of the 35 groups do you want to start with?”

Actually, Shinn understates the issue. According to the National Minority AIDS Education and Training Center, members of 28 Asian and 19 Pacific Islander groups live in the United States. About 70% of the total population in these groups live in four states: California, New York, Hawaii, and Texas.

The global geographic range covered by the AAPI designation is staggering. Ford Kuramoto, DSW, LCSW, national director of the National Asian Pacific American Families Against Substance Abuse (NAPAFASA) in Los Angeles, describes it as going from Pakistan up the globe into China, turning east to Korea, Japan, and parts of China, going south to Thailand, Indonesia, and Malaysia, and continuing into the Pacific to Guam and the six Pacific Island jurisdictions—American Samoa, the Federated States of Micronesia, Guam, the Marshall Islands, the Northern Mariana Islands, and Palau. The nearly 50 groups are reported to speak more than 100 languages and dialects. In addition, the Asian and Pacific Islander American Health Forum (APIAHF) states that about one in four AAPI households is considered linguistically isolated because no one in the home over the age of 14 speaks English well.

Furthermore, most of these nations do not share the West's concept of health and wellness, says Kuramoto: “I'm a third-generation Japanese-American, so for the most part I am familiar with and feel comfortable with Western-style medicine, but I also think that there are valuable things to learn from Eastern-style medicine, including acupuncture.”

Kuramoto says the book The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures, by Anne Fadiman, offers a good case history of how health practitioners' ideas of proper treatment clash with some Asian families' traditional healing beliefs and rituals, and how chaos can ensue. The child profiled in the book had epilepsy, an illness common in the Hmong population. The elders' understanding of the illness was literally that the spirit catches you and you fall down. Of course, American doctors had quite a different interpretation.

“The same [confusion] presents itself when it comes to how people understand alcohol and drug problems and how they think about getting treatment, what kind of treatment, and whether they will benefit,” says Kuramoto. “There's a different mind-set, you know, [about healing]. A lot of emphasis on herbal medicines and the various non-Western medical healing practices, including massage and shiatsu and meditation, were originated in Asian countries. I think much of it is useful and helpful to our Western-style attitudes and beliefs about health and wellness.”

Know why they are here

At Asian Community Mental Health Services, an agency in Oakland, California, Executive Director Betty M. Hong, MPH, says understanding immigrants and why they have come to the United States matters a great deal in the therapeutic setting.

“Vietnamese had to deal with the Vietnam War and they came to this country distraught and fragmented and having PTSD, so they have a mental health and a trauma issue. They may use drugs and alcohol to mask those behavioral problems,” Hong says. “And [many from] the Cambodian community came here as asylum refugees from the Pol Pot regime, and had to deal with torture and huge atrocities.”

Treatment professionals need to consider that getting to know the client's history constitutes the first order of business, Shinn says. “The experience of an immigrant is not the same as that of a refugee who was forced to leave the country because of war or political situations.

“With native Hawaiians and other Pacific Islanders you have to think about the whole experience from colonialism, how they were once subjugated to another race, or another people,” Shinn continues. “You have to have some knowledge of those cultural remnants that can influence how the [client] may relate to you, especially if you are a white person coming in.”

Hong adds that the Western tendency to separate addictions and mental health in treatment makes serving the Asian population difficult. “What providers see first makes a difference in terms of the treatment,” she says.

Norms related to alcohol

The way in which alcohol is used in a client's native country may differ from that seen in the United States, says Kuramoto.

“In the U.S., the idea of bars and alcohol being served in many places creates a different kind of access to alcohol and tobacco than many people would have back in their native countries, especially the countries that are less modern,” he says. “If you compare Tokyo and Seoul and maybe even a place like Bangkok, they're fairly Westernized. But then you can go to places in Laos, in Vietnam, or in parts of China and they're Third World countries, literally. The access to alcohol and partying and things like that is much different, because people are so poor they basically are malnourished.”

Hong says young Korean males in particular exhibit a high incidence of alcohol bingeing. She says this results from the strict, often religiously influenced culture they have been accustomed to at home, which then is contrasted with the freedom and exposure to alcohol that they experience in this country.

“Especially in Asian cultures, [parents] are more strict about smoking and drinking,” she says. “When you do that with teenagers, they're going to gravitate toward disobeying, and Korean boys in particular do that in a big way. It seems to be a place for them to create some freedoms for themselves.”

The stigma surrounding substance addiction and mental illness may be greater in the AAPI population than in the mainstream because the “loss of face” and the impact on family reputation have deeper meaning, says Hong.

“I don't know if it's greater but it certainly comes into play more because in the AAPI population, whatever they do reflects on their families and their communities,” says Shinn. “It probably is stronger with first-generation than with fourth-generation AAPIs, but it's still there.” The notion that one mustn't do anything wrong because it will reflect badly on all is deeply rooted.

Entering the system

What an AAPI individual does about an addiction problem often depends on generational factors, Kuramoto says.

“If they are in an immigrant generation where they speak very little English, the probability of them walking into a mainstream clinic and saying, ‘Gee, I have a drug problem and I'd like to be admitted,’ is zero for obvious reasons.”

In addition, the notion of a Western-style clinic where one checks oneself in or commits to outpatient therapy represents such a foreign concept that it doesn't even register, says Kuramoto.

“Why would you tell a stranger your problems?” he asks. “Very often they would do what they would do back home, which would be to go to some kind of healer, a shaman, or an acupuncturist. Responses to a problem vary depending on the country of origin, education, and socioeconomic situation. But their whole idea of treatment is quite different.”

Yet this doesn't mean that members of this population never seek help. If the treatment is structured in a way that makes them feel comfortable, they are more likely to come forward, says Shinn. A good example of a culturally appropriate approach for the AAPI population can be found with an opium treatment program at Hong's agency in Oakland. Asian Community Mental Health Services established the program to meet the needs of an area population from a culture whose traditional use of opium clashes with Western laws.

“There is a population of Mien, a tribal culture from the hills of Laos, who have historically used opium,” says Kuramoto. “The main treatment vehicle is group sessions that are more like social groups where people come together and give each other suggestions and support. They almost always prepare a meal. So they come together, have a meal, and talk about how they're doing, how they've progressed in their individual efforts, and how the group supports them in a very familial way.” Kuramoto finds that this approach works better for this population than a more confrontational type of group session would.

Kuramoto hopes that institutions that collect data to inform the treatment community begin to appreciate the need to recognize the AAPI population's diversity: “In the old days we were always considered part of the ‘other’ category, and then in some cases the data are reported as just ‘Asian.’ But you can imagine that if there are 20 to 30 Asian groups, just having data on ‘Asian’ doesn't help you if you're trying to develop a program.”

Sidebar

Important factors to consider when addressing a member of the AAPI population who is seeking treatment, as suggested by experts interviewed for this article, are:

• The family role is emphasized over individual identity. The feelings of shame that come with addiction can be greater in the AAPI patient who believes he/she has let his/her family down.

• Language barriers can be isolating. Using interpreters may seem to offer a solution, but interpreters might have their own culturally based biases. Choose carefully.

• Talking about one's feelings may be viewed as a sign of weakness or immaturity, or an inability to handle one's own problems.

• Showing respect for traditional approaches to healing goes beyond tolerating. It is important to show an interest in the approaches the client favors.

• Pacing the delivery of information is important to avoid overwhelming the client with information, causing the person to “shut down” or flee.

• Clients do not always feel comfortable expressing themselves directly. They may express their wishes through silence or nonverbal communication, expecting that the professional will notice and address what they need.

• Outreach involves a much longer process of engagement, because AAPIs aren't used to the notion of walking in and dealing with talk therapies and medication.

Sidebar

Resources

• Asian American Psychological Association www.aapaonline.org

• Asian American Drug Abuse Program www.aadapinc.org

• Asian and Pacific Islander American Health Forum www.apiahf.org

• Asian and Pacific Islander Wellness Center www.apiwellness.org

• Asian Community Mental Health Services www.acmhs.org

• Coalition for a Drug-Free Hawaii www.drugfreehawaii.org

• National Asian Pacific American Families Against Substance Abuse www.napafasa.org

• National Minority AIDS Education and Training Center www.nmaetc.org