Barriers to Substance Use Disorder Treatment for Asian Americans & Pacific Islanders

Editor’s note: Special thanks to Samarth Mathapathi, who gathered this research in June 2015. Samarth is a medical student at the Rosalind Franklin University School of Medicine & Science who participated in our Scaife Advanced Medical Student Fellowship.

Treating substance use disorders requires a significant degree of cultural competency. Recognizing a possible substance use disorder and providing a referral to treatment (perhaps using the SBIRT model) also requires cultural competency. In both cases, you can screw up the good work you’re trying to do by not understanding a person’s background or context.

Asian-Americans and Pacific Islanders (AAPIs) have long been lauded as the “model minority,” a term that manages to deny the diversity within this massive category and insult other minority populations in one fell swoop. The model minority notion has also contributed to a dearth of information about treatment-seeking and culturally-appropriate treatment modalities for AAPIs.

In fact, with the exception of tobacco, it appears that AAPIs do have lower rates of substance use than the average American. But even given that lesser rate of use, AAPIs seek addiction treatment less often than we would expect, compared to the national average. What’s that about? And where are opportunities to change it?

Quick Stats

In recent years, AAPIs have edged out Hispanics as America’s fastest-growing minority.
In 2010, there were 17.3 million AAPIs in America, which represents 5.6% of the total population.
According to Pew, most AAPIs don’t identify as “Asian-American;” rather, they identify with their country of origin. The six most common countries of origin for AAPIs in the U.S. are China (23.2%), The Philippines (19.7%), India (18.4%), Vietnam (10%), Korea (9.9%), and Japan (7.5%).
Overall, AAPIs are more likely to live on the West Coast, but different regions in America have different types of AAPIs. For example, more than 70% AAPIs of Japanese descent live on the west coast. People of Indian descent are the dominant AAPI subgroup in many Northeast states (including Pennsylvania). To explore these regional differences (for hours, if you want to) check out this cool map by Pew Research Center.
According to SAMHSA, AAPIs are less likely to meet the criteria for a substance use disorder than the American average (4.9 versus 9.5%).
However, among those whose substance use suggests a need for treatment, a larger proportion of AAPIs feel they do not need treatment (97.9 versus 94.7%). This number begs questions about how AAPIs regard addiction, addiction treatment, and the quality of treatment they receive.

Cultural Factors

Collectivism: AAPIs and other collective cultures tend to treat the family unit as particularly important. That is to say, an AAPI considering treatment might not only be concerned about how the prejudice will affect herself, but also its impact on her family. In interviews, AAPIs in addiction treatment have described mixed influences from family members: some were pushed into treatment by their families, whereas others said they were pressured to handle the problem within the family. One respondent said:

Although [my father] hated me using…it’s harder for him to know that I’m coming here and getting treatment than using. He’s so uncomfortable with the fact that I’m going somewhere, …[and] that I couldn’t solve the problem myself…that we couldn’t solve it in our own family…[Another issue is] how it makes the family look… how shameful, how embarrassing, and [so], what do I talk about here? What are people going to think?

High-context environments: Associated with collective cultures, a high-context environment is one where individuals more often have an implicit understanding of culturally accepted norms. In these environments, trust and non-verbal cues are more important than what is directly communicated. In the words of a business manager from Japan: “We are a homogeneous people and don’t have to speak as much as you do here. When we say one word, we understand ten, but here you have to say ten to understand one.”

Immigration: In 2012, fully 74% of AAPI adults in America were foreign-born. More so than any other minority population, AAPIs are likely to be dealing directly with issues related to immigration: language barriers, generational divides, cultural misunderstandings, and the health effects of acculturation.

Adaptations in Treatment and Treatment-Seeking

Results of a relatively small study suggest that AAPIs are less likely to use mental health services, talk to a physician, and use Alcoholics/Narcotics Anonymous, Alanon/Alateen or other associated 12-step programs, and are more likely to prefer seeking treatment or counseling from a minister, priest, or other religious leaders. These findings suggest that it is important to integrate substance use services into multiple systems, including religious settings.

There is also research showing that AAPIs tend to enter treatment with less severe addiction, but they exhibit significantly more negative attitudes towards treatment compared with non-AAPIs. A shortage of culturally-tailored, empirically-supported treatment options may contribute to this dissatisfaction.

The late David Powell, an addiction counselor and marriage and family therapist whose extensive work in Asian countries spanned 30 years, suggests a number of approaches to AAPIs in therapeutic settings. For example:

Keep in mind that for your client, the first treatment session is a crisis: discussing personal issues with a stranger is particularly unusual in Asian cultures.
Emphasize your credentials and experience to build a sense of credibility and trust.
Be aware of “face” issues. Declining gifts (even if accepting them is against your organization’s policy) can cause an AAPI client to lose face. Regularly consider face issues and be prepared to talk about them with your client. “Although I have been visiting Asia for nearly 30 years, I am still making cultural mistakes,” said Powell.
Consider the possibility that your AAPI client has an entirely different concept of mental health issues than your Western one. Many Asian cultures have a traditionally more holistic concept of physical and behavioral health.
When providing treatment for AAPIs in the United States, be aware of generational issues related to immigration. Families are likely to be experiencing “values clashes” related to the process of assimilation.

Do these suggestions resonate with you and your experiences working with AAPIs? Read the rest of Powell’s essay for more.