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Published in final edited form as: Adv Dual Diagn. 2014;7(2):90–104. doi: 10.1108/ADD-03-2014-0012

Intersection of suicidality and substance abuse among young Asian-American women: implications for developing interventions in young adulthood

Hyeouk Chris Hahm, Stephanie Tzu-Han Chang, Hui Qi Tong, Michelle Ann Meneses, Rojda Filiz Yuzbasioglu, Denise Hien
PMCID: PMC4095878  NIHMSID: NIHMS603585  PMID: 25031627

Abstract

Purpose

The purpose of this paper is to provide a review of the current literature uncovering specific factors associated with self-harm and suicidality among young Asian American women, as well as to present the Fractured Identity Model as a framework for understanding these factors. This paper offers concrete suggestions for the development of culturally competent interventions to target suicidality, substance abuse, and mental illness among young Asian American women.

Design/methodology/approach

Empirical studies and theory-based papers featured in peer-reviewed journals between 1990 and 2014 were identified through scholarly databases, such as PubMed, MEDLINE, PsycINFO, JSTOR, and Google Scholar.

Findings

We identified several factors associated with suicidality among young Asian American women: (1) family dynamics, or having lived in a household where parents practice “disempowering parenting styles,” (2) substance use/abuse, and (3) untreated mental illness(es), which are exacerbated by the stigma and shame attached to seeking out mental health services. The Fractured Identity Model by Hahm et al. (2014) is presented as a possible pathway from disempowering parenting to suicidal and self-harm behaviors among this population, with substance abuse playing a significant mediating role. Research limitations/implications – Our review focused on Asian American women, substance use among Asian Americans, and mental health among Asian Americans. Literature that focused on Asians living in Asia or elsewhere outside of the USA was excluded from this review; the review was limited to research conducted in the USA and written in the English language.

Practical implications

The complex interplay among Asian American culture, family dynamics, gender roles/expectations, and mental health justifies the development of a suicide and substance abuse intervention that is tailored to the culture- and gender-specific needs of Asian Pacific Islander young women. It is imperative for professionals in the fields of public health, mental health, medicine, and substance abuse to proactively combat the “model minority” myth and to design and implement interventions targeting family dynamics, coping with immigration/acculturative stresses, mental illnesses, suicidal behaviors, and substance abuse among Asian-American populations across the developmental lifespan.

Originality/value

This paper provides specific suggestions for interventions to adequately respond to the mental health needs of young Asian-American women. These include addressing the cultural stigma and shame of seeking help, underlying family origin issues, and excessive alcohol and drug use as unsafe coping, as well as incorporating empowerment-based and mind-body components to foster an intervention targeting suicidality among Asian-American women in early adulthood.

Introduction

Increasingly, a paradoxical picture has emerged about the status and mental health of young Asian-American women in the USA. At first glance, young Asian-American women appear to fit the stereotype of the successful “model minority,” achieving extraordinary accomplishments. Young Asian-American women are the highest educated group of women in the USA (Pew Research Center, 2012), with almost one in two having earned a college degree or higher, compared to one in three of their white counterparts (Hune, 2002). Moreover, in 2011, 44 percent of Asian-American women who were employed worked in higher paying management, professional, and related occupations – more than the percentage of working white, black, and Hispanic women (42, 34, and 25 percent, respectively) (US Bureau of Labor Statistics, 2013). Asian-American female full-time workers also received higher median weekly earnings of $751 in 2011, whereas white women received $703 (US Bureau of Labor Statistics, 2013; The American Federation of Labor and Congress of Industrial Organizations, Department of Professional Employees, 2010).

In stark contrast to these educational and occupational accomplishments, Asian-American women have one of the highest rates of depression and suicide among all racial/ethnic groups of women (Cheng et al., 2010): suicide is one of the leading causes of death among Asian-American women between the ages of 15 and 34 years (National Center for Injury Prevention and Control, 2014). There is ample evidence that rates of suicide-related behaviors differ by racial/ethnic group, and the factors associated with suicidality (Gibbs, 1990; Stiffman and Davis, 1990) also vary across different populations, gender, and ages (Perez-Rodriguez et al., 2008). Therefore, it is critical to understand the specific factors associated with suicidality (i.e. suicidal ideation and attempts) among young Asian-American women through an examination of current research findings. In this paper, we identify factors associated with suicidal behaviors among young Asian-American women and provide a cultural and conceptual framework for understanding these factors. Finally, we offer recommendations for tailoring suicide and mental health interventions to young Asian-American women, as well as offer specific guidelines for implementing these interventions.

Asian-American women, suicidality, and substance use

For Asian Pacific Islander (API) women aged 15 to 24 years, suicide was the second leading cause of death behind accidental injury between 1999 and 2007, whereas it was third for whites and sixth for blacks. For API women aged 25 to 34 years, suicide was the third leading cause of death behind malignant neoplasms and unintentional injury between 1999 and 2007, while it was third for whites and ninth for blacks (National Center for Injury Prevention and Control, 2014). More troubling, the rates of completed suicide among Asian-American women aged 15 to 24 years are rising rapidly, increasing by 96.3 percent from 2000 to 2009 (National Center for Health Statistics 2012). Asian-American college students were 1.6 times more likely than their white counterparts to attempt suicide in 1999-2000 (Kisch et al., 2005; Muehlenkamp et al., 2005). In a sample of 720 Chinese, Korean, and Vietnamese American young women between the ages of 18 and 35 years who are children of immigrants, Hahm et al. (2013) found high prevalence of lifetime suicidal ideation and suicide attempts (17.5 and 7.1 percent, respectively). These numbers are substantially higher than the prevalence among the general adult population in the USA (8.4 and 2.4 percent) and among adult women specifically (7.1 and 3.0 percent), based on data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) (Oquendo et al., 2008). Lastly, within the API population, young API individuals (ages 18-34) show higher prevalence of suicidal ideation and attempts than older API individuals, (Duldulao et al., 2009), and young API women are at greater risk than young API men (Cheng et al., 2010).

Despite the high rates of suicide among young Asian-American women, the reasons for this phenomenon remain unclear. Recent emerging literature uncovering factors associated with high suicidality among young API women identified several factors: family dynamics, or having lived in a household where parents practice “disempowering parenting styles,” substance use/abuse, and untreated mental illness(es), which are exacerbated by the stigma and shame attached to seeking out and receiving mental health services.

Literature search strategy

Empirical studies and theory-based papers featured in peer-reviewed journals between 1990 and 2014 were identified through the following scholarly databases: PubMed, MEDLINE, PsycINFO, JSTOR, and Google Scholar. Keyword and title information were also considered for this review and were identified by electronic database searches. The three categories of search terms included: population of interest (e.g. “Asian women,” “Asian-American women,” “API women”), substance use (e.g. “substance use,” “substance abuse,” “alcohol consumption,” “alcoholism,” “binge drinking,” “drug use,” “drug abuse,” “addiction”), mental health, (e.g. “depression,” “suicide,” “suicide attempt,” “mental health,” “mental health treatment, depression,” “somatization,” and “anxiety”).

Our review focused on Asian-American women, substance use among Asian-Americans, and mental health among Asian-Americans. Literature that focused on Asians living in Asia or elsewhere outside of the USA was excluded from this review; the review was limited to research conducted in the USA and written in the English language. The types of research articles in the current literature review include empirical research, as well as theory-based research, using quantitative, qualitative, or mixed methods research.

Of an original 32 articles, 12 were chosen for in-depth empirical review due to relevance to the topics at hand, quality of research, and significance of findings. Out of 12, six articles examined the barriers of mental health utilization among this population (Lin and Cheung, 1999; Alegria et al., 2008; Sue and Sue, 2003; Atkinson et al., 1995; Leong and Lau, 2001; Shea and Yeh, 2008). Another six articles examined substance use and mental health/suicidality (See Table I). Among these articles, only three examined the relationship between substance use and mental health (Hahm et al., 2013, 2014; Iwamoto et al., 2011), while the other three studied suicidality/mental health alone (Cheng et al., 2010; Duldulao et al., 2009). This shows a gap in existing literature investigating the comorbid relationship between mental health issues and substance use issues among Asian-American women. Given the extensive research on the correlation between substance use and suicidality, or substance use and mental illness among other ethnic/racial groups (Borges et al., 1999; Aharonovich et al., 2002), it is imperative to address this comorbid relationship among API women as well.

Table 1. Substance Use, Depression, and Suicidality among Asian American Women in the United States.

Authors Purpose/Design Data/Measures/Variables Sample Key Findings
Duldulao, Alfonso, Takeuchi, and Hong (2009) Examines the correlates of
suicidal ideation, suicide
plan, and suicide attempt
among Asian Americans
focusing on nativity and
gender.		 Data from the National Latino
and Asian American Study
(NLASS)		 The sample is comprised
of adults, with 998 men
(47%) and 1,097 (53%)
women. (N = 2095)		 US-born Asian American women are more
likely to endorse lifetime suicidal ideation,
planning, and attempts than US-
born Asian American men,
immigrant Asian men, and immigrant Asian
women.
Cheng, Yan, Fancher, Ratanasen, Conner, Duberstein, Sue, and Takeuchi (2010) The primary aim of this
study was to examine the
influence of culturally
related factors on lifetime
suicidal ideation and
suicide attempts in a
nationally representative
sample of Asian
Americans.

  • Correlational study, NLASS instruments were used.

  • Important covariates were sociodemographic characteristics, depressive and anxiety disorders, and number of chronic conditions.

 The current study
examined the role of
culturally related
variables (family
conflict, perceived
discrimination, and
ethnic identity) on
suicidal ideation and
suicide attempts in a
nationally representative
sample of 2,095 Asian
Americans.

  • Female gender, family conflict, perceived discrimination, and the presence of lifetime depressive or anxiety disorders were positively correlated with suicidal ideation and attempts.

  • Depressive Disorder emerged as the strongest correlate of suicidal ideation for Asian American women, OR = 6.17, p < .001, 95% CI [3.21, 11.88]
Iwamoto, Liu, and McCoy (2011) This study explored the
relationship among Asian
values, depressive
symptoms, perceived peer
substance use, coping
strategies, and substance
use among 167 Asian
American college women.

  • Five substance use outcome items measured alcohol use, binge drinking behavior, marijuana use, cocaine, and “other” illicit drug use.

  • Based on items from the national surveys Multiethnic Drug and Alcohol Survey and American Drug Abuse and Alcohol Survey (Otsuki, 2003).

 167 Asian American
College women.

  • More than 66% of the women in our sample scored higher than the clinical cutoff score on the Center of Epidemiological Depression Scale.

  • Three path analyses examining illicit drugs, alcohol use, and binge drinking indicated that perceived peer use was the most robust predictor of substance use.

  • Depressive symptoms were positively associated with illicit drug use and alcohol consumption but were not related to binge drinking.
Cheng, Lee, and Iwamoto (2012) To examine correlations of
drinking effects and
substance use among
Asian American men and
women.

  • Accordingly, six comparison groups were created (male non, light, and heavy drinkers, and female non, light, and heavy drinkers).

  • Pearson’s chi-square test was conducted to examine percentage distribution for the six groups for mental health disorders (i.e., suicidality, DSM–IV mental health endorsement for past 12-month and lifetime).

 Asian American men
and women. Research
looks at gender-specific
correlations. The
purpose of the present
study was to examine
gender differences in
heavy drinking, poor
mental health, and
substance use among a
national sample of Asian
Americans (N 581)

  • Findings suggest the need to develop gender-specific drinking interventions for Asian Americans that focus on improving mental health among women and substance treatment among men.

  • Among the drinkers 72% (n 319) were males and 28% were females (n 125). Of the females who drank, 17% (n 21) were heavy drinkers, and of the males who drank, 10% (n 33) were heavy drinkers.
Hahm, Jang, Vu, Alexander, Driscoll, and Lundgren (2013) To associate between drug
use and lifetime suicidal
behaviors among Asian
American women.

  • Drug use

  • Suicidal behaviors

 720 Asian-American
women residing in
Massachusetts in 2010-
11.		 A history of hard drug use alone or in
combination with soft drug use has a
significant association with both suicidal
ideation and suicide attempts among Asian
American women. This highlights the
importance of addressing hard drug use when
designing suicide prevention programs for
Asian American women.
Hahm, Gonyea, Chiao, and Koritsanszky (2014) Provide theoretical
framework to explain the
process of self-harm and
suicidal behaviors among
Asian-American women.		 Disempowering parenting styles 16 young Asian
American women who
are children of
immigrants and report a
history of self-harm
and/or suicidal behaviors

  • Findings suggest that the participants experienced multiple types of “disempowering parenting styles” that are characterized as: abusive, burdening, culturally disjointed, disengaged, and gender-prescriptive parenting.
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I. Literature reviews on mental health, suicidality, and substance use among API women

1. Family dynamics – disempowering parenting styles

Hahm et al. (2014) provide a framework for understanding self-harm and suicidal behaviors among Asian-American women. In a qualitative study, Hahm et al. (2014) explored the family experiences of 16 young Asian-American women (aged 18 to 35) who had immigrant parents (thus, identifying as one and a half or second generation) and had reports of a history of suicidal behaviors. The finding indicated that participants experienced multiple types of disempowering parenting styles. As a result of these negative family dynamics, participants suffered a “double bind” – conflicting desires of wanting to satisfy their parents’ expectations, while simultaneously wanting to rebel against the image of “the perfect Asian woman” and fit in with mainstream American culture. The “double bind” phenomenon specifically describes the psychological impact resulting from the acculturation gap between first generation immigrant parents and their children (who are one and a half or second generation) (Hahm et al., 2004); thus, Asian-American women whose families are more assimilated into the mainstream American host culture (e.g. parents who are second or third generation and beyond) may be less likely to experience the “double bind.” For young Asian-American women who experienced the “double bind,” the difficulties of integrating their competing identities led to the development of “fractured identities.” To deal with the confusion of resulting “fractured identities,” the women engaged in “unsafe coping” strategies such as substance use, which only intensified their “web of pain” of self-harm and suicidal behaviors.

Five types of disempowering parenting styles were identified: Abusive parenting, Burdening parenting, Culturally disjointed parenting, Disengaged parenting, and Gender prescriptive parenting (thus termed “ABCDG parenting”). A – abusive parenting entails physical, emotional, and/or sexual abuse. B – burdening parenting is described as parents who burdened their daughters in three specific ways: burden of repaying parents for their financial investments in their daughters throughout childhood and adolescence; pressure to succeed – either through academic achievement, a high-status career, or marriage to a “successful” man; and obligation to care for parents and elders. C – culturally disjointed parenting encapsulates the profound sense of disconnect between children and their parents, exacerbated by language barriers and the acculturation gap between generations. D – disengaged parents are emotionally distant or absent from their children and fail to validate their children’s feelings, which leads them to feel repeatedly dismissed and belittled. Lastly, G – gender prescriptive parents hold rigid views on how each gender should behave, leaving women feeling powerless and less valued than their male counterparts. The majority of participants who engaged in self-harm and suicidal behaviors reported having experienced multiple disempowering styles throughout childhood and adolescence.

Due to the double bind they experienced, participants were ultimately unable to incorporate all facets of their identities (“good enough daughter,” “good enough American,” “perfect Asian woman”). This inability to integrate multiple competing identities resulted in the fracturing of the self. Hahm et al.’s (2014) study suggests that young Asian-American women born to immigrant parents practicing disempowering parenting styles are at a greater risk of developing fractured identities. As a means to self-medicate, participants adopted unsafe coping mechanisms, such as excessive drinking or hard drug use, which in turn only heightened self-harm and suicidal behaviors. To “solve the problem” of fractured identities, participants exhibiting self-harm and suicidality used alcohol to “boost their self-esteem,” or in their own words, because “right now it’s kind of like a solution” (Hahm et al., 2014). The women’s relationship with substance use suggests that this phenomenon plays a significant role in the proposed causal pathway from disempowering parenting to suicidality (Figure 1).

Figure 1. Fractured Identity Model.

Figure 1

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* ABCDG Parenting: A = Abusive parenting, B = Burdening parenting, C = Culturally disjointed parenting, D = Disengaged parenting, G = Gender prescribed parenting

2. The relationship between substance use, family communication, and suicidality

An accumulating body of literature shows that Asian-American men have high substance use compared to the national average (Wechsler et al., 2000). Similarly, the prevalence of alcohol abuse among Asian-American women aged 18 to 29 years is increasing rapidly, from 0.74 in 1992 to 3.89 in 2002 – the largest increase among all ethnic groups nationally (Grant et al., 2004).

Another study shows that among Asian-American college women (n = 167), 21.6 percent reported binge drinking (four or more drinks within two hours for women) (Iwamoto et al., 2011). Though lower than the national average, growing substance abuse in the API population is shown to be related to psychological problems (O’Hare and Van Tran, 1998). Furthermore, Asian-American women who were heavy drinkers endorsed the highest percentage of lifetime depression (33.3 vs 9.1 percent among Asian-American men who were heavy drinkers). Compared with Asian-American women who were light drinkers, Asian-American women who were heavy drinkers had increased odds of reporting lifetime anxiety disorders (OR = 3.92, p = 0.46, 95 percent CI = 1.02, 15.01) (Cheng et al., 2012).

Using qualitative methodology, the fractured identity framework developed by Hahm et al. (2014) examines the psychological processes of young Asian-American women who experienced substance use. It was found that Asian-American women consumed excessive alcohol or drugs to self-medicate in order to escape from the pain of “fractured identities.” The self-medication hypothesis (Khantzian, 1997) of substance abuse posits that some individuals with mental health/psychological problems use substances such as alcohol, cocaine, barbiturates, opiates as a way (albeit maladaptive) to manage or avoid distressing feelings and emotional pains. Among participants in Hahm et al.’s (2014) study, Asian-American women utilized self-medication because the lack of family communication and the stigma attached to seeking out mental health services prevented them from acknowledging their problems and/or using other safe coping mechanisms (e.g. mental health services, psychopharmological management by a prescriber).

In addition to this 2014 qualitative study, Hahm et al. (2013) quantitatively examined the role of drug use in suicidal behaviors in a sample of 720 young Asian-American women aged 18 to 35 years old, while considering the impact of psychiatric illness and family communication. Three key findings were identified: First, there was high prevalence of drug use among Asian-American women in their sample, with approximately half (45.3 percent) reporting a history of using either soft or hard drugs. Approximately one-third of the sample (34.7 percent) reported a history of using soft drugs (cigarettes, marijuana, or a combination of both), while approximately 10.6 percent of the sample had a history of hard drug use alone or in combination with soft drug use (Hahm et al., 2013).

Second, Hahm et al. (2013) reported that suicidal ideation and attempts among Asian-American women were associated with hard drug use (alone or in combination with soft drugs). A bivariate analysis shows that those who had never used substances had the lowest reports of lifetime suicidal ideation (13.1 percent) and suicide attempts (4.6 percent), whereas those with a history of hard drug use alone or in combination with soft drugs reported the highest rates of lifetime suicidal ideation (35.5 percent) and suicide attempts (20 percent). Even after controlling for history of psychiatric diagnosis, the association between hard drug use and suicidal behaviors was robust. In comparison with those who reported no drug use, the likelihood of suicidal ideation and suicidal attempts were three to 4.3 times greater among those who had hard drug use alone or in combination with soft drugs (Hahm et al., 2013). These findings on the association between substance use and mental health were supported by another study using nationally representative data (n¼581), which found that Asian-American women who were heavy drinkers were 3.7 to four times more likely to be diagnosed with lifetime depressive disorder or anxiety disorders than those who were light drinkers (Cheng et al., 2012).

Third, Hahm et al. (2013) also found that there was a strong relationship between the level of family communication and suicidal ideation. Compared to women who reported a high level of family communication, those who reported medium and low levels of family communication were 2.6 and 3.4 times more likely to endorse suicide ideation, respectively. Similarly, a robust relationship between family conflicts and suicidality has been found among a sample of white, black, and hispanic children and adolescents: Poor communication with parents was a significant risk factor for completed suicides among children and adolescents in the state of New York (Gould et al., 1996). 3. Barriers to accessing mental health care. Epidemiological studies indicate that Asian-Americans frequently do not seek out mental health treatment; moreover, when they do, they often put off seeking help until the problem has reached a level of crisis and they have exhausted all personal resources (Lin and Cheung, 1999). Thus, Asian-Americans on average have longer lengths of stay at inpatient psychiatric units (Padgett, 1995), and they are much more likely to receive more severe diagnoses (Office of the Surgeon General et al., 2001). Furthermore, among those who suffer from depressive disorders, Asian-Americans comprised the highest proportion of individuals failing to seek professional mental health care (68.7 percent), compared to other racial/ethnic groups (40.2 percent for whites, 58.8 percent for blacks, and 63.7 percent for hispanics) (Alegria et al., 2008). Lastly, Asian-Americans who enter mental health treatment have significantly higher dropout rates than white clients (Sue and Sue, 2003; Atkinson and Gim, 1989; Snowden and Cheung, 1990).

This pattern of underutilization of mental health services among Asian-Americans can be largely attributed to the stigma associated with using mental health services in this population (Atkinson et al., 1995; Leong and Lau, 2001; Shea and Yeh, 2008). Leong and Lau (2001) identified three stigma-related barriers shaping Asian-American help-seeking behaviors: an affective barrier which makes mental health issues a topic to be avoided; a cognitive barrier exemplified by the Chinese belief that mental illness can be easily solved with willpower and an avoidance of negative thoughts; a value orientation barrier where the needs of the collective whole is prioritized over the well-being of individuals. Thus, Asian-Americans may try to resolve their problems on their own, believing that avoiding bad thoughts and exercising willpower can maintain mental health (Atkinson and Gim, 1989).

Among young Asian-American women who reported self-harm or suicidal behaviors (Hahm et al., 2014), descriptions of help-seeking patterns reflect an avoidance of discussions around mental health, as well as the Asian value of collectivism over individualism. Although participants were either born or raised in the USA, the stigma attached to seeking out mental health services influenced their help-seeking behaviors; the pressure to maintain an image of the perfect daughter and Asian woman compelled participants to suffer alone instead of seeking help. Cutting and other self-injurious behaviors (SIB) provided a way for participants to objectify their pain and inflict punishments on themselves or their parents, while regaining a sense of control; cutting and SIB were shrouded in secrecy and done at a time of the participants’ choosing. One 19-year-old, Vietnamese American woman explained her feelings of ambivalence toward getting help: “It [getting help] was kind of embarrassing ’cause it was like my thing, and I didn’t want people to know about it in the first place [y] and I didn’t like being outed.”

II. Implications and recommendations for designing an intervention for Asian-American young women

The complex interplay among Asian-American culture, family dynamics, gender roles/expectations, and mental health justifies the development of a suicide and substance abuse intervention that is tailored according to the culture- and gender-specific needs of young API women.We provide the following intervention recommendations that are based on the culturally appropriate components from empirical research and evidence-based practices to reduce rates of suicide and substance use among young Asian-American women. Specifically, we offer suggestions to help clinicians address the cultural stigma and shame of seeking help, complex family of origin issues, and excessive substance use as a means of self-medication when treating young Asian-American women. Furthermore, empowerment-based and mind-body treatment approaches are highlighted as particularly beneficial modalities when working with this specific population.

1. Addressing stigma and shame

It is critical for clinicians, researchers, and intervention designers to be cognizant of the effects of stigma on help-seeking behaviors among Asian-American women. As a first step, we recommend that clinicians develop a thorough understanding of various cultural beliefs about mental illness and associated stigma and shame as a clinical priority (Sue and Sue, 2003). When working with Asian-American clients, cultivating a zone free of judgment and criticism in treatment, while underscoring respect and privacy is of utmost importance (Vo et al., 2007). Moreover, it is recommended that clinicians engage clients in a dialogue about their attitudes and beliefs toward mental illness and mental health treatment, as a way to reduce the fears and stigma attached to seeking out mental health services (Wu et al., 2009). Exploring with Asian-American clients whether or not they experience affective, cognitive, or value orientation barriers in seeking or maintaining mental health services would be beneficial (Leong and Lau, 2001). We suggest that clinicians address the ideas of “saving face” and family loyalty, and reassure clients that they are not betraying their families by seeking out help and addressing the impact of family dysfunction. For example, for Chinese American clients, it may be useful to address the values exemplified by the Chinese saying, “Do not air family disgrace or shame in public”. Finally, clinicians can mitigate fears of being “outed” and shamed by initiating frequent discussions on confidentiality and privacy throughout the treatment (Leong and Lau, 2001; Li et al., 1999).

2. Addressing underlying family of origin issues

Encouraging an exploration of the impact of family history, parenting styles, and gender role expectations on their identity development and mental health is crucial to addressing the needs of this population. The over-arching goal of treatment is to help clients break through the double bind in order to achieve a healthy, integrated sense of identity, as the formation of a healthy sense of self is a crucial developmental task with implications into the rest of adulthood (Erikson, 1968). Young Asian-American women between the ages of 18 and 35 years are at a critical juncture of development, traversing two worlds – mainstream American culture as well as their parents’ culture, while simultaneously navigating the challenges of young adulthood (Hahm et al., 2014). For young Asian-American women caught in this double bind, it can be extremely difficult to disentangle themselves from competing impulses and desires, to uncover the value of their own internal voices, and to form an integrated sense of identity (Hahm et al., 2014). This is where a trusting relationship with a culturally competent clinician is essential to the healing process, particularly for those who are caught in the self-medicating cycle of substance abuse, self-harm, and suicidality.

The role of the therapist is to serve as a non-judgmental guide in the journey toward healing and identity integration. Due to the disempowering parenting styles of some Asian parents (ABCDG parenting) – in addition to cultural values of stoicism, collectivism, and deference toward authority – therapy may be the first time that a client has the opportunity to directly examine, process, and articulate their feelings of growing up as an Asian-American, as well as to identify the roots of their pain and unsafe coping behaviors.

The therapist can present findings on ABCDG parenting as a way to initiate conversation on the kind of parenting styles the client may have experienced growing up. It is important to note that not every Asian-American has experienced disempowering parenting, and not every Asian parent practices disempowering parenting (Kim et al., 2013). However, for those who have experienced this type of parenting, disempowering parenting styles are significantly associated with a greater likelihood of suicide-related behaviors (Gau et al., 2008; Hahm et al., 2013; Lai and McBride-Chang, 2001). The goal of treatment is to encourage a deeper exploration of the client’s identity development and to give clients tools to recognize unhealthy influences on their development. Learning about the double bind experienced by other young Asian-American women may help clients feel less alone in their struggle. Therapists can elicit discussion with questions such as:

  • In what ways were/are your parents’ parenting style similar to or different from ABCDG parenting? If you experienced ABCDG parenting growing up, what was that like for you?

  • In what ways have your parents’ parenting style influenced your life choices, such as choice of college, choice of significant others/romantic partners, or sexual behaviors (if any)?

  • How would you describe the gender expectations or prescriptions of your culture? What would happen if you were to deviate from those gender expectations?

  • Does the description of the double bind (simultaneously wanting to satisfy their own needs and to rebel against parents’ expectations) fit your experience? In what ways does it fit or not fit your experience?

  • In what ways have you experienced conflict between your parents’ culture and mainstream American culture? Where do you see yourself fitting along the continuum?

3. Treating substance use as self-medication and employing a recovery perspective

Highly relevant to considerations involving Asian-American women in young adulthood who have experienced ABCDG parenting, the self-medication model is consistent with developmental findings suggesting that exposure to childhood abuse and adversity disrupts emotion regulation processes, leading to long-term difficulties in these areas that readily manifest in self-harming and suicidal tendencies. Coping deficits as mentioned above have also been implicated in the initiation and maintenance of substance use disorders (Horowitz et al., 1992; Khantzian and Schneider, 1986; Krystal, 1997) and, thus, may play an important mediating role between ABCDG parenting and substance use dependence. For example, findings from the addictions literature show that difficulty in emotional coping and intolerance of painful feelings, inability to self-soothe, and instability of behavioral control are typical of adolescent and adult substance abusers (Krystal, 1997).

As a result of the link between maladaptive coping and substance use in Asian-American women, treatment approaches that enhance a psychoeducational framework for helping women to better identify the links between their emotions, thoughts, and behaviors are a critical foundation for recovery-oriented lifestyles. Treatment models such as Seeking Safety (Najavits, 2002) provide an appropriate context for exploring substance use issues. Such treatments are phase-based and allow participants to first begin identifying the triggers and risks for maladaptive substance use in relation to their emotions and feelings. In the context of setting goals to reduce or limit substance use as a way of maintaining “safety,” participants will then learn a collection of cognitive behavioral skills that promote emotional awareness and help women to manage their cravings, as well as to gain control over their problematic substance use and maintain their recovery. Skills such as identifying triggers, managing high-risk situations, developing assertiveness and drug refusal skills, and problem solving (especially with interpersonal conflicts) are core areas that will help women grow in their capacity to employ “safe coping.”

Although established treatment models such as Seeking Safety offer efficacious, cognitive behaviorally based interventions targeting substance abuse in the general population, such models lack critical cultural components for engaging the population of young Asian-American women. First, Seeking Safety and other existing modalities do not address the challenges of engaging Asian-American clients and preventing dropouts. These challenges underscore the need for treatment models that offer culturally competent strategies for working with Asian-American clients. Moreover, in the treatment of substance abuse, there is a need for treatment models that allow for the in-depth exploration of Asian-American family dynamics and the experience of the double bind, as they create the particular context for the maladaptive use of substances and mental health problems. An in-depth exploration of how family dynamics relates to substance use triggers, a therapist-guided exploration of how to reconcile the double bind within oneself, and strategies for effective management of family conflicts will also be critical components of treatment specific to Asian-American women.

4. Building empowerment and resiliency

We suggest that an intervention specific to Asian-American women should focus on building a sense of empowerment and resiliency through the practice of replacing unsafe coping behaviors (e.g. cutting, substance abuse) with empowering coping skills. At the heart of the double-bind and fractured identities is a profound sense of powerlessness and hopelessness. These are two themes that emerged in the qualitative analysis of interviews with young Asian-American women who struggled with suicidality and/or self-harm behaviors (Hahm et al., 2014).

Consistent with evidence-based practices involving trauma survivors, Hahm et al.’s (2014) previous study suggests that helping women to develop a sense of empowerment from within may be the key element for prevention and treatment of suicidal or self-harm behaviors among Asian-American young women. The purpose of the intervention is to help give voice to clients’ experiences of suffering, as well as to renew a sense of hope and purpose through acquiring empowering coping skills and creating new narratives.

Empowerment is a multi-faceted concept, which may be difficult to pin down into one clear and centralized definition. However, here we document specific examples of what empowerment may mean for Asian-American women. These may be used as tools to help clients explore aspects of themselves and their lives in which they hope to become more empowered and resilient (Table II).

Table 2. Multiple Dimensions of Empowerment with Corresponding Examples of Empowerment and Disempowerment.
Aspects of Empowerment Example of Empowerment Example of Disempowerment
A Healthy Sense of Identity “I am 2nd generation Taiwanese
American woman. I am a dreamer
& reformer.”		 “I feel confused about who I am.”
Safety: Ability to use safe coping
skills when under stress		 Using grounding, deep breathing,
reaching out for help		 Using substances, cutting, making
reckless decisions
Self Compassion & Self Care “I accept & love myself with my
imperfections. I have value &
worth.”		 “Sometimes I just can’t stand who I
am & all the mistakes I’ve made.”
Sense of Self-Efficacy & Control “I made this decision because I
want to not because I am forced
to.”		 “I have to choose this major or this
life partner to please my parents.”
Ability to Set & Pursue Goals “I know some of my short- and
long-term goals.”		 Inability to follow through with
goals
Boundaries: Ability to say, “No,” to
unhealthy relationships & people		 “He is not the right person for me
because he does not respect me
when I don’t want to have sex.”		 “It’s just too scary to be alone.”
Ability to advocate for one’s sexual
health by negotiating with one’s
partner		 “It is really important for both of
us to be safe & to protect each
other in this relationship.”		 “I don’t want to lose him, so I give
in when he pressures me to sleep
with him.”
Future Orientation: A positive
outlook on life		 “Good things will come my way
in the future.”		 “I’m scared to think about the
future.”
Clear sense of one’s values “I know what’s important to me
and my family.”		 “I’m pulled all over the place by
conflicting values.”
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5. Honoring the mind and body

Women with substance abuse issues have often neglected their physical health for years, resulting in the presence of increased incidences of chronic diseases and overall poor health due to bodily stress, neglect, and unhealthy behaviors (e.g. obesity, smoking, poor diet) (Deykin et al., 2001; Kimerling et al., 2000). For Asian-American women, attention to the body, as well as the mind, is an important aspect of consideration for integrated treatment models. Similar to the focus on empowerment in mental health cases, empowerment-based theories that incorporate a feminist perspective are highly recommended in work with Asian-American women around their physical and mental health. Often, women with early life trauma, such as ABCDG parenting, may experience authority in extremely threatening ways (Hahm et al., 2014). The patient-doctor relationship is one with a significant power differential, making it a potentially strong trigger for these women. Having to relinquish control in a very intimate setting may trigger unwanted memories and emotions, raising issues of mistrust, vulnerability, and an inability to assert themselves.

Due to the barriers we have discussed above, Asian-American women face unique challenges in self-care and in appropriate use of medical services related to experiences of mistrust (Sung, 1999), intrusiveness and vulnerability, low self-worth, inability to assert themselves (Rü sch et al., 2006), tendencies to avoid and deny their physical experiences, fear of being rendered powerless or further traumatized by medical procedures, and limited understanding of their own bodies and the importance of caring for their health (Uba, 1992). Failing to address these culturally related issues can often impede treatment objectives, and can result in clients being unable to follow through with treatment (Fong and Tsuang, 2007).

Due to the tendency of Asian-Americans to avoid addressing mental health issues until significant psychiatric distress or crisis, health care professionals and substance use providers working with Asian-American women need to collaborate in the care given to this population (Kimerling and Calhoun, 1994). In addition, because Asian-Americans are more likely to seek medical treatment as opposed to psychological services, physicians and nurses may have a greater opportunity to intervene (Snowden and Yamada, 2005; Vo et al., 2007). Therefore, one area of intervention may be in the training of medical providers to assess for mental health risk factors in Asian-American women and to make referrals to appropriate mental health services.

We also recommend that clinicians address the link between mental and physical symptoms in a culturally salient way, particularly as many Asian cultures are deeply rooted in traditions honoring the mind-body connection. A first step would be to help clients become aware of the connection between their negative thoughts and unsafe coping behaviors. Then, clients can acquire the cognitive behavioral skill (CBT) of creating new meanings out of negative thoughts and experiences to develop the type of thinking that supports healing and recovery. The focus of this skill development is for clients to become more aware of their own bodily sensitivities in connection to negative thoughts and unsafe coping. Mindfulness, an aspect of meditation, can be useful in the work of increasing self-awareness, including awareness of the body, physical sensations, and location of discomfort (Walsh and Shapiro, 2006).

Discussion

Although Asian-Americans are the fastest growing population in the USA, our literature review revealed that the limited research only aims to understand the intersection of suicidality, mental health, and substance abuse among this population. We also found that there are few existing interventions specifically tailored to this population. Implications for further research, public health policy, training for health providers, education, outreach, treatment for Asian-American families and young women, and intervention development are highlighted.

First, the pernicious effects of the “model minority” myth must be recognized as a public health problem, as it contributes to the under-diagnosis and under-treatment of Asian-Americans in general, and young Asian-American women in particular, as they are often suffering mental illnesses and comorbid substance abuse problems alone. Future studies should include large-scale sampling of various Asian ethnic subgroups, in order to investigate potential differences in suicidal behaviors and comorbid substance abuse among Asian subpopulations.

It is imperative for professionals in the fields of public health, mental health, medicine, and substance abuse to proactively combat the “model minority” myth and to design and implement interventions targeting family dynamics, coping with immigration/acculturative stresses, mental illnesses, suicidal behaviors, and substance abuse among Asian-American populations across the developmental lifespan. Thus, the importance of culturally competent provider training to engage, educate, and treat Asian-American families and young women cannot be overstated.

In this paper, we have identified factors associated with suicidality and substance abuse among Asian-American women, as well as a culture-specific framework, the Fractured Identity Model, for understanding these factors. Our research findings, theoretical framework, and treatment recommendations can be incorporated in trainings for providers working with Asian-American families and young women. Additionally, medical providers should be trained to assess for mental health risks and make appropriate mental health referrals when working with this population.

The stories of the Asian-American young women we interviewed speak loud and clear to how self-harm and substance abuse developed as maladaptive coping to disempowering parenting, unresolved family conflicts, and being caught in the double bind of competing cultural impulses. Intervention for Asian-Americans, then, should include starting at the family level – engaging first generation immigrant parents and their children, before the development of fractured identities, suicidal behaviors, mental illnesses, and substance abuse occurs. Since Asian immigrant populations are often suspicious of “mental health” services, educational workshops and outreach efforts can be an effective means for engaging with this population. First generation, Asian parents want the best for their children, but often do not know how to respond when their children resist or react negatively to the Asian values and expectations they place on their children. Moreover, Asian parents may not realize the negative effects of harsh parenting styles, as a commonly held Asian belief is that to criticize a child is to love the child. This is where educational workshops and materials on disempowering parenting (ABCDG parenting) and the double bind can help Asian parents understand the long-term impact their parenting styles have on their child’s mental health and emotional development.

As for treatment of young Asian-American women, those with comorbid mental health and substance use problems tend to have poorer treatment outcomes compared to those with either problem alone. Such individuals have significant difficulties in establishing and maintaining a therapeutic relationship (Dodge et al., 2005; Greenfield et al., 1998; Kodl et al., 2008). Thus, identifying underlying mental health and substance use problems is likely to enhance engagement, retention, and better treatment outcomes, which is an important step toward reducing the mental health burden of this vulnerable population.

We have provided specific suggestions for interventions to adequately respond to the mental health needs of young Asian-American women. These include addressing the cultural stigma and shame of seeking help, underlying family origin issues, and excessive alcohol and drug use as unsafe coping, as well as incorporating empowerment-based and mind-body components to foster an intervention targeting suicidality among Asian-American women in early adulthood. We conclude that the development for a culture- and gender-specific treatment for Asian-American women is warranted. An integrated, holistic intervention incorporating empowerment-based and mind-body approaches may reduce suicidality and substance use among Asian-American young women.

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Further reading

  1. Asian Pacific American Legal Center and Asian American Justice Center [accessed March 10, 2014];A community of contrasts: Asian Americans in the United States: 2011. 2011 available at: www.advancingjustice.org/publication/community-contrasts-asian-americans-us-2011.
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