F/Pilipino American substance abuse: sociocultural factors and methods of treatment.

Abstract

An analysis of related studies provides commentary on sociocultural relationships between Filipino Americans and substance abuse. This manuscript discusses specific historical and cultural background of Filipino Americans and current Filipino/Filipino American health problems. The purpose of this manuscript is to illustrate the unique experience of Filipino Americans in relation to alcohol and tobacco use. Commentary is offered for potential methods of treatment for this ethnic group. The distinction between Filipino Americans and other Asian Americans is drawn to illustrate a need for ethnocentric therapeutic practice.

Introduction

Previous research has found certain trends in regards to Asian populations and substance abuse. Flaskerud & Hu (1992) found that there were lower rates of substance abuse among Asian Americans than among Euro-Americans, African Americans, or Latino Americans. Royce & Scatchley (1996) cite two major findings. 1) The "Chinese Flush" is an innate reaction to alcohol that can be found in 60 to 83 percent of "Orientals" and in only 5 percent of Europeans. 2) An atypical form of Alcohol Dehydrogenase (ADH) in 90 percent of Japanese livers causes faster production of and slower metabolism of acetaldehyde, which leads to higher residual levels. Straussner (2001) writes about the different ethnocultural factors in substance abuse among several different ethnic groups. For Asian Americans, her ethnic-specific words focus on Chinese, Japanese, Indians, Koreans, and Cambodians. Because of the vast heterogeneity within the Asian Pacific American Diaspora, it is very important to study specific ethnic groups, in order to assess and treat them properly. The purpose of this work is to specifically address thesociocultural factors that lead to substance abuse among F/Pilipino(1) Americans.

F/Pilipino Americans are one of the largest Asian American Pacific Islander group in the United States (Crisostomo, 1996). As a specific ethnic group, F/Pilipino Americans differ from their Asian American counterparts in a variety of ways. Physically, F/Pilipinos are darker in skin tone-identifying with the color "brown" instead of "yellow" as other Asian Americans might (Ignacio, 1976). Culturally, F/Pilipino and F/Pilipino Americans have a distinct ethnic background, which consists of aboriginal Pilipino, Spanish and American cultures, along with traces of Muslim, Pacific Islander, and Indonesian influence (Rabaya, 1971). Religiously, F/Pilipino Americans differ, in that they are the only Asian American group with a strong Catholic presence. Due to four hundred years of Spanish colonization in the Philippines, over 80% of the F/Pilpino population is Roman Catholic, without including the number that is Christian (Agbayani-Siewert, Revilla, 1995). Historically, F/Pilipinos are unique, because they are only Asian American group that has been colonized and influenced from Europe, the Americans, and Asia (Rabaya, 1971).

Besides substance abuse, there are several health concerns that are drastically affecting F/Pilipino Americans, and not necessarily their Asian American cohorts. According to the Filipino Task Force on AIDS (1998), HIV/AIDS was the leading cause of death for American-born male Filipinos between 25-34 years old in the state of California (Filipino Task Force on Aids, 1998). HIV/AIDS was also the second leading cause of death for all Filipino immigrants in the state. In fact, Filipinos have the highest percentage of HIV/AIDS in the Asian Pacific American community, contributing 32.4% of the total number of reported Asian Pacific HIV/AIDS cases in California. (Chinese Americans, who ranked second, produced 14.3% of the total among of Asian Pacific HIV/AIDS cases). Because Asian Americans are not being targeted as at-risk AIDS populations, F/Pilipinos are being properly educated on safe sex practices.

Along with HIV/AIDS, according to the National Vital Statistics Report (2000), F/Pilipino American and native Hawaiian women have the highest rates of unintended pregnancy out of all Asian Pacific ethnic groups. Thirty-nine percent of childbirths to native-born F/Pilipino American women were out of wedlock, compared to 11% of Chinese Americans and 16% of Japanese Americans. High rates of unplanned childbirth may be an outcome of the dominant Catholic influence of F/Pilipinos and their belief that abortion is immoral. Nonetheless, the continuation of unintended pregnancies may result in a lower socioeconomic status and an overpopulation of the F/Pilipino American community.

Mental health issues also specifically concern the F/Pilipino American community. Studies have shown that F/Pilipinos have higher prevalence rates of depression and mental health disorders that the U.S. general population (Tompar-Tiu, 1995). Other health issues are also well known within the F/Pilipino American community. Issues such as eating disorders and sexually transmitted infections are commonly prevalent in F/Pilipino communities across the nation, but topics cannot be commented on because there is a lack of research done specifically on F/Pilipinos. The panethnic Asian American paradigm results in particular F/Pilipino health issues being overlooked and disregarded.

This familiarization with the unique experience of F/Pilipino Americans enables the reader to recognize that research that has been conducted on Asian Americans, as a panethnic group, may or may not apply to the experience of F/Pilipinos and/or F/Pilipino Americans. In analyzing F/Pilipino American substance abuse and treatment, it is important for one to understand the importance of population-specific research and therapy.

While there is a dearth of research regarding F/Pilipinos and substance abuse, the few investigations that have been completed might be misleading. First, the research has been conducted primarily on the West Coast of the U.S. mainland and in Hawaii, areas that contain large populations of high densities of F/Pilipino Americans (Berganio, Tacata, & Jamero, 1997). Therefore, F/Pilipinos in smaller Filipino-populated areas have a different experience than those residing in largely Filipino-populated areas. Second, many of the studies do not decipher between native-born or foreign-born F/Pilipino Americans. Therefore, major conclusions cannot be drawn about birth origin differences. Finally, substance abuse may be under reported or not reported at all, due to cultural factors such as shame or social acceptance of substance abuse in Filipino culture. Therefore, the research can be seen as valid, but not always reliable. Nonetheless, the findings point to a need for further research in this area, especially given the growing population and diversity of the F/Pilipino American community.

F/Pilipino Americans and Alcohol

A few studies have revealed common trends of alcohol use among F/Pilipino Americans. In a study performed in Hawaii six different racial-ethnic groups were assessed in regard to their reasons for using alcohol, abstaining from alcohol, or ceasing to use alcohol (Johnson, Schwitters, Wilson, Nagoshi, & McClearn, 1985). Six hundred fifty-four of the 3,712 in the sample were Filipino. The results disclosed that the largest proportion of Filipinos were "abstainers" from alcohol (31%), in comparison to the other groups: Chinese (17.7%), Japanese (16.7%), Hawaiian (11.1%), Hap-Haole (2) (7%) and Caucasian (4.3%). However, the Filipinos who did drink admitted to drinking for more "pathological reasons" (i.e. drinking when tense, worried, angry, or sad) than the other groups (Johnson et al., 1985). These findings can be interpreted in a number of ways. First, while it may seem positive that a greater number of F/Pilipinos are abstaining from alcohol altogether, it is negative that F/Pilipino drinkers suffer from more emotional instability and/or possible mental health disorders that other Asian American groups. This translates as F/Pilipinos abusing alcohol as a way to remedy one's problems.

In a later analysis of the same study (Johnson, Nagoshi, Ahern, Wilson, & Yuen, 1987), emphasis was placed of differences between native-born F/Pilipino Americans and foreign-born F/Pilipino Americans. Current use of alcohol was lower among foreign-born F/Pilipinos (41.1%), than those born in the Untied States (64.8% for Hawaii and 50% for the mainlanders). At the same time, a greater proportion of F/Pilipino abstainers were among the foreign-born group (39.6%), in comparison to those born in the U.S. mainland (20%) or in Hawaii (15.1%). These finding can attribute to the effect of acculturation levels on alcohol abuse. Filipinos born and raised in the United States have higher drinking patterns than their foreign born counterparts. Moreover, F/Pilipino Americans living in the United States in predominantly White areas or lower-socioeconomic settings experience more stressful situation and hence feel a greater need to turn to alcohol.

Lubben, Chi, & Kitano (1998) interviewed 145 male and 85 female F/Pilipino Americans in Los Angeles. The results revealed that approximately 50% of the females sampled were abstainers while 80% of the males were drinkers. Heavy drinking was almost exclusively a male activity. These findings reveal a gender disparity in the Philippine culture. While some may argue the F/Pilipinos have a gender-free culture, in which both men and women are encouraged to succeed academically, socially, and politically (Pido, 1986), it is important to note that there are still several gender boundaries in F/Pilipino society. Branching from the Spanish/Latino "machismo" value, it is important for F/Pilipino males to be seen as strong, macho figures, while it is important for F/Pilipino females to be seen as graceful and lady-like. Therefore, it is more acceptable for men to drink than it is for women. Men are allowed to be intoxicated in public or at social functions, while it is frowned upon for women.

In another study Chi, Lubben, and Kitano (1998) randomly sampled adult male patterns of drinking among four different Asian groups: F/Pilipino, Chinese, Japanese, Korean (n=335). Results from the F/Pilipino subjects (n=81) showed that one third of the Filipino young adults males were heavy drinkers and less than 10 percent were abstainers. Results from the interviews also disclosed that factors that led to heavy drinking were income, frequenting bars or nightclubs, and having friends who also drank alcohol. Again, these finding show that F/Pilipino men are socialized to believe that it is culturally acceptable and culturally standard for them to drink. It also reinforces the idea the F/Pilipinos are prone to engage in what is socially acceptable.

In fact, in dealing with F/Pilipino culture, one must recognize the idea of pakikisama, which can literally be translated into "social acceptance, the achievement of status and power, and getting along with the group." The Filipino will thrive on acceptance from those surrounding him/her, always wanting to be collective member of the group or community. If his/her barkada (friends) are drinkers, then it is more likely that he/she will be a drinker. Pakikisama cannot be translated into the American term "peer pressure," because peer pressure connotes that the individual is "pressured" to do something. With the F/Pilipino pakikisama, it is not that the individual is pressured to do something, but rather that the individual sees the action as a way of life. A F/Pilipino is defined by his/her community, and if drinking is what his/her community does, then that is What the F/Pilipino will choose to do.

F/Pilipino Americans and Tobacco

Some studies have focused specifically on F/Pilipino Americans and tobacco use. Data from the 1992-1994 National Health Survey show that 26.5% of male F/Pilipinos were current smokers and 23.2% were former smokers. Approximately fifty percent had never been regular smokers (Asian and Pacific Islander American Health Forum, 2001). (Chen & Unger 1999) interviewed 20,482 subjects of different racial groups-Asian American (Chinese, Japanese, Korean, and Filipino) and Non-Asian (Blacks, Whites, Hispanics)-age 12-17 years old. Results from within the Asian American subgroups revealed that Chinese Americans showed the lowest risk of smoking initiation, while F/Pilipino Americans had the highest risk. As a whole, the risk among all Asian Americans increased throughout adolescence, while the same risk among White and Black Americans leveled around 14-15 years of age.

Another study (Klatzy and Armstrong, 1991) sampled 13,031 Asian American adults during the years 1978-1985. The results showed that the highest prevalence of smoking among Asian Americans was F/Pilipino American men (32.9%), compared with "other Asians" (30.9%), Japanese, (22.7%), and Chinese (16.2%). The study indicate that F/Pilipina (3) American women had the second-to-lowest percentage of smokers among Asian American groups. It is more culturally acceptable for F/Pilipino American men to smoke than their F/Pilipina counterparts.

The same study also concluded that F/Pilipino men and women had the highest prevalence of hypertension among all Asian Americans (Klatzy and Armstrong, 1991). This may serve as further evidence that stress factors may play a critical role in substance abuse among the F/Pilipino community. F/Pilipinos are not abusing substances for entertainment purposes or curiosity. They are using substance abuse as a way to alleviate mental or emotional distress.

Sociocultural Factors for Treatment

This recognition of a unique problem with substance abuse (namely alcohol and tobacco) within the F/Pilipino American community, leads to a need for therapists to learn how to better assess their clients. In order to do so, all core values of F/Pilipino culture must be taken into account:

1) pakikisama (social acceptance, the achievement of status and power, and getting along with the group). The Filipino will thrive on acceptance of those surrounding him/her, always wanting to be a member of the collective group or community. He/She will also be encouraged to gain status and power, through education, entertainment, or politics. The Filipino will be mentally-at-best, when he/she is socially accepted and socially celebrated at the same time.

2) kapwa a (fellow being). As the core value of the Filipino personality, Kapwa is the unity of self and others and implies a shared identity or inner self.

3) hiya (loss of face or shame). The goal of the Filipino is to represent his/her family in the most honorable way possible. The Filipino will avoid hiya, at all costs, sometimes resulting in the inability to recognize mental problems and/or the inability to fail.

These three core values may be somewhat contradictory. While it is very important for the F/Pilipino to succeed and represent his/her family well (hiya), it is also important for the F/Pilipino to get along with the group and be socially accepted (pakikisama). In addition to that, the F/Pilipino must always connect him/herself to his/her other loved ones (kapwa), which means choosing between connecting to his/her family (who may want her to succeed and abstain from alcohol or tobacco) or to his/her friends (who may influence his/her that alcohol or tobacco is a customary, acceptable practice).

If a F/Pilipino does become addicted to alcohol, tobacco, or another drug form, many "side effects" can cause more distress. First, because the F/Pilipino is trying to avoid hiya (shame), he/she may be forced to hide his/her addiction from her parents and family, who upon knowing his/her addiction, may view his/her as a shameful family member. By isolating from the family, the F/Pilipino may continue abusing, especially if none of his/her peers intercede. And none of his/her peers may interject because of pakikisama- the fact that they want to get along with their friends and stay socially accepted. The need for this social acceptance (pakikisma) can lead to the unwillingness to communicate against the group standards. Even is one knows that his/her peer may be addicted to something, he/she may not say anything rather than avoid social rejection.

In addition, the F/Pilipino may not seek proper treatment, because of hiya. Not only would it be shameful for the F/Pilipino to tell his/her family about his/her addiction, but it would also be shameful for the F/Pilipino to tell anyone (including mental health specialists) about his/her addiction. In F/Pilipino culture, there is a stigma attached to use of mental health services. Araneta (1982) explains that F/Pilipinos may be ashamed of and deny their mental health problems because they think that the problems reflect hereditary flaws that shame the family. F/Pilipinos are ashamed of any deny existences of these mental health problems because they think that mental disorders are penalties meted out either by God or malevolent spirits for their immoral behavior.

Therefore, it is important for mental health specialists to take the following steps in treating F/Pilipino American patients. Enriquez (1982) cites the two most effective counseling techniques for F/Pilipinos as:

1) pagtatanung-tanong (asking around)- a relatively non-reactive, naturalistic technique based on informal inquiries adapted for research.

2) pakapa-kapa method, a generalized approach to problem solving in which the therapist proceeds as if he/she were in a state of total ignorance.

The first method of asking around (pagtatanung-tanong) is especially useful because as mentioned previously, the F/Pilipino does not like confrontation, and therefore, learns to communicate in a very roundabout way. A therapist needs to understand that a F/Pilipino will not tell his/her about his/her problems in direct, undeviating manner. That is why it is important for the therapist to learn how to communicate in a roundabout manner-asking around until he/she get to the core of the client's problems. The second method, pakapa-kapa, which translate to blank slate or tabula rasa, is also very useful with F/Pilipinos. Because of the indirect communication styles, it allows the F/Pilipino to tell his/her story from the very beginning. It consents for the F/Pilipino to feel like whatever happened was not his/her fault, because he/she is expressing his/her point of view. It also helps the F/Pilipino to overcome the hiya (shame) aspect of coming to therapy. If the F/Pilipino feels that he/she has an opportunity to tell his/her story from the very beginning, he/she will feel less threatened by the therapist. The therapist is not judging his/her, nor does the therapist know or have any connections to any of his/her family members. He/She is free to say whatever he/she wants.

Salvador, Omizo, and Kim (1997) cite commendations for counselors working with Filipino and Filipino American children. These suggestions can also be applied to counseling Filipino Americans:

1) Assess oneself as a counselor; be aware of and examine one's own beliefs, values, and behaviors that may be different from those of the Filipino client.

2) Where modern American influences may be in conflict with the family's cultural traditions, help the [client] understand any differences in requirements between the school and home as well as between local-born Filipino culture and immigrant Filipino culture.

3) Familiarize oneself with and use government agencies and Filipino organizations within the community, such as churches, businesses, and clubs for support.

The therapist must be aware of Filipino culture and values, and must be able to refer the Filipino client to different community resources or support systems.

Furthermore, (Shimabukuro, Daniels, and D'Andrea, 1999) cite that there are necessary Filipino spiritual beliefs and traditional practices that counselors should be familiar. Counselors are "urged to avoid pathologizing behaviors that are considered to be 'inappropriate' and even 'bizarre' among many people in the dominant cultural group in the United States, without first considering the appropriateness of such behaviors from the client's cultural context" (Shimabukuro et al., 1999). When assisting Filipino American clients, therapists must understand that certain Filipino practices that are considered "normal" in Filipino culture are considered "abnormal" in American culture.

Church (1986) comments that "since Filipino clients tend to be family and small-group oriented, significant numbers of family or group may need to be involved in therapy." However, cultural stigmas prevent successful group therapy from occurring. (Uba, 1994) Filipino clients diagnosed with substance abuse may not want to tell their family about their disorder. Moreover, the client's family members may not want to get involved in therapy.

Additionally, it is important to realize that F/Pilipino American clients will not be responsive to models and techniques used in Asian American Psychology. Atkinson, Marumyama, & Matsui (1978) explain that "research indicates that Asian American clients seem to prefer and benefit most from a highly structured and directive approach rather than an insight/feeling-oriented one." However, Okamura and Agbayani (1991) rationalize that "since Filipino cultures emphasize the importance of social acceptance and emotional closeness, therapists need to be more personable when working with Filipino Americans than with other Asian American than other Asian American groups." Unlike other Asian Americans, F/Pilipinos need therapists that are willing to understand and value their clients' emotions and feelings. They need therapists that are willing to be heartwarming and sympathetic. They need therapists who will treat them like a family member or loved one.

Conclusion

In conclusion, we must understand why F/Pilipino and F/Pilipino Americans should not be assessed as typical Asian American clients. Mental health therapists need to understand that there is an experience that is unique to F/Pilipinos and F/Pilipino Americans. In specifically relating to substance abuse, therapists must take into consideration several factors in assessing their clients. It is necessary F/Pilipino clients be assessed considering their gender, socioeconomic status, relationship to family, relationship to barkada (friends), and his/her level of acculturation. A client who is not seen a holistic person, with several influences that make him/her a complete person, will not be accurately or properly treated.

Additionally, F/Pilipino clients must be able to feel comfortable in their counseling environment. F/Pilipino clients must not feel judged, nor should they feel misunderstood by their therapist. Because it was likely to have been extremely difficult for the F/Pilipino client to enter the counseling arena, it is important for counselors to be extremely sensitive to their needs. A counselor/therapist cannot directly place blame on the F/Pilipino who is an alcoholic or a smoker or a drug addict. There are several cultural factors that have influenced him/her that substance abuse was a way of life. A therapist should be sincerely grateful that he/she has taken the first step to remedy his/her problem. Now it is the therapist's duty to assist him/her to resolve it.

(1) The term F/Pilipino is used because different Americans of Philippine backgrounds use different ethnic identifiers. Some F/Pilipino will us "Pilipino" as a political statement since there is no "F" in the Tagalog/Pilipino language. However, some F/Pilipinos will identify with "Filipino" since it is the term that has been commonly used in the United States and in the Philippines.

(2) Hapa Haole literally translates to "Half White" in Hawaiian language. It generally refers to persons who are half Asian Pacific Islander and white.

(3) F/Pilipina is the female counterpart to "F/Pilipino."

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Kevin L. Nadal

Michigan State University