Distress Tolerance, Family Conflict, and Ethnic Identity As Potential Therapeutic Targets of Aware Intervention for Asian American Women

Background and Purpose:  Asian American women (AAW) have the highest proportion of deaths by suicide, and one of the highest rates of suicide, of all female racial/ethnic groups in the US.  Culturally grounded and empirically based interventions are needed. To address this, we developed and tested the Asian Women’s Action for Resilience and Empowerment (AWARE) intervention.  We propose a Model of Healing for AAW, in which increasing one’s emotional distress tolerance, reducing familial conflict, and strengthening ethnic identity may help reduce suicide among young AAW.  Thus, this study aims to validate these three measures, and to establish preliminary evidence that AWARE efficaciously engages in these targets in a small-sample clinical trial at a university health service center.

Methods:  Two AAW staff clinicians at a university health center in Massachusetts were trained to facilitate the AWARE intervention.  AAW students at the university were recruited and screened using a demographic survey. Those who passed the screening (age 18-35, never married, self-identifying as AAW) were invited to participate in a baseline clinical assessment.  Eligibility for the intervention included those who met any one of the following criteria: moderate to severe depression (CESD-R ≥ 16), anxiety (HADS-A ≥ 11), post-traumatic stress diagnosis (PCL-C ≥ 30), or childhood exposure to traumatic events (ACE-IQ, any item).  As well, the three potential targets for this study were assessed using the Distress Tolerance Scale (DTS), Asian American Family Conflicts Scale (AAFCS), and the Multigroup Ethnic Identity Measure (MEIM). Once enrolled, AWARE intervention sessions were conducted in small groups (n ≤ 11).  Participants completed a post-intervention assessment consisting of the same measures as in the baseline. Two tailed paired t-test and Cohen’s d effect size calculations were performed to assess the three target measures. This study took place from February to December 2018.

Results:  Among 99 individuals who voluntarily completed the screening survey, 36 met the inclusion criteria, and 22 enrolled in the AWARE intervention.   Participants who completed the intervention (n=17) showed significant increases in distress tolerance (ΔDTS = 0.71 ± 0.68, p = 0.0005) and identification with their ethnic group (ΔMEIM = 0.15 ± 0.30, p = 0.050).  As well, participants showed significant decreases in both the “likelihood” subscale of family conflict (ΔAAFCS-L = -5.76 ± 6.26, p = 0.0016) and the “severity” subscale (ΔAAFCS-S = -4.76 ± 4.96, p = 0.0011).  The effect sizes were large for distress tolerance (Cohen’s d = 1.04), family conflict likelihood subscale (Cohen’s d = 0.92), and family conflict severity subscale (Cohen’s d = 0.96).  The effect size for ethnic identity was medium to large (Cohen’s d = 0.52).

Conclusions and Implications: Using a pre- and post evaluation design, the AWARE intervention resulted in increased distress tolerance and ethnic identification, as well as decreased family conflicts among AAW students.  A large scale study is necessary to test the mediating effect of these potential therapeutic targets on clinical mental health outcomes. Addressing these targets during therapeutic interventions may play a key role in reducing the burden of suicide among young AAW.