Develop Your "Ethnocultural Competence" and Improve the Quality of Your Practice
Saturday, 30 November 2002

"The cultural beliefs of a group of people are directly related to how alcohol and other drug problems are defined. The very definition of health differs by ethnicities and cultures. Therefore, it is of critical importance to understand how the members of an ethnic group define alcohol and other drug problems; the outcomes; and what they feel are appropriate ways to prevent these problems from occurring"(Cunningham, 1994).

It is a rare substance abuse clinician today who does not work with clients from a variety of racial, cultural, ethnic, and religious backgrounds. While there has been an increasing emphasis on ethnic and cultural sensitivity and what has been termed "cultural competence," it is not always clear what these terms mean in actual practice with clients. How does one define "culture?" How does it differ from "ethnicity?" And what about "race" - we all have checked the appropriate box under this category, but do we really understand why do we do so, and what it means in relation to the use and abuse of alcohol and other drugs (AOD)? This article will examine these concepts with specific focus on "ethnocultural competence" in relation to AOD abusing clients.

Defining race
Although awareness of differences among people has existed for ages, the modern notion of race is relatively recent. The use of the term "race" originated during the 17th century as part of the growing European colonization of the Asian, African, and American continents, and focused on attempts to classify people on the basis of genetically transmitted physical characteristics, particularly skin color and hair texture (Straussner, 2001). As pointed out by Holmes (2000) "when it comes to determining what exactly is a racial category, politics, not biology is the deciding factor ... at different times Jews, Italians and Irish were considered separate races. But as they gained more economic and political power, the larger society accepted them as white and ethnic."

Consequently, what are viewed as racial characteristics may be manifestations of socioeconomic, ethnic, and cultural differences. Thus the typical government classification of AOD using and abusing individuals within "American Indians & Alaska Natives," "White," "Black," "Hispanic American," and the more recently added "Asian/Pacific Islanders" population categories (CSAT, 1999), is not helpful since it obscures the unique ethnic and cultural background of the individual, and the distinct differences in cultural values, beliefs, and lifestyle that he or she may hold.

For example, a "black" client from a low socioeconomic background who grew up in Jamaica may have a very different view of the use of alcohol or marijuana than a "black" Muslim client whose professionally educated family emigrated from Sudan, or one who grew up with his Baptist family in South Carolina. There is, moreover, a tremendous difference in the stigma attached to being an alcoholic woman of Korean or Hawaiian background where drinking among women is more socially acceptable regardless of socioeconomic background, than for an alcoholic woman of Japanese or Chinese background where alcohol abuse by women is not socially approved, even though all of them would be classified as Asian/Pacific Islanders (Kitano, 2002).

The current "racial" categorization is particularly problematic in relation to those whom we label as being Hispanic since a substance abusing "Hispanic" or Latino client can be of black, white, or of indigenous Indian background representing a variety of different cultures and ethnicities. Moreover, it negates the identification of the growing number of people of mixed racial backgrounds, who as recent studies indicate, appear to be over-represented among substance abusing individuals (Oetting & Beauvais, 1990). In short, classification of a client into "racial" groups is a political and social notion without any therapeutic value. But what about culture and ethnicity? What do they mean and are these concepts important in treatment?

Understanding culture and ethnicity
As stated by Devore & Schlesinger (1996), "Culture is a commonly used concept that is difficult to define. It revolves around the fact that human groups differ in the way they structure their behavior, world view, perspectives on the rhythms and patterns of life, and in their concept of the essential nature of the human condition." In essence, culture is the sum total of values and life patterns shared by people within a given community. All that we do, value, and believe takes place within a cultural context - the language that we speak, the holidays that we celebrate, how we interact with authority figures, how we define illness and health, and our expectations of treatment and the helping professionals all reflect the culture in which we live. However, cultures are influenced by existing values and beliefs, and societal values and beliefs change over time. Thus while in the past, smoking cigarettes was viewed as a sophisticated, socially accepted behavior, today, smokers are increasingly stigmatized, and smoking by adults is increasingly viewed as a "disorder" rather than a socially approved activity.

A subculture can develop among different social groups who establish their own definable values and patterns of behavior within the larger culture. For example, the subculture of a gang may include a specific dress code and the use of certain substances, such as smoking "blunts," while a certain gay subculture may include using "poppers" or going to bars in order to have anonymous sex. It is within a cultural context, and more specifically, within a given subculture, that attitudes and reactions to the use and abuse of alcohol and other drugs are formed. And it is only within such context that we can understand the differential meaning of the use of Ecstasy by a group of white upper-class teens at a dance club, the drinking of beer at a local bar by a group of Polish-American working-class men, or the passing of a bottle of wine by a group of under-employed African-American men on an inner-city street corner. Understanding such cultural and subcultural contexts is crucial in providing effective treatment.

While the concept of culture is a global one, the concept of ethnicity is more narrow and refers to the sense of "peoplehood" experienced by members of the same common background. The term "ethnicity" comes from the Greek work "ethnos," meaning "people" or "nation," and refers to the notion that members of an ethnic group share common identity, ideals, aspirations, and a sense of continuity. It is the self-definition in terms of a shared past history that defines a given ethnic group, and ethnic values and identification are retained for generations. Thus, while the surrounding culture may affect an individual's access to a specific substance such as alcohol or crack cocaine, one's ethnic identity plays an important role in when and how a substance is used, and even the reactions to these substances. For example, it may be part of an ethnic expectation that one gets drunk during an Irish wake, but not during a Jewish shiva that follows a funeral. However, since ethnicity and culture interact and influence each other, clinicians and agencies need to focus on both the specific ethnicity and the broader cultural context, i.e., to become ethnoculturally competent in their delivery of substance abuse services.

Defining ethnocultural competency
Ethnocultural competency can be defined as the ability of a clinician to function effectively in the context of ethnocultural differences. It moves beyond "cultural sensitivity" and includes awareness and acceptance of ethnic and cultural differences - differences that need to be explored respectfully, without judgment, but with curiosity. In order to avoid stereotyping clients, however, it is important to understand the client's own unique experience with his or her ethnic culture and the degree to which the individual identifies with it, and not to simply apply a cookie-cutter view of what we have heard or read about a particular ethnocultural group. Ethnocultural competence also includes understanding one's own ethnocultural background and values. It is not unusual for staff members to act out what has been termed as "cultural countertransference" (Perez Foster, 1998; Westermeyer, 1993), communicating their own ethnic prejudice to their clients, thereby undermining treatment. Furthermore, "politically correct" clinicians may be afraid to explore the interrelationships between their own ethnocultural values and those of their clients, thereby "driving away those clients who we do not want to treat, covertly betraying and deftly blaming the patient for their lack of 'suitability' to the treatment process" (Perez Foster, 1999). For example, a white clinician may be afraid of confronting a black client for fear of being called a racist, at the same time blaming the client for not looking at the impact of his substance abuse problems on his life.

Ethnocultural competence also includes a basic knowledge about the ethnic culture of clients with whom one is working; a conscious commitment to working with diverse clients; and an ability to adapt practice skills to fit the client's ethnocultural background, including flexibility in reaching out to appropriate cultural resources in a given ethnic community (Amodeo & Jones, 1998; Straussner, 2001).

Ethnoculturally competent treatment approaches
Studies on specific ethnoculturally competent substance abuse treatment skills and techniques are limited. Most substance abusers entering treatment, regardless of their ethnic group, receive the same treatment approach. However, given the possible difference in treatment expectations among various ethnocultural groups, it is important to carefully describe the rationale for recommending or using a particular treatment approach and its goals. Some ethnic groups, particularly those among the newer immigrant groups, may be unfamiliar with the disease model of addiction.

There are two different approaches in dealing with this issue: One is to help clients and their family members become more familiar with the disease model, thereby helping them better utilize the treatment process and at the same time removing some of the stigma of having an AOD problem (Straussner, 1993; 2001). This approach is best done using a psychoeducational, didactic model of group lecture, or on a more private basis during individual or family sessions. The second approach is based more on the harm reduction model. Such an approach emphasizes limiting the negative consequences of substance use, while at the same time utilizing more ethnoculturally congruent treatment approaches. These may include: 1) using a culturally appropriate case management approach to help the client and family meet their basic needs before addressing the substance abuse, 2) focusing on medical problems associated with AOD abuse and working together with medical personnel to address the impact of AOD on the body, 3) and/or the utilizing native healers, religious, or cultural and community leaders to provide support and address specific life issue impacting on the individual and his/her family.

Which of the two approaches, or a combination, may be best for a given individual is highly variable depending on the client's entry point into the treatment system; the client's openness to address AOD problems directly; the availability of specific ethnic and general community resources; and on the philosophy of the agency. Specific examples of the use of these approaches with different ethnocultural groups can be seen in the book Ethnocultural Factors in Substance Abuse Treatment (Straussner, 2001).

Studies of family rituals point out their preventative and therapeutic functions in substance abuse problems (Bennett et al., 1988). Therefore, identifying and restoring ethnoculturally appropriate rituals may play an important role in treatment (Harvey & Rauch, 1997). Connecting or reconnecting clients to religious and ethnic holiday celebrations while also helping to develop and adapt new rituals, such as graduation ceremonies at a treatment center or anniversary celebrations in 12-Step programs, provides important linkages between past and present cultures. However, for many individuals whose cultural values emphasize the family more than the individual, traditional 12-Step approaches may be less beneficial than other treatment approaches, such as cognitive behavioral approaches or support groups that include the family or other significant individuals (Draguns, 1995).

Ethnocultural competence includes not only the individual clinician, but also the setting in which the individual works (Tirado, 1998). A substance abuse clinician cannot provide ethnoculturally competent services in a setting that does not support and validate such values. These include some recognition and celebration of ethnocultural holidays, customs and rituals - including food, music, and art - of the diverse ethnic groups seen in the agency; the hiring of professional and paraprofessional staff reflecting the ethnic and linguistic diversity of clients; and the ongoing provision of training and supervision to help the counseling staff understand their clientele and their own countertransferential reactions to them.
Establishing close linkages with community groups representing the ethnocultural background of clients and cross-staff training can be beneficial to all. For example, a substance abuse clinic with a number of Russian clients may offer to provide a lecture on the signs and symptoms of AOD addictions to an ethnic Russian community organization, while inviting staff from such an organization to offer in-service training regarding current issues impacting the particular ethnic group.

In addition, ethnoculturally competent organizations offer a computerized management information system that has the capacity to record data regarding clients' ethnicity, migration and immigration information, religious and spiritual beliefs, and languages spoken. They also track information regarding accessibility to, and frequency of, the need for interpreters (Tirado, 1998). Moreover, an ethnoculturally competent organization integrates treatment outcome research in order to identify its ability and deficit in providing ethnoculturally competent treatment services to its clientele (Straussner, 2001).

A crucial issue in offering ethnoculturally competent services is the question of matching the ethnocultural characteristics of the staff with those of the clients (Sue, 1998). Staff that reflects the client's culture, race, socioeconomic level and community provides an important role model. Studies show that staff members who are immediately recognizable as members of the client's ethnocultural group have an easier time in initially engaging and retaining the clients. In the long run, however, such client-worker differences did not matter. Therefore it becomes crucial that those working with clients who are unlike themselves in ethnocultural background (and probably other characteristics, such as gender and sexual identity) may need to work harder and longer to initially engage these clients in treatment.

It is important to note, however, that while clinicians who are themselves from the same ethnocultural background as their clients may find it easier to initially connect with their clients, it does not mean that they may not have their own negative countertransferential reactions and prejudices toward their clients resulting from their own internalized shame and discomfort with their own ethnocultural background. At the same time we need to realize that clients may have their own prejudices and negative transferential reactions toward the ethnocultural background of a staff member as well as toward other clients. Thus it is crucial that the power and impact of ethnicity and culture be recognized in every treatment encounter.

Dr. Lala Straussner is Professor and Coordinator, Post-Master's Program in the Treatment of Alcohol and Drug Abusing Clients, New York University School of Social Work. Among her ten books are Ethnocultural Factors in Substance Abuse Treatment (2001, Guilford Press), which serves as the basis for this article, The Handbook of Addiction Treatment for
Women (with Stephanie Brown, 2002, Jossey Bass), and the widely used textbook, Clinical Work with Substance Abusing Clients, the second edition which will be coming out in 2003 (Guilford Press). She is also the founder and editor of the new Journal of Social Work Practice in the Addictions. Dr. Straussner has a private psychotherapeutic and supervisory practice in New York City. She can be reached via e-mail at: This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
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One person has commented on this article.
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Efrain Diaz, Unregistered
Great, an excellent way to increase cultural competence.
 Posted 2008-05-12 13:30:06
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