Meeting the needs of Racially and Culturally Different Clients in Substance-Abuse Treatment

Working with individuals to help them overcome the enormous burden of drug addiction is one of the most difficult jobs in the world. It, however, is one of the most rewarding professions when one considers what a successfully broken addiction means to all of us. It restores money to the public coffers, reduces crime and, at its best, returns renewed, productive persons to families and communities. Drug abuse and involvement has a disproportionate impact on the health and well being of racial/ethnic minority communities evidenced by such indicators as increased drug-related illnesses such as HIV/AIDS, children living in foster care or with grandparents and crime infested neighborhoods. We need addiction counselors who are effective in working with all clients, those who are Black/African American, Hispanic, Asian American/Pacific Islander and Native American/Alaska Native. We need counselors who can return productive members to these communities.

The National Institute on Drug Abuse (NIDA), which supports over 85 percent of the world's research on drug abuse, has made substantial progress in substance-abuse treatment research. Principles of Drug Addiction Treatment (NIDA, 1999) summarizes from recent research the underlying factors that determine effective treatment in addition to answering frequently asked questions about treatment, describing selected scientifically based approaches to drug addiction treatment and giving information on other resources. Thirteen principles are listed. The fourth principle, 'An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs,' specifically states that the treatment approach be appropriate to the individual's ethnicity and culture.

The director of NIDA states that 'addiction is treatable if well delivered and tailored to the particular patient within a cultural context' and the director of the Center for Substance Abuse Treatment emphasizes 'the critical role that cultural perspective contributes to treatment efficacy.' But while there is general awareness and agreement that treatment must be culturally appropriate, there is not enough research on identifying the specific, significant aspects of culturally competent drug-abuse treatment for each racial/ethnic groups (and multiple identified/affiliated individuals) or guidance on how to translate this information into practice.

Some researchers are assessing the effectiveness of treatment models and innovations geared specifically to ethnic minority populations. For example, Dr. Jose Szapoczik is testing the efficacy of a family systems model as a way to facilitate the entry and retention of drug abusing African American mothers in drug-abuse treatment, and Dr. James Inciardi is evaluating innovative treatments for drug-involved prison releasees, most of whom are African American. NIDA has begun a national clinical trials study of treatment effectiveness (the Clinical Trials Network or CTN) in real-life settings, which includes a focus on addressing cultural competency. At its apex, nearly a hundred program sites will be participating. Steering committees will have representation from the local practice and client communities to ensure that issues important to local concerns and resources are heeded. Findings from the CTN will likely provide greater insight into how to make treatment programs culturally appropriate and competent.

The Office of Minority Health of the U. S. Department of Health and Human Services recently issued recommendations for national standards to assure culturally and linguistically appropriate services, and it has proposed research to assess the relationship between cultural competence activities and health outcomes (www.omhrc.gov). Fourteen standards are proposed, which address, among other factors, staff attributes and training, management strategies, client materials, community involvement and self-assessment.

But meanwhile, what is the individual counselor and local program to do? One of the first proactive steps to take is to become knowledgeable about the group(s) with whom you will be working. This includes not only familiarity with cultural experiences and beliefs, but having specific information about drug use preferences and patterns, other problems related to addiction that they have and their experiences with healthcare services. NIDA meets periodically with leaders in research, treatment and advocacy from the four major racial/ethnic populations to ensure that NIDA adequately and appropriately addresses the prevention and treatment needs of these communities. Each racial/ethnic group believes that the treatment needs of its population are not fully understood and incorporated into standard practice. Each group is right.

Common issues that are particularly important in the therapeutic process for racial/ethnic minority populations include trust, access to care, service utilization, and motivation and engagement in the treatment process. These are the stopping points, the critical junctures that can stop therapy before it begins.

Most racial and ethnic groups are initially skeptical about services provided by systems and people different from themselves. Historic and current reasons for the mistrust may vary. For example, Black/ African Americans sometimes are suspicious of the true intent of the helper. They do not believe that the helper or service system (especially if it is part of the government) has their best interest at heart.

The Tuskegee experiment in which Black men were not treated for syphilis purportedly for the sake of scientific advancement illustrates Blacks' concern about the ethical intent of governmental agencies. A more recent example of suspicion and mistrust is the belief by some African Americans that HIV/AIDS has been intentionally introduced into Black populations. This has caused skepticism about participating in clinical trials.

Native Americans will often have similar feelings based on their past and current history of broken treaties and wars over land and resources. Asian Americans and Pacific Islanders do not trust that systems know enough about their problems, especially around drug abuse, or respect their beliefs and customs around healing and medicine and family relationships. And it is true that research data on Asian American/Pacific Islanders and Native Americans/Alaska Natives, in particular, are woefully inadequate, sometimes to the point that data are not presented in national data sets like the National Household Survey on Drug Abuse because the sample numbers are too low. Moreover, much of the available data fails to address the wide diversity of experience within each racial/ethnic group, e.g., by specific group identification such as Mexican Haitian or Lakota as well as by gender and socioeconomic status.

Individuals from racial/ethnic groups may be sensitive to how information they reveal will be used. Will it be shared with the criminal justice system, e.g., pregnant women who are found to have illegal drugs in their bodies and reported to police are more likely to be poor, minority women. Can it affect employment opportunities? Will they lose their children to the child welfare system?

The greatest impact of this lack of trust is delay in seeking treatment. Research, surprisingly, indicates no significant difference at least among Blacks, Hispanics and Caucasians in drug-abuse treatment admissions, with some indication that Blacks may be more likely to seek treatment. When racial/ethnic minority individuals enter treatment, it is likely they will have a myriad of serious problems and few resources or social supports.

For example, African Americans and Hispanics may be more likely to have HIV/AIDS and possibly hepatitis. Some, especially, African American and Hispanic men, will enter with legal problems and criminal justice involvement. Actually, many of them may be receiving treatment through court mandate. Many minority women will be mothers with concerns about preventing their children from going into foster care or retrieving their children from kinship or other forms of foster care. Many will have low educational attainment, few job skills or history, and therefore difficulty in obtaining employment.

In an analysis of the household survey data, Blacks using cocaine reported more dependency problems than other groups; Whites using cocaine reported fewer dependency problems than others did. The Center for Substance Abuse Treatment has a publication entitled Cultural Issues in Substance Abuse Treatment (1999) that identifies cultural issues in substance-abuse treatment for each major racial/ethnic group. (Welte and Barnes, 1987, found that minority adolescents who drank alcohol experienced more problems than white adolescents as a result of drinking. This was strikingly true for Black and Haitian youth that drank less, but it was also true for Asian, Hispanic and Native American youth.)

Access can be affected by program proximity, hours of service, ability to pay, lack of transportation, and lack of insurance. In fact, a preliminary analysis of data from the national household survey found that factors that kept Blacks who were seeking drug-abuse treatment from receiving it were access issues; namely, inability to pay and no insurance, no openings in the program, no transportation, program too far away and inconvenient facility hours. Hispanics were much less likely to report these as problems. Some groups are more affected by access than others. For example, Native Americans on reservations and Alaska Natives may be many miles from healthcare. And good drug-abuse treatment may be even further removed. Seasonal farm workers, often Hispanic, may experience difficulty in gaining access to care, especially drug-abuse treatment which often requires a certain time commitment to a program or process. Jean Chin identifies the lack of culturally appropriate programs and materials and staff unable to communicate with the potential client in the client's language as access barriers. She argues that they should be remedied through organizational restructuring and rethinking recoverable expenses. For example, she states that the cost of interpreters should be a reimbursable expense.

Racial/ethnic communities will often underutilize certain services because of access issues like language and cultural appropriateness, transportation, service hours or financial concerns (e.g., inadequate health insurance) and because of the program's reputation. If the quality of the program is thought to be poor, persons may choose not to seek the services. This is certainly true within ethnic minority communities where word-of-mouth and personal experiences/testimonies are highly valued. For example, in Native American nations, the endorsement of the chief and elders can be key to the utilization of the program by members of the tribe and the ultimate success of the intervention. On the other hand, racial/ethnic communities may overuse some services such as emergency rooms because there is a healthcare crisis to attend to and not seeking help is no longer a feasible option. However, when the need is great or critical, when the person sees no other way to go on, most will use whatever service is available. The problem then becomes one of attrition and relapse.

Once a person enters a treatment program, successful completion requires motivation and active engagement in the process. Retaining racial/ethnic clients in treatment is a long-standing problem. For example, in 1981, Ivey found that 50 percent of Asian Americans, Blacks, Chicanos and Native Americans ended counseling after the first interview. The community-based mental-health centers of the '60s initially encountered problems with service use and retention by racial/ ethnic clients. Although attrition is a common problem in drug-abuse treatment generally, Finn (1996) reports that drug-treatment programs experience difficulties in attracting, retaining and treating minority clients.

In addition to cultural issues, factors pertaining to client (e.g., intrinsic vs. extrinsic motivation, age) and program characteristics may differentially affect retention and long-term program effectiveness. Native Americans often benefit from traditional ceremonies and practices as they seek their way back to the right path. For example, the Talking Circle or Talking Stick meeting is a form of group therapy that has been found to be effective with clients from the Plains tribes.

When individuals from racial and ethnic populations come to drug treatment, they often come with suspicion, hostility, anger and skepticism, despair and maybe some fear. Although not unusual emotions in therapy, they can take on a different tone in cross-cultural interactions. These clients also usually come with a great desire for change. This desire, no matter how obvious or masked, must be nurtured. To implement an effective treatment plan, the program must overcome the issues just delineated. We must try to get clients into treatment as early as possible and engage them in the process.

Practitioners and care systems complain that there is not enough guidance on how to do this and express frustration with how much they are expected to know (e.g., accommodate the various languages, unique treatment styles). Their concerns are legitimate. Given these challenges, is it possible or reasonable to expect one to become a good counselor with everyone? Maybe not, but it is reasonable for a person seeking help with one of the most difficult conditions to overcome to expect help that will work. It is the only ethical course of action available.

Successful addictions counselors share certain characteristics. They are knowledgeable about drugs, addiction and treatment advances, skilled in the therapeutic process, motivated and have their own network of support and resources, and they are good advocates for their clients. Suggestions are offered for how individual counselors can build on these basic characteristics to improve their competency in working with clients from racial/ethnic communities.

1. Objectively analyze your ability to offer culturally competent care to your clients. Conduct assessments of your own preparation and attitudes and your agency's programs, operating procedures and services. For guidance, see Cultural Competence: A Journey (Bureau of Primary Health Care, Health Resources and Services Administration, available at www.bphc.hrsa.gov) and Getting Started . . . Planning, Implementing and Evaluating Culturally Competent Service Delivery Systems in Primary Health Care Settings (National Center for Cultural Competence, Georgetown University, available at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ).
2. Involve clients and the community in the program review process. Most importantly, determine the stopping points for treatment entry and treatment completion (attrition) for your clients. Reviewing case files and talking to persons who have dropped out or who rotate through may help in this process. After you have assembled this data, solicit help in developing a plan to solve the problems. You may not be able to resolve all the problem areas, but acknowledging them will help increase awareness and you will be able to determine where you can make changes.
3. Understand how race/ethnicity may affect therapeutic interactions and treatment programs. Pinderhughes (1989) in her book, Understanding Race, Ethnicity, and Power, states that experiences related to cultural differences can lead to internalizations that can cause clients to misperceive or distort the intentions and interventions of practitioners. It is, therefore, crucial for the therapist to fully appreciate and attend to the many ways in which these perceptions and power issues enter and affect the therapeutic process. More recently, the January 2000 issue of the American Journal of Orthopsychiatry has a special section on racism and mental health with papers on topics such as treatment delay among Asian-American patients, racism-related stress, and the invisibility syndrome and African-American males. Moreover, questions have been raised about drug-treatment approaches that in some unintentional ways may make minority (and women) clients feel less powerful (and perhaps less competent to make life changes).
4. Be open to difficult conversations about race, racism, prejudice, discrimination and cultural heritage. Don't defend the indefensible. Do not discredit the historical and, more importantly, current reality of racism and discrimination in this country. The persistent disparities in health and other social indicators such as segregation in housing and access to loans support the unfortunate fact that these forces are still operating. Although the focus in therapy is on the individual's efforts to kick the addiction and you may not want assertions of racism or discrimination to be used as a crutch or insurmountable obstacle, the reality of its effect should not be trivialized. Sometimes, clients may not always recognize the impact of historical discrimination and inequality in opportunities on their own behavior.
5. Do not over generalize from one client to another. Although persons share a common overall culture, there is great diversity within populations.
6. Ask for help. Sources include colleagues, professional associations, churches and clients — anyone who is likely to have an answer. For example, to determine the preferred local term for a 'Hispanic' client, you might ask clients and local community leaders. Seek the advice of colleagues who are successful in working with clients with whom you wish to increase your effectiveness and comfort level.
7. Have information and resources available. Try to have onsite public information that is culturally and linguistically appropriate. Online information abounds. The National Institute on Drug Abuse and the Center for Substance Abuse Treatment have free information. Visit their Web sites at www.nida.gov or www.samhsa.gov respectively. And, an online research assistance program, www.researchassistant.com provides links to many drug information sites and will soon accommodate question-based searches. Call agencies if you are not able to access the Internet.

It then becomes your responsibility to know the effect of this on the client and how to address it in treatment (e.g., does your client believe he has 'no culture,' are her expectations low because she doubts her ability to succeed?) Prejudice and Racism, 2nd ed. (Jones, 1997) provides excellent historical information on race in this country and its social and psychological manifestations. Discussions on psychological mechanisms of adaptation and coping, cultural mistrust and reducing prejudice will be especially useful to counselors. Establishing or reaffirming cultural ties may be therapeutic, and for many minority clients affirmation and support through spiritual beliefs and rituals can be key.

Lula Beatty is director of Special Populations for
the National Institute on Drug Abuse, (NIDA), Bethesda, Md.

One person has commented on this article.

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Craig Toombs, BSW, MSW Greenvill, Unregistered

This article is so very significant to the world of counseling in substance abuse and all other fields due to the ramifications towards a severe deficiency in treatment research and available evidence-based methods of clinical work geared toward minorities and other vulnerable populations. We need many more articles and studies along this venue. This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

 Posted 2008-03-29 14:24:36

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