Latinos face several challenges when searching for substance abuse treatment services in the United States because of stereotypes, cultural dynamics, and the lack of linguistic and culturally competent personnel and facilities.

According to the U.S. Census Bureau, the number of Hispanics — the nation’s largest minority group — rose 13 percent between April 2000 and July 2003 to 39.9 million, far outpacing the 3 percent growth in the American populace during the same time, to 290.8 million. In the state of Georgia alone, 436,000 people identified themselves as Latinos in the 2000 census. This number was updated to 516,000 by July 2002, making Georgia the state with the most rapidly growing Latino population, with a 17 percent increase. Because of undercounting and other issues, such as undocumented immigrants, the number of Latinos in Georgia is actually estimated to be between 750,000 and one million people.

The Clinic for Education, Treatment and Prevention of Addiction, Inc. (CETPA) was founded in 1999 to address the financial, linguistic and cultural challenges for this fast growing population in the state of Georgia. Although this article focuses on addiction treatment for the Latino population in Georgia, it points to the need for nationwide addiction treatment for this growing segment of the population. The article also identifies and explains the various factors that influence how Latinos present to treatment, in particular, the potential barriers faced by these members of the population when seeking treatment. In addition, the article examines the effects of the drug culture on monolinguistic Spanish-speaking adult immigrants who come to the United States, taking into account their country of origin, length of stay in this country, and other socio-economic factors. In addition, the effects on the adolescent population are discussed, taking into account that many of these youths are fluent in English and/or bilingual, while their family members are often monolinguistic Spanish-speaking adults.

Historical influences
Latinos have been present in the United States for more than 500 years. They are made up of European, African, Asian, and indigenous (native) backgrounds, each bringing their own culture, values, attitudes, race, color, and spirituality. There are 21 Spanish-speaking countries, including the United States, which is the fifth largest Spanish-speaking country in the world with more than 35 million Spanish speakers. Within 10 years, the United States is positioned to be second only to Mexico in the number of Spanish-speaking residents.

The three major Latino immigrant countries are Mexico, Puerto Rico, and Cuba, and it is important to understand the history of each one of these countries with the United States, in order to understand the frame of mind of the potential clients. Puerto Ricans enjoy the privilege of American citizenship, given by birth due to the island’s Commonwealth status. Cubans who touch American soil are granted refugee status, which gives them immediate access to social services. Every other immigrant from Latin America must receive permission to enter the country from the U.S. Citizenship and Immigration Services — a bureau of the U.S. Department of Homeland Security.

Historically, Latinos have been geographically categorized by region — Mexicans in the Southwest, Cubans in Florida, and Puerto Ricans in New York. Georgia’s Latino population accounts for representation from all the countries in Latin America and Spain. The same is being observed in other southeast states.
History plays a vital role in how Latinos will access services in the United States. A Mexican national will have different feelings and migratory history with this country than someone from Puerto Rico who is born a U.S. citizen. That fact alone may keep them from accessing services if they feel they are going to be mistreated or denied services due to their ethnicity.

Language and communication barriers
The primary connection among members of the Latino community is language. There are monolinguistic Spanish-speaking Latinos, bilingual Latinos, and Americans of Hispanic heritage who speak only English. To account for these varying situations, treatment facilities must be prepared to provide services in both Spanish and English. In addition, there are many factors that treatment centers and substance abuse counselors should bear in mind with regard to providing services for Latinos.

Service providers should take into account the socio-economic and educational level of their clients. Having brochures printed in Spanish is a great step toward being culturally sensitive, but it may not be enough when facing clients who cannot read Spanish. At the same time, providers may encounter clients who have achieved great business or academic success in either the United States or their native country, but who may be unfamiliar with the clinical terminology for a certain service, except in their native language.

Acculturation also plays a role in that Latinos begin to leave behind some of their norms and adopt new ones learned in the United States. Nonverbal behaviors are, to a large extent, culturally determined. In the Latino culture, avoidance of eye contact by some should not be regarded as rude, inattentive, passive aggressive or disinterested, but rather, as a sign of respect. Latinos soon come to learn that in the United States, avoiding eye contact is taken as a sign that they are either guilty or hiding something. Also, when conversing, Latinos tend to use a closer stance than is normally comfortable for an Anglo individual; for them, the closer they are to someone, in terms of personal space, the greater the probability that the person will be open to communicate.

In addition, the cultural dimensions of Simpatía, Personalismo and Respeto play a role in client care. Simpatía is described as politeness and pleasantness in the face of stress, which sometimes may hide pain or discomfort. Personalismo is defined as the warm and personal relationship with the provider; the higher the level of comfort, the more the client will share openly. Clients also will tend to have a closer personal space with the provider. Respeto is defined as the rule dictating that providers are authority figures who must be shown respect; it can result in reluctance of the client to ask questions.

In serving a group of people who usually are regarded as homogeneous because of language, it is important to recognize the diversity of the population. The differences in socio-economic status, educational levels, immigration status, and family composition all are indicators that counselors and treatment centers cannot use the same methods that are commonly used for treating the general population.

Cultural differences
In addition to language, it is important to note there are several other differences among the members of the Latino community, which may influence how clients seek and utilize addictive disease and mental health services. For instance, there are several different classifications of immigrants, including: permanent residents; individuals who hold work and student visas; individuals who have visitor visas; and people who are in the country with undocumented status.

The personal conditions affecting quality of life also differ since the socio-economic position of the members of this community varies greatly. There are wealthy Latinos who identify more with the host culture, and those who identify more with their Latino roots. Conversely, there are immigrants who have recently arrived in the U.S. and have chosen to forego their Latino roots in order to try to “fit in” faster or become “Americanized.”

The issue of limited English proficiency, which will be discussed later, underscores the vastly different levels of proficiency. There are conversational, functional and academic English levels that dictate the level of service the client may have available.

The Diagnostic Statistical Manual IV — Text Revision (DSM IV-TR) identifies five major areas that must be addressed when working with individuals from other cultures, including: cultural identity of the individual; cultural explanation of individual’s illness; cultural factors related to psychosocial environment and levels of functioning; cultural elements of the relationship between individual and clinician; and an overall cultural assessment for diagnosis and care.

The primary barrier for Latinos in accessing current available services for addictive disease and mental health is language. The lack of Spanish-speaking clinicians is a major problem for many Spanish-speaking people. Nearly 40 percent of Latinos living in the United States do not speak English well (U.S.Census Bureau, 2002), which means that a significant proportion of Latinos need Spanish-speaking providers. On average, second language conversational skills are acquired in one or two years, while academic language proficiency is acquired over a longer period of time of five to seven years (Ortiz). Diagnosis and treatment of mental disorders depends greatly on the ability of the patient to explain the symptoms to a clinician and understand steps for treatment. The triangulation of this critical phase through a chance interpreter, a family member, and an unqualified or untrained translator can be devastating.

However, studies indicate that there are few Spanish-speaking and Latino providers. One survey found that there were 29 Latino mental health professionals for every 100,000 Latinos in the U.S. population. For whites, the rate was 173 white providers per 100,000 (Center for Mental Health Service [CMHS], 1999).

To provide culturally appropriate services, barriers should be identified and discussed. Organizational barriers address the current systems of care, including the health policies and the people entrusted to carry them out. It is imperative that the people charged with the delivery of services include members of the Latino community within the ranks of its leadership, boards, staff, and providers.

Systemic barriers in the structures of the health care system create major challenges for Latinos seeking addictive disease and mental health services. The operating circumstances include location, transportation, long wait times, bureaucratic intake procedures, and the lack of qualified interpreters (or any interpreter services) and bilingual services.

Clinical barriers include the chronic shortage of qualified Spanish-speaking support personnel and staff. For example, the number of bilingual/bicultural psychiatrists, psychologists, and licensed counselors in Georgia is totally disproportionate to the explosive growth of the Latino community in the state. The absence of qualified personnel gives way to ineffective and inappropriate therapies including offering services to clients who may only speak functional or conversational English. In some levels of care, it has become common practice to ask a client to bring an interpreter to the evaluation or the actual therapy session.

Clinicians who identify themselves as Latino, speak Spanish, or originate from Latin America are not necessarily culturally competent to serve this community. To ensure adequate treatment for members of the Latino community, treatment centers and clinicians need to address socio-cultural barriers. Specifically, they need to: provide language appropriate services; acknowledge and address underutilization rates for addictive disease and mental health services among members of the Latino community; take into account each patient’s level of acculturation; address the stigma associated with addiction-related illnesses in the Latino culture; have intimate knowledge of available resources; understand the client’s uncertainty about established educational, social, financial, and medical systems; and respect Latino beliefs in spirits or sins as reason for illness or hardship.

Addressing the language issue
The system of care may address the issue of providing services to persons with limited English proficiency in several different ways. It may choose to provide the very minimum level of service in order to meet the aforementioned requirements or it may choose to truly apply the research-based data and provide the highest level of service, linguistic and culturally appropriate direct services, to serve the Latino community. Not addressing this issue is unacceptable and may result in decreased access to health services, poor patient comprehension, low patient satisfaction, reduced quality of care, and an increase in health care costs.

Many Latinos today are suffering in silence from addictive diseases and mental illness, in part, because of these barriers. Those who receive services for these illnesses are living healthy and productive lives today thanks, in part, to the advances achieved in pharmacology and psychotherapy. Still, many who have received successful treatment choose not to share the fact that they were helped for fear of being judged or labeled negatively. Continued efforts from advocates, providers, and community members is needed to deliver to the Latino community the very important message that addiction is treatable and that there is no shame in acknowledging the fact that they have been helped.

Demographics -Addiction Treatment for Latinos in Georgia
Prior to the opening of CETPA, treatment was not available for Spanish-speaking individuals in Georgia. Multiple offenders for driving under the influence were mandated to risk reduction programs but only a handful of these programs had Spanish-speaking instructors. Others would just have the Spanish-speaking clients sit in the 20-hour class — which was taught in English — with a Spanish booklet. These clients were asked to bring their own interpreters.

CETPA began providing services in English and Spanish through bilingual, bicultural counselors. Because of the varying needs of the community, CETPA offered educational and treatment levels as defined by the American Society of Addiction Medicine (ASAM).
Between August 2001 and October 2003, CETPA admitted 221 adults into Intensive Outpatient Drug Abuse Treatment (ASAM Level II). Between April 2002 (when the Adolescent Program opened) and October 2003, there were 99 adolescent admissions into Intensive Outpatient Treatment.

The trend of admission drug of choice in our adult program began to shift after the first two years of operation. During 2001 and 2002, 54 percent of adult admissions were for alcohol dependence; 27 percent were for cocaine; and 19 percent were for marijuana dependence. During 2003, only 37.5 percent of clients were being admitted for alcohol dependence only. Amphetamines, methamphetamines, crack and heroin were found to be the primary drugs of choice. This trend continued in 2004 with an increase in adult admissions for methamphetamine use.

The adolescent program showed a tremendous increase in amphetamine use going from 16 percent of client report of use to 75 percent in 2003. In addition, CETPA began to see hallucinogens present in clients’ current use patterns. Most adolescents reported polysubstance use patterns with nearly 100 percent of clients using alcohol and marijuana.

The number of adult clients entering treatment on a voluntary basis versus those who were mandated to treatment by the criminal justice system has fluctuated over the past few years. For example, in 2000, 50 percent of adult admissions were mandated and 50 percent voluntary. In 2001, the number of mandated clients rose to 57 percent; however, by October 2003, the number of voluntary admissions had increased to 54 percent. In the adolescent program, voluntary admissions have remained steady from 2002 to 2004 at 75 percent, with mandated admissions at 25 percent. Through client interviews, CETPA found that prior to 1999 (for adults) and 2002 (for adolescents), there were no drug abuse treatment facilities providing linguistic and culturally appropriate services in the state of Georgia. Even today, CETPA continues to be the only licensed and CARF accredited agency that provides Spanish-speaking drug abuse treatment to Latinos in Georgia.

Race/Ethnicity and Gender
Ethnicity plays a role in the delivery of culturally competent services. Latinos are comprised of European, African, Asian, and other indigenous backgrounds, each possessing their own culture, values, attitudes, race, color, and spirituality. It is difficult to measure ethnicity because clients are asked to identify themselves by a category to which they are not accustomed. The breakdown was as follows: 50 percent of adults identified themselves as Indo-Latinos, meaning that they saw a closer relationship with the indigenous roots of their ancestors; 38 percent identified themselves as white; and 12 percent as black. Adolescent clients were very confused by the ethnicity issue, primarily because they came from families where one parent was from one country and the other from another. Most of them identified themselves as multi-racial.

In the adult program at CETPA, 84 percent of client admissions are men. Although data was collected until October 31, 2003, the gender figures included three female adult admissions in December 2003, primarily to highlight this great oddity and to emphasize the need for further efforts in reaching addicted Latina women. In the adolescent program, one-third of the admissions are girls. (Table 1).

Length of stay in United States vs. drug of choice
The shift of drug of choice when compared with length of stay in the United States was both surprising and encouraging. Surprisingly, adult, immigrant, monolinguistic Spanish-speaking Latinos, generally move from exclusive alcohol use to polysubstance drug use within five years of coming to the United States (Table 2). This information is encouraging because it provides an opportunity to educate new arrivals on alcoholism and addiction within their first five years which, hopefully, will help them avoid the progression of risky behaviors.

Adolescent numbers were not so encouraging; within one year of arriving in the United States, Latino youth were using all the drugs that are generally abused by the nation’s youth culture, even though the majority of these Latino youth had no documented history of alcohol and drug use prior to coming into the United States (Table 3). In addition to peer pressure, Latino youth reported loneliness, communication barriers with parents, and adjustment difficulties (acculturation problems) as primary reasons for drug use.

Discharge statistics
Analyses of discharge data for Latinos revealed findings that were comparable with statistics from the rest of the nation. For instance, mandated admissions were shown to have better discharge outcomes, and some drugs were shown to have higher relapse rates than others. However, one disturbing trend was noted regarding the adolescent program.

Many adolescent clients received ‘absent without leave’ (AWOL) or ‘administrative’ discharges. The primary reason given was that parents saw improvement in their child’s behavior after a few weeks, and because of their limited understanding of addictive disease and treatment, they stopped bringing their children to the agency prior to the completion of their recommended length of stay. Follow-up interviews also discovered that transportation was an issue since some parents had to drive 20 or more miles to bring their children to treatment; most youth did not drive and public transportation in some areas is not available.

Conclusions and recommendations
In summary:
• Between 2001 and 2003 the number of adult and adolescent admissions into Intensive Outpatient Treatment has remained steady.
• Admissions by gender vary greatly with males accounting for 84 percent of adult admissions and 67 percent of adolescent admissions; and females accounting for 16 percent of adult and 33 percent of adolescent admissions.
• 50 percent of adults identified themselves as Indo-Latinos; 38 percent white; and 12 percent black. In contrast, most adolescents identifed themselves as multi-racial.
• Between 2000 and 2002, 54 percent of adult admissions were for alcohol. By 2003, only 37.5 percent of adult admissons were for alcohol, and most were polysubstance abusers.
• In 2004 there was an increase in methamphetamine admissions. This trend has continued and increased in early 2005.

This limited research project clearly demonstrates that factors affecting drug use among this population include: country of origin, length of stay in the United States, gender, and socio-economic issues. Furthermore, limited treatment opportunitites exist for immigrant and monolinguistic Spanish-speaking drug abusers in Georgia and limited, or no, opportunities exist in other southeastern states that have undergone tremendous growth in their Latino communities over the past 10 years.

Further research should be conducted with clients who are currently enrolled in treatment.
Additionally, and perhaps most importantly, research must be conducted within these new communities — new arrivals, who are not trusting of government in general and who are not willing to share personal information with people they do not know — in order to determine further areas of need, and to plan interventions that will stop their rapid drug acculturation in their new country.

Affordable, linguistic and culturally appropriate substance abuse services should be made available to those who need them. It is unrealistic to expect for someone to master English (and suffer those three to seven years) before they can receive services. It is not a question of having to change our ways to accommodate new arrivals; it is a matter of helping a fellow human being at his or her level of need.

Pierluigi Mancini, Ph.D., NCAC II, is the Founder and Executive Director of the Clinic for Education, Treatment and Prevention of Addiction, Inc. (CETPA), a nonprofit agency dedicated to providing affordable, linguistic and culturally appropriate substance abuse and mental health services to the Latino community in Georgia.

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This article is published in Counselor,The Magazine for Addiction Professionals, August 2005, v.6, n.4, pp.26-33.

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