Felipe González Castro, Jeanne L Obert, Richard A Rawson, Courtney V Lin, Ron Denne Jr. Handbook of Racial & Ethnic Minority Psychology. Editor: Guillermo Bernai. Sage Publications. 2003.
General Issues in Drug Abuse Treatment
This chapter presents a sociocultural perspective on drug abuse treatment with members of the major ethnic/racial populations of the United States: Hispanics/Latinos, African Americans, Asian Americans, and Native American Indians. Unfortunately, at present, conventional drug abuse treatment programs have not been culturally appropriate or gender specific to meet the needs of diverse groups of people of color who have become addicted to tobacco, alcohol, and/or to illicit drugs. Today and into the future, there will be a growing need and demand for culturally relevant interventions (both prevention and treatment) as delivered by culturally competent staff (both professional and paraprofessional). Accordingly, clear approaches to the provision of such services are needed. These approaches include the following:
- Improved conceptualization (both in theory and in practice) and the development of culturally relevant interventions,
- The use of an empirical evaluation (both research and program evaluation) to evaluate the efficacy of these interventions,
- The development of new or expanded theories and models that explicitly include and test the potential effects of specific cultural factors as these may affect the efficacy of treatments for drug abuse, and
- Upgrading the level of cultural competence of organizations and their staff so that they are able to provide culturally relevant and culturally proficient interventions in a cost-effective manner.
The present chapter address these and other related issues with the aim of contributing toward the development of culturally responsive drug abuse treatments for various people of color.
NIDA Principles of Drug Addiction Treatment
The National Institute on Drug Abuse (NIDA) has developed a research-based guide that describes 13 principles and related issues in the effective treatment of drug abuse (National Institute on Drug Abuse, 1999). These principles are the following:
- No single treatment is appropriate for all individuals;
- Treatment needs to be readily available;
- Effective treatment attends to the client’s multiple needs and not just to drug treatment;
- Continual assessment and modification of the treatment plan are necessary;
- Remaining in treatment is crucial to treatment effectiveness;
- Behavioral treatments are essential for effective outcomes;
- Medications, especially in combination with counseling, are important for many patients;
- For patients with coexisting mental and drug abuse disorders, both should be treated;
- Medical detoxification is only a first step in a full treatment;
- Treatment does not need to be voluntary to be effective;
- Possible drug use during treatment must be monitored continuously;
- Patient behaviors that risk infectious diseases such as HIV/AIDS should be addressed in treatment; and
- Recovery often involves multiple episodes of treatment.
From these principles, it is clear that treatment for drug abuse must address the complex of psychiatric, legal, familial, personal, and other factors that will influence progress toward full recovery from drug abuse and dependence. Thus, treatment program staff must attend to co-occurring psychiatric disorders and health problems, including HIV infection, because each of these forms of comorbidity will complicate the process of recovery. Moreover, for many racial/ethnic minority clients, the drug treatment program must also take into account salient sociocultural and community factors that can prompt high-risk behavior. Unfortunately, many of these factors constitute stressors, including the effects of cravings, that can easily prompt a return to illicit drug use, even among clients who express the most sincere intentions to avoid ever using drugs again.
General Treatment Approaches
In the 1990s, general treatment approaches for dependence on cocaine, heroin, and other illicit substances typically involved treatment referral to an inpatient or outpatient treatment program, with additional referrals as needed to therapeutic communities and to self-help groups.
Inpatient Treatment. In the past, inpatient treatments have typically followed the “Minnesota model,” a program of treatment that lasts 14 to 28 days, depending on the extent of insurance coverage. The treatment components of typical hospital-based inpatient programs have included (a) detoxification, (b) an overview of the Alcoholics Anonymous 12-step philosophy, (c) group therapy in which the individual is confronted with psychological issues involved in addiction, (d) brief individual therapy aimed at personalizing issues and developing an understanding of one’s unique process of addiction and recovery, and (e) self-management approaches, such as anger management and time management, designed to help the individual recover health and focus on improving patterns of living.
Under today’s managed care environment, there remain only a few inpatient treatment programs. Their cost for inpatient services have typically ranged from $15,000 to $25,000 for a single course of treatment lasting 2 to 4 weeks, with most of these costs being paid by the client, given that today insurance companies will seldom pay for such inpatient treatment services (Rawson & Obert, 2001). In response to this limitation, a few shorter-term, acute hospitalized care programs have been developed that provide detoxification, assessment, and short-term medical treatment to drug abuse patients who have withdrawal symptoms that are severe enough to require intensive short-term medical and nursing care (Rawson & Obert, 2001).
Outpatient Treatment. By contrast, outpatient treatment typically involves sessions offered once a week or more during the early stages of the recovery. Most outpatient treatment programs incorporate cognitive-behavioral approaches, including relapse prevention education, 12-step program activities, family involvement, psychoeducation, and alcohol and drug testing (Rawson & Obert, 2001).
A typical outpatient treatment program has several phases, including an initial 1-month-long phase that includes detoxification if needed, a drug use assessment, an orientation to treatment, and early recovery treatment activities. This phase is followed by a second phase of approximately 5 months that consists of the core of the treatment program. A third phase may include a follow-up program that focuses on skill building to further reduce the risk of relapse and to promote a more complete recovery from addiction.
Both for inpatient and outpatient treatments, an aftercare phase is often involved that seeks to ensure that prior treatment gains have been and will be maintained. Aftercare can include continued treatment sessions on an outpatient basis or referral to a residential treatment program in cases where the individual is still not able to return to active recovery within the community.
Residential Treatment/Therapeutic Communities. Residential treatment involves the client in a longer-term sheltered environment for 6 months or more. This isolation keeps the client away from drugs and immerses that client in a complete therapeutic environment. In the past, successfully recovered addicts have been employed as counselors and as role models or “parental figures.” More recently, these therapeutic communities have added traditional medical and other professional staff (Rawson & Obert, 2001). In these drug-free environments, former substance abusers live, work, and socialize while receiving multimodal treatments (e.g., detoxification, individual therapy, family therapy, group therapy, and self-help groups). These therapeutic communities may also provide transitional services to facilitate the recovering addict’s reintroduction into the community (Comer, 1995).
Treatment goals of therapeutic communities are to produce lasting lifestyle changes by treating “the whole person.” The aim is to develop a new and positive social identity that emphasizes being drug free and crime free. Treatment community interventions include addiction education, the development of personal and life skills, and skills training for seeking a new job, especially for clients who have had a poor history of employment. Thus, this approach not only emphasizes “rehabilitation” but also “habilitation,” the learning of new life skills never before acquired by addicts, many of whom have life histories involving greatly arrested social and emotional development (Nielsen, Scarpitti, & Inciardi, 1996).
Self-Help Organizations. In addition, the inclusion of or referral to Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and/or Cocaine Anonymous (CA) is a regular feature of many inpatient and outpatient programs. Self-help groups provide peer support with spiritual and moral components to help people overcome substance abuse and dependence (Moos & Finney, 1983). Meetings take place one or more times per week, and certain members who participate as “sponsors” are available to help 24 hours a day. These self-help groups encourage members to live substance free, “one day at a time.” They urge their members to accept that they are powerless over disease and that only through permanent abstention will they be able to live normal lives (Alcoholics Anonymous, 1976).
Conceptualizing Issues of Culture, Race, and Ethnicity
Understanding Culture, Race, and Ethnicity in Drug Abuse Treatment. The concept of culture is rich yet complex, but it is also often amorphous when used in relation to drug abuse treatment. However, culture is important to a people because it gives them a sense of identity, purpose, and direction (Locke, 1998). Drug abuse counselors can benefit from considering two components of culture: (a) objective culture, which refers to social norms or rules established by family and/or environments that define appropriate conduct, and (b) subjective culture, which refers to a person’s own beliefs, attitudes, values, expectations, and introjected norms (rules) regarding appropriate conduct. Thus, people’s current subjective cultural views shape their ethnic identity, as well as their current ways of thinking. Such thinking is typically the product of the integration of the views from one or more cultures, and it influences a person’s current life preferences and behavioral choices.
The concept of race is often used as a biological trait variable, despite the contemporary recognition that race is more of a socially defined variable than a biological one (Sue et al., 1998). In contrast to race, ethnicity refers to a group or collectivity of people who have a “common ancestral origin” and thus share many cultural characteristics in common (Harwood, 1981; Sue et al, 1998). Wyatt (1991) has indicated that ethnicity, as opposed to race, more aptly reflects a people’s cultural values and behavioral patterns that relate to risk behaviors and to the risk of disease.
Finally, minority status refers to a subgroup of people within a larger society that has experienced differential and unequal treatment, often in the form of collective discrimination (Sue et al., 1998). Each of the major racial/ethnic minority groups in the United States has suffered historically from discrimination that still yields collective memories and life situations (e.g., living on a reservation) that shape their collective identities, lifestyles, sense of mutual belongingness, and overall experience of being a racial/ ethnic minority person—a person of color.
Development of Cultural Capacity. The goal of increasing the cultural capacity of an organization and its staff is an important health services strategy for the new millennium, one that is aimed at improving relevance and quality of health services. Cultural capacity is evaluated within three areas: knowledge, attitudes, and skills (Orlandi, Weston, & Epstein, 1992; Sue et al, 1998). The acquisition of progressively greater depth of cultural capacity involves a greater ability to work effectively with various people of color. Cultural capacity is conceptualized as a progressive gradient with the following levels: cultural destructiveness (-3), cultural incapacity (-2), cultural blindness (-1), cultural sensitivity (+1), cultural competence (+2), and cultural proficiency (+3) (Castro, 1998).
The most negative level of cultural capacity is described as cultural destructiveness, which involves low levels of knowledge and skills and, beyond this, a negative, rejecting, and active discrimination. Cultural incapacity involves the philosophy that separate and equal facilities are a way of addressing the need for health services to minority clients. The approach, although seeming fair, often involves passive discrimination. Cultural blindness, although seemingly fair and impartial, nonetheless involves an attitude that discounts the importance of cultural issues. Cultural sensitivity, the first positive level of cultural capacity, involves a positive attitude and an acknowledgment of the importance of cultural issues. However, under cultural sensitivity, knowledge level solely involves an awareness of cultural issues. Accordingly, this limited level of knowledge is consistent with the perception of “ethnic glosses” (Trimble, 1995) and with stereotypical thinking wherein the person is aware of cultural traits but is unable to understand the meaning of observed cultural beliefs and behaviors.
Cultural competence moves beyond sensitivity in the capacity to appreciate and understand the rich within-group variability that occurs within any diverse racial/ethnic group. Under cultural competence, the clinician also understands the conditional and contextual relationships that occur daily within complex “real-world” situations faced by their clients. Finally, cultural proficiency involves a progression to a deeper level of analysis and understanding that is characterized by the capacity to detect and understand cultural nuances and more complex aspects of a culture. This deeper capacity involves the ability to accurately distinguish cultural paradoxes from contradictions and to distill correct meaning from complex beliefs and behaviors that occur among members of a cultural group. A counselor may become culturally competent in working with members of one cultural group while lacking competence with members of another culture group; level of cultural capacity is specific for each cultural group. For each drug abuse counselor or therapist, the quest toward cultural proficiency in cultural skills development should be a lifelong “professional odyssey” (Castro, 1998).
Conceptualizing Ethnocultural Factors. Nemoto and colleagues (1998) have pointed out that drug and AIDS problems among racial/ethnic clients are products of historical forces that still exert their effects today. This constitutes a “historical ripple effect” that influences the current beliefs and behavior of today’s clients, even if these clients are themselves unaware of these ripple effects. Thus, drug abuse counselors must understand clients and their families within the context of these historical forces (Locke, 1998; Nemoto et al, 1998).
An important treatment question in the contemporary drug abuse treatment environment, which unfortunately remains for the most part “culturally blind,” is how basic inpatient, outpatient, and aftercare programs should be modified to address the unique needs of various racial/ethnic minority clients. An aid in conceptualizing within-group variability of client cultural identity is the work of Ramirez (1999). Ramirez proposed that people’s cultural styles can be conceptualized along a continuum ranging from traditionalism to modernism (Ramirez, 1999; Ramirez & Castaneda, 197A). Under a traditional cultural orientation, strong family identification and loyalty are emphasized. By contrast, under a modernistic cultural orientation, individualism and independence are more highly valued. As a social context, ethnic clients residing in the United States live within a “modernized” Eurocentric culture that mostly emphasizes Protestant ethics involving individual initiative, upward social mobility, consumerism, and freedom of expression and action. Accordingly, dominant culture personal attributes associated with a greater level of “acculturation” into this environment include having a strong sense of individualism, small nuclear families, a limited involvement with one’s nuclear and extended family, personal choice in relationships, social status that is attained by individual effort, and nonadherence to traditional moral constraints imposed by conservative family norms (Jackson & Lopez, 1999).
As noted previously, at present, very few drug treatment programs nationally have incorporated cultural factors as an integral part of their treatment and recovery programs. (Castro & Hernandez-Alarcon, 2002). For example, among less acculturated (low acculturated and bicultural) Hispanics/ Latinos, cultural issues such as traditional family dynamics, the role of ethnic identity in recovery, and the availability of culturally relevant strategies to avoid relapse constitute important areas involving cultural factors that have not been yet should be incorporated into a culturally relevant drug treatment program for Hispanic/Latino clients. It is noteworthy here that a subgroup of highly acculturated Hispanic clients may not require the addition of culturally relevant intervention components. Conversely, bilingual/bicultural and low-acculturated Hispanic clients may well benefit from the meaningful life context for recovery offered by a culturally relevant intervention that aims to develop an understanding of how a “new cultural self” may facilitate recovery from addiction.
In an analysis of ethnocultural factors that affect substance abuse among racial/ethnic minority persona, Terrell (1993) identified three substantive ethnocultural areas: (a) the acculturation experience; (b) sources of stress, coping, and social supports; and (c) beliefs and attitudes regarding substance abuse. Terrell also noted that many prevention interventions do not take into account the role that cultural differences may play in drug use initiation and its progression. By implication, this same inattention appears in the area of drug abuse treatment. As noted by Terrell, at present, a few strategic approaches have been proposed to promote culturally relevant interventions for ethnic clients. However, still missing are the specific culturally relevant program components, especially as organized in the form of a treatment manual that outlines specific cultural activities and how to evaluate their treatment efficacy under a well-conceptualized program evaluation protocol.
Ethnic Family Systems. The extent to which family involvement is essential to the recovery process may vary in relation to the cultural norms that prevail within a given family. Many traditional and low-acculturated members of the Asian Pacific Islander (API) cultures (Chinese, Japanese, Korean, Thai, Vietnamese, Cambodian, etc.) have been socialized to accept certain “Pan-Asian ideals” that emphasize respect for authority and social hierarchies (Dana, 1993). This exposure to strong group-oriented norms would produce extreme stress if failing to live up to family or group expectations or if bringing shame to the family. Thus, among low-acculturated/ traditional members of these cultures, to be involved in treatment without the permission and support of their families would be unrealistic. Also, these clients would be concerned over the stigma of “losing face” because the very act of admitting to having a problem with alcohol or drugs is a source of shame, and this concern would serve as a barrier to treatment seeking among many API clients (Ja & Aoki, 1993). Accordingly, within this cultural context, treatment programs must find ways to educate family members about treatment in a culturally relevant manner that involves connecting with these families despite the stigma while also engendering family support for the recovering person (Ja & Aoki, 1993).
Many people of color and their cultures, including American Indians, African Americans, and Hispanics/Latinos, give considerable attention and high value to interpersonal relationships, a pattern of behavior that may describe these cultures as “relational cultures.” Through their language and rules regarding proper conduct in relationships, members of these cultures attend closely to personal ways of relating to others, a pattern described as “field dependence” (Ramirez, 1999; Ramirez & Castaneda, 1974). This level of attention to nuances in family relationships is based in part on their upbringing within an extended family network that often includes aunts, sisters, cousins, and grandparents, each of whom has an important role in sustaining the family’s well-being. However, in relation to such family closeness, some of these clients and their families can also be distrustful of persons outside their immediate family circle. Moreover, a value of “keeping it within the family” imposes a resistance to revealing problems publicly and fosters a resistance to intrusions into their privacy by persons from outside their cultural sphere (Szapocznik & Kurtines, 1989).
Along these lines, among many African American families, relationships with both nuclear family members (parents and siblings) and extended family members (relatives, friends, church clergy, and various fictive kin) are very important (Paniagua, 1998). Thus, during treatment, the social influence of both biological and nonbiological members of the client’s family (including fictive kin) should be examined in understanding the role of the family in the process of recovery and relapse prevention among African American clients.
Similarly, many American Indian communities and their residents have experienced the historical ripple effect of the U.S. government’s efforts at assimilating them into the American culture (Olson & Wilson, 1986). In part, this assault on their indigenous culture has generated some negative health and social consequences, including excessive alcohol use. For many years, their experiences with alcohol and drugs appeared to be quantitatively and qualitatively more harsh than for any other group in the United States (Indian Health Service, 1995; Wing, Crow, & Thompson, 1995). Effective drug treatment approaches with American Indians appear to be those that are holistic and that include traditional values, beliefs, ceremonies, and processes (Freese, Obert, Dickow, Cohen, & Lord, 2000). Incorporating these elements for American Indian clients involves bringing into treatment their respected ancestors and families.
Within traditional family systems, conservative cultural expectations, values, and attitudes may well influence the way in which the recovering addict is accepted back into the family setting and how that individual will be supported in his or her efforts at recovery from substance abuse. An ethnic family’s history of experiences with drug problems may serve as an important factor that determines how the family system will help or hinder the recovering addict’s efforts to remain sober and drug free. For example, among young heroin-addicted Mexican American females, Moore (1990) noted that multigeneration drug-using families had developed a system of support that allows the recovering young woman to return home and function adaptively in the street and in the family environment. By contrast, young Mexican American women from more conservative “traditional” families that had never before contended with drug problems had families that were less able to provide sufficient support and, to the contrary, expressed negative reactions to their young daughters’ illicit drug use.
Most recovering addicts feel stigmatized regarding their addiction and are very sensitive to rejection from society and family. A return to a punitive, enmeshed, nonsupportive, rejecting, guilt-inducing family system will set the stage for failure in recovery and promote drug relapse (Szapocznik & Kurtines, 1989). By contrast, an overly permissive family system may also set the stage for relapse by not setting appropriate limits and by not fostering with the recovering addict a sense of responsibility to the family and the community. Clearly, a balance in family supportive style is needed to reduce the risk of relapse.
Future drug treatment and recovery research should examine the effects of an overly punitive and of an overly permissive ethnic family system in the recovery of a drug-using family member. It should also consider the drug addict’s preparedness for recovery within the context of more traditional values espoused by many ethnic family systems. Within this context, further research is needed to understand the factors within traditional indigenous cultural beliefs and values that facilitate recovery from drug abuse and those that hinder recovery.
Gender Expectations and Roles. A second culturally related issue for racial/ethnic minority clients involves differences in gender expectations and roles as these may influence the process of the client’s involvement in treatment and recovery (Castro & Gutierres, 1997). Although illicit drug use is seldom acceptable in traditional ethnic cultures, alcohol and drug use by males has been tolerated or reluctantly accepted. By contrast, strong ostracism and rejection are typical reactions within traditional ethnic families to female drug use. Families not prepared to help their female drug-addicted family member may well impose more punitive demands that may prompt a return to drug use in the form of relapse.
Currently, most treatment programs nationally include little or no information on how various types of racial/ethnic families can be helped in providing needed support for their recovering women. Gutierres and Todd (1997) reported that as compared with men, women are less likely to successfully complete drug treatment programs often because conventional programs are insensitive to the needs of women. These investigators thus called for the design of women-sensitive programs that include gender-relevant components, such as child care, that address the specific needs of recovering women.
An example of a strong woman-sensitive approach is the PROTOTYPES program of Southern California (V. Brown, personal communication, August 30, 2000). This program consists of a residential treatment community that provides integrated care for women affected by the co-occurring problems of (a) domestic violence/victimization, (b) substance abuse, and (c) mental disorder. Within this nurturing and supportive organizational culture, professional and peer women counselors offer several treatment services that include outreach, screening, substance abuse counseling, trauma-supportive services, and peer counseling. These services are designed to be culturally and gender relevant for various women who have had a long history of victimization and multiple life problems that include mental disorder and substance abuse.
Sexual Orientation. Nemoto and colleagues (1998) have noted that the little-understood process of acculturation often occurs in relation to more than one culture. For example, a gay API client may acculturate to each of three cultural groups: to the Asian, to the mainstream American, and to the gay culture. Given this complex social and personal process of identity formation, it is important for the therapist to understand the client’s level of involvement in each of these cultures and the nuances that accompany various patterns of this involvement; the counselor must develop cultural competence in understanding the total life context in which these clients live their lives. This involvement might be measured in part by the client’s frequency of contacts with members of each culture, as well as by the client’s avowed sense of “belongingness” to each of these cultures. Here, it must also be recognized that racial/ethnic minority lesbian, gay, and bisexual (LGB) clients often face the added psychological stress of negotiating among the complex and at times conflicting beliefs, values, and norms from both the mainstream and the minority cultures (Committee on Lesbian, Gay, and Bisexual Concerns, 2000).
Illicit Drug Use in Ethnic/Racial Populations
Sociocultural Context to Illicit Drug Use
General Issues for People of Color. Given the significant social and cultural forces that shape the lives of many ethnic clients, the use of illicit drugs, progression to addiction, recovery, and risk of relapse must be examined within an integrative sociocultural context. Accordingly, the drug abuse counselor or therapist must recognize that persistent poverty, unemployment and underemployment, low educational attainment, and acculturation stressors are some of the many factors that compromise the life chances of many racial/ethnic minority clients (Enchautegri, 1995). Other factors include barriers to health care such as lack of health insurance and language discrepancies between provider and client/patient (Giachello, 1994; Molina, Zambrana, & Aguirre-Molina, 1994).
Various accounts regarding the role of “culture” in thought and behavior depict “culture” as a core source of information and beliefs that influences the thinking and behavior of various ethnic persons. Here, for each of the four major racial/ethnic groups in the United States, a few specific cultural themes are identified as important core cultural factors that influence an ethnic person’s beliefs and behavior.
Culturally Specific Issues for Hispanics. For Hispanics, important cultural themes include familism, simpatía, personalismo, respeto, confianza, and dignidad (Locke, 1998). Familism refers to a strong emphasis placed on family unity. This prompts a way of relating to others called simpatía, agree-ableness and deference to the wishes of others, which aims to maintain harmony within the family (Marín & Marín, 1991). This deference occurs often at the expense of deferring one’s own wishes in favor of the needs of other family members. However, this concern for the well-being of others within the family may also create conflict avoidance, which at times can extend to denying the existence of a significant family problem such as the abuse of alcohol and other drugs.
Regarding interpersonal relations, personalismo, the value of genuine interpersonal relationships, motivates persons to treat others with respect (respeto), although only the most intimate relationships rise to the level of full and complete trust (confianza). The value of personal integrity in relationships also prompts a concern for maintaining a sense of self-worth and dignity (dignidad). These patterns of interpersonal relationships are idyllic, although aspects of these patterns are visible to varying degrees in the daily interactions of various Hispanic individuals.
Culturally Specific Issues for African Americans. For African Americans, the following are some major cultural themes. Many African Americans are concerned about continued instances of racism, discrimination, economic disadvantage, and inequality of treatment in various social areas. These concerns exist as a legacy of the historical effects of slavery and continued and overt discrimination that lasted into the 1960s. Another major cultural theme is the importance of the extended family network that serves as a source of kinship, belongingness (Weness), and social support. As a coping strategy, there is the acceptance of life’s harsh realities with aims to “keep on keepin’ on.” Such coping includes the significance of African spirituality as a source of vitality for life’s activities, including religion, art, and music. Some politically active African Americans have emphasized the importance of Afrocentrism, an attitude of cultural pride that serves as a source of identity, self-worth, dignity, and motivation to endure despite adversity (Dana, 1998; Locke, 1998). Although considerable within-group variability exists among African Americans in the extent to which they acknowledge these themes and are concerned about them on a day-to-day basis, the counselors’ understanding of these themes provides a cultural context for understanding an individual African American client’s life situation when in need of drug abuse treatment.
Culturally Specific Issues for Asian Americans. For Asian Americans, major cultural themes center on a set of traditional “Pan-Asian values,” derived from Confucianism, Taoism, and Buddhism (Dana, 1993). These hemes include the observation of obligations, loyalty, and respect conferred to family and group; a high regard for social hierarchies; and obedience to social norms in order to enact correct action. This also involves the avoidance of incorrect action that brings shame to self and family (a loss of face). There is also a strong value of education and achievement, an ethic of hard work, and the avoidance of complaint even if experiencing pain (suffering in silence) (Dana, 1998; Locke, 1998). Adherence to these strong cultural norms on the part of many Asian Americans leads to the notion that Asian Americans are a “model minority,” one that is successful academically and socially. Although many Asian Americans have been successful in this society, Asian American scholars have noted that this notion is often stereotypical because there are also many and growing numbers of Asians and Pacific Islanders (API) who do suffer from various social problems, including substance abuse (Ja & Aoki, 1993).
Culturally Specific Issues for American Indians. For American Indians, these cultural themes include the living of a holistic lifestyle and a Being orientation that gives reverence to nature, time, and mystical experiences. Many American Indians value natural learning and the avoidance of coercion and punishment as a way of promoting learning and child rearing. American Indians have an oral tradition whereby learning occurs via storytelling. Many have a reverence for the group and group unity and for the value of giving as a way of contributing to the survival of the group. There is also a reverence for spiritual well-being and natural processes in which the person should seek to live in harmony with natural elements and not seek to control them.
Regarding the family, traditional American Indians value old age and the wisdom of the elders. They value ancestral worship and a preference for cooperation over competition. Moreover, humility and modesty are seen as virtues that favor integration as a member of the group rather than emphasizing the achievements of an individual (Dana, 1998; Locke, 1998).
Today, many American Indian elders are concerned about the loss of Indian culture among the young that has been occurring as some Indian youth leave the reservation in the quest for economic advancement, as well as among Indian youth in cities who lack contact with their Indian traditions. As with other racial/ethic minority groups, considerable within-group variability exists in terms of the degree to which a particular American Indian client identifies with Indian ways and observes them on a day-to-day basis.
The Process of Drug Addiction for Racial/Ethnic Clients
Illicit drug use and addiction develop in various ways and are influenced by multiple factors (Newcomb & Bentler, 1988). The concepts of the problem behavior syndrome (Jessor & Jessor, 1977) and conduct disorder (American Psychiatric Association, 1994) constitute two related behavioral syndromes involving impulsive and maladaptive behaviors that lie at the core of the high risk for drug and alcohol abuse (Santisteban, Szapocznik, & Kurtines, 1995). Among these impulsive youth, dropping out of school is a related high-risk outcome that is also associated with antisocial and nonconformist attitudes; affiliation with deviant peers, including gangs; and the use of “gateway drugs” (alcohol and cigarettes) in early adolescence. Among Mexican American adolescents, rates of school dropout are especially high, thus setting the stage for street life and the use of illicit drugs. Among some Hispanic adolescents, illicit drug use may also be affected by sociodemographic factors such as low level of education and poor school grades (Schinke et al., 1992). Relative to other youth, those youth who had earned grades of C and under in school and whose mothers had failed to complete high school were observed to be more likely to use illicit drugs.
Among Hispanic and other minority youth, other factors such as acculturation stressors, identity conflicts, economic disillusionment, and unique community or cultural prompts within a ghetto neighborhood may impose additional and unique social or environmental influences that may also prompt drug use and abuse (Castro, Boyer, & Balcazar, 2000).
Among API populations, drug abuse is not often viewed from the popular Western perspective of being a chronic relapsing condition for which the primary problem involves the person’s inability to cope with the world. In the Thai culture, as in many other Asian and Buddhist cultures, drug use is regarded as a response to either availability, cultural acceptance of drug use, peer and familial pressure to use (or lack of pressure to not use), performance enhancement at work, and/or factors such as poverty, depression, social isolation, boredom, or risk taking (Rawson & Obert, 2001).
When a person becomes a user of illicit drugs, life focus narrows such that a large portion of that person’s waking hours is focused on procuring that drug (Peele & Brodsky, 1991). Both the habitual and the pharmacological effects of illicit drug use force the person to continue using to avoid the discomforts of withdrawal and/or cravings. Criminal behavior involving various illegal acts to procure money to maintain one’s drug addiction can also become a central feature of that person’s daily activities. Depending on the type of drug used and route of administration (e.g., snorting, smoking, or injection), it is now well known that sharing needles also promotes the risk of HTV infection.
After years of drug use, entry into treatment occurs when the individual’s significant others, or that individual himself or herself, realize that the problem has gotten out of control or when the individual has been referred to mandatory treatment by the courts. At that point, the addicted individual may have lost or compromised work, social relations, and health, thus creating an acute need for treatment. As noted, some drug-addicted individuals, however, are unwilling to enter treatment voluntarily and thus are brought in under coercion from the courts or from insistent family members. Entry into treatment under coercion raises questions about the client’s preparedness for treatment.
Regarding preparedness for treatment, Prochaska and Prochaska (1999) developed the transtheoretical approach, which defines five stages of preparedness for behavior change. These stages are as follows: (a) pre-contemplation, a state in which the person cannot change without special help; (b) contemplation, a state in which the person is not sure whether he or she wants to change; (c) preparation, a state in which the person wishes to change but does not know how to change; (d) action; and (e) maintenance. Clients entering treatment in these early stages of readiness have traditionally been termed in denial or unmotivated. Program personnel have traditionally believed that these clients could not be treated successfully until they experienced the full consequences of their use and were ready for treatment. Miller and Rollnick (1991) have articulated a manner of interacting with clients in these early stages of readiness for treatment. This approach, motivational interviewing, has been shown to be more effective than waiting for the natural process of preparedness to occur, beginning treatment regardless of readiness, or confronting the individual with the program expectations. For various ethnic minority clients, little is known about the factors that promote effective treatment and recovery and how these are similar or different from the factors for effective recovery among nonminority Euro-American clients.
Cultural Issues in Drug Abuse Treatment with Ethnic Clients
Culturally Responsive Assessment and Treatment Planning. Clients who enter a drug treatment program are often users of multiple drugs and alcohol and often have a history of legal and family problems. These patterns have also been observed among various ethnic minority drug addicts. Maddox and Desmond (1992) reported on a 10-year longitudinal study of 95 male methadone maintenance clients and a comparison group of 77 male opiate users who were eligible for but not admitted to a methadone maintenance program. The majority of these clients in both groups (more than 87%) were Mexican Americans. Among these participants, more than 50% had come from broken families, more than 33% had disciplinary problems in school, and more than 60% had been arrested prior to their first use of opioids. Also, these clients had more than 14 years of opioid use prior to treatment entry, more than 67% had a problem with alcohol abuse before admission (or eligibility) to methadone maintenance, their mean age at first admission (or eligibility) to methadone maintenance treatment was 33 to 34 years of age, and they had been in prior drug treatments an average of three or more times prior to seeking methadone treatment.
These Mexican American heroin addicts were similar to many other heroin addicts in that they have undergone a series of social, legal, and other drug problems that preceded or occurred concurrently with their heroin abuse. Thus, their level of severity of drug abuse and related sociocultural problems was high, suggesting that a more intense program of recovery would be needed to modify their addiction to heroin, as well as to improve their personal and social capacity to remain off heroin and other illicit drugs (Simpson, Joe, Fletcher, Hubbard, & Anglin, 1999).
Culturally Responsive Treatment Planning. In one of the few culturally oriented studies of heroin addicts, Jorquez (1984) found that many Mexican American heroin addicts reject conventional forms of treatment. Jorquez suggested that treatment of Chicano heroin addicts should include a recognition of the difficulties involved in permanently eliminating addiction to heroin while helping the tecato, the Chicano heroin addict, to avoid discouragement and a perceived lack of progress in treatment. Jorquez also asserted that important psychosocial issues must also be addressed to provide a more complete and successful program for a full drug rehabilitation of these Mexican American/Chicano heroin users.
Regarding gender issues, Gutierres and Todd (1997) found that a high percentage of their American Indian female clients completed a certain treatment (87%) as compared with their Mexican American peers (56%) and Anglo American peers (58%). This higher completion rate for the American Indian clients was attributed to the culturally sensitive residential program that was provided for the American Indian women, a program that included traditional healing practices, a sweat lodge ceremony, a talking circle, and a program accommodation for these women that encouraged them to bring their children into the therapeutic community.
Relapse Prevention and Promoting Effective Treatment Outcomes
For users of illicit drugs such as cocaine and heroin, relapse after undergoing drug treatment involves a return to drug use at pretreatment levels in terms of frequency and quantity of use (Brownell, Marlatt, Lichtenstein, & Wilson, 1986). Regarding important aspects of relapse, Marlatt and Gordon (1985) made an important distinction between a lapse and a relapse in their relapse prevention theory (RPT). Marlatt and Gordon defined a lapse as a brief episode of drug use (a slip) that is followed by an expeditious return to abstinence. By contrast, a relapse is a full-blown return to use for an extended period of time and typically at the original levels of use (quantity and frequency) or beyond. Besides amount and duration of use, the critical factor that governs whether a lapse progresses to a relapse is the attributional process by which the addicted person evaluates the meaning of an episode of drug use. Under this self-evaluation process, if an episode of use is followed by feelings of guilt and failure, the “abstinence violation effect,” then the individual is likely to continue drug use (Marlatt & Gordon, 1985).
In the treatment of cocaine- and heroin-addicted patients, the goal of relapse prevention is attained via skills training in recognizing, avoiding, and exerting control over events that produce relapse (Marlatt & Gordon, 1985). Thus, a complete program for relapse prevention in the clinical setting should address at least seven key areas: (a) addressing client ambivalence in treatment motivation, (b) reducing drug availability, (c) coping with high-risk situations, (d) overcoming cravings related to conditioned cues, (e) avoiding “apparently irrelevant decisions,” (f) providing lifestyle modification toward healthier behaviors, and (g) coping with the abstinence violation effect (Carroll, Rounsaville, & Keller, 1991).
In an extension of Marlatt and Gordon’s (1985) RPT, Walton, Castro, and Barnngton (1994) developed an eight-level index of lapse/relapse outcomes (abstinence, three levels of lapse, and four levels of relapse). In this index, the major measurable distinction between lapses and relapses was that a lapse is generally an “isolated” episode of use in which such instances are separated by at least 1 week, whereas relapses are “clustered” episodes of use, binges that occur two or more times within the period of 1 week. These patterns of use aid in the classification of users as “lapsers” and “relapsers.”
It has been observed that persons who ultimately remain lapsers as compared with persons who go on to become relapsers make different cognitive attributions. A lapse is seen as a “unique” event, one that is not likely to occur for other drugs (a specific attribution), whereas a relapse is seen as an event likely to occur for other drugs as well (a global attribution) (Walton et al., 1994). Thus, as compared with clients who achieve total abstinence, clients who experience a full-blown relapse also develop feelings of loss of control and self-blame. In a spiraling process, these negative views about self are perpetuated across time and, in turn, contribute to a greater likelihood of continuing to use.
In preventing relapse among persons addicted to cocaine, education and training have focused on the identification of “triggers,” events, or situations (i.e., cues) that prompt or initiate a return to drug use. These cues, events, or triggers can include cravings that can occur when the recovering addict observes drug paraphernalia or receives encouragement from others to use drugs as before. Learning to recognize and avoid triggers greatly reduces the potential for relapse. When avoiding triggers is not possible, clients can be taught to use visualization techniques to reduce the power of the craving process and avoid careening out of control (Obert et al, 2000). Skills such as “thought stopping,” avoidance of triggers, and time scheduling are critical elements for clients to learn who are being treated primarily in outpatient modalities. These are the techniques that, when successfully executed, provide the structure within which recovery can succeed. Being able to develop these skills allows the client to operate in the “real world” during treatment and to begin to gain a sense of personal control, empowerment, and success.
However, relapse avoidance is not always an individual or a rational process. Regarding the influence of dual diagnosis (the co-occurrence of mental disorder with illicit drug use), Carroll et al. (1991) indicated that many users of cocaine (and users of heroin) also have coexisting Axis I and Axis II psychiatric disorders (such as depression or antisocial personality disorder). The presence of mental disorder complicates the process of coping with stressors, which prompts a return to drug use. Drug-addicted persons who experience psychiatric complications cannot cope exclusively on their own but instead are in need of stable and supportive sources of encouragement and support from family and friends.
To date, little work has been conducted on how the principles of RPT and the complications of psychiatric disorder may apply to various racial/ethnic minority clients. Besides the need for the individual addict to make a formal commitment to sobriety/drug avoidance, a requirement for successful relapse prevention may also involve enhancing the ethnic minority client’s self-concept by building ethnic pride and personal pride and also by mobilizing family support. Given the importance of the family in minority cultures, family issues may require an added focus in treatment to promote effective relapse prevention among recovering minority drug addicts (Castro & Barrington, 1993). Instilling pride in family and ethnic heritage, where such pride may have been compromised by drug involvement, may foster a new and positive concept of self. Thus, in minority families, this self-concept may include an emerging view of the self as a member of the family who must be responsible in avoiding drugs to contribute to the well-being of the family (Szapocznik, 1995).
In addition, establishing a new circle of friends (a sober reference group) and advising family on how to be supportive while also setting limits on maladaptive behavior are two critical systems-oriented interventions that place family members in the role of confidants who support the drug-addicted person’s recovery (Castro, Sharp, Barrington, Walton, & Rawson, 1991). Prompts by even one confidant that discourage heroin and other drug use can serve as a potent deterrent to relapse (Castro & Tafoya-Barraza, 1997). As noted, the role of significant others may be stronger for ethnic/racial clients who place a strong cultural value on harmony (simpatía) in social and family relations (Marín & Marín, 1991). In summary, the presence of one or more significant others who discourage drug use would appear to be an important factor in successful relapse prevention among racial/ethnic minority clients.
Future Directions in Research and Treatment
Treatment Outcome Research with Ethnic Clients
General Research Considerations. Typical group comparison studies found in the research literature often use a categorical variable (e.g., Caucasian, Black, Hispanic) to categorize members of a sample into a racial/ethnic category. By doing so, they treat all minority persons subsumed under that category (e.g., Asian Americans as if they were “all alike”) in the trait of “ethnicity.” This level of analysis constitutes “ethnic gloss” (Trimble, 1995), which involves a shallow level of analysis. In essence, this resorts to a group average and ignores subgroup variability on this dimension of “ethnicity.” This simplistic level of analysis is often problematic, especially when a group is extremely diverse, as is the case for Asians and Pacific Islanders, which include more than 32 distinct groups or nationalities, and American Indians, which include more than 505 federally recognized and 365 state-recognized tribal groups (Ja & Aoki, 1993; Locke, 1998).
Cultural competence in instrumentation and data analysis requires the use of variable conceptualizations and measures that are compatible with the perceptions and needs of members of a target population in terms of language, cultural idioms, and usage. Furthermore, such instruments should directly examine clients’ experiences, including their beliefs and perceptions regarding how well they are being understood by the service provider or researcher (Nemoto et al., 1998).
Acculturation Effects. For work with various ethnic clients, level of acculturation has been a useful, albeit a limited, indicator of within-group variability. Beyond this, level of acculturation should be examined as a moderator variable in future studies that examine and test models that relate predictors and moderators to important outcomes in prevention and in treatment (Jessor, Van den Bos, Vanderryn, Costa, & Turbin, 1995). Such studies would be aided by the further development of culturally sound theory, conceptualization, and measurement of acculturation and other related indicators of within-group variability (Kim, Atkinson, & Yang, 1999; Klonoff & Landrine, 2000; Rogler, Cortes, & Malgady, 1991). Conceptually, the use of moderator variables (Baron & Kenny, 1986) is important in moving from a stage of “cultural sensitivity” to “cultural competence” in research methodology with racial/ethnic minority clients. Such variables that can serve as ordered indicators of within-group variability for any racial/ethnic minority group include level of acculturation, Afrocentricity, traditional versus nontraditional orientation, and immigrant versus U.S. native-born status. A general aim in the use of such moderator variables with racial/ethnic populations is to identify important subgroups that can be ordered and understood in relation to an important dimension of within-group variability.
Zane and Huh-Kim (1998) indicated that several variables, including level of acculturation, generational status, nationality or ethnic group, place of birth, and gender, should be considered when analyzing patterns of alcohol and drug use among Asian American clients. Moreover, as discussed by Oetting and Beauvais (1991), the level and extent of cultural identification or enculturation (the reciprocal process to acculturation) are not clearly conveyed by a single continuum. That is, a person can be acculturated or enculturated in varying degrees to the mainstream culture while also identifying in varying degrees with his or her own racial/ethnic minority culture. Moreover, some racial/ethnic minority persons can report identifying with two or more racial or ethnic backgrounds and thus having a multiple racial/ethnic identity. These are all real yet challenging cultural issues that must be considered in total when designing and implementing culturally competent research.
Moreover, there is a growing view that ethnic individuals who develop into truly bicultural persons have developed stronger social skills to cope with the competing and at times conflicting demands of each of the two cultures (Felix-Ortiz & Newcomb, 1985). By contrast, a person who is “acultural” or “culturally marginalized” may not have the skills to access resources and support in either culture (LaFromboise, Coleman, & Gerton, 1993). For this and other reasons, a bicultural person may well be better adjusted and capable of achieving a more positive treatment outcome (Castro et al., 2000). By contrast, many drug-addicted persons have experienced arrested social and personal development, often remaining “acultural” or “culturally marginalized” throughout their lives. For these persons, the prognosis for full drug rehabilitation is less favorable, unless a treatment program specifically addresses these important needs. Future research needs to develop psychometrically sound methods of assessing level of acculturation and cultural identification, especially when it involves the multiple identities observed among certain drug-using clients (e.g., a gay, bicultural Asian American male).
General Clinical Interventions
In the process of relapse prevention, developing skills for recognizing and avoiding cues that trigger a return to drug use operate as a form of personal empowerment. More research is needed to identify culturally relevant factors that may influence the process of relapse among racial/ethnic minority clients. Among these clients, potential moderators of relapse may include the person’s level of cultural identifications and how he or she relates to various ethnic cultural values and traditions. It appears that acculturation to mainstream American culture can have both positive and negative effects. It is often difficult to predict under what conditions a client’s high level of acculturation will facilitate or impede positive treatment outcomes. More process-oriented and qualitative research is needed to clarify the ways in which the process of acculturation might contribute to the risk of illicit drug use among racial/ethnic minority clients and how it might influence treatment outcomes.
Currently, it is hypothesized that the availability of culturally relevant treatment activities (i.e., programs that promote cultural identity and pride) and certain types of traditionalism (e.g., family loyalty and social responsibility) may help reduce the risks of illicit drug use among certain racial/ethnic minority clients (Castro & Gutierres, 1997). However, only the conduct of controlled treatment outcome studies that explicitly examine these issues of culture and identity will provide scientific evidence that will confirm or refute this hypothesis. Within this context, how basic inpatient, outpatient, residential treatment, and other aftercare programs may need to be modified to accommodate the unique needs of various racial/ethnic minority clients remains an interesting and important treatment question.
Developing Culturally Responsive Drug Abuse Treatments
Regarding research methodology, issues of sampling are important in reaching hidden and stigmatized subpopulations or sectors within a given racial/ethnic population (Nemoto et al., 1998; Stueve, O’Donnell, Duran, San Doval, & Blome, 2001). Here it is noted that few group differences would be expected when comparing the acculturated or assimilated members of any racial/ethnic minority group with members of the White mainstream Westernized U.S. population. More remarkable cultural differences would be expected in examining the subgroup of members within any racial/ethnic minority group that are hidden and hard to access (e.g., African American male-to-female transgender persons who are addicted to cocaine) (Nemoto et al., 1998).
In the process of cultural program adaptation, a dynamic tension exists between sensitivity to the unique cultural needs of such cultural subgroups and the competing need to provide members of that subgroup with new learning, thus “acculturating” them to adopt certain contemporary “Western” behaviors that promote survival and success within this society. In this process, the treatment program developer must (a) recognize the adaptive challenges of acculturation to U.S. mainstream cultural norms and (b) recognize and respect the need and desire of many racial/ethnic minority people to retain aspects of their ethnic traditions that have great personal significance to them.
Thus, “universal” drug treatment programs that ignore issues of culture can be described as “culturally blind” and will likely be insensitive to one or more specific needs of a given racial/ethnic minority client (Ja & Aoki, 1993). Such needs depend on the background and identity of a specific minority client. However, such needs include (a) feelings of being discriminated, alienated, or not feeling accepted; (b) identity conflicts in addition to the typical adolescent or young adult developmental issues; (c) value conflicts imposed by social processes that force acculturation or conformity with mainstream American lifeways; and (d) racial/ethnic family dynamics that can inadvertently interfere with treatment and can promote relapse (Locke, 1998; Ramirez, 1999).
Culturally competent relapse prevention efforts must also address issues of family support for the recovering addict. In working with ethnic minority drug addicts, it is important to offer an integrated program of treatment (LaFromboise, Trimble, & Mohatt, 1990) that, for certain ethnic minority clients, includes treatment in their native language and treatment that includes cultural, psychological, and spiritual activities that are important to them. Thus, clinic administrators must recognize the need for such treatments and thus to develop a parallel treatment track. Alternately, a less costly approach is to offer a set of treatment components or modules that address these relevant and specific cultural issues. Such modules can be designed as supplements to a conventional treatment program. Various relevant and effective approaches can be designed, provided that clinic staff recognize the importance of sociocultural issues and make a commitment to address these in a therapeutic manner.
- Initially, preparing to provide effective services locally involves conducting a needs assessment, whether large or small, to identify the unique profile of needs of clients from the local community who are current or prospective clients (McKenzie & Smeltzer, 2001). Agency staff can determine whether the agency is now receiving a sizable percentage of clients from a special subgroup (e.g., low-acculturated, Spanish-speaking adolescents referred to drug abuse treatment by the courts) or clients who present specific treatment issues not now addressed by the current treatment program.
- Next, an important factor is hiring and training staff who are culturally competent to provide drug abuse treatment within the local community. This involves increasing the cultural capacity of these staff members by providing training on knowledge, attitudes, and skills that promote cultural sensitivity, competence, and, beyond this, cultural proficiency.
- Next, it will be important to examine the “universal” or currently offered drug abuse treatment program for sources of “cultural incongruence in program assumptions or practices. That is, areas of “nonfit” should be examined to consider the development of treatment modules that provide greater “cultural congruence” (i.e., a better fit) in treatment offered to members of a targeted subgroup of clients.
- In a cultural adaptation phase, it will be important to collect empirical data from consumers, expert consultants, and community key informants. These are community leaders who can represent the views of a specific cultural subgroup. These persons can be invited as one-time consultants, or they can serve a term on an agency advisory board. These people would help to plan and evaluate new models or other modifications to the current treatments in response to the unique cultural needs of an identified subgroup of clients.
- Next, there is a need to conduct a small but viable formative evaluation that provides evaluative feedback on a short-term basis. Such quick feedback helps in revising the activities or modules that have been developed. At the end of this cycle, the aim is to develop a local “best practice” that enhances treatment and that is effective in reducing relapse and in improving other treatment outcomes.
- Finally, it will be important to develop a treatment manual that provides a clinically grounded and stable yet revisable protocol that clearly, in step-by-step fashion, outlines what the therapist should do in offering this culturally relevant treatment. The aim is to standardize this culturally enhanced treatment that could now serve as an “evidence-based practice,” one that uses culturally competent activities that have been tested for cultural relevance and effectiveness with members of the local targeted subgroup of clients (Center for Substance Abuse Treatment, 2001).
In summary, an agency’s concerted efforts in attending actively to issues of culture within their current drug abuse treatment program constitute a commitment toward cultural competence in service delivery. This effort can enhance services to members of specific cultural subgroups. In other words, the very act of attending and taking concerted action serves as a concrete expression of this commitment toward cultural competence. It is hoped that more agencies will conduct a closer and systematic examination of their current drug treatment services in efforts to upgrade them with the infusion of culturally competent interventions that aim to improve quality of care and treatment outcomes for their racial/ethnic minority clients.