America is a country comprised of people from many different nationalities and cultures. It is a nation of individuals who are adolescents, teens, young adults, adults, and the elderly. There are language disparities, cultural differences, and differences in sexual preference. There is discrimination and stigma attached to those with HIV/AIDS and co-occurring mental health disorder. And we are also a nation with a serious problem with substance abuse and addiction – none of which is limited to any one race, religion, creed, or lifestyle. Treatment and recovery services, in order to be effective, must reflect such diversity.
Magnitude of Substance Abuse
According to the National Survey on Drug Use and Health (NSDUH), an estimated 22.2 million persons aged 12 or older were classified with substance dependence or abuse during the past year in 2008. During 2008, an estimated 23.1 million persons aged 12 or older needed treatment for a problem with illicit drug or alcohol use (9.2 percent of the population aged 12 and older). But only 2.3 million (0.9 percent of those aged 12 and older and 9.9 percent of those who needed treatment) actually received it at a specialized facility. This leaves the vast majority – 20.8 million (8.3 percent of the population aged 12 and older) – needing treatment but not receiving it.
While these numbers aren’t dramatically different from what they were in 2007 and 2002 (previous NSDUH reports), they are, nonetheless, indicative of the magnitude of the problem of substance abuse in America.
Substance Abuse and Serious Mental Illness
In 2008, according to NSDUH data, there were 9.8 million adults aged 18 and older classified with a serious mental illness (SMI). Rates of SMI were lowest among Asians (2.9 percent) and blacks (3.5 percent). SMI rates for other ethnic/racial groups were 4.0 percent among Hispanics, 4.2 percent among American Indians or Alaska Natives, 4.7 percent among whites, and 5.6 percent among persons reporting two or more races. Note that estimates of SMI among Native Hawaiians or other Pacific Islanders could not be reported due to low survey sample.
Of 9.8 million adults with SMI, 2.5 million (25.2 percent of adults aged 18 and older with SMI) were dependent upon or abused illicit drugs or alcohol in 2008. Of the adults with SMI and substance abuse, 30.0 percent had past year illicit drug use, 50.5 percent smoked cigarettes, 29.4 percent engaged in binge drinking within the previous 30 days, and 11.6 percent reported heavy alcohol use (drinking five or more drinks on the same occasion on each of five or more days during the past 30 days).
In terms of treatment for SMI and substance abuse, of the 2.5 million population requiring it, 60.5 percent received it, while 39.5 percent received no treatment. Among those receiving treatment, 45.2 percent received mental health care treatment only, 11.4 percent received mental health care and treatment for substance use problems, and 3.7 percent received treatment for substance use problems only. Mental health care, in this sense, involves receiving inpatient or outpatient care or having used prescription medication for problems with emotions, nerves, or mental health.
Alcohol and Drugs – Equal Opportunity Substances of Abuse
Rich or poor, young or old, living in cities, suburbs or rural areas, homeless, sick, traumatized – alcohol and drugs are equal opportunity substances of abuse. It doesn’t matter who you are, if you’ve never before touched harmful substances, or if you’ve been able to tolerate them up to now, abuse and addiction cross all lines in society.
Illicit drugs include the following:
• Marijuana and hashish
• Cocaine (including crack)
• Hallucinogens (including LSD, PCP, ecstacy and more)
• Nonmedical use of psychotherapeutics (including pain relievers, such as OxyContin, sedatives, tranquilizers, and stimulants, such as methamphetamine)
Compounding the problem of illicit drug use (including nonmedical use of prescription medications), is abuse of over-the-counter (OTC) medicines.
Culture and Cultural Diversity
Culture refers to shared values, norms, customs, traditions, arts, history, folklore, and institutions of a group of people. It shapes how people see their world and how they structure their family life and community. Cultural affiliation often determines the individual’s values and attitudes about health issues, responses to messages, and use of alcohol, tobacco, and drugs.
Cultural diversity refers to differences in ethnicity, nationality, race, language, or religion among various groups within a community, organization, or the nation. A community is said to reflect cultural diversity if its residents include members of different groups. However, diversity ultimately functions at the individual level. It’s how each individual constructs his or her own identity comprised of many cultures based on nationality, age, sex, religion, health conditions, socioeconomic class, ethnicity, sexual orientation, political affiliation, and interests.
Differences in Communication in Cultures
Any discussion of cultural diversity in treatment and recovery services has to take into account the differences in verbal and nonverbal communication, personal space, and family in members of various cultures.
Verbal and Nonverbal Communication
• In Hispanic culture, males value machismo, which conveys a strong self-image. An air of coolness, stares, and silence
characterizes machismo. Hispanic men resist taking orders from women and non-Hispanics. Treatment and services practitioners, if they are women, should declare her official role in the first meeting with a Hispanic male client. This will both increase her credibility and help to reduce future resistance. One-to-one direct communicaton works best when dealing with members of this cultural group.
• Among American Indian cultures, however, silence and stares convey an altogether different message. Maintaining eye contact is a sign of disrespect, while a firm look is seen as indicating seriousness. In Asian cultures, silences are used to emphasize meaning and to show power.
• Eye contact is also seen as disrespectful in Hispanic and African-American cultures. In white cultures, in contrast, direct eye contact conveys trustworthiness, sincerity, and forthrightness. White cultures view lack of eye contact as a lack of integrity.
Various studies have shown differences in the amount of touching within cultures. Handshaking, slapping hands, and hugging are generally used for added expression within the Hispanic and African-American cultures. In white cultures, however, close physical proximity or touching while speaking may be looked upon as an invasion of space.
How much a family is valued is also different across cultures. Family relationships are crucial and highly regarded in Hispanic, African-American, and Asian cultures. In African-American cultures, the family consists of extended households frequently headed by an older woman. Family welfare in these extended households is considered a primary obligation. In Asian cultures, family pride, honor, interdependence, cooperation, and mutual support are considered important. Asian cultures handle their own problems within the family and outside influences are not welcome. In Hispanic cultures, affection and fondness signifies caring for and protection of each other in the family.
Culturally Competent Treatment and Recovery Programs and Services
A culturally competent program is one that demonstrates understanding of and sensitivity to cultural differences in program or services design, implementation, and evaluation. Culturally competent programs:
• Acknowledge culture as the major force shaping values, behaviors, and institutions
• Accept and acknowledge that cultural differences exist and have an effect on the delivery of services
• Believe that diversity within cultures is as important as diversity between cultures
• Respect the unique and culturally defined needs of each of its various client populations
• Recognize that concepts of family and community are different for various cultures and subgroups within those cultures
• Understand that people from different ethnic and racial groups and other cultural subgroups are best served by those who are either part or or are in tune with their culture
• Recognize that taking the best of both worlds enhances the capacity of all
In addition, a culturally competent service provider needs to be skilled in understanding the diverse factors that affect the individual with respect to all aspects of treatment and recovery. This is true even in cases where that individual is not aware of factors that may constitute a barrier to treatment and recovery.
Cultural Competence in Various Groups and Communities
Cultural competence in treatment and recovery services for different racial/ethnic groups requires responsiveness. Cultural responsiveness is important to recognizing multiple aspects of the client’s identity, barriers to recovery that must be overcome, or to participation in the counseling process, and addressing stress sources that may be contributing to substance abuse. Four techniques to ensure cultural responsiveness include acting to build trust, avoiding assumptions, individualizing the counseling approach, and identifying issues that affect the client’s chance of recovery.
The following are examples of issues that are important for cultural competence in treatment and recovery for two groups: lesbian, gay, bisexual and transgender (LGBT), and persons with physical and cognitive disabilities and substance abuse. These examples are mentioned only to be indicative of the types of issues that may be important when developing culturally diverse treatment and recovery services.
Cultural competence in treatment and recovery for lesbian, gay, bisexual, and transgender (LGBT) individuals requires an understanding of and appropriate action for the following:
• Some LGBT individuals may resort to substance abuse in order to cope with negative feelings. Counselors and clients alike need to understand that these effects are the result of prejudice and discrimination and are not because of the individual’s sexuality. LGBT persons in therapy often report feeling anxious, angry, fearful, depressed, isolated, and have difficulty trusting others.
• Some members of a marginalized community (such as being a member of the LGBT community) may resort to use of mind-altering substances to manage the stigma and resulting tension of being a member of that marginalized community.
• Substance use is a large part of the social life of some segments of the LGBT community. This is especially true of alcohol use.
• Culturally sensitive treatment for the LGBT community often results in more effective treatment. But there is much debate over what actually constitutes LGBT culture. It is important to note that people who are LGBT come from all cultural backgrounds and racial groups, can be any age, can live in all geographic areas of the United States, and can have achieved any income or educational level.
Persons with physical and cognitive disabilities and substance use also have special needs. In order to make treatment most effective, those with coexisting disabilities require specific accommodations. Plans for treatment must also be revised in order to accommodate their needs, with a recognition that not all clients will respond equally well to the same treatment types. Treatment plans should be drawn up for each individual, if at all possible. An understanding of how the patient feels about his or her own disabilities will also help enhance treatment. Flexibility is required in drawing up treatment plans for persons with coexisting disabilities in order to take into account changes that occur in the person’s condition or new knowledge that is gained during treatment. While the law requires that people with disabilities have equal access to all components of treatment programs, planning and understanding on the part of providers is required in order to make such accommodations available.
Finding Service Providers Responsive to Culturally Diverse Needs
It’s also important that patients seeking treatment and recovery services be able to find providers that are responsive to their culturally diverse needs. The following criteria (taken from a 12-point platform developed by the New York State Alcoholism and Substance Abuse Providers, Inc.) can be used by patients and providers in assessing cultural competence within treatment and recovery programs and services:
• Management and staff of the program should be reflective of the diverse clients they serve.
• Commitment to diversity should be institutionalized and articulated in the program’s mission, vision, values, and
strategic plan of the organization.
• Staff and management should undergo regular and formal training in diversity and competency.
• The program should develop a written strategy to recruit, retain, and promote diverse, culturally competent individuals in administrative, managerial, clinical, and support staff who are trained and qualified to address the specific needs of the ethnic and racial communities served.
• Policies and procedures of the program need to reflect its commitment to diversity and competency. These should include the areas of intake, treatment and discharge planning, as well as client satisfaction.
• Written materials should be readily accessible to all clients served. Such materials – including rules and regulations, forms, consent requests for disclosure of information – should be written in a variety of languages, making them easily understood by the populations served by the program.
• A practical, written policy and procedure manual must be maintained for the program that includes how the program addresses the needs of applicants, clients, and collateral contacts who are disabled.
• In the process of credentialling and recredentialling, credentialling agencies should require that applicants complete a minimum number of hours of training in the areas of diversity and competency.
• There should also be a peer review process to evaluate whether systems are in place to address the needs of the diverse populations and communities served by the program.
Change of Culture and Cultural Differences Continues
Cultures change on a continual basis. Cultural differences are both related to and affected by economic status, age, education, sex, and religion. It is important to remember that culture, and members of a culture, should not be stereotyped.
As such, the importance of diversity in treatment and recovery services cannot be underestimated. As cultures change, so, too, must culturally diverse treatment and recovery services. In order to best meet the needs of the clientele they serve, providers must stay on top of the issues, undergo regular training in the areas of culture and diversity, and recognize that treatment and services need to be tailored to each individual.