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Behavioral Health 5 Treatment for Major Racial and Ethnic Groups

IN THIS CHAPTER John, 27, is an American Indian from a Northern Plains Tribe. He recently entered an outpatient treatment program in a midsized • Introduction Midwestern city to get help with his drinking and subsequent low • Counseling for African mood. John moved to the city 2 years ago and has mixed feelings and Black about living there, but he does not want to return to the reserva- • Counseling for Asian tion because of its lack of job opportunities. Both John and his Americans, Native counselor are concerned that (with the exception of his girlfriend, Hawaiians, and Other Sandy, and a few neighbors) most of his current friends and Pacific Islanders coworkers are “drinking buddies.” John says his friends and family • Counseling for on the reservation would support his recovery—including an uncle and Latinos and a best friend from school who are both in recovery—but his • Counseling for Native contact with them is infrequent. Americans • Counseling for White John says he entered treatment mostly because his drinking was Americans interfering with his job as a bus mechanic and with his relationship with his girlfriend. When the counselor asks new group members to tell a story about what has brought them to treatment, John explains the specific event that had motivated him. He describes having been at a party with some friends from work and watching one of his coworkers give a bowl of beer to his dog. The dog kept drinking until he had a seizure, and John was disgusted when peo- ple laughed. He says this event was “like a vision;” it showed him that he was being treated in a similar fashion and that alcohol was a poison. When he first began drinking, it was to deal with bore- dom and to rebel against strict parents whose Pentecostal Christian beliefs forbade alcohol. However, he says this vision showed him that drinking was controlling him for the benefit of others. Later, in a one-on-one session, John tells his counselor that he is afraid treatment won’t help him. He knows plenty of people back

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home who have been through treatment and healing, help-seeking behavior, and treatment still drink or use drugs. Even though he expectations and preferences. Adopting Sue’s doesn’t consider himself particularly tradition- (2001) multidimensional model in developing al, he is especially concerned that there is cultural competence, this chapter identifies nothing “Indian” about the program; he dis- cultural knowledge and its relationship to likes that his treatment plan focuses more on treatment as a domain that requires proficien- changing his thinking than addressing his cy in clinical skills, programmatic develop- spiritual needs or the fact that drinking has ment, and administrative practices. This been a poison for his whole community. chapter focuses on patterns of substance use and co-occurring disorders (CODs), beliefs John’s counselor recognizes the importance of about and traditions involving substance use, connecting John to his community and, if beliefs and attitudes about behavioral health possible, to a source of traditional healing. treatment, assessment and treatment consider- After much research, his counselor is able to ations, and theoretical approaches and treat- locate and contact an Indian service organiza- ment interventions across the major racial and tion in a larger city nearby. The agency puts ethnic groups in the . him in touch with an older woman from John’s Tribe who resides in that city. She, in Introduction turn, puts the counselor in touch with another member of the Tribe who is in recovery and Culture is a primary force in the creation of a had been staying at her house. This man person’s identity. Counselors who are culturally agrees to be John’s sponsor at local 12-Step competent are better able to understand and meetings. With John’s permission, the counse- respect their clients’ identities and related lor arranges an initial family therapy session cultural ways of life. This chapter proposes that includes his new sponsor, the woman who strategies to engage clients of diverse racial serves as a local “clan mother,” John’s girl- and ethnic groups (who can have very differ- friend, and, via telephone, John’s uncle in ent life experiences, values, and traditions) in recovery, mother, and brother. With John’s treatment. The major racial and ethnic groups permission and the assistance of his new in the United States covered in this chapter sponsor, the counselor arranges for John and are , some other members of his treatment group to (including and other Pacific attend a sweat lodge, which proves valuable in Islanders), Latinos, Native Americans (i.e., helping John find some inner peace as well as Natives and American Indians), and giving his fellow group members some insight . In addition to providing into John and his culture. epidemiological data on each group, the chap- To provide culturally responsive treatment, ter discusses salient aspects of treatment for counselors and organizations must be commit- these racial/ethnic groups, drawing on clinical ted to gaining cultural knowledge and clinical and research literature. This information is skills that are appropriate for the specific racial only a starting point in gaining cultural and ethnic groups they serve. Treatment pro- knowledge as it relates to behavioral health. viders need to learn how a client’s identifica- Understanding the diversity within a specific tion with one or more cultural groups culture, race, or ethnicity is essential; not all influences the client’s identity, patterns of information presented in this chapter will substance use, beliefs surrounding health and apply to all individuals. The material in this chapter has a scientific basis, yet cultural beliefs,

102 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Multidimensional Model for Developing Cultural Competence: Cultural Knowledge of Behavioral Health

traditions, and practices change with time and environmental context affects behavioral are not static factors to consider in providing health. However, to provide a framework for services for clients, families, or communities. understanding many diverse cultural groups, some generalizations are necessary; thus, broad Although these broad racial/ethnic categories categories are used to organize information in are often used to describe diverse cultural this chapter. Counselors are encouraged to groups, the differences between two members learn as much as possible about the specific of the same racial/ can be greater populations they serve. Sources listed in than the differences between two people from Appendix F provide additional information. different racial/ethnic groups (Lamont and Small 2008; Zuckerman 1998). It is not possi- Counseling for African and ble to capture every aspect of diversity within each cultural group. Behavioral health workers Black Americans should acknowledge that there will be many individual variations in how people interact According to the 2010 U.S. Census definition, with their environments, as well as in how African Americans or Blacks are people whose

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origins are “in any of the black racial groups of consumption as they grow older (Center for Africa” (Humes et al. 2011, p. 3). The term Substance Abuse Treatment [CSAT] 1999a; includes descendants of African slaves brought Galvan and Caetano 2003). Rates of overall to this country against their will and more substance use among African Americans vary recent immigrants from Africa, the Caribbean, significantly by age. Several researchers have and South or Central America (many individ- observed that despite Black youth being less uals from these latter regions, if they come likely than White American youth to use from Spanish-speaking cultural groups, iden- substances, as African Americans get older, tify or are identified primarily as Latino). The they tend to use at rates comparable with term “Black” is often used interchangeably those of White Americans (Watt 2008). This with African American, although sometimes increase in substance use with age among the term “African American” is used specifi- Blacks is often referred to as a crossover effect. cally to describe people whose families have th However, Watt (2008), in her analysis of 4 been in this country since at least the 19 years of National Survey on Drug Use and century and thus have developed distinct Health (NSDUH) data (1999–2002), found African American cultural groups. “Black” can that when controlling for factors such as drug be a more inclusive term describing African exposure, marriage, employment, education, Americans as well as more recent immigrants income, and family/social support, the cross- with distinct cultural backgrounds. over effect disappeared for Blacks ages 35 and Beliefs About and Traditions older; patterns for drug and heavy alcohol use Involving Substance Use among Black and White American adults remained the same as for Black and White In most African American communities, American adolescents (i.e., White Americans significant alcohol or drug use may be socially were significantly more likely to use substanc- unacceptable or seen as a sign of weakness es). Watt concludes that systemic issues, such (Wright 2001), even in communities with as lower incomes and education levels, and limited resources, where the sale of such sub- other factors, such as lower marriage rates, stances may be more acceptable. Overall, contribute to substance use among Black African Americans are more likely to believe adults. Additional research also suggests that that drinking and drug use are activities for exposure to discrimination increases willing- which one is personally responsible; thus, they ness to use substances in African American may have difficulty accepting alcohol youth and their parents (Gibbons et al. 2010). abuse/dependence as a disease (Durant 2005). When comparing African Americans with Substance Use and Substance Use other racial and ethnic groups, NSDUH data Disorders from 2012 suggest that they are somewhat To date, there has not been much research more likely than White Americans to use illicit analyzing differences in patterns of substance drugs and less likely than White Americans to use and abuse among different groups of use alcohol. They also appear to have an inci- Blacks, but there are indications that some dence of alcohol and drug use disorders simi- gender differences exist. For example, alcohol lar to that seen in White Americans consumption among African American wom- (Substance Abuse and Mental Health Services en increases as they grow older, but Caribbean Administration [SAMHSA] 2013d). Crack Black women report consistently low alcohol cocaine use is more prevalent among Blacks

104 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups than White Americans or Latinos, whereas Some preliminary evidence suggests that rates of abuse of methamphetamine, inhalants, African Americans are less likely to develop most hallucinogens, and prescription drugs are drug use disorders following initiation of use lower (SAMHSA 2011a). Phencyclidine use (Falck et al. 2008), yet more research is needed also appears to be a more serious problem, to identify variables that influence the devel- albeit affecting a relatively small group, among opment of drug use disorders. Even though African Americans than among members of African Americans seem less likely than other racial/ethnic groups. White Americans to develop alcohol use disorders, a number of older studies have There appear to be some other differences in found that they more frequently experience how African Americans use substances com- liver cirrhosis and other alcohol-related health pared with members of other racial/ethnic problems (Caetano 2003; Polednak 2008). In groups. For example, Bourgois and Schonberg tracking 25 years of data, Polednak (2008) (2007) observed that among people who inject- found that the magnitude of difference has ed heroin in San Francisco, White Americans decreased over time; nonetheless, health dispar- tended to administer the drug quickly whether ities continue to exist for African Americans in or not they could find a vein, which led them terms of access to and quality of care, which to inject into fat or muscle tissue and resulted can affect a number of health problems in a higher rate of abscesses. However, African (Agency for Healthcare Research and Quality Americans who injected heroin were more 2009; Smedley et al. 2003). methodical and took the time to find a vein, even if it took multiple attempts. This, in turn, Mental and Co-Occurring often resulted in using syringes that were Disorders already bloodied and increased their chances of contracting HIV/AIDS and other blood- A number of studies have found biases that borne diseases. African Americans who inject- result in African Americans being overdiag- ed heroin were significantly more likely to also nosed for some disorders and underdiagnosed use crack cocaine than were White Americans for others. African Americans are less likely who injected heroin (Bourgois et al. 2006). than White Americans to receive treatment for anxiety and mood disorders, but they are African American patterns of substance use more likely to receive treatment for drug use have changed over time and will likely contin- disorders (Hatzenbuehler et al. 2008). In one ue to do so. Based on treatment admission study evaluating posttraumatic stress disorder data, admissions of African Americans who (PTSD) among African Americans in an injected heroin declined by 44 percent during outpatient mental health clinic, only 11 per- a 12-year period, whereas admissions declined cent of clients had documentation referring to by only 14 percent among White Americans PTSD, even though 43 percent of the clients (Broz and Ouellet 2008). Additionally, during showed symptoms of PTSD (Schwartz et al. this period, the peak age for African Americans 2005). Black immigrants are less likely to be who injected heroin increased by 10 years, yet diagnosed with mental disorders than are it decreased by 10 years for White Americans. Blacks born in the United States (Burgess et This suggests that the decrease in injectable al. 2008; Miranda et al. 2005b). heroin use among African Americans was largely due to decreased use among younger African Americans are more likely to be individuals. diagnosed with schizophrenia and less likely to be diagnosed with affective disorders than

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White Americans, even though multiple African Americans are less likely than White studies have found that rates of both disorders Americans to report lifetime CODs (Mericle among these populations are comparable et al. 2012). However, limited research indi- (Baker and Bell 1999; Bresnahan et al. 2000; cates that, as with other racial groups, there are Griffith and Baker 1993; Stockdale et al. 2008; differences across African American groups in Strakowski et al. 2003). African Americans are the screening and symptomatology of CODs. about twice as likely to be diagnosed with a Seventy-four percent of African Americans psychotic disorder as White Americans and who had a past-year major depressive episode more than three times as likely to be hospital- were identified as also having both alcohol and ized for such disorders. These differences in marijuana use disorders (Pacek et al. 2012). diagnosis are likely the result of clinician bias Miranda et al. (2005b) found that American- in evaluating symptoms (Bao et al. 2008; born Black women were more than twice as Trierweiler et al. 2000; Trierweiler et al. likely to be screened as possibly having depres- 2006). Clinicians should be aware of bias in sion than African- or Caribbean-born Black assessment with African Americans and with women, but this could reflect, in part, differ- other racial/ethnic groups and should consid- ences in acculturation (see Chapter 1). How- er ways to increase diagnostic accuracy by ever, research findings strongly suggest that reducing biases. For an overview of mental cultural responses to some disorders, and health across populations, refer to Mental possibly the rates of those disorders, do vary Health United States, 2010 (SAMHSA among different groups of Blacks. Differences 2012a). do not appear to be simply reflections of differences in acculturation (Joe et al. 2006). In some African American communities, For a review of African American health, see incidence and prevalence of trauma exposure Hampton et al. (2010). and PTSD are high, and substance use ap- pears to increase trauma exposure even further Treatment Patterns (Alim et al. 2006; Breslau et al. 1995; Curtis- African Americans may be less likely to re- Boles and Jenkins-Monroe 2000; Rich and ceive mental health services than White Grey 2005). Black women who abuse sub- Americans. In the Baltimore Epidemiologic stances report high rates of sexual abuse Catchment Services Area study conducted (Ross-Durow and Boyd 2000). Trauma histo- during the 1980s, African Americans were less ries can also have a greater effect on relapse for likely than White Americans to receive mental African American clients than for clients from health services. However, at follow-up in the other ethnic/racial groups (Farley et al. 2004). early 1990s, African American respondents There are few integrated approaches to trau- were as likely as White Americans to receive ma and substance abuse that have been evalu- such services, but they were much more likely ated with African American clients, and to receive those services from general practi- although some have been found effective at tioners than from mental health specialists reducing trauma symptoms and substance (Cooper-Patrick et al. 1999). Stockdale et al. use, the extent of that effectiveness is not (2008) analyzed 10 years of data from the necessarily as great as it is for White National Ambulatory Medical Care Survey; Americans (Amaro et al. 2007; Hien et al. they found significant improvements in diag- 2004; SAMHSA 2006). nosis and care for mental disorders among African Americans in psychiatric settings

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between 1995 and 2005, but they also found SAMHSA, CBHSQ 2011; Schmidt et al. that disparities persisted in the diagnosis and 2006). Data analyzed by Perron et al. (2009) treatment of mental disorders in primary care indicate that among African Americans with settings. Fortuna et al. (2010) suggest that lifetime diagnoses of drug use disorders, 20.8 persistent problems exist in the delivery of percent had received some type of treatment, behavioral health services, as evidenced by as defined broadly to include resources such as lower retention rates for treating depression. pastoral counseling and mutual-help group attendance. This made them more likely to Even among people who enter substance have received treatment than White Ameri- abuse treatment, African Americans are less cans (15.5 percent of whom received treat- likely to receive services for CODs. A study of ment) or Latinos (17.3 percent of whom administrative records from substance abuse received treatment). Although data indicate and mental health treatment providers in New that African Americans were less likely to Jersey found that African Americans were receive services from private providers, they significantly more likely than White Americans also indicate that African Americans were to have an undetected co-occurring mental more likely to use more informal services (e.g., disorder, and, if detected, they were signifi- pastoral counseling, mutual help). cantly less likely than White Americans or Latinos to receive treatment for that disorder Although most major studies have found that (Hu et al. 2006). Among persons with sub- race is not a significant factor in receiving stance use disorders and co-occurring mood or treatment, African Americans report lengthier anxiety disorders, African Americans are waiting periods, less initiation of treatment, significantly less likely than White Americans more barriers to treatment participation (e.g., to receive services (Hatzenbuehler et al. 2008). lack of childcare, lack of insurance, lack of African Americans who do receive services for knowledge about available services), and CODs are more likely to obtain them through shorter lengths of stay in treatment than do substance abuse treatment programs than White Americans (Acevedo et al. 2012; mental health programs (Alvidrez and Brower and Carey 2003; Feidler et al. 2001; Havassy 2005). Grant 1997; Hatzenbuehler et al. 2008; Marsh et al. 2009; SAMHSA 2011c; Schmidt et al. According to the Treatment Episode Data 2006). In SAMHSA’s 2010 NSDUH, 33.5 Sets (TEDS) from 2001 to 2011, African percent of African Americans who had a need American clients entering substance abuse for substance abuse treatment but did not treatment most often reported alcohol as their receive it in the prior year reported that they primary substance of abuse, followed by mari- lacked money or the insurance coverage to pay juana. However, gender differences are evident, for it (SAMHSA, CBHSQ 2011). Economic indicating that women report a broader range disadvantage does leave many Africans Amer- of substances as their primary substance of icans uninsured; approximately 16.1 percent of abuse than men do (SAMHSA, Center for non-Latino Blacks had no coverage in 2004 Behavioral Health Statistics and Quality (Schiller et al. 2005). [CBHSQ], 2013). Most recent research sug- gests that African Americans are about as Likewise, some researchers have found that likely to seek and eventually receive substance African Americans are less likely than White abuse treatment as are White Americans Americans to receive needed services or an (Hatzenbuehler et al. 2008; Perron et al. 2009; appropriate level of service (Alegria et al.

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2011; Bluthenthal et al. 2007; Marsh et al. value and use of specialized behavioral health 2009). For example, African Americans and services among some African Americans may Latinos are less likely than White Americans limit service use. Hines-Martin et al. (2004) to receive residential treatment and are more found a positive relationship between famili- likely to receive outpatient treatment, even arity and use of mental health services among when they present with more serious substance African Americans. Additionally, factors such use problems (Bluthenthal et al. 2007). Other as social and familial prejudices (Ayalon and studies have found that African Americans Alvidrez 2007; Mishra et al. 2009; Nadeem et with severe substance use or CODs were less al. 2007) and fears relating to past abuses of likely to enter or receive treatment than White African Americans within the mental health Americans with equally severe disorders system (Jackson 2003) can contribute to the (Schmidt et al. 2006, 2007). lack of acceptance and subsequent use of these services. An essential step in decreasing dis- African Americans are overrepresented among parity in behavioral health services among people who are incarcerated in prisons and African Americans involves conducting cul- jails (for review, see Fellner 2009), and a sub- turally appropriate mental health screenings stantial number of those who are incarcerated and using culturally sensitive instruments and (64.1 percent of jail inmates in 2002) have evaluation tools (Baker and Bell 1999). substance use disorders (Karberg and James 2005) and mental health problems (SAMHSA Beliefs and Attitudes About 2012a). However, according to Karberg and Treatment (James 2005), African Americans with sub- stance dependence disorders who were in jail According to 2011 NSDUH data, African in 2002 were less likely than White Americans Americans were, next to Asian Americans, or Latinos to participate in substance abuse the least likely of all major ethnic and racial treatment while under correctional supervision groups to state a need for specialized sub- (32 percent of African Americans participated stance abuse treatment (SAMHSA, CBHSQ compared with 37 percent of Latinos and 45 2013a). Still, logistical barriers may pose a percent of White Americans). In the 2010 greater challenge for African Americans than TEDS survey, African Americans entering for members of other major racial and ethnic treatment were also less likely than Asian groups. For example, 2010 NSDUH data Americans, White Americans, Latinos, Native regarding individuals who expressed a need Hawaiians/Pacific Islanders, or American for substance abuse treatment but did not Indians in the same situation to be referred to receive it in the prior year indicate that treatment through the criminal justice system African Americans were more likely than (SAMHSA, CBHSQ 2012). Notwithstand- members of other major ethnic/racial groups ing, African Americans are more likely to be to state that they lacked transportation to the referred to treatment from criminal justice program or that their insurance did not cover settings rather than self-referred or referred by the cost of such treatment (SAMHSA other sources (Delphin-Rittmon et al. 2012) 2011a). African Americans experience several challenges in accessing behavioral health Beyond issues related to diagnosis and care treatment, including fears about the therapist that can prevent African Americans from or therapeutic process and concerns about accessing mental health services, research discrimination and costs (Holden et al. 2012; suggests that a lack of familiarity with the

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Holden and Xanthos 2009; Williams et al. Most importantly, providers need to demon- 2012). strate multicultural experience. In a study comparing outcomes among Black and White Longstanding suspicions regarding established clients at community mental health centers, healthcare institutions can also affect African the only clinician factor that predicted more Americans’ participation in, attitudes toward, favorable outcomes was clinicians’ general and outcomes after treatment (for review, see experiences and relationships with people Pieterse et al. 2012). Historically, the mental from racial/ethnic and cultural groups other health system has shown bias against African than their own (Larrison et al. 2011). Americans, having been used in times past to control and punish them (Boyd-Franklin and Treatment Issues and Karger 2012; Jackson 2003). After controlling Considerations for socioeconomic factors, African Americans are significantly more likely to perceive the African American clients generally respond healthcare system as poor or fair and signifi- better to an egalitarian and authentic relation- cantly more likely to believe that they have ship with counselors (Sue 2001). Paniagua been discriminated against in healthcare (1998) suggests that in the initial sessions with settings (Blendon et al. 2007). Attitudes to- African American clients, counselors should ward psychological services appear to become develop a collaborative client–counselor rela- more negative as psychological distress in- tionship. Counselors should request personal creases (Obasi and Leong 2009). In many information gradually rather than attempting African American communities, there is a to gain information as quickly as possible, persistent belief that social and treatment avoid information-gathering methods that services try to impose White American values, clients could perceive as an interrogation, pace adding to their distrust of the treatment sys- the session, and not force a data-gathering tem (Larkin 2003; Solomon 1990). agenda (Paniagua 1998; Wright 2001). Coun- selors must also establish credibility with African Americans, even when receiving the clients (Boyd-Franklin 2003). same amount of services as White Americans, are less likely to be satisfied with those services Next, counselors should establish trust. Self- (Tonigan 2003). However, recent evidence disclosure can be very difficult for some clients suggests that, once engaged, African American because of their histories of experiencing clients are at least as likely to continue partici- racism and discrimination. These issues can be pation as members of other ethnic/racial exacerbated in African American men whose groups (Harris et al. 2006). Because distrust of experience of racism has been more severe or the healthcare system can make it more diffi- who have had fewer positive relationships with cult to engage African American clients ini- White Americans (Reid 2000; Sue 2001). tially in treatment, Longshore and Grills Counselors, therefore, need to be willing to (2000) recommend culturally congruent moti- address the issue of race and to validate African vational enhancement strategies to address American clients’ experiences of racism and its African American clients’ ambivalence about reality in their lives, even if it differs from treatment services. Providers also need to craft their own experiences (Boyd-Franklin 2003; culturally responsive health-related messages Kelly and Parsons 2008). Moreover, racism for African Americans to improve treatment and discrimination can lead to feelings of engagement and effectiveness (Larkin 2003). anger, anxiety, or depression. Often, these feelings are not specific to any given event;

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rather, they are pervasive (Boyd-Franklin et al. overview of core guiding principles in work- 2008). Counselors should explore with clients ing with African American clients. the psychological effects of racism and develop approaches to challenge internal negative Theoretical Approaches and messages that have been received or generated Treatment Interventions through discrimination and prejudice (Good- Research suggests that culturally congruent ing 2002). interventions are effective in treating African Additional methods that may enhance en- Americans (Longshore and Grills 2000; gagement and promote participation include Longshore et al. 1998a; Longshore et al. peer-supported interventions and strategies 1998b; 1999). Although there are conflicting that promote empowerment by emphasizing results on the effectiveness of motivational strengths rather than deficits (Paniagua 1998; interviewing among African American clients Tondora et al. 2010; Wright 2001). It is (Montgomery et al. 2011), some motivational important to explore with clients the interventions have been found to reduce sub- strengths that have brought them this far. stance use among African Americans What personal, community, or family (Bernstein et al. 2005; Longshore and Grills strengths have helped them through difficult 2000). Longshore and Grills (2000) describe a times? What strengths will support their culturally specific motivational intervention recovery efforts? Exhibit 5-1 gives an for African Americans involving both peer and professional counseling that makes use of the core African American value of commu- Exhibit 5-1: Core Culturally nalism by addressing the ways in which the Responsive Principles in Counseling African Americans individual’s substance abuse affects his or her whole community. The motivational program According to Schiele (2000), culturally respon- affirms “the heritage, rights, and responsibili- sive counseling for African American clients ties of African Americans…using interaction involves adherence to six core principles: 1. Discussion of clients’ substance use should styles, symbols and values shared by members be framed in a context that recognizes the of the group” (Longshore et al. 1998b, p. 319). totality of life experiences faced by clients So too, African American music, artwork, and as African Americans. food can help programs create a welcoming 2. Equality is sought in the therapeutic coun- and familiar atmosphere, as is the case for selor–client relationship, and counselors are less distant and more disclosing. other racial and ethnic groups when familiar 3. Emphasis is placed on the importance of cultural symbols appear in the clinical setting. changing one’s environment—not only for the good of clients themselves, but also for Many of the interventions developed for the greater good of their communities. substance abuse treatment services in general 4. Focus is placed on alternatives to sub- have been evaluated with populations that stance use that underscore personal rituals, were at least partly composed of African cultural traditions, and spiritual well-being. Americans; many of these interventions are as 5. Recovery is a process that involves gaining power in the forms of knowledge, spiritual effective for African Americans as they are for insight, and community health. White Americans (Milligan et al. 2004; To- 6. Recovery is framed within a broader con- nigan 2003). One intervention that appears to text of how recovery contributes to the work better for African American (and Latino) overall healing and advancement of the clients than for White American clients— African American community. perhaps because it focuses on improving

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client–counselor communication—is node- Another therapy that has been evaluated with link mapping (visual representation using African American clients and found effective information diagrams, fill-in-the-blank graph- is supportive–expressive psychotherapy, which ic tools, and client-generated diagrams or reduces substance use and improves psycho- visual maps). This approach was associated logical functioning for individuals in metha- with lower rates of substance use, better treat- done maintenance (Woody et al. 1987; Woody ment attendance, and better counselor ratings et al. 1995). Medications for substance abuse of motivation and confidence among African can also work well with African American Americans than among White Americans clients. In one large study, African Americans (Dansereau et al. 1996; Dansereau and were more likely than Latinos or White Simpson 2009). Americans to indicate that they found metha- done helpful (Gerstein et al. 1997), and in In addition, cognitive–behavioral therapy another study, they reported greater perceived (CBT) has certain distinct advantages for quality of life as a result of participation in a African American clients; it fosters a collabo- methadone program (Geisz 2007). Schroeder et rative relationship and recognizes that clients al. (2005) also reported that African Americans are experts on their own problems (Kelly and in a methadone program had significantly Parsons 2008). Maude-Griffin et al. (1998) fewer adverse medical events (e.g., infections, compared CBT and 12-Step facilitation for a gastrointestinal complaints) than did White group of mostly African American (80 per- American participants. African Americans cent) men who were homeless and found that who were being treated for cocaine depend- CBT achieved significantly better abstinence ence remained in treatment significantly outcomes, except among those who considered longer than did other African Americans if themselves very religious (these individuals they received disulfiram (Milligan et al. 2004). had better outcomes with 12-Step facilitation). A review of cultural adaptations of evidence- Other interventions that use CBT principles based practices is given by Bernal and have also been effective with African American Domenech Rodriguez (2012). For an over- populations. For example, a number of studies view of gender-specific treatment considera- have evaluated contingency management tions for mental and substance use disorders approaches with predominantly African among African American men and women, American client populations, finding that this see Shorter-Gooden (2009). model was effective at reducing cocaine and illicit opioid use, improving employment Family therapy outcomes for clients in methadone mainte- African American clients appear more likely nance (Silverman et al. 2002; Silverman et al. to stay connected with their families through- 2007), reducing substance use during and after out the course of their addiction. For instance, treatment, and improving self-reported quality Bourgois et al. (2006) reported that in compar- of life (Petry et al. 2004; Petry et al. 2005; Petry ing African American and White American et al. 2007). The Living in the Balance inter- individuals who injected heroin, African vention, which uses psychoeducation and CBT Americans appeared to be more likely to techniques, has also been evaluated with a maintain contact with their extended families. mostly African American sample and has been Some research also suggests that African shown to improve treatment retention and Americans with substance use disorders are reduce substance use (Hoffman et al. 1996). more likely to have family members with

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histories of substance abuse, suggesting an Advice to Counselors: Strengths of even greater need to address substance abuse African American Families within the family (Brower and Carey 2003). African American kinship bonds have historically Strong family bonds are important in African been sources of strength. Although substance abuse lessens the strength of the family and American cultural groups. African American can erode relationships, counselors can use the families are embedded in a complex kinship inherent strengths of the family to benefit network of biologically related and unrelated clients and their families (Boyd-Franklin and persons. Hence, counselors should be willing Karger 2012; Larkin 2003; Reid 2000). Bell- to expand the definition of family to a more Tolliver et al. (2009) and Hill (1972) suggest that strengths of African American family life include: extended kinship system (Boyd-Franklin • Strong bonds and extensive kinship. 2003; Hines and Boyd-Franklin 2005). Clients • Adaptability of family roles. need to be asked how they define family, • A strong family hierarchy. whom they would identify as family or “like • A strong work orientation. family,” who resides with them in their homes, • A high achievement orientation. • A strong religious orientation. and whom they rely on for help. Hines and Boyd-Franklin (2005) discuss the importance of both blood and nonblood kinship networks system. Network therapy, which involves for African American families. To build a clients’ extended social networks, has also been support network for African American clients, found to improve substance use outcomes for counselors should start by asking clients to African American clients when added to identify people (whether biological kin or not) standard treatment (Keller and Galanter who would be willing and able to support 1999). Likewise, the family team conference their recovery and then ask clients for permis- model can be a useful approach, given that it sion to contact those people and include them also engages both families and communities in in the treatment process. the helping process by attempting to stimulate extensive mobilization of activity in the formal Family therapy is often a productive approach and informal relationships in and around cli- to treatment with African Americans (Boyd- ents’ families (State of Department Franklin 2003; Hines and Boyd-Franklin of Human Services 2004). 2005; Larkin 2003). However, the extended family can be large and have many ties with Brief structural family therapy and strategic other families in a community; therefore, the family therapy reduce substance use as well, family therapist sometimes needs to take on but research has primarily focused on African other roles to assist with case management or American youth (Santisteban et al. 1997; other activities, including involvement in Santisteban et al. 2003; Szapocznik and community-wide interventions (Sue 2001). In Williams 2000). Multidimensional family reviewing specific family therapy approaches therapy has increased abstinence from sub- for African Americans, Boyd-Franklin (2003) stance use among African American adoles- discusses the use of a multisystem family cents and produced more lasting effects than therapy approach, which incorporates an CBT, but it also has not been evaluated with extended network of relationships that play a adult clients (Liddle et al. 2008). In reviewing part in clients’ lives. Using this model, social specific family programs, Larkin (2003) reports service and other community agencies can be promising preliminary data on a family therapy considered a significant part of the family intervention among African Americans in public housing that addresses substance abuse.

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The program initially engages families via problems to people who are relative strangers. psychoeducation on substance abuse and its African Americans seem less likely to self- effects on the family, followed by a strength- disclose about the past in group settings that based family therapy intervention. Despite the include non- Whites (Johnson et al. small sample size, all 10 families admitted to 2011; Richardson and Williams 1990). Con- the program completed treatment, and 7 of 10 sequently, groups composed only of African family members with substance abuse prob- Americans can be more beneficial. Homoge- lems entered recovery and continuing care. nous African American groups can also be Participant surveys indicated that 60 percent good venues for clients to deal with systemic of families preferred multiple-family therapy problems, such as racism and lack of economic over single-family therapy, and 80 percent opportunities in the African American com- preferred services delivered in the housing munity (Jones et al. 2000). project community center to other venues. Mutual-help groups Engaging Moms is another family-oriented A variety of mutual-help groups are available program and intervention developed specifi- for African Americans entering recovery from cally for African American mothers that has substance use and mental disorders. However, been shown to significantly improve treatment most of the literature focuses on 12-Step engagement (Dakof et al. 2003). The interven- groups, including Alcoholics Anonymous tion is designed for women who have children (AA) and Narcotics Anonymous. Some find and have been identified as cocaine users. The that the 12-Step approach warrants careful program focuses on mobilizing family members consideration with African Americans, who who would be likely to motivate the mothers to can find the concept of powerlessness over enroll and remain in substance abuse treatment. substances of abuse to be too similar to experi- Research has shown no long-term impact, yet ences of powerlessness via discrimination. women who received the intervention were Additionally, the disease concept of addiction significantly more likely to enter treatment (88 presented in 12-Step meetings can be difficult percent of women involved in the program for many African Americans (Durant 2005). versus 46 percent of the control group) and In some instances, the Black community has remain for at least 2 weeks. changed the mutual-help model for substance Group therapy use and mental health to make it more em- powering and relevant to African American Because of the communal, cooperative values participants. For additional information on the held by many African Americans, group ther- 12 Steps for African Americans, visit Alcohol- apy can be a particularly valuable component ics Anonymous World Services (AAWS), AA of the treatment process (Sue and Sue 2013b). for the Black and African American Alcoholic, A strong oral tradition is one of many forms available online (http://www.aa.org/ of continuity with African tradition main- pdf/products/p-51_CanAAHelpMeToo.pdf). tained in the African American experience; therefore, speaking in groups is generally Despite their emphasis on the concept of acceptable to African American clients. How- powerlessness, 12-Step programs are significant ever, Bibb and Casimer (2000) note that Black support systems for many African Americans. Caribbean Americans can be less comfortable In AA’s 2011 membership survey, 4 percent of with the group process, particularly the re- members identified their race as Black quirement that they self-disclose personal (AAWS 2012). Analysis of 2006–2007

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NSDUH data showed that African Americans express a greater degree of comfort with shar- were less likely to use mutual-help groups in ing in meetings, and they are more likely to the past year for substance use (about 11 engage in AA services and state that they had percent did) than White Americans (about 67 a spiritual awakening as a result of AA partic- percent did) or Latinos (about 16 percent did; ipation (Bibb and Casimer 2000; Kaskutas et SAMHSA 2013d). However, the National al. 1999; Kingree 1997). Epidemiologic Survey on Alcohol and Related Research suggests that African Americans Conditions (NESARC) survey did find that who attend 12-Step programs have higher African Americans who had a lifetime drug levels of affiliation than White Americans in use disorder diagnosis and had sought help the same programs (Kingree and Sullivan were more than three times as likely to have 2002). However, they are less likely to have a attended mutual-help meetings as were White sponsor or to read program materials (Kaskutas Americans or Latinos (Perron et al. 2009). et al. 1999), and their abstinence appears to be Several other surveys suggest that African less affected by meeting attendance (Timko et Americans with alcohol-related problems are al. 2006). Other research has found that at least as likely to participate in AA as White African Americans who participate in 12-Step Americans and that greater problem severity is groups report an increase in the number of associated with increased likelihood of partici- people within their social networks who sup- pation (Kingree and Sullivan 2002). Of the port their recovery efforts (Flynn et al. 2006). participants who attended mutual-help group Other mutual-help groups for African sessions for mental health in the past year, Americans are available, particularly faith- approximately 10 percent were Black or Afri- based programs to support recovery from can American, 75 percent were White Ameri- mental illness and substance use disorders and can, and 11.4 percent were Latino (SAMHSA to aid individuals in the process of transition- 2010). ing from correctional institutions. For exam- Durant (2005) observes that African American ple, the has been involved in 12-Step participants tend to participate differ- successful substance abuse recovery efforts, ently in meetings where participants are most- especially for incarcerated persons (Sanders ly White Americans than in meetings where 2002; White and Sanders 2004). most participants are African American. In Traditional healing and some areas, there are 12-Step meetings that complementary methods are largely or entirely composed of African American members, and some African In general, African Americans are less likely to American clients feel more comfortable par- make use of popular alternative or comple- ticipating in these meetings. Mutual-help mentary healing methods than White Ameri- groups can be particularly helpful for African cans or Latinos (Graham et al. 2005). Americans who consider themselves religious. However, the African American culture and Maude-Griffin et al. (1998) found that indi- history is steeped in healing traditions passed viduals who identified as highly religious did down through generations, including herbal significantly better when receiving 12-Step remedies, root medicines, and so forth (Lynch facilitation than when receiving CBT, but that and Hanson 2011). The acceptance of tradi- pattern was reversed for those who did not tional practices by African American clients consider themselves highly religious. Other and their families does not necessarily indicate studies have found that African Americans that they oppose or reject the use of modern

114 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups therapeutic approaches or other alternative a central role in education, politics, recreation, approaches. They can accept and use all forms and social welfare in African American com- of treatment selectively, depending on the munities. To date, African Americans report perceived nature of their health problems. the highest percentage (87 percent) of reli- That said, psychological and substance abuse gious affiliation of any major racial/ethnic problems can be seen as having spiritual causes group (Kosmin and Keysar 2009; Pew Forum that need to be addressed by traditional heal- on Religion and Public Life 2008). Even ers or religious practices (Boyd-Franklin though most are committed to various 2003). Moreover, African Americans are much Christian denominations (with the Baptist and more likely to use religion or spirituality as a African Methodist Episcopal churches ac- response to physical or psychological problems counting for the largest percentages), a growing (Cooper et al. 2003; Dessio et al. 2004; number of African Americans are converts to Graham et al. 2005; Nadeem et al. 2008). Islam, and many recent immigrants from Africa to the United States are also Muslims African American cultural and religious insti- (Boyd-Franklin 2003; Pew Forum on Religion tutions (see advice box below) play an im- and Public Life 2008). portant role in treatment and recovery, and African Americans who use spirituality or Relapse prevention and recovery religion to cope with health problems are nearly African Americans appear to be responsive to twice as likely as other African Americans to continuing care participation and recovery also make use of complementary or alterna- activities associated with substance use and tive medicine (Dessio et al. 2004). Likewise, mental disorders, yet research is very limited. African American churches and mosques play According to NESARC data (Dawson et al.

Advice to Counselors: The Role of African American Religious Institutions in Treatment and Recovery Within African American communities, religious institutions and clergy often function as service providers as well as counselors (Boyd-Franklin 2003; Reid 2000; Taylor et al. 2000). It is not uncom- mon for African Americans to approach clergy first when faced with their own or family members’ mental health or substance abuse problems, but many African American clergy members believe they are not well-prepared to address those problems (Neighbors et al. 1998; Sexton et al. 2006). According to NESARC data, African Americans are twice as likely as Latinos and nearly three times as likely as White Americans to receive pastoral counseling for their drug use (Perron et al. 2009).

For many African Americans in recovery, churches play a significant role in helping them maintain abstinence (Perron et al. 2009). Beyond pastoral counseling, research suggests that other means of engagement within the church can lead to recovery. For example, participation in religious services has been associated with significantly better outcomes for African American men in continuing care following court-mandated treatment (Brown et al. 2004). Stahler et al. (2007) also report successful use of peer mentors drawn from churches for African American women in treatment, marked by significantly fewer drug-positive urine samples in the 6 months following treatment.

Counselors working with African American clients should prepare to include churches, mosques, or other faith communities in the therapeutic process, and they should develop a list of appropriate spiritual resources in the community. Treatment providers may consider involving African American clergy in treatment programs to improve clergy members’ understanding of behavioral health prob- lems and treatments and to better engage clients and their families. Programs can conduct outreach with local faith-based institutions and clergy to facilitate treatment referrals (Taylor et al. 2000).

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2005), African Americans in recovery from secure resources and appropriate support when alcohol dependence were more than twice as needed, or engage in coping behaviors condu- likely as White Americans to maintain absti- cive to maintaining recovery. Counselors can nence rather than just limiting alcohol con- help clients practice coping skills by role- sumption or changing drinking patterns. In playing, even if clients are confident that they another study analyzing the use of continuing can manage difficult or high-risk situations. care following residential treatment in the U.S. Department of Veterans Affairs care system, Counseling for Asian African American men were significantly Americans, Native more likely than White Americans to partici- pate in continuing care (Harris et al. 2006). Hawaiians, and Other Other research evaluating continuing care for Pacific Islanders African American men who had been man- dated to outpatient treatment by a parole or Asian Americans, per the U.S. Census Bureau probation office found that participants as- definition, are people whose origins are in the signed to a continuing care intervention were Far East, Southeast Asia, or the Indian sub- almost three times as likely to be abstinent and continent (Humes et al. 2011). The term in- five times less likely to be using any drugs on a cludes East Asians (e.g., Chinese, Japanese, and weekly basis during the 6-month follow-up ), Southeast Asians (e.g., period compared with those who did not Cambodian, Laotian, and Vietnamese receive continuing care (Brown et al. 2004). Americans), Filipinos, Asian Indians, and In evaluating appropriate relapse prevention Central Asians (e.g., Mongolian and Uzbek strategies for African American clients, Americans). In the 2010 Census, people who Walton et al. (2001) found that African identified solely as Asian American made up American clients leaving substance abuse 4.8 percent of the population, and those who treatment reported fewer cravings, greater use identified as Asian American along with one of coping strategies, and a greater belief in or more other races made up an additional 0.9 their self-efficacy. However, they also expected percent. Census data includes specific infor- to be involved in fewer sober leisure activities, mation on people who identify as Asian Indian, to be exposed to greater amounts of substance Chinese, Filipino, Japanese, Korean, use, and to have a greater need for continuing Vietnamese, and “other Asians.” The largest care services (e.g., housing, medical care, Asian populations in the United States are assistance with employment). Walton notes , , that these findings could reflect a tendency of Asian , Korean Americans, African American clients to underestimate the and . Asian Americans difficulties they will face after treatment; they overwhelmingly live in urban areas, and more report a greater need for resources and greater than half (51 percent) live in just three states exposure to substance use, but they still have a (NY, CA, and HI; Hoeffel et al. 2012). greater belief in their ability to remain free of Not all people with origins in Asia belong to substances. Although an individual’s belief in what is commonly conceived of as the Asian coping can have a positive effect on initially race. Some Asian Indians, for example, self- managing high-risk situations, it also can lead identify as White American. For this reason, to a failure to recognize the level of risk in a among others, counselors should be careful to given situation, anticipate the consequences, learn from their Asian American clients how

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they identify themselves and which national (Iversen 2000; Martin 1975). However, some heritages they claim. Counselors should rec- Asian Americans tend to view illicit substance ognize that clients who appear to be Asian use and abuse as a serious breach of acceptable may not necessarily think of themselves pri- behavior that cannot readily be discussed. marily as persons of Asian ancestry or have a Nonetheless, there are broad differences in deep awareness of the traditions and values of Asian cultures’ perspectives on substance use, their countries of origin. For example, Asian thus requiring counselors to obtain more orphans who have been adopted in the United specific information during intake and subse- States and raised as Americans in White quent encounters. American families may have very little con- Acknowledging a substance abuse problem nection with the cultural groups of their bio- often leads to shame for Asian American logical parents (St. Martin 2005). Counselors clients and their families. Families may deny should not make generalizations across Asian the problem and inadvertently, or even inten- cultures; each culture is quite distinct. tionally, isolate members who abuse substances Little literature on substance use and mental (Chang 2000). For example, some Cambodian disorders, rates of co-occurrence, and treatment and Korean Americans perceive alcohol abuse among Asian Americans focuses on behavioral and dependence as the result of moral weak- health treatment for Native Hawaiians and ness, which brings shame to the family Pacific Islanders; thus, a text box at the end (Amodeo et al. 2004; Kwon-Ahn 2001). of this section summarizes available information. Substance Use and Substance Use Disorders Beliefs About and Traditions According to the 2012 NSDUH, Asian Involving Substance Use Americans use alcohol, cigarettes, and illicit Within many Asian societies, the use of intox- substances less frequently and less heavily than icants is tolerated within specific contexts. For members of any other major racial/ethnic example, in some Asian cultural groups, alco- group (SAMHSA 2013d). However, large hol is believed to have curative, ceremonial, or surveys may undercount Asian American beneficial value. Among pregnant Cambodian substance use and abuse, as they are typically women, small amounts of herbal medicines conducted in English and Spanish only with an alcohol base are sometimes used to (Wong et al. 2007b). Despite the limitations of ensure an easier delivery. Following childbirth, research, data suggest that although Asian similar medicines are generally used to in- Americans use illicit substances and alcohol crease blood circulation (Amodeo et al. 1997). less frequently than other Americans, sub- Some Chinese people believe that alcohol stance abuse problems have been increasing restores the flow of qi (i.e., the life force). The among Asian Americans. The longer Asian written Chinese character for “doctor” con- Americans reside in the United States, the tains the character for alcohol, which implies more their substance use resembles that of the use of alcohol for medicinal purposes. other Americans. Excessive alcohol use, intox- ication, and substance use disorders are more Some Asian American cultural groups make prevalent among Asians born in the United allowances for the use of other substances. States than among foreign-born Asians living Marijuana, for instance, has been used medici- in the United States (Szaflarski et al. 2011). nally in parts of Southeast Asia for many years

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Among Asian Americans who entered sub- to use illicit drugs, whereas Filipino Americans stance abuse treatment between 2000 and had the highest rate of illicit drug use 2010, methamphetamine and marijuana were (Nemoto et al. 1999). In that same study, the most commonly reported illicit drugs Filipino American immigrants were also (SAMHSA, CBHSQ 2012). Methampheta- significantly more likely to have begun using mine abuse among Asian Americans is partic- substances prior to immigrating than were ularly high in and on the West Coast Chinese or Vietnamese immigrants. Other (OAS 2005a). As with other racial and ethnic studies have found that Filipino Americans are groups, numerous factors—such as age, birth more likely to use illicit drugs and to inject country, immigration history, acculturation, drugs than other Asian American populations employment, geographic location, and in- (see review in Nemoto et al. 2002). come—add complexity to any conclusions To date, the largest national study to assess about prevalence among specific Asian cultur- substance use and mental disorders across al groups. Asian Americans who are recent Asian American groups is the NLAAS immigrants, highly acculturated, unemployed, (Takeuchi et al. 2007). This study found that or living in Western states are generally more Filipino American men were 2.38 times more likely than other Asian Americans to abuse likely to have a lifetime substance use disorder drugs or alcohol (Makimoto 1998). For exam- than were Chinese American men, whereas ple, according to the National Latino and the differences among women of diverse Asian Asian American Study (NLAAS), Asians who ethnicities were much smaller. Other research are more acculturated are at greater risk for suggests that Korean Americans are more prescription drug abuse (Watkins and Ford likely to have family histories of alcohol de- 2011). pendence than are Chinese Americans There are variations among particular groups (Ebberhart et al. 2003). of Asians; some Asian cultural groups have Besides the variations across different cultures, different attitudes toward substance use than substance use and abuse among Asian Ameri- others, and these differences tend to be ob- cans is also influenced by age. Substance abuse scured in large-scale surveys. Researchers have appears higher for young Asian Americans found that Korean American college students than for those who are older (possibly reflect- drank more frequently and drank greater ing differences in acculturation). A study quantities than did Chinese American stu- conducted in City showed that dents at the same schools and were more likely Asian American junior and senior high school to consider drinking socially acceptable students had the lowest percentage of heavy (Chang et al. 2008). Another study in the drinkers of any ethnic group, but those who District of Columbia and surrounding metro- were heavy drinkers drank twice as much daily politan area compared substance use among as those who did not drink heavily (Makimoto different groups of Southeast Asians (i.e., 1998). Asian American youth, especially im- Cambodian, Laotian, and Vietnamese migrants, tend to start using substances at a Americans); Vietnamese Americans had the later age than members of other ethnic groups, highest rates of alcohol use, but Cambodian which could be a factor in the lower levels of Americans had the highest rates of illicit drug abuse seen among Asian Americans. use (Wong et al. 2007b). Research in San Francisco found Chinese Americans to be less Despite rates of substance use disorders likely than Vietnamese or Filipino Americans among Asian Americans having increased over

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time, research has regularly found that, of all Americans are more likely to present with major racial/ethnic groups in United States, somatic complaints and less likely to present Asian Americans have the lowest rates of with symptoms of psychological distress and alcohol use disorders (Grant et al. 2004; impairment (Hsu and Folstein 1997; Kim et SAMHSA 2012b). This phenomenon has al. 2004; Room et al. 2001; U.S. Department typically been explained in part by the fact of Health and Human Services [HHS] 2001; that some Asians lack the enzyme aldehyde Zhang et al. 1998), even though mental illness dehydrogenase, which chemically breaks down appears to be nearly as common among Asian alcohol (McKim 2003). Thus, high levels of Americans as it is in other ethnic/racial acetaldehyde, a byproduct of alcohol metabo- groups. In 2009, approximately 15.5 percent of lism, accumulate and cause an unpleasant Asians reported a mental illness in the past flushing response (Yang 2002). The alcohol year, but only 2 percent reported past-year flushing response primarily manifests as flush- occurrence of serious mental illness (SAMHSA ing of the neck and face but can also include 2012a). Asian Americans have a lower inci- nausea, headaches, dizziness, and other dence of CODs than other racial/ethnic groups symptoms. because the prevalence of substance use disor- ders in this population is lower. In the 2012 Additional factors that could play a part in NSDUH, 0.3 percent of Asian Americans increasing the likelihood of substance use indicated co-occurring serious psychological disorders among Asian Americans include distress and substance use disorders, and 1.1 experiences of racism and the absence of percent had some symptoms of mental distress ethnic identification. Compared with Asian along with a substance use disorder—the low- Americans who do not have alcohol use disor- est rates of any major racial/ethnic group in the ders, Asian Americans who have alcohol use survey (SAMHSA 2013c). disorders are more than five times as likely to report unfair treatment because of their race Considerable variation in the types of mental and are more than twice as likely to deny disorders diagnosed among diverse Asian strong ethnic identification (Chae et al. 2008). American communities is evident, although it Compared with other racial and ethnic is unclear to what extent this reflects diagnostic groups, Asian Americans who drink heavily and/or self-selection biases. For example, are more likely to have friends or peers who Barreto and Segal (2005) found that Southeast also drink heavily (Chi et al. 1989). Asians were more likely to be treated for major depression than other Asians or mem- Mental and Co-Occurring bers of other ethnic/racial groups; East Asians Disorders were the most likely of all Asian American Overall, health and mental health are not groups to be treated for schizophrenia (nearly seen as two distinct entities by Asian Ameri- twice as likely as White Americans). Traumat- can cultural groups. Most Asian American ic experiences and PTSD can be particularly views focus on the importance of virtue, difficult to uncover in some Asian American maturity, and self-control and find full emo- clients. Although Asian Americans are as tional expression indicative of a lack of ma- likely to experience traumatic events (e.g., turity and self-discipline (Cheung 2009). wars experienced by first-generation immi- Given the potential shame they often associate grants from countries such as Vietnam and with mental disorders and their typically Cambodia) in their lives, their cultural respons- holistic worldview of health and illness, Asian es to trauma can conceal its psychological

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effects. For instance, some Asian cultural year, Asian Americans were also the most groups believe that stoic acceptance is the likely of all major racial/ethnic groups to most appropriate response to adversity (Lee report that they could not afford or had no and Mock 2005a,b). insurance coverage for substance abuse treat- ment (SAMHSA, CBHSQ 2011). Treatment Patterns Beliefs and Attitudes About Treatment-seeking rates for mental illness are low among most Asian populations, with rates Treatment varying by specific ethnic/cultural heritage Compared with the general population, Asian and, possibly, level of acculturation (Abe-Kim Americans are less likely to have confidence in et al. 2007; Barreto and Segal 2005; Lee and their medical practitioners, feel respected by Mock 2005a,b). Asian Americans who seek their doctors, or believe that they are involved help for psychological problems will most in healthcare decisions. Many also believe that likely consult family members, clergy, or tradi- their doctors do not have a sufficient under- tional healers before mental health profession- standing of their backgrounds and values; this als, in part because of a lack of culturally and is particularly true for Korean Americans linguistically appropriate mental health ser- (Hughes 2002). Even so, Asian Americans, vices available to them (HHS 2001; Spencer especially more recent immigrants, seem more and Chen 2004). However, among those Asian likely to seek help for mental and substance Americans who seek behavioral health treat- use disorders from general medical providers ment, the amount of services used is relatively than from specialized treatment providers high (Barreto and Segal 2005). (Abe-Kim et al. 2007). Many Asian American Asian Americans tend to enter treatment with immigrants underuse healthcare services due to less severe substance abuse problems than confusion about eligibility and fears of jeopard- members of other ethnic/racial groups and izing their residency status (HHS 2001). have more stable living situations and fewer As with other groups, discrimination, accul- criminal justice problems upon leaving treat- turation stress, and immigration and genera- ment (Niv et al. 2007). However, for Asian tional status, along with language needs, have Americans involved in the criminal justice a large influence on behavioral health and system, there is a more pronounced relation- treatment-seeking for Asian Americans (Meyer ship between crime and drug abuse than for et al. 2012; Miller et al. 2011). The NLAAS other ethnic and racial groups. In the early found that although rates of behavioral health 1990s, an estimated 95 percent of Asian service use were lower for Asian Americans Americans in prisons were there who immigrated recently than for the general because of drug-related crimes (Kuramoto population, those rates increased significantly 1994). According to SAMHSA’s 2010 TEDS for U.S.-born Asian Americans; third- data, 48.5 percent of Asian Americans in generation U.S.-born individuals’ rates of ser- treatment were referred by the criminal justice vice use also were relatively high (Abe-Kim et system in that year, compared with 36.4 per- al. 2007). Of those Asian Americans who had cent of African Americans and 36.6 percent of any mental disorder diagnosis in the prior year, White Americans (SAMHSA, CBHSQ 62.6 percent of third-generation Americans 2012). According to 2010 NSDUH data sought help for it in the prior year compared regarding individuals who reported a need for with 30.4 percent of first-generation treatment but did not receive it in the prior Americans.

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Overall, Asian Americans place less value on biopsychosocial explanations for substance use substance abuse treatment than other popula- and mental disorders. Counselors should tion groups and are less likely to use such promote discussions focused on clients’ under- services (Yu and Warner 2012). Niv et al. standing of their presenting problems as well (2007) found that Asian and Pacific Islanders as any approaches the clients have used to entering substance abuse treatment programs address them. Subsequently, presenting prob- in California expressed significantly more lems need to be reconceptualized in language negative attitudes toward treatment and rated that embraces the clients’ perspectives (e.g., an it as significantly less important than did imbalance in yin and yang, a disruption in chi; others entering treatment. Seeking help for Lee and Mock 2005a,b). It is advisable to substance abuse can be seen, in some Asian educate Asian American clients on the role of American cultural groups, as an admission of the counselor/therapist, the purpose of thera- weakness that is shameful in itself or as an peutic interventions, and how particular aspects interference with family obligations (Masson of the treatment process (e.g., assessment) can et al. 2013). Among 2010 NSDUH respond- help clients with their presenting problems ents who stated a need for substance abuse (Lee and Mock 2005a,b; Sue 2001). Asian treatment in the prior year but did not receive American clients who receive such education it, Asian Americans were more likely than participate in treatment longer and express members of all other major racial/ethnic greater satisfaction with it (Wong et al. 2007a). groups to say that they could handle the prob- As with other racial/ethnic groups, Asian lem without treatment or that they did not American clients are responsive to a warm and believe treatment would help (SAMHSA empathic approach. Counselors should realize, 2011c). Combining NSDUH data from 2003 though, that building a strong, trusting rela- to 2011 NSDUH, Asian Americans who tionship takes time. Among Asian American needed but did not receive treatment in the clients, humiliation and shame can permeate past year were the least likely of all major the treatment process and derail engagement ethnic/racial groups to express a need for such with services. Thus, it is essential to assess and treatment (SAMHSA, CBHSQ 2013c). discuss client beliefs about shame (see the Treatment Issues and “Assessing Shame in Asian American Clients” Considerations advice box on the next page). In some cases, self-disclosure can be helpful, but the counse- It is important for counselors to approach lor should be careful not to self-disclose in a presenting problems through clients’ culturally way that will threaten his or her position of based explanations of their own issues rather respect with Asian American clients. than imposing views that could alter their acceptance of treatment. In Asian cultural Asian American clients may look to counse- groups, the physical and emotional aspects of lors for expertise and authority. Counselors an individual’s life are undifferentiated (e.g., should attempt to build client confidence in the physical rather than emotional or psycho- the first session by introducing themselves by logical aspect of a problem can be the focus title, displaying diplomas, and mentioning his for many Asian Americans); thus, problems as or her experience with other clients who have well as remedies are typically handled holisti- similar problems (Kim 1985; Lee and Mock cally. Some Asian Americans with traditional 2005a,b). Asian American clients may expect backgrounds do not readily accept Western and be most comfortable with formalism on

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Advice to Counselors: Assessing verbal messages than on the explicit content of Shame in Asian American Clients messages (Hall 1976). Asian Americans often use indirect communication, relying on subtle Shame and humiliation can be significant barri- ers to treatment engagement for Asian Ameri- gestures, expressions, or word choices to con- cans. Gaw (1993) suggests that the presence of vey meaning without being openly confronta- the following factors may indicate that a client tional. Counselors must not only be observant has shame about seeking treatment: of nuances in meaning, but also learn about • The client or a family member is extremely verbal and nonverbal communication styles concerned about the qualifications of the counselor. specific to Asian cultural groups (for a review • The client is hesitant to involve others in of guidelines to use when working with Asian the treatment process. Americans, see Gallardo et al. 2012). • The client is excessively worried about confidentiality. Asian American clients appear to respond • The client refuses to cover expenses with more favorably to treatment in programs that private insurance. provide services to other Asian clients. • The client frequently misses or arrives late for treatment. Takeuchi et al. (1995) found that Asian • Family members refuse to support treat- Americans were much more likely to return to ment. mental health clinics where most clients were • The client insists on having a White Ameri- Asian American than to programs where that can counselor to avoid opening up to an- was not the case (98 percent and 64 percent other Asian. returned, respectively). When demographic • The client refuses treatment even when severe problems are evident. differences were controlled for, those who attended programs that had predominantly Asian clients were 15 times more likely to the part of counselors, especially at the begin- return after the initial visit. Asian Americans ning of treatment and prior to assessment of were also more likely to stay in treatment clients’ needs (Paniagua 1998). Many Asian when matched with an Asian American coun- American clients expect counselors to be selor regardless of the type of program they directive (Leong and Lee 2008). Passivity on attended. Sue et al. (1991) also found that the part of the counselor can be misinterpret- Asian American clients attended significantly ed as a lack of concern or confidence. more treatment sessions if matched with an Counselors who are unaccustomed to working Asian American counselor. with Asian populations will likely encounter Among Asian American women, crucial conflict between their theoretical worldview of strategies include reducing the shame of sub- counseling and the deference to authority and stance abuse and focusing on the promotion of avoidance of confrontation that is common overall health rather than just addressing among more traditional Asian American substance abuse. Such strategies reduce the clients. Some clients can be hesitant to con- chance of a woman and her family seeing tradict the counselor or even to voice their substance abuse as an individual flaw. Home own opinions. Confrontation can be seen as visits, when agreed in advance with the client, something to avoid whenever possible. Fur- can be appropriate in some cases as a way to thermore, many Asian cultural groups have gain the trust of, and show respect for, Asian high-context styles of communication, mean- American women. Asian American women ing that members often place greater im- may not be as successful in mixed-gender portance on nonverbal cues and the context of

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Advice to Administrators: Culturally Responsive Program Development Behavioral health service program administrators can improve engagement and retention of Asian clients by making culturally appropriate accommodations in their programs. The accommodations required will vary according to the specific cultural groups, language preferences, and levels of acculturation in question. The following culturally responsive program suggestions were initially identified for Cambodian clients but can be adapted to match the unique needs of other Asian clients from different ethnic and cultural backgrounds: • Create an advisory committee using representatives from the community. • Incorporate cultural knowledge and maintain flexible attitudes as a counselor. • Use cotherapist teams in which one member is Asian and bilingual. • Provide services in the clients’ primary language. • Develop culturally specific questionnaires for intake to capture information that may be missed by standard questionnaires. • Conduct culturally appropriate assessments of trauma that ask about the traumatic experiences common to the population in question. • Visit client homes to improve family involvement in treatment. • Provide support to families during transitions from and to professional care. • Emphasize traditional values. • Explore client coping mechanisms that draw upon cultural strengths. • Use acupuncture or other traditional practices for detoxification. • Integrate Buddhist ideas, values, and practices into treatment when appropriate. • Emphasize relationship-building; help clients with life problems beyond behavioral health concerns. • Provide concrete services, such as housing assistance and legal help. Sources: Amodeo et al. 2004; Park et al. 2011.

groups if strict gender roles exist whereby be more effective if providers avoid approaches communication is constricted within and out- that target emotional responses and instead side the family; women will likely remain silent use strategies that are more indirect in discuss- or defer to the men in the group (Chang 2000). ing feelings (e.g., saying “that might make For more information on treating women, see some people feel angry” rather than asking Treatment Improvement Protocol (TIP) 51, directly what the client is feeling; Sue 2001). Substance Abuse Treatment: Addressing the Asian Americans often prefer a solution- Specific Needs of Women (CSAT 2009c). focused approach to treatment that provides Theoretical Approaches and them with concrete strategies for addressing Treatment Interventions specific problems (Sue 2001). Even though little research is available in evaluating specific Some Asian cultural groups emphasize cogni- interventions with Asian Americans, clinicians tions. For instance, Asian cultural groups that tend to recommend cognitive–behavioral, have a Buddhist tradition, such as the Chinese, solution-focused, family, and acceptance view behavior as controlled by thought. Thus, commitment therapies (Chang 2000; Hall et they accept that addressing cognitive patterns al. 2011; Iwamasa et al. 2006; Rastogi and will affect behaviors (Chen 1995). Some Asian Wadhwa 2006; Sue 2001). Asian American cultural groups encourage a stoic attitude clients are likely to expect that their counselors toward problems, teaching emotional suppres- take an active role in structuring the therapy sion as a coping response to strong feelings session and provide clear guidelines about (Amodeo et al. 2004; Castro et al. 1999b; Lee what they expect from clients. CBT has the and Mock 2005a,b; Sue 2001). Treatment can

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advantages of being problem focused and time For most Asian Americans, particularly those limited, which will likely increase its appeal for who are less acculturated, successful treatment many Asian Americans who might see other involves the client’s family (Chang 2000; Kim types of therapy as failing to achieve real goals et al. 2004; Rastogi and Wadhwa 2006). Even (Iwamasa et al. 2006). Although specific data in individual treatment, it is important to on the effectiveness of CBT among Asian understand the client’s family and his or her Americans is not available, there is some relationship with its members, the dynamics research indicating that CBT is effective for and style of the family, and the family’s role in treating depressive symptoms in Asians (Dai the client’s substance abuse (Meyer et al. et al. 1999; Fujisawa et al. 2010). In China, a 2012). Particularly among Asian American Chinese Taoist version of CBT has been women, family involvement can be essential developed to treat anxiety disorders and was due to the client’s concern about being re- found to be effective, especially in conjunction sponsive to her family’s needs. Nonetheless, with medication (Zhang et al. 2002). involving the family can be quite difficult, as Family therapy both male and female clients may wish to conceal their substance abuse from their fami- Some Asian Americans, particularly those lies because of the shame that it brings. who are less acculturated, prefer individual therapy to group or family interventions be- Advice to Counselors: Culturally cause it better enables them to save face and Responsive Family Therapy keep their privacy (Kuramoto 1994). Some Guidelines for Asian Families clients may wish to enter treatment secretly so Kim et al. (2004) reviewed references that that they can keep their families and friends provide guidelines for family therapy with from knowing about their problems. Once Korean Americans. They established 11 essen- treatment is initiated, counselors should tial ingredients applicable to Korean and other Asian American groups and families. To pro- strongly reinforce the wisdom of seeking help vide culturally responsive therapy to Asian through statements such as “you show concern Americans, counselors should: for your husband by seeking help” or “you are • Assess support from community and ex- obviously a caring father to seek this help.” tended family systems. • Assess immigration history, if appropriate. The norm in Asian families is that “all prob- • Establish credibility as a professional in the lems (including physical and mental problems) initial meeting with the family. must be shared only among family members”; • Explain the key principles and expectations of family therapy and the family roles (es- sharing with others can cause shame and guilt, pecially elders/decisionmakers) in the pro- exacerbating problems (Paniagua 1998, pp. cess. 59–60). Counselors should expect to take • Enable clients, particularly male elders or more time than usual to learn about clients’ decisionmakers, to save face. situations, anticipate client needs for reassur- • Validate and address somatic complaints. • Be both problem focused and present ance in divulging sensitive information, and focused. frame discussions in a culturally competent • Be directive in guiding therapy. way. For example, counselors can assure cli- • Respect the family’s hierarchy. ents that discussing problems is a step toward • Avoid being confrontational and facilitate resuming their full share of responsibility in interactions that are nonconfrontational. • Reframe problems in positive terms. their families and removing some of the stress their families have been feeling. Source: Kim et al. 2004.

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To engage family members in the client’s group goals in this framework can garner treatment, the counselor first needs to be active participation. Still, in group settings and familiar with the way the family functions. in other instances, Asian American clients Different acculturation levels among individu- may expect a fair amount of direction from the al family members and across generations can group leader. Chen (1995) described leader- affect how the family functions, producing ship of a culturally specific therapy group for significant stress and internal conflict. Also, Chinese Americans, noting that clients expect the counselor must be aware of how gender a group leader to act with authority and give roles and generational status influence the more credence to his or her expertise than to communication patterns and rules within each other group members. If members of the family (e.g., expectations of how a child ad- group belong to the same Asian American dresses a parent, the potential relegation of community, the issue of confidentiality will authority among female family members). loom large, because the community is often Even more than for other clients, it is critical small. Asian cultural groups generally appreci- for Asian Americans to “avoid embarrassing ate education in more formal settings, so the family members in front of each other. psychoeducation groups can work well for The counselor should always protect the Asian Americans. It is possible for a psy- dignity and self-respect of the client and his or choeducational group with Asian American her family” (Paniagua 1998, p. 71). participants to evolve comfortably into group Group therapy therapy. Mutual-help groups Group therapy may not be a good choice for Asian Americans, as many prefer individual According to 2012 NSDUH data, Asian therapy (Lai 2001; Sandhu and Malik 2001). Americans were less likely than other racial Paniagua (1998, p. 73) suggests that “group and ethnic groups to report the use of mutual- therapy…would be appropriate in those cases help groups in the past year (SAMHSA in which the client’s support system (relatives 2013d). Mutual-help groups can be challeng- and close friends) is not available and an ing for Asian Americans who find it difficult alternative support system is quickly needed.” and shaming to self-disclose publicly. The Some Asian Americans participating in group degree of emotion and candor within these therapy will find it difficult to be assertive in a groups can further alienate traditional Asian group setting, preferring to let others talk. American clients. Furthermore, linguistically They can also abide by more traditional roles appropriate mutual-help groups are not always in this context; men might not want to divulge available for people who do not speak English. their problems in front of women, women can Highly acculturated Asian Americans may feel uncomfortable speaking in front of men, perceive participation in mutual-help groups and both men and women might avoid con- as less of a problem, but nevertheless, Asian tradicting another person in group (especially Americans can benefit from culture-specific an older person). It may not make sense to mutual-help groups where norms of interper- Asian American clients to hear about the sonal interaction are shared. Asian American problems of strangers who are not part of their 12-Step groups are available in some locales. community. It is important for counselors to assess client attitudes toward mutual-help participation Asian Americans are likely to be motivated to and find alternative strategies and resources, work for the good of the group; presenting

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including encouragement to attend without through a variety of culture-specific interven- sharing (Sandhu and Malik 2001). tions. For example, some Southeast Asian cultural groups practice cao gio—massaging Although they are not mutual-help groups in the skin with ointment and hot coins (Chan the traditional sense, mutual aid societies and and Chen 2011). The Chinese have developed associations are important in some Asian enormously complex systems of medical American communities. Some mutual aid treatment over centuries of pragmatic experi- societies have long histories and have provided mentation. Traditional herbal medicine com- assistance ranging from financial loans to help bines plant substances according to precise with childcare and funerals. The Chinese have formulas to have the desired influence on the family associations for people with the same affected organs of the body. Acupuncture last name who share celebrations and offer techniques involve regulating the flow of each other help. Japanese, Chinese, and South energy (qi) through the body by inserting Asians have specific associations for people needles at precise locations called acupuncture from the same province or village. For some points. In traditional Chinese medicine, which Asian American groups, such as Koreans, has influenced traditional medical practices in churches are the primary organizational vehi- other Asian cultural groups, illness is seen as cles for assistance. These social support groups an imbalance of yin and yang; a return to can be important resources for Asian American physical wellness can require introducing clients, their families, and the behavioral elements such as herbs to increase yin or yang health agencies that provide services to them. as needed (Torsch and Ma 2000). Traditional healing and Among less acculturated Asian Americans, complementary methods Western medicine, including Western behav- Asian Americans are twice as likely as other ioral health services, can be insufficient to deal Americans to report making use of acupunc- with a problem such as substance abuse and its ture and traditional healers. Even though there effects on clients and their families. For exam- is considerable variation in their use of com- ple, all health problems for the Hmong plementary and traditional medicine (Hughes (whether physical or psychological) are con- 2002), many Asian Americans highly regard sidered spiritual in nature; if providers ignore traditional healers, herbal preparations, and the clients’ understanding of their problems as other culturally specific interventions as a spiritual maladies, they are unlikely to effect means of restoring harmony and balance. positive change (Fadiman 1997). Even for However, Asian American clients do not more acculturated Asian Americans, the use of always readily disclose the use of traditional traditional healing methods and spirituality medicine to Western treatment providers. Ahn can be a very important aspect of treatment et al. (2006) found that about two-thirds of (see Chan and Chen 2011 for an overview of Chinese and Vietnamese Americans who health beliefs and practices). Such use can spoke no or limited English had used tradi- provide a spiritual connection that helps man- tional medicine, but only 7.6 percent had age feelings that are especially difficult to discussed the use of these therapies with their express to others. Many practices associated Western medical providers. with meditation, yoga, and Eastern religious traditions can help disperse the stress and Traditional treatment to restore physical and anxiety experienced during treatment and emotional balance for Asian Americans occurs recovery. In the United States, there are few

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Behavioral Health Counseling for Native Hawaiians and Other Pacific Islanders The ancestors of Native Hawaiians and other Pacific Islanders were the original inhabitants of Hawaii, Guam, Samoa, and other Pacific islands. The population of Native Hawaiians and other Pacific Islanders grew more than three times faster than the total U.S. population from 2000 to 2010. More than half of Native Hawaiian and other Pacific Islanders live in Hawaii and California. The largest Pacific Islander populations in the United States comprise Hawaiians, Samoans, and Chamorros—the indigenous people of the Mariana Islands, of which Guam is the largest (Hixson et al. 2012).

Native Hawaiians and other Pacific Islanders make up a relatively small proportion of the total United States population. In the 2010 Census, 540,000 people, or 0.2 percent of the population, reported their race as Native Hawaiian or other Pacific Islander, and another 685,000 people (0.2 percent of the population) stated that they were Native Hawaiian or other Pacific Islander in addition to one or more other races (Hixson et al. 2012). The largest concentration of Native Hawaiians and other Pacific Islanders is in Hawaii, where individuals with at least some of this ancestry made up 23.3 percent of the population.

In 2012, according to NSDUH data, 5.4 percent of Native Hawaiians and other Pacific Islanders interviewed had a substance use disorder in the prior year, and 7.8 percent engaged in current illicit drug use (SAMHSA 2013d). Binge and heavy drinking appear to be relatively high, especially among Native Hawaiian/Pacific Islander women. Data from the 2001–2011 TEDS surveys indicate that the most common primary substances of abuse among Native Hawaiians and other Pacific Islanders entering substance abuse treatment are alcohol, cannabis, and methamphetamine (SAMHSA 2013c). Because of its relatively small size, many studies have either ignored or been unable to make conclu- sions about substance use and abuse in this population; other research has grouped Native Hawaiians and other Pacific Islanders together with Asians (more for the sake of convenience than for underlying cultural similarities).

According to NSDUH data, 1.8 percent of adult Native Hawaiians and other Pacific Islanders report- ed serious mental illness. Insufficient data were available to analyze past-year mental illness rates (SAMHSA 2013c). Similar to substance use data, specific mental health data are limited across national studies, primarily because the population has been grouped with Asians. However, the evidence that is available suggests that Native Hawaiians are less likely than other racial/ethnic groups in Hawaii to access treatment services even though they experience higher rates of mental health problems (for a review of health beliefs and practices, see Mokuau and Tauili’ili 2011).

A few examples of culturally specific interventions for Native Hawaiians have been presented in the literature. For example, the Rural Hawai’i Behavioral Health Program, which provides substance abuse and mental health services to Native Hawaiians living in rural areas, incorporates Native Hawaiian beliefs and practices into all areas of the program, emphasizing the value of ‘ohana (family) relations, including the importance of respecting and honoring ancestors and elders and passing on cultural ways to the next generation. Program staff members are trained in Native Hawaiian culture and beliefs, including spirituality and the essential value of graciousness, the honoring of mana (life energy), healing rituals such as pule (prayer), the use of healing herbs, and Native Hawaiian beliefs about the causes of illness, such as wrongdoing and physical disruption (Oliveira et al. 2006).

Ho’oponopono is a form of group therapy used by Native Hawaiians; it involves family members and is facilitated by a Küpuna (elder). A qualitative study by Morelli and Fong (2000) of Ho’oponopono with pregnant or postpartum women with substance use disorders (primarily methamphetamine abuse) reported high client satisfaction and positive outcomes (80 percent were abstinent 2 years after treatment). The Na Wahine Makalapua Project, sponsored by the Hawaii Department of Health’s Alcohol and Drug Abuse Division and SAMHSA’s Center for Substance Abuse Prevention, uses elements of Hawaiian culture to treat women with substance use disorders, such as by having Küpuna counsel younger generations.

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examples of culturally specific treatment pro- abstinence difficult for Asian clients. Counse- grams that focus on Asian religious or spiritual lors should take this into account and address treatment; however, there are programs over- difficulties that can arise for clients with fami- seas, such as the Thai Buddhist treatment lies who have shame about mental illness or center described by Barrett (1997). substance use disorders. To date, there are no indications that standard approaches are un- Asian Americans are much more likely than suitable for Asian American clients. For more members of other racial/ethnic groups to label information on these approaches, see the themselves as secular, agnostic, or atheist planned TIP, Relapse Prevention and Recovery (Kosmin and Keysar 2009; Pew Forum on Promotion in Behavioral Health Services Religion and Public Life 2008). That said, a (SAMHSA planned e). substantial number of Asian Americans still have religious affiliations. About 45 percent Counseling for Hispanics are Protestant; 17 percent, Catholic; 14 per- cent, Hindu; 9 percent, Buddhist; and 4 per- and Latinos cent, Muslim (Pew Forum on Religion and Public Life 2008). More acculturated Asian The terms “Hispanic” and “Latino” refer to Americans are likely to enter treatment people whose cultural origins are in Spain and through medical settings and to be comforta- Portugal or the countries of the Western ble with a medical model for treatment, but Hemisphere whose culture is significantly those who are less acculturated or are foreign- influenced by Spanish or Portuguese coloniza- born can prefer the use of traditional healing tion. Technically, a distinction can be drawn and/or religious traditions and beliefs as part between Hispanic (literally meaning people of their treatment ( Ja and Yuen 1997). Reli- from Spain or its former colonies) and Latino gious institutions can play an important part (which refers to persons from countries ranging in the treatment of some groups of Asian from Mexico to Central and South America Americans. For example, Kwon-Ahn (2001) and the Caribbean that were colonized by notes that many Korean Americans, particu- Spain, and also including Portugal and its larly more recent immigrants, turn to Chris- former colonies); this TIP uses the more tian clergy or church groups for assistance inclusive term (Latino), except when research with family and personal problems, such as specifically indicates the other. The term substance abuse, before seeking professional “Latina” refers to a woman of Latino descent. help. Amodeo et al. (2004) suggest that, in Latinos are an ethnic rather than a racial working with Cambodian immigrants, provid- group; Latinos can be of any race. According ers integrate Buddhist philosophy and practic- to 2010 Census data, Latinos made up 16 es into treatment, and, if possible, partner with percent of the total United States population; Buddhist temples to facilitate treatment entry they are its fastest growing ethnic group (Ennis or to provide services for clients who choose et al. 2011). Latinos include more than 30 to reside in Buddhist temples. national and cultural subgroups that vary by Relapse prevention and recovery national origin, race, generational status in the United States, and socioeconomic status Little research has evaluated relapse preven- (Padilla and Salgado de Snyder 1992; tion and recovery promotion strategies specifi- Rodriguez-Andrew 1998). According to Ennis cally for Asian Americans. However, issues et al. (2011), of Latinos currently living in the involving shame can make the adjustment to United States (excluding Puerto Rico and

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other territories), are the and Glassman 1999). The authors concluded largest group (63 percent), followed by Central that “losing control” has a different cultural and South Americans (13.4 percent), Puerto meaning for these two groups, which in turn Ricans (9.2 percent), and Cubans (3.5 percent). affects how they use alcohol. Beliefs About and Traditions For many Latino men, drinking alcohol is a Involving Substance Use part of social occasions and celebrations. By contrast, solitary drinking is discouraged and Attitudes toward substance use vary among seen as deviant. Social norms for Latinas are Latino cultural groups, but Latinos are more often quite different, and those who have likely to see substance use in negative terms substance abuse problems are judged much than are White Americans. Marin (1998) more harshly than men. Women can be per- found that Mexican Americans were signifi- ceived as promiscuous or delinquent in meet- cantly more likely to expect negative conse- ing their family duties because of their quences and less likely to expect positive substance use (Hernandez 2000). Amaro and outcomes as a result of drinking than were Aguiar (1995) note that the heavy emphasis White Americans. Similarly, Hadjicostandi on the idealization of motherhood contributes and Cheurprakobkit (2002) note that most to the level of denial about the prevalence of Latinos believe that prescription drug abuse substance use among Latinas. Women who could have dangerous effects (85.7 percent), use injection drugs feel the need to maintain that individuals who abuse substances cause their roles as daughters, mothers, partners, and their whole families to suffer (81.4 percent), community members by separating their drug and that people who use illicit drugs will use from the rest of their lives (Andrade and participate in violent crime (74.9 percent) and Estrada 2003), yet research suggests that act violently toward family members (78.9 substance abuse among women does not go percent). Driving under the influence of alco- unrecognized within the Latino community hol is one of the most serious substance use (Hadjicostandi and Cheurprakobkit 2002). problems in the Latino community. Among families, Latino adults generally show Other research suggests that some Latinos strong disapproval of alcohol use in adoles- hold different alcohol expectancies. When cents of either gender (Flores-Ortiz 1994). comparing drinking patterns and alcohol Adults of both genders generally disapprove of expectancies among college students, Velez- the initiation of alcohol use for youth 16 years Blasini (1997) found that Puerto Rican partic- of age and under (Rodriguez-Andrew 1998). ipants were more likely than other students to Long (1990) also found that even among see increased sociability as a positive expectan- Latino families in which there has been multi- cy related to drinking and sexual impairment generational drug abuse, young people were as a negative expectancy. Puerto Rican partici- rarely initiated into drug abuse by family pants were also significantly more likely to members. However, evidence regarding paren- report abstinence from alcohol. In another tal substance use and its influence on youth study comparing Puerto Ricans and Irish has been mixed; most studies show some Americans, Puerto Rican participants who correlation between parental attitudes toward expected a loss of control when drinking had alcohol use and youth drinking (Rodriguez- fewer alcohol-related problems, whereas Irish Andrew 1998). For instance, research with Americans who expected a loss of control had college students found that family influences a greater number of such problems (Johnson

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had a significant effect on drinking in Latinos Although data are available from a number of but not White Americans; the magnitude of studies regarding Latino drinking and drug this effect was greater for Latinas than for use patterns, more targeted research efforts are Latino men (Corbin et al. 2008). needed to unravel the complexities of sub- stance use and the many factors that affect use, Substance Use and Substance Use abuse, and dependence among subgroups of Disorders Latino origin (Rodriguez-Andrew 1998). For According to 2012 NSDUH data, rates of example, some studies show that Latino men past-month illicit substance use, heavy drink- are more likely to have an alcohol use disorder ing, and binge drinking among Latinos were than are White American men (Caetano lower than for White Americans, Blacks, and 2003), whereas others have found the reverse Native Americans, but not significantly so to be true (Schmidt et al. 2007). Disparities (SAMHSA 2013d). The same data showed in survey results may reflect varying efforts to that 8.3 percent of Latinos reported past- develop culturally responsive criteria (Carle month illicit drug use compared with 9.2 2009; Hasin et al. 2007). The table in Exhibit percent of White Americans and 11.3 percent 5-2 shows lifetime prevalence of substance of African Americans. use disorders among Latinos based on

Exhibit 5-2: Lifetime Prevalence of Substance Use Disorders According to Ethnic Subgroup and Immigration Status

Any Alcohol Drug Ethnic Substance Use Alcohol Dependence, Drug Dependence, Subgroup Disorder, % Abuse, % % Abuse, % % Puerto Ricans (born in the U.S. 15.9 7.7 5.6 4.6 4.3 mainland) Puerto Ricans (born in 11.1 4.6 5.3 4.3 3.6 Puerto Rico) (born in 20.9 6.5 8.2 3.6 5.7 the U.S.) Cuban Americans 6.4 3.4 2.2 2.2 1.9 (foreign-born) Mexican Ameri- cans (born in the 21.4 9.4 7.7 5.8 5.3 U.S.) Mexican Ameri- 7 3.5 2.8 2.0 1.7 cans (foreign-born) Other Latino (born 20.4 10.4 5.3 8.4 5.2 in the U.S.) Other Latino 5.7 3.2 2.2 2.1 1.0 (foreign-born)

Source: Alegria et al. 2008a.

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immigration status and ethnic subgroup than men in the same age group across other (Alegria et al. 2008a). racial/ethnic populations. Among diverse Latino cultural groups, differ- Latino youth appear to start using illicit drugs ent patterns of alcohol use exist. For example, at an earlier age than do members of other some older research suggests that Mexican major ethnic/racial groups. Cumulative data American men are more likely to engage in from 28 years of the Monitoring the Future binge drinking (having five or more drinks at Study show Latino eighth graders as having one time; drinking less frequently, but in higher rates of heavy drinking, marijuana use, higher quantities) than other Latinos but use cocaine use, and heroin use than African or alcohol less frequently (Caetano and Clark White Americans in the same grade. Among 1998). There are also differences regarding the youth in grade 12, the rates of use among abuse of other substances. Among Latinos Latino and White American students are entering substance abuse treatment in 2006, more similar, but Latinos still had the highest heroin and methamphetamine use were espe- rates of crack cocaine and injected heroin use cially high among Puerto Ricans and Mexican ( Johnston et al. 2003). Americans, respectively. Other research has Patterns of substance use and abuse vary based found that Puerto Ricans are more likely to on Latinos’ specific cultural backgrounds. inject drugs and tend to inject more often Among Latinos, rates of past-year alcohol during the course of a day than do other dependence were higher among Puerto Rican Latinos (Singer 1999). and Mexican American men (15.3 percent and Patterns of substance use are also linked to 15.1 percent, respectively) than among gender, age, socioeconomic status, and accul- South/Central American or Cuban American turation in complex ways (Castro et al. 1999a; men (9 percent and 5.3 percent, respectively). Wahl and Eitle 2010). For instance, increased Among Latinas, past-year alcohol dependence frequency of drinking is associated with great- rates were significantly higher for Puerto er acculturation for Latino men and women, Rican women (6.4 percent) than for Mexican yet the drinking patterns of Latinas are affect- American (2.1 percent), Cuban American (1.6 ed significantly more than those of Latino percent), or South/Central American (0.8 men (Markides et al. 2012; Zemore 2005). percent) women (Caetano et al. 2008). Age appears to influence Latino drinking Mental and Co-Occurring patterns somewhat differently than it does for Disorders other racial/ethnic groups. Research indicates that White Americans often “age out” of As with other populations, it is important to heavy drinking after frequent and heavy alco- address CODs in Latino clients, as CODs hol use in their 20s, but for many Latinos, have been associated with higher rates of drinking peaks between the ages 30 and 39. treatment dropout (Amodeo et al. 2008). Latinos in this age range have the lowest There are also reports of diagnostic bias, sug- abstention rates and the highest proportions gesting that some disorders are underreported of frequent and heavy drinkers of any age and others are overreported. Minsky et al. group (Caetano and Clark 1998). In the same (2003) found that, at one large mental health study, Latino men between 40 and 60 years of treatment site in New Jersey, major depression age had higher rates of substance use disorders was overdiagnosed among Latinos, especially Latinas, whereas psychotic symptoms were

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sometimes ignored. Among Latinos with linguistically and/or culturally appropriate CODs, other mental disorders preceded the services (SAMHSA 2011c). They were about development of a substance use disorder 70 twice as likely to state the former and four percent of the time (Vega et al. 2009). times as likely to state the latter as members of the group that was the next most likely to Overall, research indicates fewer mental disor- make such statements. ders and CODs among Latinos than among White Americans (Alegria et al. 2008a; Vega A significant problem prohibiting participa- et al. 2009). However, data from the 2012 tion in substance abuse treatment among NSDUH indicate that the magnitude of the Latinos is the lack of insurance coverage to difference may be decreasing; 1.2 percent of pay for treatment. In SAMHSA’s 2010 Latinos had both serious mental illness and NSDUH, 32 percent of Latinos who needed substance use disorders in the prior year, as did but did not receive substance abuse treatment White Americans, similar to the rate seen in the past year reported that they lacked mon- among African Americans (0.9 percent; ey or insurance coverage to pay for it compared SAMHSA 2013c). When any mental disorder with 29.5 percent of White Americans and symptoms co-occurring with a substance use 33.5 percent of African Americans disorder diagnosis were evaluated, Latinos had (SAMHSA 2011c). Other national surveys a slightly higher rate of co-occurrence (3.4 also found that Latinos with self-identified percent) than did African Americans (3.3 drinking problems were significantly more percent; SAMHSA 2013c). Rates of mental likely than either White Americans or African disorders and CODs also vary by Latino Americans to indicate that they did not seek subgroup (Alegria et al. 2008a), and accultura- treatment because of logistical barriers, such as tion can play a confounding, but inconsistent, a lack of funds or being unable to obtain role in the identification and development of childcare (Schmidt et al. 2007). CODs in Latino populations (Alegria et al. Latinos with substance use disorders are about 2008a; Vega et al. 2009). as likely to enter substance abuse treatment Treatment Patterns programs as White Americans (Hser et al. 1998; Perron et al. 2009; Schmidt et al. 2006). Barriers to treatment entry for Latinos in- Latinos tend to enter treatment at a younger clude, but are not limited to, lack of Spanish- age than either African Americans or White speaking service providers, limited (Marsh et al. 2009). There are also proficiency, financial constraints, lack of cul- significant differences in treatment-seeking turally responsive services, fears about immi- patterns among Latino cultural groups. For gration status and losing custody of children example, Puerto Ricans who inject heroin are while in treatment, negative attitudes toward much more likely to participate in methadone providers, and discrimination (Alegria et al. main-tenance and less likely to enter other 2012; Mora 2002). Among all ethnic/racial less-effective detoxification programs than groups included in the 2010 NSDUH, Lati- are Dominicans, Central Americans, and nos were the most likely to report that they other Latinos (Reynoso-Vallejo et al. 2008). had a need for treatment but did not receive it The researchers note, however, that this could because they could not find a program with be due partially to the fact that Puerto Ricans, the appropriate type of treatment or because compared with other Latinos, have a greater there were no openings in programs that they awareness of treatment options. wished to attend, which may reflect a lack of

132 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Beliefs and Attitudes About 1998; Perron et al. 2009; Schmidt et al. 2006). Treatment Latinos who receive substance abuse treatment also report less satisfaction with the services In general, Latino attitudes toward health care they receive than White or African Americans are shaped by a lack of access to regular quality (Wells et al. 2001). Even when receiving a care, including inability to afford it (see review level of substance abuse treatment services of health beliefs and help-seeking behaviors comparable to those received by White and among Mexican Americans and Mexicans African Americans, Latinos are more likely to dwelling in the United States in Rogers 2010). be dissatisfied with treatment (Tonigan 2003). DeNavas-Walt et al. (2006) found that Lati- nos are less likely to have health insurance Treatment Issues and (32.7 percent were uninsured in 2005) than Considerations either non-Latino White Americans (11.3 percent were uninsured) or African Americans Latino clients’ responsiveness to therapy is (19.6 percent were uninsured). They are also influenced not only by counselor and program less likely to have had a regular place to go for characteristics, but also by individual charac- conventional medical care (Schiller et al. teristics, including worldview, degree of accul- 2005). Lack of knowledge about available turation, gender orientation, religious beliefs, services can be a major obstacle to seeking and personality traits. As with other cultural services (Vega et al. 2001). In their review, groups, efforts to establish clear communica- Murguia et al. (2000) identified several factors tion and a strong therapeutic alliance are that influence the use of medical services, essential to positive treatment outcomes including cultural health beliefs, demographic among Latino clients. Foremost, counselors barriers, level of acculturation, English profi- should recognize the importance of—and ciency, accessibility of service providers, and integrate into their counseling style and ap- flexibility of intake procedures; they found proach—expressions of concern, interest in that many Latinos only seek medical care for clients’ families, and personal warmth (person- serious illnesses. alismo; Ishikawa et al. 2010). Research on substance abuse indicates that Counselors and clinical supervisors need to be Latinos who use illicit drugs appear to have educated about culturally specific attributes relatively unfavorable attitudes toward treat- that can influence participation and clinical ment and perceive less need for treatment than interpretation of client behavior in treatment. do illicit drug users among every other major For instance, some Latino cultural groups view ethnic and racial group but Native Americans time as more flexible and less structured; thus, (Brower and Carey 2003). However, in the rather than negatively interpreting the client’s 2011 NSDUH, Latinos were more likely than behavior regarding the keeping of strict White Americans, African Americans, or schedules or appointment times, counselors Asian Americans to indicate that they had a should adopt scheduling strategies that pro- need for substance abuse treatment in the vide more flexibility (Alvarez and Ruiz 2001; prior year but did not receive it (SAMHSA Sue 2001). However, counselors should also 2012b). Other studies have found that Latinos advise Latino clients of the need to take rele- with substance use disorders are about as likely vant actions with the aim of arriving on time to enter substance abuse treatment programs for each appointment or group session. Coun- as other racial and ethnic groups (Hser et al. selors should try to avoid framing noncompli- ance in Latino clients as resistance or anger. It

133 Improving Cultural Competence

is often, instead, a pelea nonga (relaxed fight) (Field and Caetano 2010). Available literature showing both a sense of being misunderstood and research highlight four main themes sur- and respeto (respect that also encompasses a rounding general counseling issues and pro- sense of duty) for the counselor’s authority grammatic strategies for Latinos, as follows. (Barón 2000; Medina 2001). Socializing the client to treatment: Latino Unfortunately, many providers who work with clients are likely to benefit from orientation Latino cultural groups continue to have mis- sessions that review treatment and counseling perceptions and can even see culture as a processes, treatment goals and expectations, hindrance to effective treatment rather than as and other components of services (Organista a source of potential strength (Quintero et al. 2006). 2007). For instance, in treating the alcohol Reassurance of confidentiality: Regardless of problems of Latinas, many counselors believe the particular mode of therapy, counselors that they should not incorporate endorsement should explain confidentiality. Many Latinos, of traditional and possibly harmful cultural especially undocumented workers or recent patterns into the services they provide (Mora immigrants, are fearful of being discovered by 2002). However, other counselors note that authorities like the United States Citizenship the transformative value of the most positive and Immigration Services and subsequently aspects of Latino cultural groups can be em- deported back to their countries of origin phasized: strength, perseverance, flexibility, (Ramos-Sanchez 2009). and an ability to survive (Gloria and Peregoy 1996). Respecting women’s choices can mean Client–counselor matching based on gen- supporting empowerment to pursue new roles der: To date, research does not provide con- and make new choices free of alcohol, guilt, sistent findings on client–counselor matching and discrimination (Mora 2002). For others, it based on similarity of Latino ethnicity. How- can mean reinvigorating the positivity of ever, client–counselor matching based on Latina culture to promote abstinence while gender alone appears to have a greater effect respecting and maintaining traditional family on improving engagement and abstinence roles for women (Gloria and Peregoy 1996). among Latinos than it does for clients of other ethnicities (Fiorentine and Hillhouse 1999). Because some research has found that Latinos have higher rates of treatment dropout than Client–program matching: Matching clients other populations (Amaro et al. 2006), pro- to ethnicity-specific programs appears to grams working with this population should improve outcomes for Latinos. Takeuchi et al. consider ways to improve retention and out- (1995) found that only 68 percent of Mexican comes. Treatment retention issues for Latinos American clients in programs that had a can be similar to those found for other popu- majority of White American clients returned lations (Amodeo et al. 2008), but culturally after the first session compared with 97 per- specific treatment has been associated with cent in those programs where the majority of better retention for Latinos (Hohman and clients were Mexican American. Galt 2001). Research evaluating ethnic match- ing with brief motivational interventions also Theoretical Approaches and found more favorable substance abuse treat- Treatment Interventions ment outcomes at 12-month follow-up when Overall, research evaluating cultural adoption clients and providers were ethnically matched of promising or evidence-based practices in

134 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

treatment specifically for Latinos is scarce Family therapy (Carvajal and Young 2009). For instance, Family therapy is often recommended for empirical literature evaluating CBT specifical- treating Latinos with substance use disorders ly for substance abuse and substance use dis- (Amaro et al. 2006; Barón 2000; Hernandez orders in Latinos is quite limited. Still, a 2000). Although there is little research evalu- number of authors recommend CBT for ating the effectiveness of family therapy for Latinos in mental health and substance abuse adults, both multidimensional family therapy treatment settings because it is action oriented, (Liddle 2010) and brief strategic family thera- problem focused, and didactic (Alvarez and py (Santisteban et al. 1997; Santisteban et al. Ruiz 2001; Organista 2006; Organista and 2003; Szapocznik and Williams 2000) have Muñoz 1998). CBT’s didactic component can been found to reduce substance use and im- educate Latinos about disorders and frame prove psychological functioning among Latino therapy as an educational (and hence less youth. The term familismo refers to the cen- shameful) experience. However, Organista’s trality of the family in Latino culture and can (2006) review of available research on CBT include valuing and protecting children, re- for mental disorders among Latinos suggests specting the elderly, preserving the family that this approach is not always as effective name, and consulting with one another before with Latinos as it is with other populations. making important decisions. As highlighted in Other effective interventions include contin- the case study of a Puerto Rican client on the gency management and motivational inter- next page, counselors must consider the poten- viewing; see the review by Amaro et al. (2006) tially pivotal roles families can play in support- for more on these interventions. Methadone ing treatment and recovery. Latino families are maintenance, too, has been associated with likely to have a strong sense of obligation and long-term reductions in the use of alcohol as commitment to helping their members, in- well as heroin and other illicit drugs among cluding those who have substance use disor- Mexican Americans with opioid use disorders, ders. Even so, the level of family support for although 33 percent of the original cohort people who have substance use or mental died before the 22-year longitudinal study disorders varies among Latinos depending on concluded (Goldstein and Herrera 1995). country of origin, level of acculturation, degree Another therapeutic intervention that can of family cohesion, socioeconomic status, and improve outcomes for Latino clients is node- factors related to substance use (Alegria et al. link mapping (visual representation using 2012). For example, Reynoso-Vallejo et al. information diagrams, fill-in-the blank graph- (2008) concluded that significantly higher ic tools, and client-generated diagrams or rates of homelessness found among people visual maps), which has been associated with from Central American countries who inject- lower levels of opioid and cocaine use, better ed heroin compared with other Latinos could treatment attendance, and higher counselor stem from lower levels of tolerance for injec- ratings of motivation and confidence for tion drug use among their families. Latinos in methadone maintenance treatment For counselors who lack cultural understand- (Dansereau et al. 1996; Dansereau and Simp- ing, it can be easy to simply label and judge son 2009). For a review of Latino outcome families’ behavior as enabling or codependent. studies in health, substance abuse, and mental Instead, counselors should move away from health in social work, refer to Jani and col- labeling the behavior and focus more on help- leagues (2009). ing families recognize how their behavior can

135 Improving Cultural Competence

Case Study: A Puerto Rican Client Anna is a 27-year-old woman who was born in New York and self-identifies as Puerto Rican. She has a 12th-grade education, is unemployed, and lives with her parents, her 4-year-old daughter, and a nephew. Anna is separated from her partner, who is also her daughter’s father. She entered treat- ment as a result of feeling depressed ever since her partner physically assaulted her because she refused to use heroin (the event that sparked their separation). She states, “I want to be clean and take care of my family.” At intake, she had just undergone detoxification and had stopped using alcohol, crack cocaine, and heroin.

Anna states that she feels guilty about her drug use and the way it caused her to neglect her family. She has been having serious problems with her mother, who is critical of her substance use, but believes that her mother is important in her recovery because of the structure she provides at home. She describes her father as a very important figure with whom she enjoys spending time. Her father had stopped drinking 9 years before and is very supportive of her abstinence. He is willing to help in any way he can but has been very sick lately and was diagnosed with prostate cancer. Her father had never received treatment for his drinking problem, and her mother believes that Anna should be able to stop just like her father did. As she describes her situation in treatment, Anna’s vergüenza (shame) and sense of hopelessness is very evident. She fears her father’s death and her mother’s subsequent rejection of her for not helping out.

Anna’s treatment includes family therapy to restructure communication patterns, rules, expecta- tions, and roles. For family sessions, either her mother or both parents participate, depending on her father’s physical condition. Initially, her parents displayed a tendency to focus on the problems of the past, but the counselor directed them to focus on changes needed to help Anna’s recovery. The counselor has also worked with other family members to rally support and use their strengths while also clarifying perceptions, feelings, and behaviors that will help them function as a family unit. Anna’s counselor recognizes that, within the context of her culture, her reliance on her family can be used to aid her recovery and that her family, as defined by Anna, can be used as a support system. Source: Medina 2001. Adapted with permission.

affect one member’s substance abuse and how of the rules of the system. Otherwise, mem- best to handle it. The advice box on the next bers could see group therapy as oppressive. page provides general therapeutic guidelines Facilitators in groups consisting mostly of for working with Latino families. Latino clients must establish trust, responsibil- Group therapy ity, and loyalty among members. In addition, acculturation levels and language preferences Little information is available concerning should be assessed when forming groups so Latinos’ preferences in behavioral health that culturally specific or Spanish-speaking services, but a study evaluating mental health groups can be made available if needed. treatment preferences for women in the Unit- Mutual-help groups ed States found that Latinas were significantly more likely to prefer group treatment Findings on the usefulness of 12-Step groups (Nadeem et al. 2008). According to Paniagua for Latino clients are inconsistent. Member- (1998), the use of group therapy with Latino ship surveys of AA indicate that Latinos clients should emphasize a problem-focused comprise about 5 percent of AA membership approach. Group leaders should allow mem- (AAWS 2012). Latinos who received inpatient bers to learn from each other and resist func- treatment were less likely to attend AA than tioning as a content expert or a representative White Americans (Arroyo et al. 1998). Rates

136 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Advice to Counselors: Family Therapy of engagement than for White American Guidelines for Latino Families participants (Hoffman 1994; Tonigan et al. 1998). For some Latinos, 12-Step groups can • Provide bilingual services. • Use family therapy as a primary method of appeal to religious and spiritual beliefs. Her- treatment. nandez (2000) suggests that mutual-help • Assess cultural identity and acculturation groups composed solely of Latinos make it level for each family member. easier for participants to address the cultural • Determine the family’s level of belief in context of substance abuse. Some Latino 12- traditional and complementary healing practices; integrate these as appropriate. Step groups do not hold that substance abuse • Discuss the family’s beliefs, history, and is a biopsychosocial problem, instead concep- experiences with standard American be- tualizing the disorder as a weakness of charac- havioral health services. ter that must be corrected. Hoffman (1994) • Explore migration and immigration experi- studied Latino 12-Step groups in Los Angeles ences, if appropriate. • Provide additional respect to the father or and observed that, in addition to a more father figure in the family. traditional form of AA, there were groups that • Interview family members or groups of practiced terapia dura (i.e., rough therapy), family members (e.g., children) separately which often uses a confrontational approach to allow them to voice concerns. and endorses family values related to machismo • Generate solutions with the family. Do not force changes in family relationships. (e.g., by reinforcing that overcoming substance • Provide specific, concrete suggestions for abuse rather than drinking is manly). Howev- change that can be quickly implemented. er, these groups were not overly welcoming of • Focus on engaging the family in the first female members and gay men. In such cases, session using warmth and personalismo. gay Latino men and Latinas can benefit from Sources: Bean et al. 2001; Hernandez 2005; attending 12-Step groups that are not cultur- Lynch and Hanson 2011. ally specific or that do not use terapia dura. Traditional healing and of mutual-help participation among people complementary methods with drug use disorders are also lower for Latinos (Perron et al. 2009). Language can In a study of the use of alternative and com- present a barrier to mutual-help group partici- plementary medical therapies, Latinos were pation for Spanish-speaking Latinos; however, less likely to use medical alternatives than Spanish-language meetings are held in some were White Americans (Graham et al. 2005). locations. Counselors should consider the However, those who did use such approaches appropriateness of 12-Step participation on a were more likely to do so because they could case-by-case basis (Alvarez and Ruiz 2001). not afford standard medical care (Alegria et al. For example, Mexican American men who 2012). As in other areas, the use of comple- identify with attitudes of machismo can feel mentary and traditional medicine likely varies uncomfortable with the 12-Step approach. according to acculturation level and country of Concern about divulging family issues in public origin. For instance, the use of faith and reli- can cause hesitation to address substance- gious practices to cope with mental and emo- related problems in public meetings. tional problems is significantly more common among foreign-born Latinos than among For Latinos who do participate in 12-Step those born in the United States (Nadeem et al. programs, findings suggest higher rates of 2008; Vega et al. 2001). abstinence, degree of commitment, and level

137 Improving Cultural Competence

Many Latinos place great importance on the Data are lacking on long-term recovery for practice of Roman Catholicism. Yamamoto Latinos. Given the many obstacles that block and Acosta (1982) describe the central tenets accessibility to treatment for Latinos, continu- of Latino Catholicism as sacrifice, charity, and ing care planning can benefit from greater use forgiveness. These beliefs can hinder assertive- of informal or peer supports. For example, ness in some Latinos, but they can also be a White and Sanders (2004) recommend the source of strength and recovery. Traditionally, use of a recovery management approach with Latinos have been Catholic, although several Latinos. They point to an early example of the Protestant and evangelical groups have con- East Harlem Protestant Parish’s work, which verted millions of Latinos to their religions helped Puerto Rican individuals recovering since the 1970s. Some Latinos also believe in from heroin dependence connect to social syncretistic religions (e.g., Santería or clubs and religious communities that sup- Curanderismo) or practices derived from them ported recovery. Latinos use community and and make use of a variety of traditional heal- family support in addition to spirituality to ing practices and rituals to heal mental and address mental disorders (Lynch and Hanson spiritual ailments (Lefley et al. 1998; Sandoval 2011; Molina 2001). Castro et al. (2007) also 1979). Among Puerto Ricans, espiritismo note that family support systems can be espe- (spiritualism) is a popular traditional healing cially important for Latinos in recovery. system successfully used to address mental health issues (Lynch and Hanson 2011; Moli- Counseling for Native na 2001). Some Mexican Americans rely on Americans curanderos, folk healers who address problems that might be framed as psychological (Falicov There are 566 federally recognized American 2005, 2012). For a review of culturally respon- Indian Tribes, and their members speak more sive interventions with Latinos, refer to than 150 languages (U.S. Department of the Gallardo and Curry (2009). Interior, Indian Affairs 2013a); there are Relapse prevention and recovery numerous other Tribes recognized only by states and others that still go unrecognized by There are no substantial studies evaluating the government agencies of any sort. According to use of relapse prevention and recovery promo- the 2010 U.S. Census (Norris et al. 2012), the tion with Latinos, yet literature suggests that majority (78 percent) of people who identified they would be appropriate and effective for as American Indian or Alaska Native, either this population (Blume et al. 2005; Castro et alone or in combination with one or more al. 2007). Overall, Latinos can face somewhat other races, lived outside of American Indian different triggers for relapse relating to accul- and Alaska Native areas. Approximately 60 turative stress or the need to uphold particular percent of the 5.2 million people who identi- cultural values (e.g., personalismo, machismo; fied as American Indian or Alaska Native, Castro et al. 2007), which can lead to higher alone or in combination with one or more rates of relapse among some Latino clients. other races, reside in urban areas (Norris et al. For example, in a study of relapse patterns 2012). The category of in- among White American and Latino individu- cludes four recognized Tribal groups— als who used methamphetamine, Brecht et al. Alaskan Athabascan, , Eskimo, and (2000) found that Latino participants relapsed Tingit-Haida—along with many other inde- more quickly than White American pendent communities (Ogunwole 2006). participants.

138 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Native Americans who belong to federally among Native Americans, see the planned TIP, recognized Tribes and communities are mem- Behavioral Health Services for American Indians bers of sovereign Indian nations that exist and Alaska Natives (SAMHSA planned a). within the United States. On lands belonging to these Tribes and communities, Native Beliefs About and Traditions Americans are able to govern themselves to a Involving Substance Use large extent and are not subject to most state Few American Indian Tribes and no Alaska laws—only to federal legislation that is specif- Natives consumed alcoholic beverages prior to ically designated as applying to them (Henson contact with non-Native people, and those 2008). Although health care (including sub- who did used alcohol primarily for special stance abuse treatment) is provided to many occasions and ceremonies. Most Tribes first Native Americans by Indian Health Services encountered the use of alcohol when they (IHS), Tribal governments do have the option encountered European settlers and traders. of taking over those services. Counselors Because of this lack of experience with alco- working with these populations should re- hol, few Native Americans had a context for member that Native Americans, by virtue of drinking besides what they learned from these their membership in sovereign Tribal entities, non-Natives, who at the time drank in large have rights that are different from those of quantities and often engaged in binge drink- other Americans; this distinguishes them from ing. Although patterns of alcohol consump- members of other ethnic/racial groups. tion in the mainstream population of the American Indians live in all 50 states; the United States changed over time, they re- states with the largest populations of Ameri- mained relatively the same in the more isolat- can Indians are Oklahoma, California, and ed Native American communities. According Arizona. The 2000 Census allowed people to to an NSDUH report on American Indian identify, for the first time, as a member of and Alaska Native adults, binge drinking more than one race. Of persons who checked continues to be a significant problem for these two or more races, nearly one in five indicated populations. Both binge drinking and illicit that they were part American Indian or Alaska drug use is higher among Native Americans Native (U.S. Census Bureau 2001a,b). than the national average (30.2 percent versus 23 percent and 12.7 percent versus 9.2 percent, Behavioral health service providers should respectively; SAMHSA 2013d). recognize that Native American Tribes repre- sent a wide variety of cultural groups that American Indian drinking patterns vary a differ from one another in many ways (Duran great deal by Tribe. Tribal attitudes toward et al. 2007). Alaska Natives who live in coastal alcohol influence consumption in complicated areas have very different customs from those ways. For example, in communities, inhabiting interior areas (Attneave 1982). The excessive drinking was acceptable if done in a diversity of Native American Tribes notwith- group or during a social activity. However, standing, they also share a common bond of solitary drinking (even in lesser amounts) was respect for their cultural heritages, histories, considered to be deviant (Kunitz et al. 1994). and spiritual beliefs, which are different from Kunitz et al. (1994) observed that during the those of mainstream American culture. For 1960s, binge drinking was acceptable among more information on the treatment and pre- the Navajo during public celebrations, whereas vention of substance abuse and mental illness any drinking was considered unacceptable among the neighboring Hopi population,

139 Improving Cultural Competence

wherein regular drinkers were shunned or, in show that Alaska Natives are significantly some cases, expelled from the community. more likely to abstain than are other Alaskans Hopi individuals who did drink tended to do (Wells 2004). so alone or moved off the reservation to bor- The most common pattern of abusive drink- der towns where heavy alcohol use was com- ing among American Indians appears to be mon. The ostracism of Hopi drinkers seemed binge drinking followed by long periods of to lead to even greater levels of abuse, given abstinence (French 2000; May and Gossage that there were much higher death rates from 2001). A similar pattern is seen among Alaska alcoholic cirrhosis among the Hopi than Natives (Seale et al. 2006; Wells 2004). As an among the Navajo. example, the Urban Indian Health Institute Native American recovery movements have (2008) found that binge drinking was signifi- often viewed substance abuse as a result of cantly more common among the Native cultural conflict between Native and Western American population (with 21.3 percent cultures, seeing substances of abuse as weapons engaging in binge drinking in the prior 30 that have caused further loss of traditions days compared with 15.8 percent of non- (Coyhis and White 2006). To best treat this Native Americans) and that, among those who population, substance abuse treatment provid- drank, 40.7 percent of Native American par- ers need to expand their perspectives regarding ticipants engaged in binge drinking compared substance abuse and dependence and must with 26.9 percent of non-Natives. embrace a broader view that explores the There are a number of historical reasons for spiritual, cultural, and social ramifications of the development of binge drinking among substance abuse (Brady 1995; Duran 2006; Native Americans. The existence of dry reser- Jilek 1994). vations (which can limit the times when indi- Substance Use and Substance Use viduals are able to get alcohol), high levels of Disorders poverty, lack of availability (e.g., in remote Alaska Native villages), a history of trauma, According to 2012 NSDUH data, American and the loss of cultural traditions can all con- Indian and Alaska Native peoples have the tribute to the development and continuation highest rates of substance use disorders and of this pattern of drinking. Native Americans binge drinking (SAMHSA 2013d). Although are also more likely than members of other rates of substance abuse are high among major racial/ethnic groups to have had their Native Americans, so too are rates of absti- first drink before the age of 21 or before the nence. American Indians and Alaska Natives age of 16, which also may shape drinking are more likely to report no alcohol use in the patterns (SAMHSA 2011c). past year than are members of all other major racial and ethnic groups (OAS 2007). The However, data on heavy and binge drinking do American Indian Services Utilization and not reflect the same pattern of alcohol con- Psychiatric Epidemiology Risk and Protective sumption for all Native American Tribes. One Factors Project (AI-SUPER PFP) also found analysis of alcohol dependence among mem- that rates of lifetime abstinence from alcohol bers of seven different Tribes found rates of for American Indians in the study were signif- dependence varying from 56 percent of men icantly higher than lifetime abstinence rates and 30 percent of women in one Tribe to 1 among the general population (Beals et al. percent of men and 2 percent of women in 2003). Data on alcohol consumption also another (Koss et al. 2003). Other research

140 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups confirms significant differences in alcohol use diagnosis of an alcohol use disorder (Gilman among diverse Native American communities et al. 2008). Illicit drug use is also more com- (O’Connell et al. 2005; Whitesell et al. 2006). mon for Native Americans than for members of other major racial/ethnic groups. In addition to alcohol, methamphetamine and inhalant abuse are major concerns for a num- Among Native Americans entering treatment ber of Native American communities. None- in 2010, alcohol use disorders alone or in theless, there are considerable regional conjunction with drug use disorders were the differences in patterns and prevalence of drug most pressing substance-related problem, with use (Miller et al. 2012). According to the cannabis and opioids other than heroin being National Congress of American Indians the next most common primary substances of (2006), 74 percent of Tribal police forces abuse. One of the largest studies on American ranked methamphetamine as the drug causing Indian substance use and abuse to date, the the most problems in their communities. AI-SUPER PFP, found that 31.2 percent of Methamphetamine abuse can be even more American Indians met criteria for a lifetime serious for Native Americans living in rural diagnosis of a substance use disorder, and 13.4 areas than for those in urban areas, but it is percent met criteria for a past-year diagnosis also a serious problem for growing numbers of (Beals et al. 2003). The study found that rates American Indians, especially women, entering of alcohol use disorders were high among men treatment in urban areas (Spear et al. 2007). from the three Tribes represented but varied to a greater degree among women across American Indians and Alaska Natives are Tribes (Mitchell et al. 2003). more likely to report having used inhalants at some time during their lives, but use tends to American Indians have high rates of certain peak in 8th grade and then decrease (Miller et diseases and conditions. In particular, the al. 2012). In some Native American communi- incidence of diabetes is increasing among ties (e.g., on the Kickapoo reservation in Tex- Native Americans, and approximately 38 as), inhalants have been a major drug of abuse percent of elder Native Americans have diabe- for adults as well as youth. During the early tes (Moulton et al 2005). Diabetes is also 1990s, about 46 percent of the adult popula- associated with both substance use disorders tion on that reservation were thought to abuse and depression in this population (Tann et al. inhalants (Fredlund 1994). Although more 2007). Other health problems associated with recent data are not available, reports from the alcohol use include fetal alcohol syndrome, area suggest that inhalant abuse remains a cirrhosis, and depression. significant problem (Morning Star 2005). Mental and Co-Occurring Rates of substance use disorders appear to be Disorders higher in individuals who consider themselves exclusively Native American than for those According to the 2012 NSDUH, 28.3 percent who identify as more than one race/ethnicity, of American Indians and Alaska Natives but even when surveys ask whether people are report having a mental illness, with approxi- of mixed race, those who report themselves to mately 8.5 percent indicating serious mental be partially Native American still have high illness in the past year (SAMHSA 2013c). rates of substance use disorders (OAS 2007). Native Americans were nearly twice as likely Native Americans are about 1.4 times more to have serious thoughts of suicide as members likely than White Americans to have a lifetime of other racial/ethnic populations, and more

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than 10 percent reported a major depressive Treatment Patterns episode in the past year. Common disorders Despite a number of potential barriers to include depression, anxiety, and substance use. treatment (Venner et al. 2012), Native Ameri- As with other groups, substance use disorders cans are about as likely as members of other among Native Americans have been associated racial/ethnic groups to enter behavioral health with increased rates of a variety of different programs. According to data from the 2003 mental disorders (Beals et al. 2002; Tann et al. and 2011 NSDUH (SAMHSA, CBHSQ 2007; Westermeyer 2001). The 2012 NSDUH 2012), Native Americans were more likely to revealed that 14 percent of Native Americans have received substance use treatment in the reported both past-year substance use disor- past year than persons from other racial/ethnic ders and mental illness. Among those who groups (15.0 percent versus 10.2 percent). reported mental illness, nearly 5 percent re- Other studies indicate that about one-third of ported several mental illnesses co-occurring Native Americans with a current substance use with substance use disorders (SAMHSA disorder had received treatment in the prior 2013c). year (Beals et al. 2006; Herman-Stahl and Chong 2002). The 2012 NSDUH reported Native American communities have experi- that approximately 15 percent of Native enced severe historical trauma and discrimina- Americans received mental health treatment tion (Brave Heart and DeBruyn 1998; Burgess (SAMHSA 2013c). et al. 2008). Studies suggest that many Native Americans suffer from elevated exposure to Native Americans were least likely of all major specific traumas (Beals et al. 2005; Ehlers et al. ethnic/racial groups to state that they could not 2006; Manson 1996; Manson et al. 2005), and find the type of program they needed and were they may be more likely to develop PTSD as a the next least likely after Native Hawaiians and result of this exposure than members of other other Pacific Islanders to state that they did not ethnic/racial groups. PTSD comparison rates know where to go or that their insurance did taken from the AI-SUPER PFP study and not cover needed treatment. Among Native the National Comorbidity Study show that Americans who identified a need for treat- 12.8 percent of the Southwest Tribe sample ment in the prior year but did not enter treat- and 11.5 percent of the Northern Plains Tribe ment, the most commonly cited reasons for sample met criteria for a lifetime diagnosis of not attending were lack of transportation, lack PTSD compared with 4.3 percent of the of time, and concerns about what one’s neigh- general population (Beals et al. 2005). Trauma bors might think (SAMHSA 2011c). histories and PTSD are so prevalent among Many Native Americans, especially those Native Americans in substance abuse treat- residing on reservations or other Tribal lands, ment that Edwards (2003) recommends that seek mental health and substance abuse treat- assessment and treatment of trauma should be ment through Tribal service providers or IHS a standard procedure for behavioral health (Jones-Saumty 2002; McFarland et al. 2006). programs serving this population. For exam- However, an analysis using multiple sources ple, Native American veterans with substance found that 67 percent of Native Americans use disorders are significantly more likely to entering substance abuse treatment over the have co-occurring PTSD than the general course of a year did so in urban areas, and the population of veterans with substance use majority of those urban-based programs were disorders (Friedman et al. 1997). not operated by IHS (McFarland et al. 2006).

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The same research also found that Native beliefs about treatment providers that can Americans were somewhat more likely than influence not only willingness to participate in the general treatment-seeking population to treatment services, but also the level of trust enter residential programs. clients have for providers. Counselors and other behavioral health workers must develop Native Americans were more likely to enter ongoing relationships within local Native treatment as a result of criminal justice refer- American communities to gain knowledge of rals than were White Americans or African the unique attributes of each community, to Americans: 47.9 percent of American Indians show investment in the community, and to and Alaska Natives entering public treatment learn about community resources (Exhibit 5- programs in 2010 were court-ordered to 3). Identifying and developing resources with- treatment compared with 36.6 percent of in Native communities can help promote White Americans and 36.4 percent of African culturally congruent relationships. Americans (SAMHSA, CBHSQ 2012). The lack of recognition of special needs and Exhibit 5-3: Native Americans and knowledge of Native American cultures within Community behavioral health programs may be the main Many Native Americans believe that recovery reasons for low treatment retention and un- cannot happen for individuals alone and that deruse of help-seeking behaviors among their entire community has become sick. Native Americans (LaFromboise 1993; Sue Coyhis calls this the “healing forest” model: and Sue 2013e). one cannot take a sick tree from a sick forest, heal it, and put it back in the same environ- Beliefs and Attitudes About ment expecting that it will thrive. Instead, the Treatment community must embrace recovery. Today, community development models are Duran et al. (2005) evaluated obstacles to being implemented in American Indian and treatment entry among American Indians on Alaska Native communities to address preven- three different reservations; most frequently tion and treatment issues for mental and sub- mentioned were the perception that good- stance use disorders as well as related issues, such as suicide prevention (Edwards and quality or suitable services were unavailable Egbert-Edwards 1998; HHS 2010; May et al. and the perceived need for individuals to be 2005). Using these models, communities move self-reliant. They also found social relation- toward greater commitment to social problem- ships to be extremely important in overcoming solving and the development of effective, these barriers. Jumper-Thurman and Plested culturally congruent strategies relevant to their Tribes or villages. According to Edwards et al. (1998) reported that focus groups of American (1995), community approaches often lead to: Indian women listed mistrust as one of the • A reduction of substance use. primary barriers for seeking treatment. This is • Breaking intergenerational cycles of alco- due, in part, to the women’s belief that they hol abuse. would encounter people they knew among • Increased community support. • The strengthening of individual and group treatment agency staff; they also doubted the cultural identity. confidentiality of the treatment program. • Leadership development. • Increased interpersonal and inter-Tribal Treatment Issues and problem-solving skills and solidarity. Considerations For an example, see Jumper-Thurman et al. Each Tribe and community will likely have (2001). different customs, healing traditions, and

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To provide culturally responsive treatment, They also, for the most part, have a holistic providers need to understand the Native view of health that incorporates physical, American client’s Tribe; its history, traditions, emotional, and spiritual elements (Calabrese worldview, and beliefs; the dimensions of its 2008), individual and community healing substance abuse problem and other communi- (Duran 2006; McDonald and Gonzalez 2006), ty problems; the incidence of trauma and and prevention and treatment activities abuse among its members; its traditional (Johnston 2002). For many, culture is the path healing practices; and its intrinsic strengths. to prevention and treatment. Providers who work with Native Americans However, not all Native Americans have a but do not have an understanding of their need to develop stronger connections to their cultural identity and acculturation patterns are communities and cultural groups. As Brady at a distinct disadvantage (Ponterotto et al. (1995) cautions, culture is complex and chang- 2000). Before beginning any treatment, pro- ing, and a return to the values of a traditional viders should routinely seek consultation with culture is not always desired. An initial inquiry knowledgeable professionals who are experi- into each client’s connection with his or her enced in working with the specific Tribal culture, cultural identity, and desire to incor- group in question (Duran 2006; Edwards and porate cultural beliefs and practices into Egbert-Edwards 1998; Straits et al. 2012) and treatment is an essential step in culturally should conduct thorough client assessments competent practice. When appropriate, pro- that evaluate cultural identity (see Appendix F viders can help facilitate the client’s reconnec- and Chapter 2 for resources). Some Native tion with his or her community and cultural American persons have a strong connection to values as an integral part of the treatment their cultures and others do not; some identify plan. In addition, treatment providers need to with a blend of American Indian cultural adapt services to be culturally responsive. In groups called pan-Indianism or inter-Tribal doing so, outcomes are likely to improve not identity. Still others are comfortable with a only for Native American clients, but for all dual identity that embraces both Native and clients within the program. Fisher et al. (1996) non-Native cultural groups. modified a therapeutic community in Alaska Native Americans often approach the begin- to incorporate Alaska Native spiritual and ning of a relationship in a calm, unhurried cultural practices and found that retention manner, and they may need more time to rates improved for White and African Ameri- develop trust with providers. Concerns about can clients as well as Alaska Native clients confidentiality can be an important issue to participating in the program. address with Native American clients, espe- In working with Native American clients, cially for those in small, tightly-knit commu- providers should be prepared to address spirit- nities. For providers, it is very important to uality and to help clients access traditional make clear to clients that what they say to the healing practices. Culturally responsive treat- counselor will be held in confidence, except ment should involve community events, group when there is an ethical duty to report. activities, and the ability to participate in Native American cultural groups generally ceremonies to help clients achieve balance and believe that health is nurtured through balance find new insight (Calabrese 2008). Stronger and living in harmony with nature and the attachment to Native American cultural community (Duran 2006; Garrett et al. 2012). groups protects against substance use and

144 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups abuse; therefore, strengthening this connection client strengths and empowerment, recognize is important in substance abuse treatment the need to accept personal responsibility for (Duran 2006; Moss et al. 2003; Spicer 2001; change, and make use of learning styles that Stone et al. 2006). many Native Americans find culturally ap- propriate (Heilbron and Guttman 2000; Theoretical Approaches and McDonald and Gonzalez 2006). Motivational Treatment Interventions interviewing is also recommended for Native Some clinicians caution that a model of coun- American clients. In a small study, Villanueva seling that requires self-disclosure to relative et al. (2007) found that all treatment modali- strangers can be counterproductive with Native ties resulted in improvements at 15-month American clients. Other authors recommend follow-up, but clients who received motiva- CBT and social learning approaches for tional enhancement therapy reported signifi- Native American clients, as such approaches cantly fewer drinks per drinking day during typically have less cultural bias, focus on prob- the 10- to 15-month posttreatment follow-up lem-solving and skill development, emphasize period. Venner et al. (2006) wrote a manual for motivational interviewing with Native Advice to Counselors: Counseling American clients. Native Americans Family therapy When working with Native American clients, Family involvement in treatment leads to providers should: • Use active listening and reflective re- better outcomes for Native Americans at the sponses. time of discharge from treatment (Chong and • Avoid interrupting the client. Lopez 2005). Research also suggests that • Refrain from asking about family or per- family and community support can have a sonal matters unrelated to substance abuse significant effect on recovery from substance without first asking the client’s permission to inquire about these areas. use disorders for this population ( Jones- • Avoid extensive note-taking or excessive Saumty 2002; Paniagua 1998). Family therapy questioning. can be quite helpful and perhaps even essential • Pay attention to the client’s stories, experi- for American Indian clients (Coyhis 2000), ences, dreams, and rituals and their rele- especially when other social supports are vance to the client. . • Recognize the importance of listening and lacking ( Jones-Saumty 2002) focus on this skill during sessions. American Indians place high value on family • Accept extended periods of silence during sessions. and extended family networks; restoring or • Allow time during sessions for the client to healing family bonds can be therapeutic for process information. clients with substance use disorders. Moreo- • Greet the client with a gentle (rather than ver, Native American clients are sometimes firm) handshake and show hospitality (e.g., by offering food and/or beverages). less motivated to engage in “talk therapy” and • Give the client ample time to adjust to the more willing to participate in therapeutic setting at the beginning of each session. activities that involve social and family rela- • Keep promises. tionships ( Joe and Malach 2011). Treatment • Offer suggestions instead of directions approaches should remain flexible and in- (preferably more than one to allow for cli- ent choice). clude clients’ families when appropriate. Counselors should be able to recognize what Sources: Aragon 2006; Trimble et al. 2012. constitutes family, family constellations, and

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family characteristics. The Native American adapted, group therapy can be very beneficial concept of family can include elders, others and culturally congruent. It is important, from the same clan, or individuals who are not however, to determine Native American clients’ biologically related. In many Tribes, all mem- level of acculturation before recommending bers are considered relatives. Families can be Western models of group therapy, as less matrilineal (i.e., kinship is traced through the acculturated Native clients are likely to be less female line) and/or matrilocal (i.e., married comfortable with group talk therapy (Mail and couples live with wife’s parents). Shelton 2002). Group therapy for Alaska Natives should also be nonconfrontational and When families do enter treatment, they may focus on clients’ strengths. initially prefer to focus on a concrete problem, but not necessarily on the most significant Group therapy can incorporate Native family issue. Discussion of a clearly defined American traditions and rituals to make it presenting problem enables families to assess more culturally suitable. For example, the the therapeutic process and better understand talking circle is a Native tradition easily what is expected of them in treatment. Provid- adapted for behavioral health treatment. In ers should be aware that the entire clan and/or this tradition, the members of the group sit in Tribe could know about a given client’s treat- a circle. An eagle feather, stone, or other sym- ment and progress. Family therapy models bolic item is passed around, and each person such as network therapy, which makes use of speaks when he or she is handed the item. support structures outside the immediate Based on a review of the literature, Paniagua family and which were originally developed (1998) recommends that providers using for Native American families living in urban group therapy with Native American clients: communities, can be particularly effective with • Earn support or permission from Tribal Native clients, especially when they have been authorities before organizing group therapy. cut off from their home communities because • Consult with Native professionals. of substance abuse or other issues. For more • If group members consent, invite respected information on network therapy and similar Tribal members (e.g., traditional healers or approaches, see TIP 39, Substance Abuse elders) to participate in sessions. Treatment and Family Therapy (CSAT 2004b). Mutual-help groups Group therapy Native American peoples have a long history Although researchers and providers once of involvement in mutual-help activities that viewed group therapy as ineffective for Ameri- predates the 12-Step movement (Coyhis and can Indian clients (Paniagua 1998), opinion White 2006). Depending on acculturation, has shifted to recognize that, when appropri- availability of a community support network, ately structured, group therapy can be a pow- and the nature of their presenting problems, erful treatment component (Garrett 2004; Native American clients may be more likely to Garrett et al. 2001; Trimble and Jumper- solicit help from significant others, extended Thurman 2002). Garrett (2004) notes that family members, and community members. many Native American Tribes have traditional Contemporary manifestations of Native healing practices that involve groups; for many American mutual-help efforts include adapta- of these cultural groups, healing needs to occur tions of the 12 Steps (Exhibit 5-4) and of 12- within the context of the group or community Step meeting rituals and practices (Coyhis and (e.g., in talking circles). Thus, if properly White 2006). Another modified element of

146 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

Exhibit 5-4: The Lakota Version of the 12 Steps The Lakota Tribe has adapted the 12 Steps to suit its particular belief system as follows: 1. I admit that because of my dependence on alcohol, I have been unable to care for myself and my family. 2. I believe that the Great Spirit can help me to regain my responsibilities and model the life of my forefathers (ancestors). 3. I rely totally on the ability of the Great Spirit to watch over me. 4. I strive every day to get to know myself and my position within the nature of things. 5. I admit to the Great Spirit and to my Indian brothers and sisters the weaknesses of my life. 6. I am willing to let the Great Spirit help me correct my weaknesses. 7. I pray daily to the Great Spirit to help me correct my weaknesses. 8. I make an effort to remember all those that I have caused harm to and, with the help of the Great Spirit, achieve the strength to try to make amends. 9. I do make amends to all those Indian brothers and sisters that I have caused harm to whenever possible through the guidance of the Great Spirit. 10. I do admit when I have done wrong to myself, those around me, and the Great Spirit. 11. I seek through purification, prayer, and meditation to communicate with the Great Spirit as a child to a father in the Indian way. 12. Having addressed those steps, I carry this brotherhood and steps to sobriety to all my Indian brothers and sisters with alcohol problems and together we share all these principles in all our daily lives.

Source: CSAT 1999b, p. 56. Reprinted from material in the public domain.

the 12 Steps is use of a circular, rather than a considerable number also continue to partici- linear, path to healing. The circle is important pate in traditional 12-Step groups. In the AI- to American Indian philosophy, which sees the SUPER-PFP, 47 percent of Northern Plains great forces of life and nature as circular Tribe respondents and 28.8 percent of South- (Coyhis 2000). In addition, staff members of west Tribe respondents with a past-year sub- the White Bison program have also rewritten stance use disorder reported 12-Step group the AA “Big Book” from a Native American attendance in the prior year (Beals et al. 2006). perspective (Coyhis and Simonelli 2005). The Mohatt et al. (2008b) found that more Alaska principles of the 12 Steps, which involve using Natives in recovery reported participation in the group or community to provide support 12-Step groups than in substance abuse treat- and motivation while emphasizing spiritual ment. In Venner and Feldstein’s (2006) re- reconnection, appeal to many Native Ameri- search with American Indians in recovery, 84 cans who see treatment as social in nature and percent of respondents had attended some who view addiction as a spiritual problem. mutual-help meetings. The Native American Wellbriety movement is Traditional healing and a modern, indigenous mutual-help program complementary methods that has its roots in 12-Step groups but incor- Native American peoples have a range of be- porates Native American spiritual beliefs and liefs about health care—from traditional beliefs cultural practices (Coyhis and Simonelli 2005; to strong support for modern science—and Coyhis and White 2006; White Bison, Inc. may use a number of strategies when address- 2002; also see http://www.whitebison.org). ing health problems. Traditional healing prac- Although the Wellbriety movement is popular tices are often used in conjunction with modern with many Native Americans in recovery, a medicine. For example, American Indians

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traditionally view all things as deeply inter- 2002; White 2000). The sweat lodge, in par- connected. Disruption of the physical, mental, ticular, is frequently used in substance abuse spiritual, or emotional sides of a person can treatment settings (Bezdek and Spicer 2006; result in illness. A Native American client may Schiff and Moore 2006). consult a medical doctor to address part of the Alaskan behavioral health programs have problem and a traditional healer to help regain developed recovery camps to provide a treat- balance and harmony. ment setting that incorporates Native beliefs The use of traditional healing for substance and seasonal practices (e.g., Old Minto Family abuse and mental health problems is fairly Recovery Camp: common among Native Americans (Herman- http://www.tananachiefs.org/ health- Stahl and Chong 2002; Herman-Stahl et al. services/old-minto-family-recovery-camp- 2003). For example, among Native American new/). Recovery camps are based on the mod- individuals who reported a substance use el of traditional Native Alaskan fishing camps disorder in the past year, 57.4 percent of those and provide a context in which clients can from a Southwest Tribe and 31.7 percent from learn about traditional practices, such as suste- a Northern Plains Tribe used traditional heal- nance activities. Another program, the Village ers or healing practices (Beals et al. 2006). In a Sobriety Project, incorporates traditional survey of American Indians from three differ- Yup’ik and Cup’ik Eskimo traditions of hunt- ent Arizona Tribes, 27.4 percent stated that ing, chopping wood, berry picking, and taking they had used traditional healers and/or heal- tundra walks (Mills 2003). See Niven (2010) ing practices to help with mental health prob- for a review of client-centered, culturally lems (Herman-Stahl and Chong 2002). responsive behavioral health techniques for Overall, many Native Americans believe that use with Alaska Natives. culture is the primary avenue of healing and It is difficult to measure the effectiveness of that connecting with one’s culture is not only a Native American healing practices using means of prevention, but also a healing treat- ment (Bassett et al. 2012) There are a number of potential pitfalls that can occur when trying to integrate Each Native American culture has its own Native spiritual and cultural practices into specific healing practices, and not all of those treatment. Cultural groups are complex practices are necessarily appropriate to adapt systems; removing pieces of them for to behavioral health treatment settings. How- implementation as part of a treatment ever, many traditional healing activities and program can be a disservice to the culture as well as the clients (Kunitz et al. 1994; ceremonies have been made accessible during Moss et al. 2003); a breach of customs treatment or effectively integrated into treat- and traditions; and a sign of disrespect for ment settings (Castro et al. 1999b; Coyhis the community and Tribe, Tribal lead- 2000; Coyhis and White 2006; Mail and ership, and Native American practices. It Shelton 2002; Sue 2001; White 2000). These is important to take the time to build practices include sacred dances (such as the relationships and seek consultation with Plains Indians’ sun dance and the ’s Tribal elders, and other Tribal leaders to gourd dance), the four circles (a model for ensure that the best and most appropriate conceptualizing a harmonious life), the talking steps are taken in creating a culturally relevant and responsive treatment circle, sweat lodges, and other purification model and program. practices (Cohen 2003; Mail and Shelton

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Western standards and practices. Limited or (Garrity 2000). In 2001, roughly 20 percent of inconsistent funding, migration patterns, American Indians identified as Baptist, 17 culturally incompetent or incongruent evalua- percent as Catholic, 17 percent as having no tion practices, and abuses incurred during or religious preference, and 3 percent as following after data collection are major confounding a Tribal religion (Kosmin et al. 2001). variables that have limited knowledge on the The relative importance of religion can also effectiveness of incorporating traditional vary among diverse Native American commu- practices into Western approaches to the nities. Before pursuing traditional methods, treatment of substance abuse and mental assessment of clients’ spiritual orientation is illness. Nonetheless, Mail and Shelton (2002) important. Spirituality is a personal issue that reviewed earlier literature on the use of “indig- treatment providers must respect; clients enous therapeutic interventions” for alcohol should choose which spiritual and cultural abuse and dependence and suggest that a methods to incorporate into treatment. Pro- number of these interventions have been of viders should also be wary of an obsession value to Native Americans with substance use with their clients’ cultural activities, which may disorders. Other authors have concurred be considered intrusive (LaFromboise et al. (Coyhis and White 2006; Sabin et al. 2004). 1993). Checking with community resources Regardless of whether a program adapts spe- on the subject and asking the client “What cific Native American healing practices, pro- feels right for you?” are appropriate steps to viders working with this population should take in identifying whether traditional healing recognize that spirituality is central to its practices will have therapeutic value. Providers values and is perceived as an integral part of should consult with Native healers or Tribal life itself. It is through spiritual experiences leaders about the appropriateness of using a that Native Americans believe they will find particular practice as part of behavioral health meaning in life. Some Native languages have services. Rather than using traditional healing words that refer to spirituality as “walking methods themselves, counselors may wish to around” or “living the path.” In many cases, the refer clients to a Native American healer in spiritual traditions of Native Americans are the community or in the treatment program. not (and have never been) conceived of as a Relapse prevention and recovery religion, but rather as a set of beliefs and practices that pervades every aspect of daily Despite limited data on long-term recovery life (Deloria 1973). for Native Americans who have substance use disorders, a few studies have found high rates Despite religion and spirituality often playing of relapse following substance abuse treatment important roles in recovery from mental and (see review in Chong and Herman-Stahl substance use disorders for Native Americans, 2003). White and Sanders (2004) recommend providers should not assume that only indige- that long-term recovery plans for Native nous spirituality is relevant. The majority of Americans make use of a recovery manage- Native Americans do not practice their tradi- ment rather than a traditional continuing care tional spirituality exclusively, and Christian approach. Such an approach emphasizes the religious institutions like the Native American use of informal recovery communities and Church and Pentecostal churches have been traditional healing approaches to provide instrumental in helping many Native Ameri- extended monitoring and support for Native cans overcome substance use disorders Americans leaving treatment.

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Researchers have conducted interviews with of the population in the 2010 Census; Mather both American Indians (Bezdek and Spicer et al. 2011). 2006) and Alaska Natives (Hazel and Mohatt White Americans, like other large ethnic and 2001; Mohatt et al. 2008; People Awakening cultural groups, are extremely heterogeneous Project 2004) who have achieved extended in historical, social, economic, and personal periods of recovery. Bezdek and Spicer (2006) features, with many (often subtle) distinctions identified two key tasks for American Indians among subgroups. Perhaps because White entering recovery. First, they need to learn how Americans have been the majority in the to respond to family and friends who drank United States, it is sometimes forgotten how with them and to those who supported their historically important certain distinctions recovery. Next, they have to find new ways to between diverse White American ethnic deal with boredom and negative feelings. By heritages have been (and continue to be, for accomplishing these tasks, Native clients can some). Conversely, many White American build new social support systems, develop people prefer not to see themselves as such effective coping strategies for negative feelings, and instead identify according to their specific and achieve long-term recovery. The People ethnic background (e.g., as Irish American). Awakening Project found that, among Alaska For similar reasons, certain cross-cutting Natives who had a substantial period of recov- cultural issues (see Chapter 1) like geographic ery, the development of active, culturally ap- location, sexual orientation, and religious propriate coping strategies was essential (e.g., affiliation are important in defining the cul- distancing themselves from friends or family tural orientations of many White Americans. who drank heavily, getting involved in church, doing community service, praying; Hazel and Beliefs About and Traditions Mohatt 2001; Mohatt et al. 2008; People Involving Substance Use Awakening Project 2004). Historically, use of alcohol was accepted Counseling for White among White/European cultural groups because it provided an easy way to preserve Americans fruit and grains and did not contain bacteria that might be found in water. Over time, the According to the 2010 U.S. Census definition, production and consumption of alcohol be- White Americans are people whose ancestors came an often-integral part of cultural activi- are among those ethnic groups believed to be ties, which can be seen in the way some White the original peoples of Europe, the Middle cultural groups take particular pride in nation- East, or North Africa (Humes et al. 2011). al brands of alcoholic beverages (e.g., Scotch The racial category of White Americans whisky, French wine; Abbott 2001; Hudak includes people of various ethnicities, such as 2000). A number of European cultural groups , , Polish (e.g., French, Italian) traditionally believed Americans, and Americans (i.e., people that daily alcohol use was healthy for both with origins in England), among others. Many mind and body (Abbott 2001; Marinangeli Latinos will also identify racially (if not ethni- 2001), and for others (e.g., English, Irish), the cally) as White American. Non-Latino White bar or pub was the traditional center of com- Americans constitute the largest racial group munity life (O’Dwyer 2001). Despite some in the United States (making up 63.7 percent variations in cultural attitudes toward appro- priate drinking practices, alcohol has been and

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remains the primary recreational substance for often more accepting of prescription medica- Whites in the United States. Predominant tion abuse and less likely to perceive prescrip- attitudes toward drinking in the United States tion medications as potentially harmful more closely reflect those of Northern Europe; (Hadjicostandi and Cheurprakobkit 2002). alcohol use is generally accepted during cele- Despite illicit drug use now being as common brations and recreational events, and, at such among White Americans as people of color, times, excessive consumption is more likely to White Americans still tend to perceive drug be acceptable. use as an activity that occurs outside their Typically, White European cultural groups families and communities. In a 2001 survey, accept alcohol use as long as it does not inter- only 54 percent of White Americans ex- fere with responsibilities, such as work or pressed concern that someone in their family family, or result in public drunkenness (Hamid might develop a drug abuse problem compared 1998). However, among certain groups of with 81 percent of African Americans (Pew White Americans (usually defined by religious Research Center for the People and the Press beliefs), the use of alcohol or any other intoxi- 2001). In the same survey, White Americans cant is considered immoral (van Wormer expressed less concern about drug abuse in 2001). These religious beliefs, combined with their neighborhoods than did other racial and concerns about the effects of problematic ethnic groups. However, in terms of seeing drinking patterns (especially among men in drugs as a national problem, White Americans the frontier; White 1998), became the impetus and other racial and ethnic groups are in closer for the early 19th-century creation of the agreement. Perhaps as a result of this misper- Temperance Movement and culminated in the ception about the prevalence of drug use in passing of the 18th Amendment to the United their homes and communities, White States Constitution, which enacted Prohibition. American parents are less likely to convey Although the Temperance Movement is no disapproval of drug use to their children than longer a major political force, belief in the African American parents (National Center moral and social value of abstinence continues on Addiction and Substance Abuse 2005) and to be strong among some segments of the much more likely than Latino or African White American population. American parents to think that their children have enough information about drugs (Pew Illicit drug use, on the other hand, has histori- Research Center for the People and the Press cally been demonized by White American 2001). cultural groups and seen as an activity engaged in by people of color or undesirable subcul- There are also differences in how White Amer- tures (Bonnie and Whitebread 1970; Hamid icans, Latinos, and African Americans perceive 1998; Whitebread 1995). For example, White drug and alcohol addictions. White Americans Americans typically link drug use to per- are less likely than African Americans, but ceived threat of crime—particularly crimes more likely than Latinos, to state that they perpetrated by people of color (Hamid 1998; believe a person can recover fully from addic- Whitebread 1995). Attitudes have changed tion (Office of Communications 2008). How- over time, but White American cultural ever, White Americans are more likely than groups continue to enforce strong cultural African Americans to indicate that substance prohibitions against most types of illicit drug use disorders should be treated as diseases use. At the same time, White Americans are (Durant 2005).

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Substance Use and Substance Use White Americans who use heroin are less likely Disorders than people who use heroin from all other major racial/ethnic groups except African According to 2012 NSDUH data, rates of Americans to have injected the drug past-year substance use disorders were higher (SAMHSA 2011c). White Americans are also for White Americans than for Native more likely than members of other major Hawaiians, other Pacific Islanders, and Asian racial/ethnic groups, except Native Hawaiians Americans; rates of current alcohol use were and other Pacific Islanders (for whom esti- higher than for every other major ethnic/racial mates may not be accurate), to have tried group (SAMHSA 2013d). Alcohol has tradi- ecstasy. Except for Native Americans (some of tionally been the drug of choice among White whom may use the hallucinogen peyote for Americans of European descent; however, not religious purposes), they are also more likely all European cultural groups have the same than other racial/ethnic groups to have tried drinking patterns. Researchers typically con- hallucinogens (SAMHSA 2011c). Research trast a Northern/Eastern European pattern, in confirms that prescription drug misuse is which alcohol is consumed mostly on week- more common among White Americans than ends or during celebrations, with that of African Americans or Latinos (Ford and Southern Europe, in which alcohol is con- Arrastia 2008; SAMHSA 2011c), and they are sumed daily or almost daily but in smaller more likely to have used prescription opioids quantities and almost always with food. The in the past year and to use them on a regular Southern European pattern involves more basis. regular use of alcohol, but it is also associated with less alcohol-related harm overall (after Comparative studies indicate that White controlling for total consumption; Room et al. Americans are more likely than all other major 2003). The pattern of White Americans typi- racial/ethnic groups except Native Americans cally follows that of Northern and Eastern to have an alcohol use disorder (Hasin et al. Europe, but individuals from some ethnic 2007; Perron et al. 2009; Schmidt et al. 2007). groups maintain the Southern European White Americans are at a greater risk of having pattern. severe alcohol withdrawal symptoms (such as delirium tremens) than are African Americans White Americans, on average, begin drinking or Latinos with alcohol use disorders (Chan et and develop alcohol use disorders at a younger al. 2009). So too, White Americans are more age than African Americans and Latinos likely than African Americans or Latinos to (Reardon and Buka 2002). White Americans meet diagnostic criteria for a drug use disorder are more likely to have their first drink before at some point during their lives (Perron et al. the age of 21 and to have their first drink 2009). Overall, substance use disorders vary before the age of 16 than members of any considerably across and within non-European other major racial/ethnic group except Native White American cultural groups. For example, Americans (SAMHSA 2011c). Some data rates of substance abuse treatment admissions suggest that White Americans begin using in from 2005 suggest that substance illicit drugs at an earlier age than African use disorders may be considerably lower for Americans (Watt 2008) and that the mean age Arab Americans than other White Americans for White Americans who inject heroin has (Arfken et al. 2007). decreased (Broz and Ouellet 2008).

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Mental and Co-Occurring Americans and about 60 percent lower for Disorders Asian Americans (Grant et al. 2005). A simi- lar pattern exists for major depressive disorder About 20 percent of White Americans report- (Hasin et al. 2005). ed some form of mental illness in the past year, and they were more likely to have past-year Treatment Patterns serious psychological distress than other popu- White Americans are more likely to receive lation groups excluding Native Americans mental health treatment or counseling than (SAMHSA 2012a). other racial/ethnic groups (SAMHSA 2012b). White Americans appear to be more likely White Americans are more likely than African than Latinos or Asian Americans to have Americans to receive substance abuse treat- CODs (Alegria et al. 2008a; Vega et al. 2009) ment services from a private physician or and more likely to have concurrent serious other behavioral health or primary care profes- psychological distress and substance use disor- sional (Perron et al. 2009). Among White ders (SAMHSA 2011c). White Americans American clients entering substance abuse with CODs are also more likely to receive treatment programs in 2010, alcohol (alone or treatment for both their substance use and in conjunction with illicit drugs) was most mental disorders than are African Americans often the primary substance of abuse, followed with CODs (Alvidrez and Havassy 2005; by heroin and cannabis. However, findings are Hatzenbuehler et al. 2008), but they are per- inconsistent concerning the relative frequency haps less likely to receive treatment for their with which White Americans enter substance substance use disorder alone (Alvidrez and abuse treatment. Some studies have found that Havassy 2005). White Americans are more White Americans are more likely to receive likely to receive family counseling and mental needed behavioral health services than both health services while in substance abuse treat- African Americans and Latinos (Marsh et al. ment and less likely to have unmet treatment 2009; Wells et al. 2001). In contrast, other needs (Marsh et al. 2009; Wells et al. 2001). In studies have found that African Americans addition, White Americans are significantly with an identified need are somewhat more less likely than Latinos or African Americans likely to enter treatment for drug use disorders to believe that antidepressants are addictive and about as likely to receive treatment for (Cooper et al. 2003). alcohol use disorders when compared with White Americans (Hatzenbuehler et al. 2008; The most common mental disorders among Perron et al. 2009; SAMHSA, CBHSQ 2012; White Americans are mood disorders (par- Schmidt et al. 2006). ticularly major depression and bipolar I disor- der) and anxiety disorders (specifically Beliefs and Attitudes About phobias, including social phobia, and general- Treatment ized anxiety disorder; Grant et al. 2004b). Among White Americans, these disorders are White Americans appear to be generally more prevalent than in any other ethnic/racial accepting of behavioral health services. They groups save Native Americans (Grant et al. have better access to health care and are more 2005; Hasin et al. 2005). For example, rates of a likely to use services than people of color, but lifetime diagnosis of generalized anxiety disor- this varies widely based on socioeconomic der are about 40 percent lower for African status and cultural affiliation. Most treatment Americans and Latinos than for White services have historically been developed for

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White American populations, so it is not opposed to being in partial remission or drink- surprising that White Americans are more ing without symptoms of alcohol dependence likely than other racial/ethnic groups to be (Dawson et al. 2005). satisfied with treatment services (Tonigan 2003). Treatment Issues and Considerations Still, attitudes differ among certain cultural subgroups of White Americans. For example, Most major treatment interventions have been Russian immigrants from the former Soviet evaluated with a population that is largely or Union have a longstanding distrust of mental entirely White American, although the role of health systems and hence may avoid substance White American cultural groups is rarely abuse treatment (Kagan and Shafer 2001). considered in evaluating those interventions. Other groups who have a strong family orien- For example, as Straussner (2001) notes, “the tation, such as Italian Americans or Scotch- paradox of writing about substance abusers of , might avoid treatment that European background is that they are a group asks them to reveal family secrets (Giordano that is believed to be the group for whom the and McGoldrick 2005; Hudak 2000). traditional alcohol and other drug treatment models have been developed, and yet they are According to 2010 NSDUH data regarding a group whose unique treatment needs and people who recognized a need for substance treatment approaches have rarely been ex- abuse treatment in the prior year but did not plored” (p. 165). Very few evaluations of receive it, White Americans were more likely treatment strategies and interventions (wheth- than members of other major racial/ethnic er based on research or clinical observation) groups to state that it was because they had no have taken into account ethnic and cultural time for treatment, that they were concerned differences among White American clients, what their neighbors might think, that they and therefore it is generally not possible to did not want others to know, and/or that they make culturally responsive recommendations were concerned about how it might affect for specific subgroups of White Americans. their jobs (SAMHSA 2011c). Other research confirms that White Americans are significant- Culturally responsive treatment for many ly more likely to avoid treatment due to fear of White Americans will involve helping them what others might think or because they are in rediscover their cultural backgrounds, which denial (Grant 1997). White Americans may sometimes have been lost through acculturation also have different attitudes toward recovery, at and can be an important part of their long- least regarding alcohol use disorders, than do term recovery. Giordano and McGoldrick members of other ethnic/racial groups. Ac- (2005) note that ethnic identity and culture cording to NESARC data on people who can be more important for some White met criteria for a diagnosis of alcohol de- Americans “in times of stress or personal pendence at some point during their lives, crisis,” when they may want to “return to White Americans were more likely than familiar sources of comfort and help, which African Americans, Latinos, or other non- may differ from the dominant society’s norms” Latinos to have achieved remission from that (p. 503). Appendix B provides information on disorder but were also less likely than African instruments for assessing cultural identifica- Americans or other non-Latinos (but not tion. For an overview of challenges in main- Latinos) to currently abstain from drinking, as taining mental health, access to health care,

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and help-seeking among White Americans, ethnic heritages, and there is no approach that see Downey and D’Andrea (2012). is effective for all White Americans in family therapy (Hanson 2011). Hierarchical families, Theoretical Approaches and such as German American families, may Treatment Interventions expect the counselor to be authoritative, at Overall, the optimum treatment approach least in the initial sessions (Winawer and with White Americans is a comprehensive Wetzel 2005), although a more egalitarian one; the more tools in the toolkit, the greater German American family might not respond the chance of success (McCaul et al. 2001). well to such imperatives. In the same vein, one Within-group differences arise regarding client of French background could readily education level, socioeconomic status, gender, accept direct and clear therapeutic assign- and other factors, which must be considered. ments that contain measurable goals (Abbot Providers can, however, assume that most 2001), whereas another French American well-accepted treatment approaches and inter- client may value counseling that is more pro- ventions (e.g., CBT, motivational interviewing, cess oriented. Thus, it is imperative to assess 12-Step facilitation, contingency management, the cultural identification of clients and their pharmacotherapies) have been tested and families, along with the treatment needs that evaluated with White American clients. best match their cultural worldviews. Still, treatment is not uniformly appropriate In some White American families, there is a even for White Americans. Approaches may longstanding culture of drinking. Attempts at need modification to suit class, ethnic, reli- abstinence can be perceived by family mem- gious, and other client traits. Providers should bers as culturally inappropriate. In other fami- establish not only the client’s ethnic back- lies, there is deep denial about alcohol abuse or ground, but also how strongly the person dependence, especially when talking about identifies with that background. Few clinicians substance use to those outside the family. For have made observations on best therapeutic example, some Polish American families can approaches for members of particular White be resistant to the idea that drinking is the American cultural/ethnic subgroups. cause of family problems (Folwarski and Smolinski 2005) and sometimes believe that Family therapy to admit an alcohol problem, especially to In White American families, individuals are someone outside the family, signals weakness. generally expected to be independent and self- Group therapy reliant; as a result, families in therapy can have trouble adjusting to work that focuses more on Standard group therapies developed for men- communication processes than specific prob- tal health and substance abuse treatment lems or content (McGill and Pearce 2005). programs have generally been used and evalu- Van Wormer (2001) notes that many White ated with White American populations. For Americans need help addressing communica- details on group therapy in substance abuse tion issues. In family therapy, useful approach- treatment, see TIP 41, Substance Abuse Treat- es include those that encourage open, direct, ment: Group Therapy (CSAT 2005c). and nonthreatening communication. Mutual-help groups There is no singular description that fits Mutual-help groups, of which AA is the most White American families within or across prevalent, have a largely White American

155 Improving Cultural Competence

membership (AAWS 2008; Atkins and Traditional healing and Hawdon 2007). In a 2011 survey, 87 percent complementary methods of AA members indicated their race as White Only 12 percent of White Americans consider (AAWS 2012). In research with largely White themselves atheist, agnostic, or secular without populations, AA participation has been found a religious affiliation, meaning that, as a group, to be an effective strategy for promoting White Americans are more religious than recovery from alcohol use disorders (Dawson Asian Americans but less so than Latinos or et al. 2006; McCrady et al. 2004; Moos and African Americans (Pew Forum on Religion Moos 2006; Ritsher et al. 2002; Weisner et al. and Public Life 2008). As with other groups, 2003). Other mutual-help groups, such as White Americans belong to many different Self-Management and Recovery Training, religions, although the vast majority belong to Secular Organizations for Sobriety/Save Our various Christian denominations, with approx- Selves, and Women for Sobriety, also have imately 57 percent identifying as Protestant predominately White American membership and 25.9 percent as Catholic (National Center and are based on Western ideas drawn from on Addiction and Substance Abuse, 2001). psychology (Atkins and Hawdon 2007; White White Americans also make up 91 percent of 1998). practitioners of Judaism in the United States, The appeal of mutual-help groups among 14 percent of followers of Islam, and 32 per- White Americans rests on the historical ori- cent of the American Buddhist population gins of this model. The 12-Step model was (Kosmin et al. 2001). For more religious originally developed by White Americans White Americans, pastoral counseling or based on European ideas of spirituality, faith, prayer can be useful aids in the treatment of and group interaction. Although the model substance use disorders. However, White has been adopted worldwide by different Americans are significantly less likely to use cultural groups (White 1998), the 12-Step prayer as a method of coping (Graham et al. model works especially well for White ethnic 2005). White Americans are more likely than groups, including Irish Americans, Polish members of other major racial/ethnic groups Americans, , and Scotch- to use complementary or alternative medical Irish Americans, because it incorporates therapies, such as herbal medicine, acupunc- Western cultural traditions involving spiritual ture, chiropractors, massage therapy, yoga, and practice, public confession, and the use of special diets (Graham et al. 2005). anonymity to protect against humiliation Relapse prevention and recovery (Abbott 2001; Gilbert and Langrod 2001; Hudak 2000; McGoldrick et al. 2005; Taggart Factors that promote recovery for White 2005). Americans include the learning and use of coping skills (Litt et al. 2003; Litt et al. 2005; In addition to mutual-help groups for sub- Maisto et al. 2006). Even though some research stance abuse, numerous recovery support suggests that White Americans are less likely groups, Internet resources, Web-based com- to use coping skills than African Americans munities, and peer support programs are (Walton 2001) and have lower levels of self- available to promote mental health recovery. efficacy upon leaving treatment (Warren et al. Many resources are available through the 2007), the development of these skills and of National Alliance on Mental Illness self-efficacy is important in managing relapse (http://www.nami.org). risks and in maintaining recovery. Counselors

156 Chapter 5—Behavioral Health Treatment for Major Racial and Ethnic Groups

may offer psychoeducation on the value of 2002; McIntosh and McKeganey 2000; coping strategies, specific skills to manage Rumpf et al. 2002). Other important factors stressful situations or environments, and op- include continuing care, the development of portunities to practice these skills during substitute behaviors (i.e., reliance on healthy treatment. Some coping skills or strategies or positive activities in lieu of substance use), may be more important than others in manag- the creation of new caring relationships that ing high-risk situations, but research suggests do not involve substance use, and increased that greater use of a variety of coping strate- spirituality (Valliant 1983). Valliant (1983) gies is more important than the use of any one and others (e.g., Laudet et al. 2002; McCrady specific skill (Gossop et al. 2002). et al. 2004; Moos and Moos 2006) conclude, based on research with mostly White partici- Social and family supports are also important pants, that mutual-help groups often play an in maintaining recovery and preventing re- important role in maintaining recovery. lapse among White Americans (Laudet et al.

TIPs That Provide Supplemental Information on Topics in This Chapter TIP 34: Brief Interventions and Brief Therapies for Substance Abuse (CSAT 1999a)

TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999c)

TIP 39: Substance Abuse Treatment and Family Therapy (CSAT 2004b)

TIP 41: Substance Abuse Treatment: Group Therapy (CSAT 2005c)

TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005d)

TIP 44: Substance Abuse Treatment for Adults in the Criminal Justice System (CSAT 2005b)

TIP 47: Substance Abuse: Clinical Issues in Intensive Outpatient Treatment (CSAT 2006c)

TIP 51: Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT 2009c)

TIP 57: Trauma-Informed Care in Behavioral Health Services (SAMHSA 2014) Planned TIP: Relapse Prevention and Recovery Promotion in Behavioral Health Services (SAMHSA planned e)

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