Culturally Competent Treatment of Clients with Co-Occurring Disorders

Course ContentsCulturally Competent Treatment of Clients with Co-Occurring Disorders (COD) Overview: Course Goals Lesson 1: What is cultural competence? Lesson 2: Reasons for medical mistrust; stigma and

stereotypes Lesson 3: What drugs are our clients using? Lesson 4: African-Americans and COD Lesson 5: Latinos and COD Lesson 6: Asian-Americans and COD Lesson 7: Additional cultural factors Summary

Course Goals

Learn how to better provide culturally competent treatment to clients with co-occurring mental health, substance use, and health problems

Learn about your own cultural biases Learn which SFBHC clients are at highest

risk of COD Learn more about the cultural factors that can

impact clients’ response to treatment

Lesson 1

What is Cultural Competence?

What is Cultural Competence?

Let’s first define culture. Culture is a way of life, shared by a group of people, and passed

on over time. One's culture includes deeply held beliefs, attitudes, or values that come from one's ethnicity or other cultural factor, personality, or life experience.

What is Cultural Competence? Cultural competence refers to an ability to interact effectively with

people of different cultures. Developing cultural competence results in an ability to understand, communicate with, and effectively interact with people across different cultures.

What are Common Indicators of Culturally Competent Mental Health and Substance Abuse Treatment?

Staff is fluent in or at least knowledgeable about the primary language of the client

Staff understands the cultural nuances of the client population

Staff has backgrounds/life experiences similar to the client population

Treatment methods reflect the culture-specific values and individualized treatment needs of clients

Inclusion of the client population in program governance and decision-making

What Does a Culturally Competent Staff Member Do?

Holds all cultures in high esteem Has awareness of his/her own worldview Has awareness of his/her positive and negative

attitudes toward cultural differences Seeks to add to his/her own knowledge base

and that of the organization Applies cross-cultural skills in ways that promote

the rehabilitation and recovery of the client Advocates continuously for cultural competence

Are we biased?

Yes. We all carry bias toward others we perceive different from ourselves. We need to understand our own biases toward cultural differences. If you doubt you are biased, take one of the demonstration tests at:

https://implicit.harvard.edu/implicit/demo/

Bias is evident, so how do we provide culturally competent services?

We need to understand and resolve common sources of cross-cultural misunderstanding. Thoughtful self-assessment and a willingness to engage in Open, non-judgmental communication is essential.

What biases about people of other cultures do I have?

What assumptions have others made about my culture?

What misunderstandings have arisen because of this?

What steps do I take to prevent these misunderstandings from impacting my work with clients and co-workers?

Is there more we can do?

We need to develop sound clinical strategies for culture-informed assessment and treatment.

Some of these include: Assessing/treating clients in their preferred language Using references and symbols that clients understand Factoring in racial identity and personality development

when individualizing treatment Assessing how each client’s culture affects their beliefs

about mental health and substance use and their goals during treatment

Lesson 2

Reasons for Medical Mistrust

Stigma

Stereotypes

“Each racial/ethnic group believes that the treatment needs of its population are not fully understood and incorporated into standard practice. Each group is right.” -Lula Beatty, Director of Special Populations for the National Institute on Drug Abuse, (NIDA)

Most racial and ethnic groups are initially skeptical about the services provided by systems and people different from themselves. Why?…

…One reason for this is history

For example: The Tuskegee Syphilis Experiment For forty years between 1932 and 1972, the U.S. Public Health

Service (PHS) conducted an experiment on 399 Black men in the late stages of syphilis. These men, for the most part illiterate sharecroppers from one of the poorest counties in Alabama, were never told what disease they were suffering from or of its seriousness. Informed that they were being treated for “bad blood,” their doctors had no intention of curing them of syphilis at all

Another reason for mistrust is…

…Institutional Bias in Research

Increasing the representation of women and racial and ethnic minorities in human research has become a national priority

The need for this stems from historical bias favoring white men

To date, federal efforts to remedy this institutional bias have not been very successful

It should come as no surprise why many clients mistrust our ability to safely and effectively treat them

Another reason is…

…Fear About How the Information

a Client Reveals Will Be Used

Will we report it to law enforcement? Their employers? Their family? Will they lose their children to the child welfare

system? Will it result in a longer length of stay in treatment? All of these factors have been shown to more

frequently and more negatively affect non-Caucasian clients.

So why are people with substance use andmental health problems looked upon differently?

In a Word, It’s STIGMA

Stigma refers to having negative attitudes toward a group or class of people

Both psychiatric and substance-related diagnoses carry significant stigma in society

People with these diagnoses are judged unfairly and are frequent targets of discrimination

Thus the impact of discrimination a person may experience from some cultures may double or triple once they are diagnosed with these conditions

If they have other disabilities or financial difficulties they may also have problems even accessing treatment

Because of the Stigma of Substance Abuse Some people don’t get addiction treatment Some doctors won’t treat addicts Some pharmaceutical companies won’t work toward

developing new treatments for addicts Some addicts’ pain isn’t treated Many people believe addicts don’t really want help or are

weak or morally flawed Some families either deny the problem or cut off contact

with addicts in their families

Because of the Stigma of Mental Illness

Some people don’t get mental health treatment Some doctors are afraid to treat mental health consumers Some pharmaceutical companies won’t work toward

developing new treatments for consumers Many people believe consumers can’t really be helped or

are dangerous or incapable of a meaningful life Some families either deny the problem or cut off contact

with consumers in their families

We all have attitudes and judgments that affect how we think about and behave toward others. When we talk about negative attitudes and behavior toward others based on their gender, sexual orientation, culture, race or religion, we use the words prejudice and discrimination.So let’s call stigma what it really is.Centre for Addiction and Mental Health

Stereotypes are Not Helpful

What is helpful is understanding the basic norms in each culture so we can approach our clients more sensitively

Individual clients may or may not adhere to the beliefs and norms about substance use or disability in their particular culture. Do not base your assessment or treatment on stereotypes: Get to know the individual and how he/she relates to the world.

There is no such thing as “the Black family” “the Mexican-American family”, etc. All families are unique as are the people in them.

Lesson 3

What Drugs Are Our Clients Using?

What Drugs are Americans Using ?Past Month illicit drug use rates 2007 - SAMHSA

1) Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens,

inhalants, or prescription-type psychotherapeutics used non-medically.

Who is at highest risk of negative outcomes related to substance use?A) Chinese-Americans

B) Transitional Age Youth

C) African-Americans

D) Caucasians

E) Older Adults

F) Mexican-Americans

The correct answer is:

Transitional Age Youth

(people ages 18 – 25)

They are the group with the highest rates of substance use across all races/ethnicities

Transitional Age Youth and Illicit Drug Use – SAMHSA - 2007

Race/Ethnicity and past month illicit drug use rates – SAMHSA – 2007

Lesson 4

African-Americans and Co-Occurring Disorders

African Americans: Cultural SnapshotCultural Strengths

Extended family and spirituality often provide much support

Strong belief in the value of education and work

Strong communities with mutual aid

Resilience Pride Mutual respect for people of

status (due to gender, age, education, etc.)

Cultural Difficulties

Frequently discriminated against and scapegoated

Internalized feelings of oppression can lead to poor self image and increased rates of mental illness and substance abuse

High unemployment rates High rates of violence Disproportionate number of men

with drug problems and in prison per capita

Differences in language or behavioral style can be mistaken for resistance or denial

African Americans and Substance Use Slightly higher rates of illicit drug dependence than Caucasians Almost double the rate of crack cocaine use compared to

Caucasians though overall rates of cocaine (powder or crack) use are comparable.

African-Americans have been arrested on drug charges between 2.8 to 5.5 times more, relative to the population, than white Americans and are convicted much more frequently even though their rates of substance use are very similar to Caucasians.

Double the rates of substance abuse treatment vs. Caucasians (probably partially related to arrest rates – going to treatment often reduces the time in jail/prison one is sentenced to).

African Americans and Mental Illness Overall rates of mental illness appear to be similar to those of non-

Hispanic whites More likely to suffer from phobias, less likely to suffer from depression,

compared to non-Hispanic whites Somatization is more common in African Americans (15%) than whites

(9%) African Americans are over-represented in high-need populations that

are particularly at risk for mental illness: homeless (40%), incarcerated adults (50%), children in foster care (45%), children and adults exposed to violence who met diagnostic criteria for PTSD (25%)

African Americans are under represented in outpatient treatment but overrepresented in inpatient treatment.

Nearly 1 in 4 African Americans is uninsured, compared to 16% of the U.S. population

Lesson 5

Latinos and Co-Occurring Disorders

Latinos/Hispanic Americans: Cultural Snapshot

Cultural Strengths

Familismo – family and community very important (compared to Caucasian culture)

Strong connection to religion Strong work ethic Respect – strong value on

mutual respect Personalismo – warmth and

responsiveness

Cultural Difficulties

Less education and income Immigration often very stressful Language barrier makes this worse

for some Politeness and respect are valued

vs. assertiveness and criticism. Listener may appear to agree with a message, but may not have understood or have no intention to follow through

Belief in fatalism (that things are ‘meant to be’ discourages some people from engaging in treatment)

Latinos/Hispanic Americans and Substance Use

Alcohol use rates similar to African Americans – lower than Caucasians

Illegal drug use rates also low – lower than Caucasians, higher than Asians – but likely underreported due to fear of arrest/deportation

Higher rates of inhalant use in Mexican-Americans vs. Caucasians in some areas

Receive (along with blacks) longer sentences for drug-related convictions compared with Caucasians.

Higher rates of cirrhosis of the liver due to alcohol use vs. Caucasians

There are many Spanish-speaking AA and NA meetings in San Francisco

Latinos/Hispanic Americans and Mental Illness

Adult Mexican immigrants have lower rates of mental disorders than Mexican Americans born in the U.S.

Latino youth experience proportionately more anxiety-related and delinquency problem behaviors and depression than non-Hispanic white youth

More reports of depression related to physical health (26%) vs. those who report depression without physical health problems (5.5%)

Hispanic adolescents report more suicidal ideation and attempts compared to non-Hispanic whites and blacks.

PTSD rates ranging from 33% - 60% among refugees 37% of Hispanic Americans are uninsured compared to 16% for all

Americans

Lesson 6

Asian-Americans and Co-Occurring Disorders

Asian Americans: Cultural Snapshot

Cultural Strengths

Values hard work and education

Acceptance of what life brings Respect for and harmonious

existence with nature Family loyalty, respect for

elders Self-control Self-actualization Interdependence, collectivism

Cultural Difficulties

Immigration often very stressful

Often discriminated against Language barrier makes this

worse for some Being seen as ‘model minority’

sometimes leads to discrimination against Chinese-Americans by Blacks and Latinos

Mental and physical illnesses often treated only after a crisis

Asian Americans and Substance Use Low rates of all substance use compared with other cultures in

U.S. – in part likely due to under-diagnosis due to heavy stigma and denial and family members covering up substance-related problems

Most C-As who drink do so only at meals. Opioids (e.g. opium, heroin) have been used in China for

centuries – leading to higher rates of addiction to these substances than others

About 1/3 of C-As develop a “flush” reaction to drinking alcohol (red face). This is a risk factor for cancer of the esophagus – it also discourages drinking

Myth: Chinese people view addiction as a disease. Reality: As in most nations, substance abuse is seen as "a bad habit" in China, to be overcome by willpower

Clients can get help at San Francisco’s Asian-American Recovery Services: http://www.aars-inc.org/index.html

Asian Americans and Mental Illness Asian Americans (AA) and Pacific Islanders (PI) represent an extremely

diverse population, with about 43 different ethnic subgroups AA/PI’s speak over 100 languages and dialects and about 35% live in

households that are significantly isolated because of language issues Knowledge of the mental health needs of AA/PI’s is limited Chinese Americans are more likely to exhibit somatic complaints of

depression compared to blacks and non-Hispanic whites Asian American women have the highest suicide rate of all women over

the age of 65 in the U.S. Many refugees are at risk for PTSD Nearly 1 out of 2 AA/PI’s will have difficulty accessing treatment

because they do not speak English or cannot find language-appropriate services

About 21% of AA/PI’s are uninsured compared to 16% for all Americans

Lesson 7

Additional Cultural Factors

Additional Cultural Factors

In addition to differences in substance abuse rates across racial/ethnic lines, there are many other cultural differences that influence patterns of substance abuse across any given population in time

Cultural differences – as evidenced by age, gender, sexual orientation, religion, and socio-economic status – are often key factors in understanding the needs of the client.

We encourage you to seek out and advocate for additional training in these areas.

Most people with co-occurring mental health and substance-related problems only get treatment for their mental health problems if they get any help at all.

The graph on the next page shows this in detail.

Past Year Mental Health Care among Adults Aged 18 or Older with Both Serious Psychological Distress and a Substance Use Disorder: 2007

SAMHSA

What’s the correlation between substance abuse and psychiatric illness?

The following slide offers a snapshot of the percentage of substance-related disorders based on psychiatric diagnosis.

Co-occurring Disorders

Diagnosis % with Substance-Related Disorder

Antisocial PD 83Borderline PD 60Schizophrenia 47Bipolar Disorder 65Anxiety Disorder 35Depression 35Phobia 23

*PD = Personality Disorder

Summary

And Additional Resources

You can make a difference!

Please help our clients of all cultures feel welcome Do your homework so you can provide the most culturally

competent treatment you can. Ask your supervisor or Jennifer Baity Carlin, LCSW, the

BHC Co-Occurring Disorders Specialist, (206-6342) if you have questions about any of the content you’ve reviewed today.

MANY THANKS FOR THE GREAT WORK YOU DO EVERY DAY!!!

Credits/Resources

SAMHSA/CSAT TIP 46, Chapter 4: “Preparing a Program to Treat Diverse Clients” Teaching Tolerance: www.tolerance.org http://www.tuskegee.edu/Global/Story.asp?s=1207586 Centre for Addiction and Mental Health – Stigma brochure SAMHSA African American Substance Use: Epidemiology, Prevention, and Treatment William

L Turner and Beverly Wallace Nancy Boyd-Franklin – Black Families in Therapy Latinos and HIV: Cultural Issues in AIDS Prevention, UCSF The Sentencing Project Ethnocultural Factors in Substance Abuse Treatment (Paperback) by Shulamith Lala

Ashenberg Straussner DSW (Editor) The Gender Similarities Hypothesis -Janet Shibley Hyde http://www.psychiatrictimes.com/display/article/10168/46496?pageNumber=2 http://www.public-health.uiowa.edu/pattc/lgbttrainingcurriculum/ http://goliath.ecnext.com/coms2/gi_0199-3004454/Oppression-and-discrimination-am

ong-Lesbian.html http://www.who.int/mental_health/prevention/genderwomen/en/