The Impact of Culture on RecoveryMARRCH Conference September 14, 2011

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The Impact of Culture on RecoveryMARRCH Conference September 14, 2011

Information regarding African American, American Indian, Hispanic Latino, Hmong/Lao and Seniors has been compiled from the ADAD Population Specific Community needs assessment, various research articles and the training and experience of our Grantees including:

Sherman Lightfoot, Coordinator – African American Recovery Maintenance Services (TC-AARMS) Recovery Resource Center, 1900 Chicago Ave, Mpls, MN 55404 612-728-2019 in partnership with Farris Glover, Dir. My Home Inc 1010 University Ave #1, St. Paul, MN 55104 and 250 2nd Ave S., #280, Mpls, MN 55410 (651-659-0359)

Peggy Roy, Sacred Journey Director, Amy Hamid – Healing Journey (Adult American Indian women) and Shauuna McBride - Oshkiniigikwe Project (Adolescent American Indian women), 2300 15th Ave S., Mpls, MN 55404 (612-728-2019)

Cheryl Secola, Coordinator, Niminosemin Program – Division of Indian Work, 1001 E. Lake Street, Mpls, MN 55407 (612-722-8722)

Debb Sheehan, Director – Danielle Aasen, Coach - Guia Project Hispanic/Latino Services: PACT 4, 2200 23rd St NE #2030, Willmar, MN 56201 (320-231-7036)

Lee Yang Coordinator – SE Asians Living Chemically Free Partnership between NW Hennepin Human Services Council, Brooklyn Center, MN; Lao Assistance Center of MN; and Individual Hmong Consultants (763-503-2520)

Gwen Delger, LADC Coordinator – Fountain Center Older Adult Program, 404 W. Fountain St, Albert Lea, MN 56007 (507-377-6411)

Jill Spanier, LADC – Seniors Providing Elderly Care (SPEC), 253 State Street, St. Paul, MN 55107 (651-773-0473), Kim Jenkins, Dir.

Karen Christensen, MN DHS – Principal Planner/ Project Consultant 540 Cedar St, St. Paul, MN 55155 (651-431-4239)

Past Contributors: Deatrick LaPointe, Fawn Edberg, Tom Gerenz, Alex Espinoza, Saengmany Ratsabout, Xee Thao Lee, Chiengla Thao, Chrystal Lee, Vora Savengseuksa, Gwen Garcia, Bernie Polyak, Jennifer Mendoza, Kirk Crowshoe, Rosa Eddy, Farris Glover

Supported through the ADAD Population Specific Grant

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Cultural Intersections:Individualism vs. CollectivismAccess to supportCultural and Linguistic barriersFamily composition and connectivnessGenderAcculturation levelResilienceAssetsEducationRacismTraumaReligion/SpiritualityEmploymentNeighborhoodRisk FactorsCultural IdentityConcepts and language used to describe Mental Health – Chemical

Abuse/Addiction Time Orientation

Cultural Adaptation : “…any modification to evidence-based treatment that involves changes in the approach to service delivery, or in the nature of the therapeutic relationship, or in components of the treatment itself to accommodate the cultural beliefs, attitudes, and behaviors of the target population…” (Whaley & Davis, 2007)

Evidence Based Practices: “The integration of the best available research with clinical expertise in the context of patient characteristics culture and preferences (American Psychological Association, 2005)

Practice Based Evidence : “A range of treatment approaches and supports that are derived from, and supportive of, the positive cultural attributes of the local society and traditions. Practice Based Evidence services re accepted as effective by the local community, through community consensus, and address the therapeutic and healing needs of individuals and families from a culturally-specific framework. Practitioners of practice based evidence models draw upon cultural knowledge and traditions for treatments and are respectfully responsive to the local definitions of wellness and dysfunction…” (Isaacs, Huang, Hemendex, Echo-Hawk, 2006).

PBE is a set of practices that are unique and inherent in a culture that have proven to be effective based upon community consensus. (Martinez, 2007)

Community Defined Evidence: A set of practices that communities have used and determined to yield positive results as determined by community consensus over time and which may or may not have been measured empirically but have reached a level of acceptance by the community (CDEP Working Group).

CDE includes world view, contextual aspects and transactional processes that do not limit it to one manualized treatment but is usually made up of a set of practices that are culturally rooted – a supplemental approach.

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AFRICAN AMERICAN

Some scholars trace the history of African American people in North America to 1619 (Bennett, 1966) while others propose that Africans came to the Americas several centuries before that (Van Sertima, 1976). Historically, African Americans were direct descendants of captive West Africans who survived the slavery era. More recently, African Americans are voluntary immigrants from Egypt, Ghana, Nigeria, Haiti, the Caribbean, Central America or the South America nations, or refugees from Africa.

African Americans are the second largest racial group after Whites in the United States, with12.5% having European heritage as well (Wycopedia), yet the Black population has more recently, one of the slowest growth rates of all US populations -currently at about 1.3% per year. In Minnesota, 4.1% of our population is African American yet they make up 11% of our Chemical Dependency Treatment admissions.

Patterns of substance use/abuse began in slavery. Rum and tobacco trades were pervasive with alcohol being the only available anesthetic for injuries. The common Saturday night drunk quelled slave revolts, and kept them happy (Jonathan Lofgren, MARRCH - 2009).

White privilege supports superiority of Whites - affecting self esteem and negative self-perceptions within the Black community. Media (News etc) often emphasizes negative aspects of the African American community - supporting discrimination and fear within the public in general, weakening the sense of “the village” in the African American community. Blacks often continue to experience high numbers of lower socio-economic status, less success in schools (though changing) and worse health outcomes, and young men are often marginalized in society. 46% of Blacks who enter CD Treatment successfully complete it.

Negative experience with police, courts and jails, exceeds the general population experience by more than 13 times. The unique legacy of slavery, racism, sexism and economic oppression has left a sense of distrust for many systems including law enforcement, the courts, schools systems and health care.

During the Vietnam era (1960-70s), a high number of African Americans volunteered as soldiers and many were killed in action. Of those returning – a significant number experienced addiction to heroin.

A crack/cocaine epidemic erupted within the African American community in the 80’s, which evolved into a crime epidemic- that decimated the community. The result included an even greater over representation of African American men (and increasingly women) in prison.

Around the same time – an increase in teen pregnancy and an increase of poverty for single parent families was occurring. Grandmothers and great-grandmothers stepped up to raise their grandchildren, stretching this support system.

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Cultural disruptions resulting from increased education and socio-economic status have created new patterns of diversity and class divisions within African American communities, (“The Providers Guide to Quality & Culture”).

Significant numbers of East African immigrants and refugees coming to the United States has redefined the term African American. The population faces enormous language and cultural differences, racism, literacy and economic challenges with resulting high levels of depression and increasing chemical abuse. War trauma, social isolation, and change in social status have impacted acculturation. Services and culturally specific professionals are limited and stigma hinders and interest in access.

According to Drug Trends 2010, Patients admitted to addiction treatment programs by primary substance problem Among the African American’s who abuse chemicals; preferences have included cocaine, marijuana, heroin, and alcohol.

There are few African American-specific Chemical Dependency treatment services in Minnesota available, given the need. (African American Family Services, Recovery Resource Center, My Home Inc. and Turning Point are licensed Rule 31 programs in the metro area).

There is only one open-ended, culturally appropriate recovery maintenance support for African Americans in Minnesota -TC-AARMS.

Professionals may misdiagnose individuals who isolate themselves or who show hyper-vigilance due to feelings of being displaced, resulting in incorrect diagnoses, case planning, and poor outcomes.

African American Healing Supports: Beliefs; Values; Traditions

Beliefs/Practices Strong Christian, Church based belief with a strong sense of right and wrong. Moral

values have a shared religious core. (“Providers Guide to Quality and Culture”). The belief that God will take care of it - sustained many African Americans through slavery experience.

African American women must be strong and independent.

African American leaders have provided strong role modeling through enhancing gains through the Civil Rights and Black Power movements, obtaining rights and changing American society.

There is an emerging east African population due to the collapse of the 1991 Somali government and subsequent civil war. (Estimate: 50,000 Somalis in MN). The majority of Somalis are Muslim Sunnis (99%).

Africans believe in and practice hexing and voodoo with related ramifications.

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Don’t shake hands unless one is extended. Don’t use an index finger to call someone to you. Young people avoid eye contact for respect. Indirect speech and humor helps to save face. Fasting during Ramadan Interdependence of body, mind and spirit. Drinking alcohol and eating pork is prohibited. Possible areas of cultural differences:

Use of time, space Relationship to the earth Individualism and unique familial obligation and care-giving

responsibility – interdependence. Father is the decision-maker and wage earner for the family and

represents the family outside of the home.

African American Values The family is seen as a major support (i.e. we’ll get your mother/grandmother down

here if you don’t shape up). God/ Spirituality is the core of existence. African Pride

African American Traditions The “village” supports children as family Storytelling and Song emits history and culture. Literature, art, language, dance and music emit culture and strife Tradition influenced the cultivation of many important agricultural products. Strong female headed households evolved from family separation

African American Practices/Celebrations

Matunda ya Kwanza – “first fruits” (Swahili):

Kwanza, celebrated Dec. 26 - Jan 1st beginning in 1966 is a celebration of family, community and culture throughout the world – but primarily in America.

Organized around five fundamental activities common to other African first-fruit celebrations: 1) Gathering of family, friends, and community

2) Reverence for the creator and creation (thanksgiving and recommitment to respect the environment and heal the world)

3) Commemoration of the past (honoring ancestors, lessons and achievements of African history)

4) Recommitment to cultural ideals of the African community: truth, justice, respect for people and nature, care for the vulnerable, and respect for elders

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5) Celebration of the “Good Life” (struggle, achievement, family, community and culture) in the development of rituals, dialogue, narratives, poetry, dancing, singing, drumming and other music and feasting.

Practice includes the lighting of the seven Kwanzaa candles: umoja (unity), kujichagulia (self-determination); ujima (collective work and responsibility; ujamaa (cooperative economics); nia (purpose); kuumba (creativity); and imani (faith).

The celebration ends with a day of assessment - raising and answering questions of cultural and moral grounding with consideration of their worthiness in family, community and culture.

Juneteenth:Celebration of the ending of slavery in the United States. Originated in Galveston, Texas in 1865, and now, each June 19th, commemorates African American freedom and emphasizes education and achievement.

Martin Luther King Junior’s Birthday:Celebrated the third Monday of January, to honor Dr. King’s work as a nonviolent activist in the civil rights movement to successfully protest racial discrimination in federal and state law.

We as Helping Professionals Can :

Ensure all staff serving African American clients are culturally sensitive and aware of cultural and community/environmental factors , remembering African American male youth best relate to African American men.

African American women may avoid reporting incidents surrounding African American men.

Avoid saying “color doesn’t matter” Don’t make assumptions or predispose based on biases Support enhancement, strength and the rebuilding of African American culture Apply the concept of “health” not only to the individual served, but within the family

and the community as well by identifying, strengthening and rebuilding: *cultural traditions founded on relationships *shared responsibilities *personal and institutional anchors *a sense of joined destinies.

Don’t just treat the Individual (the disease) but build the capacity of the immune system (the community)”. (“The Providers Guide to Quality & Culture”).

Utilize research supported models of motivational incentives, Motivational Interviewing, and Peer Mentors as successful and appropriate recovery supports.

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AMERICAN INDIAN

Colonization of Indian territory by the United States government fostered on-going trauma for American Indians. With the provision of alcohol prior to treaty signing, promises that were made were ultimately unfounded, and there was minimal follow-up by the colonists identifying which of the many treaties were finalized.

Indian children were taken from their homes and brought to governmental boarding schools to civilize them. This cut parental ties and forced Native language and cultural refusal and loss. Conservative English Christianity was imposed on the children, and the parents.

Forced assimilation of English language and western philosophy depleted Indian culture and identity and developed a high level of personal and cultural shame resulting in a fear of institutions.

Fear and shame continues today and has resulted in high unemployment and poverty, insufficient health care, substandard housing/ homelessness, high levels of depression, and resulting physical, emotional and spiritual (mental health) abuse.

Alcohol and drug abuse became a solution for severe depression and anxiety. Binge drinking and drug abuse has resulted in a high level of suicides. The age-adjusted alcohol-related mortality rate for American Indians is 5.3 times greater than the mainstream population. In Minnesota, 1.4% of our population is American Indian, yet they have 8.6% of all treatment admissions with a 49% successful completion rate for those who do enter treatment.

Violence and resulting fear has impacted both the individual and the community’s ability to look to the future. Historical genocide resulted from military gifts of diseased blankets, food rations and human disregard. The profound cultural loss and lack of health care support has impacted pervasive depression, heart disease and diabetes yet today.

The gap between native cultural values and life experiences has provided extreme stress. The American Indian culture keeps you connected and insulates you from mainstream stressors, yet it can also limit you from integrating or moving upward. There is a pull between the goal of family relationships as priority and technology focus for adolescents.

Remote Reservations provide more isolation and feelings of disconnection which has produced some alienation with resulting retaliation and anger.

Poor quality education and extremely low graduation rates have resulted in a high rate of unemployment or employment opportunity - followed by illegal activity.

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Jurisdictions between Reservations and Non-Reservation territories and varying laws are often unclear and administered inequitably.

The loss of culture and Indian identity has resulted in “passive parenting” being passed down through extended family aunties and uncles and there is work going on to recapture culture.

Traditional Native American gender roles have devolved. Men abusing chemicals are emasculinated when they can’t provide for their families (hunter role). Youth are less able to benefit from strong positive male role models and there is intergenerational struggle.

The strongest health issue in the American Indian community is alcoholism. (Drug Trends, Jan. 2010, indicate a high use of other opiates as well for Patients admitted to addiction treatment programs).

The average treatment access age for American Indians in MN is now 16 and as many as 1 out of 7 Indian youth go to treatment compared to 1 out of 50 mainstream youth.

American Indian Healing Supports: Beliefs; Values; Traditions

Beliefs/Practices:American Indians believe that all aspects of each individual (physical, mental, emotional, and spiritual) must be acknowledged for a successful self-sufficiency, health and wellness. All things come from the Creator. Spiritual beliefs transcend into all aspects of life.

Some Christianity is practiced White Bison curriculum speaks to the spiritual energy through structure of intention, will power, thoughts, beliefs and actions as connected to the seen (physical) and unseen (spiritual) world.

Spiritual Leaders and elders care for the people as positive role models. Smudging - cleanses Sweats provide spiritual and physical renewal Sundance participation provides self-efficacy.

Values: Cultural values support respect, integrity, and the courage to make wise life-choices. Community teachings include the value of compassion and love for others, generosity,

respect, resilience, creativity, bravery, pride, humor, wisdom, honesty, kindness, helpfulness, humbleness, and responsibility.

The value of gender respects the energy of men (as providers) and women (as nurturers). This shared balance is key to family structure and healthy attachments.

The value and concept of family extends kinship affiliations to spiritual inter-connectedness.

Resilience is learned over time, for survival.

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There is extremely strong connection to the land. The connection is strengthened with storytelling and oral traditions of our ancestors. Mother Earth is respected.

Family, rather than peer groups, is the most powerful contributor to health and non-use among youth (“The Providers Guide to Quality and Culture”), and extended Family is the safety net.

Sacred Burial Grounds provide geological proof of the American Indian History and culture.

Tribal Nations have separate political structures from the US. Reservations are sovereign nations, and each tribe has its own traditions, ceremonies and languages that are being “recovered”.

Traditions: Storytelling Humor Hunting and Gathering traditions Giveaways Ceremonies:

Sweat Lodge, Full Moon ceremony, Dark Room and Naming Ceremony Families may identify a member who has problems with alcohol/ drugs

and offer a ceremony of healing. (May include others who might be using alcohol and/or other drugs, but as yet, do not experience problems).

An individual, who might otherwise be lost in “the system”, may become the focus of the communal ceremony for healing and prevention. Traditional healing properties are water, plants, animals and food.

American Indian Practices related to Treatment success: Smudging can cleanse the body and mind. Culturally specific in-patient chemical dependency treatment is most

successful. Outreach is most effective for individuals reluctant to accept services.

The “Wellbriety Movement” (White Bison), focuses on healing the community, the family and the individual. It supports a sober and healthy lifestyle that is balanced emotionally, mentally, physically, and spiritually based on the principles of the Four Laws of Change:

1) Change is from within; 2) For development to occur, it must be preceded by a vision;

3) A Great Learning must take place; 4) You must create a Healing Forest (community). Community

leadership is modeled through group support with individual responsibility for gaining knowledge and cultural perspectives that support healing.

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As Helping Professionals We Can :

Respect and understand traditional Native American healing practices. Provide culturally specific, age and gender focused substance abuse treatment to

support successful outcomes, and understand that culture is prevention and treatment. Recognize the 1978 “Indigenous Freedom of Religion Act” to allow and support

American Indian language and spiritual practices. Understand the unique relationship between American Indians and the US Government.

(Note: There are 562 federally recognized Tribes – each with its own history, culture and language), and several Tribes exist without federal recognition.

Remember that American Indians have a reason to be suspicious of outsiders and outside or institutional ideas.

Don’t make assumptions Take time to find the key players; one leader does not necessarily speak for all. Understand that questions may be answered only when thoroughly thought through, or

after consultation with others. Tribes object to being consulted or studied by those who have little intention of doing

anything in response to their concerns. Negotiate their concerns and be prepared to respond with reasons why the advice may or may not be followed.

Meetings with Tribal Council officials and Tribal program staff should, if possible, be conducted between the same levels of officials.

Tribal officials may not have support staff that assist in correspondence or follow-up support.

Formal notices or invitations should be addressed to the Tribal Chairperson or the appropriate Council or Committee Member, with a copy to the Tribal Chair.

Face-to-face communication may be better as traditional authorities often do not relate well to written communications.

Be prepared to discuss all aspects of an issue at hand simultaneously rather than sequentially.

Respect Tribal Council representatives as elected officials. Honesty and integrity are highly valued. A sense of humor is appreciated, as is serious

business-like behavior. Always shake hands when introduced, meeting with someone, or departing. It is

customary to shake hands with everyone in the room. Meetings with refreshments or meals are a strong cultural practice and value. (Protocol when working with Tribes: (Adapted from MN Indian Affairs Council

http://www.mniac.org)

Etiquette – Do’s Learn how the community refers to itself as a group of people (e.g. Tribal name) Be honest and clear about your role and expectations and be willing to adapt to

meet the needs of the community. Show respect by being open to other ways of thinking and behaving.

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Listen and observe more than you speak. Observe community members’ typical length of time between turns at talking.

Casual conversations are important to establish rapport so be genuine and use self-disclosure.

Avoid jargon. A community member may nod politely and not understand what you are saying.

It is acceptable to admit limited knowledge of American Indian cultures, and invite people to educate you about specific cultural protocols in their community.

Etiquette – Don’ts Avoid stereotyping based on looks, language, dress and other outward

appearances Avoid intrusive questions early in conversation Do not interrupt others during conversation or interject during pauses or long

silences Do not stand too close and/or talk too loud or fast Don’t impose your personal values, morals or belief Be careful about telling stories of distant American Indian Relatives in your

genealogy as an attempt to establish rapport unless you have maintained a connections with that Indian community

Don’t point your finger as it may be interpreted as rude in many tribes. Avoid looking at your watch Avoid pressing all family members to participate in a formal interview If the person you are working with begins to cry – support the crying without

asking further questions until they compose themselves. Do not touch sacred things: medicine bags, ceremonial items, hair, jewelry, and

other personal or cultural things. Never use any information gained by working in the community for personal

presentations, case studies, research etc without written consent of the Tribal government.

(“Guide to Build Cultural Awareness Culture Card” (SAMHSA)

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HISPANIC/LATINO

Hispanic/Latinos constitute the largest and fastest growing ethnic community in the US. 60% of Hispanics in the US are born here. 5% are naturalized citizens and it’s estimated that 35% are undocumented. This has resulted in chemical health treatment access being constrained due to the fear of exposure and deportation. In Minnesota, 3.5% of our population is Hispanic.

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Linguistically appropriate service supports are extremely limited and linguistically inadequate here, yet 55% of those who do enter CD treatment, successfully complete the program

Many H/Ls are under-insured or have no health care coverage, so don’t go to the doctor. Illness is private, so most health care is ultimately received through hospital Emergency Departments. Help requests are crisis oriented (i.e. “I need help today” – not several days later with an appointment), which is stressful for programs.

When interpretation support is needed, the quality of interpretation and the gender of the interpreter are critical to what is shared.

Few (CLUES) to no language specific chemical dependency treatment programs in out-state Minnesota are available, especially for adolescents. AA and NA support groups and/or CD professionals who speak Spanish are available intermittently but not consistently.

The need for treatment is experienced as a “breakdown” of the whole family.

Language issues and poverty, even though parents and youth are often working multiple jobs, results in lapses in child supervision. A fear/stigma of asking for help impedes parents (and especially single parents) in their ability to parent. Youth gang involvement becomes difficult to control when the parent has their own gang and/or chemical abuse issues. Families fear involving authorities due to their own tenable legal status. Gang recruitment and membership dissipates the core family structure, redefining “family”.

There a high use of alcohol within the Hispanic communities, and among those who drink, use of other drugs including marijuana and methamphetamines may also be prevalent. (Drug Trends, Jan. 2010, patients admitted to addiction treatment programs by primary substance problem).

Cocaine use occurs within the older Hispanic population but is not as prevalent with adolescents.

Hispanic/Latino Beliefs and impact on Treatment Intervention:

Familismo— The strong family orientation of Hispanic/Latino culture results in a tendency to seek

solutions to problems, including those related to alcohol and drug abuse, within the family unit.

Latino family may often result in the sharing of problems and the seeking of advice among extended family members.

Confianza (Trust) Refers to intimacy and familiarity in a relationship Informality and interpersonal comfort

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Highly attuned to others’ non-verbal messages Treatment relationship – Spanish Speaking Providers who are able to develop a bond of trust (confianza) may notice a level of

improvement in treatmentRespeto – respect Dictates appropriate differences behavior towards others based on age, sex, social position, economic status and authority. Respect within the Hispanic culture implies a mutual and reciprocal deference Premature termination from treatment may occur if they perceive that respect is not shown

Personalismo – personalizing A cultural trait or value reflected is the tendency for Hispanic clients to relate to the

service provider personally rather than in an institutional or interpersonal manner Hispanic clients may expect appropriate physical contact, such as a hand shake or a

hand on the shoulder, in some circumstances. Are more concerned about the relationship between themselves and the provider of care

and less concerned about the institution that delivers the services

Simpatia / sympathy - values harmonious relationships and avoids conflict. Relates to what many call buena gente (nice person) Hispanic are drawn to individuals who are easy going, friendly and fun to be with Simpatía is a value place on politeness and pleasantness Avoidance of hostile confrontation is a vital component of this specific ethnic cultural

value The Hispanic client may view a relative neutral attitude on part of the services

practitioner “as negative”

Machismo – Negative connotation (-)Machismo on the cult of manliness among Latino meno Man should be physically strongo Dominant in charactero Sexual potent – virile Macho man o Better men is the one can drink the mosto Defend himself the besto Dominates his wife – including physical force or violence to regain his position over

hero Demand respect of his childreno Have more sexual relationshipso Possessive, jealous of his wife o Has high risk behaviors

Machismo -- Positive trait (+)Devoted to his own biological familyo His own mother above allo Sense of fairness and justice

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o Deep feeling of family and friends o Proud of his familyo Hard workero Welfare of his family honor

o Treatment opportunity o Bridge to treatment - use welfare of family

o Misconception of not accepting women as authority

Marianismo and Hembrismo• Refers to the Virgin Mary or the Madonna Women• A good woman is made in the image of the sacred mother. She is submissive and

self-sacrificial. She is religious and humble, modest like the Virgin Mary. Sexuality is more a duty than and enjoyment.

• Marianismo has many positive aspects• Increase women self-esteem• The ability to be the giver• Generous mother• She is respected by the family and protects their children and husband• Young women struggle with strong traditions, such as familismo, personalismo,

respecto, simpatía (brings stress to the family).

Religion and Spiritualityo Hispanics have been identified as a cultural group with strong adherence and

connections to tradition, such as catholic, evangelicals and ancestral religions and spiritual beliefs.

o The Hispanic culture tends to view health form a more integrated or synergistic point of view. This view is expressed within a continuum that includes body, mind and spirit.

Acculturation issues and problems as they relate to addictions in the Hispanic/Latino community

• Poverty and occupational opportunities• Culture and Value Orientation• Language and Bilingualism• Migration and Mobility• Societal Perceptions• Adaptability to dominant culture• Unemployment – a threat to self-esteem, economic instability, (menial jobs).• Discrimination: creates resentments (immigration, institutions, racism).• Poor Housing: promotes isolation and conditioning to accept a poor environment

(Asi lo quiere Dios).

Ethnic Traditional Values Dominant Contemporary Values

Age, wisdom, experience Youth Oriented

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AcademicHarmony with nature, Varied perception of time

Control over natureHere-Now

Intact ethnic identity Diffuse ethnic identityValue of process relationships, sharing Product OrientedNon Verbal Verbal, Speak UpPassivity, Deference AssertiveCooperation, Sharing (extended family)Mi casa su casa

Competitiveness, self-relianceIndividual/independence

Word of honor & loyalty Written contract lawNon display of public affection Public display of sexuality

Unmet Need in the Hispanic/Latino Community:

• In 2007, there was an estimated 2,933,000 Hispanic/Latinos who needed treatment for an illicit drug or alcohol problem in the past year.

• However, only 177,000 actually received care in a specialty facility.• Consequently, 2,756,000 did not receive the necessary care for their illicit drug or

alcohol problem. 6% of those who needed care got it 94% of those who needed care did not get it

•Multiple challenges:

• Reaching those in need of services• Providing adequate resources• Developing culturally-appropriate, evidence-based interventions• Building and sustaining a qualified workforce • Integrating substance use disorder services into the public health paradigm model

As Helping Professionals We Can:

Learn more about immigration law and practices Learn about the political issues in Mexico, Central and South American Learn the language(s). Avoid stereotyping based on looks, language, dress and other outward

appearances Avoid intrusive questions early in conversation Don’t impose your personal values, morals or belief Move to become more culturally knowledgeable. Because of the fast growing

population most treatment providers will be working with Hispanic/Latino clients. Remember Hispanic/Latino values may differ from yours, be respectful of their

framework. Integrate traditional Hispanic/Latino values in all case plans and activities for

better client outcomes. EX: Use the authority given to you in a positive way to

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demonstrate a client will gain their respect again through sobriety/to steer clear of drugs.

Be cognizant of the person’s experience as a Hispanic/Latino in mainstream culture and the many pressures experienced and balances needed.

SOUTH EAST ASIAN (Hmong/Lao)

Minnesota has the third largest Lao population (20-25,000) in the US, and the second largest Hmong population (41-65,000). Hmong refugees were admitted into the US from the Thailand refugee camps between 1975 and the early 2000’s. The country of Laos includes a population of 7 million – with 60 ethnic groups. These groups are divided into three groups: Lao Loum (lowland Lao - Lao); Lao Theung (upland Lao - Khmu); and Lao Sung (highland Lao – Hmong). They had a strong role in the CIA’s Secret War in Laos from 1963 to 1975.

• Over ½ of Lao and Hmong families indicate that English is spoken “less than well” at home

• 40-50% work in production and transportation jobs• Poverty rate is between 35-40%

Traditional Clan system provides for each Clan to be represented on the 18 Clan Council by a designated respected elder. The Clan Council and organization provides a hierarchy for community and family leadership.

War-based trauma grief and loss, flashbacks, unplanned re-location, and related and often undiagnosed and untreated Post Traumatic Stress Disorder, depression and mental illness has impacted cultural adaptation and community stress. Refugee: “A foreign-born resident who cannot return to his or her country of origin

because of a well-founded fear of persecution due to race, religion, nationality, political opinion or membership in a particular social group.

High racial and ethnic tension is prevalent both within the various SE Asian communities and between the various communities and mainstream society.

SE Asians have difficulty accessing the service system and don’t understand the roles of service providers….especially when there are multiple providers.

Services are best accepted from familiar staff that look and talk like the participants. Contributing factors to substance abuse/addiction include ceremony expectations and

peer pressure, isolation, cultural dislocation, intergenerational conflicts, emerging gang activities, poor self-esteem and family role reversal / changing gender issues. Often families wait to seek help in crisis.

Drug abuse among immigrant youth is a serious problem (National Youth Anti-Drug Media Campaign Seminar). Substance abuse among Asian American college students was higher than in a “general” national sample.

Substance abuse impacts older Asian Americans. SE Asians who drink, often drink heavily and consume more alcohol. Stigma surrounds illegal drugs and not alcohol abuse. The concept of addiction is foreign and taboo. Most of the community is in denial surrounding chemical abuse as a problem for the community even though use is extremely high.

The most common chemical use is alcohol. Methamphetamine, marijuana and other opiates are also prevalent for patients admitted to addiction programs (Drug Trends,

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Jan. 2010). “Meth is the “number one growing drug of choice among Asian American Pacific Islanders” (Sentencing Project, Asian American Recovery Services).

High denial surrounding addiction as a factor in the community. In a communal culture this is shaming for a Clan and a family. No SE Asian terms define chemical abuse or addiction.

Hmong Last Names include: Chang; Chue; Cheng; Fang; Hang; Her; Khang;Kong; Kue; Lee; Lor; Moua; Pha; Thao; Vang; Vue; Xiong; Yang

Lao Last Names: Chathavong; Thammavong; Phivilay; Saengdara; Khotsombath; Phitaksounthone; Siriouthay; Sengsouriyah; Phetsarath; Vongrassamy.

Southeast Asian Beliefs:

Spirituality: Animist practices, Lao Buddhism based with concepts of health and healing linked to spirits, possession and karma, and/or Christianity. Christianity is increasing, with affiliation to many mainstream denominations and may be practiced in tandem with traditional beliefs. Hmong who continue to practice Animism and Shamanism believe that a spiritual world continues to coexist with the physical world. Life is a continuous journey, rather than having a beginning and an end.

Belief that there are many spirit types including ancestral spirits, house spirits and spirits in the natural world. Every object has a spirit.

Shamans maintain communication between the physical and spiritual world. Pain or illness results from the “loss of soul”. This could occur due to sudden fright, fear, excessive grief, inappropriate behavior, etc and is it believed that one or more of the individual’s six souls was captured by an evil spirit and must be returned to regain health. Souls are like children wandering around – vulnerable.

Negativity is avoided as it calls up negative spirits and consequences. Hmong spiritual support includes ancestral devotion and belief in reincarnation. Re-

incarnation is affected by your previous life and your karma (cause and effect). Karma from good and bad actions contributes to your long-term wellbeing. Ritual ceremonies are performed for the purpose of fulfilling the will of ancestors and natural spirits.

Illness falls into three categories: Natural causes (environment or longevity) Spiritual or Religious causes that affect nature. Evil spirits can cause illness to

people in certain situations when they are offended (i.e. mental illness is a fate, punishment from the spirit world, providing imbalance in the body, mind and spirit).

Curses (done when wronged by the other person).

SE Asian Values: Family comes first, then community and then the individual. The individual

“never” comes first. Traditions and reverie about the home country Education is highly valued as the way to success.

SE Asian Traditions & Practices: Patriarchal Society

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Healing: Buddhist monks serve as both Spiritualists and Herbalists. Healing procedures include both cultural and religiously inspired rituals,

such as the blessing of an individual, a family, or a place of residence to void evil spirits.

Shamans are spiritual advisors that maintain communication between the physical and spiritual worlds.

Procedures include “cupping, “coining”, “pinching” or “rubbing”. Herbalists provide natural medicines which may be utilized at the same

time as, or in lieu of prescriptions. Some believe western medicine may conflict with traditional practices and hinder reincarnation (i.e. surgery; drawing blood; organ donation; autopsies). Distrust in western medicine practices has been strong. Developing distrust of “natural” medicines by second and third generations as ingredients are not marked.

When there is a death in the family, proper burial and worship of ancestors influences health, safety and prosperity of the family. Extensive rituals and ceremonial songs are used within the funeral. Services follow protocol and last up to three days and nights.

New Year celebration is a major social gathering and a means of young men and women connecting with the intent toward marriage.

Marriages are negotiated between a young man and young lady’s clans and are based on the relationship between the two families and clans. An individual may not marry within his/her own clan. Dowries are provided by the man’s family to the woman’s family, and they are negotiated by the clans. The wife generally moves in with the husband’s family. Taking a second or more wives helped to have more children to help with agricultural work and has helped to provide for widows.

Divorce has been taboo – but is now gaining acceptance as part of Westernization. Traditional healers have been male Shamans, however, now more female Shamans are

evolving. One must be chosen by the spirit, to become a Shaman. This status often runs within a family.

As Helping Professionals We Can:

o Learn about the history of the Hmong and Lao community. War and migration has been a big part of these communities which has led to mental health and chemical abuse issues.

o Know that the Hmong/Lao community does not view ATOD as a problem, and therefore isn’t something to be addressed.

o Learn the language(s) and customso Attend Hmong and Lao New Year celebrations; Soccer Tournaments, etc.o Ensure existing programs provide linguistically, culturally appropriate and sensitive

services that can be segregated by gender and age.o Encourage Hmong/Lao individual recruitment and training as CD professionals o Educate the community regarding the disease and fight the stigma of addiction.o Support leveraging of the many cultural protective factors.

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o Develop service models that are flexible and culturally infused with other community organizations by engaging them in the development and implementation.

o When conversing with program participants and their families– ask to speak with the head of the household. Ask about relationships between family members.

Males and females keep a distance when conversing. Traditionally Hmong men do not shake hands with women. Direct eye contact may be considered rude.

Ensure services address the beliefs and values of SE Asians and their cultures. Don’t make assumptions. Remember there are often not comparable words in their languages for things like

addiction, mental health, issues surrounding sexuality or body parts, etc. Be aware of conflicting messages being given within the family and the institutions within the community.

Develop community-based strategies hat reach out to community members and leaders Provide native language staff or minimally interpreters of the same ethnicity as the

client, that are neutral, gender appropriate, and sensitive and professional around the issues of confidentiality. Ideally, the same staff or interpreter would be assigned to the client for consistent service. Staff should be bi-lingual and be able to effectively communicate with program participants.

Consider if it may be more appropriate to address the group or family before greeting the specific members.

Respect for authority may appear as agreement. Family members are incorporated into the healing process Important to provide trauma informed treatment and support when clients have

experienced torture, war, social and political oppression. Clients may show little emotion in their facial expressions and have a low level of

verbal communication. This does not necessarily portray agreement with a diagnosis or case plan.

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SENIORS (50+)

Abuse increases when people are lonely, confused, and cut off from those who care about them and/or in pain. Estimated that 17% of older adults are isolated, and many experience multiple pains.

Majority of seniors are women. Many are experiencing bereavement and sadness, medical problems, diminished insurance coverage/pensions, and greater likelihood of becoming poor.

Often experience hurried office visits and chemical dependency symptoms mimic other medical and behavioral disorders such as diabetes, dementia, and depression which are more likely to be diagnosed and treated.

Substance induced dementia (Werner’s - Korsakoff syndrome) and/or sleep disorder may be evident and undiagnosed.

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Alcohol use is historically a positive social component. Retirement “happy hour” begins earlier in retirement communities and is daily. Greater impact from Chemical Abuse when bodies’ age.

Seniors may also be more likely to be isolated, drink alone, and less likely to engage in behaviors that reveal alcoholism.

Senior addiction rate is 23 - 33%. Average age of full-fledged addiction for senior women is 83. Often began abusing

chemicals in their 40’s, more affluent, and waited to get help until they are in their 50’s or higher.

Increasing use of prescription medications and resulting cost impacts seniors. This may result in cutting doses for cost saving or taking too much - unknowingly. Seniors take an average of 6 prescriptions regularly. Medications may be mixed with alcohol, taken in improper dosage or forgotten which greatly impacts already existing health issues.

The current chemical dependency treatment system doesn’t address the unique geriatric specific needs of seniors including: multi-generational issues, values and drug use patterns. Additional health concerns: sight, hearing and medical challenges including mobility and the ability to ask for or access support.

There is limited research or data in the area of seniors and the evolving chemical abuse patterns including marijuana and other drugs besides alcohol.

When County or Tribal assessment and placement process results in referral to a Medicare (65+) facility, Medicare is billed first and the Consolidated Treatment fund subsequently pays treatment costs not covered by Medicare.

Medicare will only pay for “inpatient” hospital based care, which has depleted community based programs interest in serving seniors.

Seniors Beliefs; Values; Traditions; Practices

Beliefs/Issues:• Belief: At their age, just let them have “fun”. The actuality of addiction is quite the

opposite.• Seniors are too old to get full benefit from the investment in their treatment or

rehabilitation. (Note: the success rate for ongoing recovery among seniors who complete treatment is higher than the average rate among 20-55 year olds.

• Treatment Episode Data Set Report (6/17/10): older substance abuse treatment admissions (age 50 or older) increased from 6.6 % of all admissions to 12.2% in 2008; the proportion of older admissions reporting primary alcohol use decreased between 1992 and 2008 while heroin use doubled; multiple substance abuse tripled from 13.7% to 39.7% and increase in abuse of noted prescription pain relievers went from 5.4% to 25.8%.

Senior Values:• Historical events and experiences.• Family and Friendships.• Faith and Spirituality• Positive health and longevity.• Maintaining leadership as head of the family

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• Self-sufficiency• Adequate nest-egg to sustain the rest of life.• Grandchildren; Great-grandchildren• Respect, positive regard and being cared about/valued.

Senior Traditions:• Maintaining individual and family traditions, often with cultural components. These

may be confounded due to loss of roles (mother/father/grandparent) and capabilities (i.e. holding Holiday events at Grandma’s). Holidays, birthdays and other special occasions may have either positive or negative remembrances.

Senior Practices:• Retirement planning (or lack thereof) and resulting decisions/concerns surrounding

retirement: loss of income, severance of social networks, career and personal identity loss.

• Sustaining key friends and coping with ongoing loss • Household upkeep and responsibilities become physically more challenging, and may

require more volunteer or purchased help.• Social Security and Medicare applications.• Depleted savings/retirement accounts may result in hoarding or tightening of assets and

expenditures.• Downsizing and give a-ways of memories and precious posessions• More doctor appointments with increased medications.• Emotional and physical preparation for death and funeral arrangements.• Insurance and bill coordination• Support for adult children and grandchildren – physically, financially and emotionally,

(providing housing support, child care or back-up responsibilities, etc.).• Decisions surrounding sale of primary residence and move (child’s home, assisted

living, nursing care).• Loss of dreams and coping skill development

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CROSS-CULTURAL COMMON FACTORS

Addiction crosses all cultures, generations and genders.

Historical Trauma and racism/oppression is pervasive and continues to provide a multi-generational impact for diverse communities, immigrants, and American Indians.

The gap between an individual’s cultural values and real life experiences causes enormous stress, with debilitating consequences.

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Isolation due to language, gender/role identity, socio-economic circumstances, racism, age and/or stigma exacerbates chemical abuse and addiction.

Cultural identity is on a continuum ranging from deeply ingrained to a lack of connectedness or even disdain for our ethnicity or culture. For successful support outcomes it is crucial to assessed this in case planning and service delivery.

Cultural identity and affiliation significantly determines our world view, our values, experiences, thoughts, beliefs and actions.

To address the needs of our changing Minnesota population, it is imperative we develop and provide culturally specific programming that builds on community strengths, accepted beliefs, values and practices and address the major issues of stigma and denial.

The service roadmap must identify risks and protective factors, the client’s and community’s definitions of health and addiction and the goals considered to be success.

Programs that are culturally sensitive by definition include 50% of the staff, administration and Board members resembling those who receive services.

Access to culturally relevant treatment is limited due to lack of culturally specific professionals, increased cost of doing business including time to develop relationships, Language differentials, high denial, incredible stigma, fear and conflict with western models and bureaucratic requirements.

Treatment assists an addict to get meaning back into his/her life by understanding the disease. Help to be able to mend and build supportive social networks, deal with anxiety, depression and issues triggering use and providing support for long-term recovery.

Support for family change needs to occur simultaneously to sustain the benefits of recovery.

Chemical Abuse is often perceived as a problem of character or virtue and the concept varies between cultures.

Individuals who hide or deny addiction find a reality in resulting legal and/or financial problems.

When chemical dependency becomes more chronic, it is more difficult to treat or successfully move toward recovery.

Roles and responsibilities become altered with chemical abuse. Men can’t provide for their family (i.e. hunter/provider responsibilities) as

expected. Family roles and relationships are strained. Employment problems cause increased financial stress.

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Women’s role as primary caretaker for the children is depleted and families can encounter Child Protection and/ or Probation including removal of their children with Court intervention and time lines for problem remediation.

Poor behavior (or spirituality), including addiction, is perceived as affected by issues surrounding reincarnation, hexes, or sin. Positive spirituality/beliefs for hope and participation in recovery programs is a strong support for overcoming addiction (i.e. 12 steps/ AA/NA, Minnesota Recovery Connection (MRC) and S-MRC.

The partnership of traditional healers and credentialed professionals provides longer-term recovery success.

The naming and cultural design of the treatment or recovery program model, who provides the service and who participates in the program (“people like me”), impacts ultimate success.

Research is needed to enhance Evidence Based Programming for underserved communities to support effective programing and sustainability.

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