Cultural Compentency and Co-occurring Disorders

Culturally Competent Treatment of Clients with Co-Occurring Disorders

Course Contents Culturally 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 and mental 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 Snapshot
Cultural 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
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
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 83
Borderline PD 60
Schizophrenia 47
Bipolar Disorder 65
Anxiety Disorder 35
Depression 35
Phobia 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-among-Lesbian.html
http://www.who.int/mental_health/prevention/genderwomen/en/

Cultural Compentency and Co-occurring Disorders

by Frederick Ryan

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Cultural Compentency and Co-occurring Disorders Presentation Transcript