California Latina Substance Abuse Treatment Program
CALIFORNIA LATINASUBSTANCE ABUSE TREATMENT PROGRAM A Proposal to Congress Christine Kimmel
PROGRAM OVERVIEW• Goal: provide statewide, affordable, culturally sensitive substance abuse treatment for Latinas in the state of California• Service Delivery: government- and foundation-funded community centers in which professionally trained culturally and linguistically appropriate clinicians (bilingual in English and Spanish, female and, ideally, racially/ethnically Latina) provide Latina clients with targeted educational and psychotherapeutic services specifically designed to treat substance abuse in the Latina population
RATIONALE• Why substance abuse treatment for Latino/as? • Latino/as are the largest and fastest growing ethnic/racial minority group in the U.S. (Welland & Ribner, 2010) • Currently, 15% of the total U.S. population and 36.6% of the California population is Latino/a (Public Policy Institute of California, 2008; Welland & Ribner, 2010) • It is estimated that, by 2050, the majority of California residents will be Latino/a (Public Policy Institute of California, 2008) • Substance abuse is a growing concern in the U.S. Latino/a community (Gallardo & Curry, 2009) • Between 2002 and 2003, among U.S.-residing Latino/a youth age 12-17, 16.4% reported alcohol use and 10.8% reported illicit drug use within the past month (Substance Abuse and Mental Health Services Administration, 2004) • In 2002, Latino/as had the highest rate of illicit drug abuse/dependence (7.8%) of all racial/ethnic groups in the U.S. (including Caucasians) (Substance Abuse and Mental Health Services Administration, 2002)
RATIONALE• Why substance abuse treatment for Latino/as? (cont’d) • Many Latino/as turn to substances to emotionally escape from the ever-present stress of poverty, insufficient educational or job opportunities, acculturation difficulties, and problems associated with minority status (e.g., discrimination and isolation) (Gallardo & Curry, 2009; Nyamathi & Vasquez, 1995; Torres-Rivera, Wilbur, Phan, Maddux, & Roberts-Wilbur, 2004) • 21.4% of U.S.-residing Latino/as are living below the poverty level (as compared to only 7.8% of U.S.-residing Caucasians) (Gallardo & Curry, 2009) • Due to economic, cultural, and linguistic/communication barriers, many Latino/as are unable to benefit from adequate mental health services; they are thus at risk for not only substance abuse but for criminal and violent behavior in the community and family environment (Gallardo & Curry, 2009; Zarza, Ponsoda, & Carrillo, 2009) • The more acculturated Latino/as are, the higher the rate of substance abuse in the Latino/a population (Myers et al., 2008) • This means that the rate of substance abuse will continue to increase in the U.S. Latino/a population as Latino/as become more acculturated
RATIONALE• Why substance abuse treatment for Latinas specifically? • Gender-specific substance abuse treatment has been universally shown to be more effective than mixed-gender substance abuse treatment (Grella, 2008) • This is especially true of cultures that are very gendered, such as the Latino/a culture (Gallardo & Curry, 2009) • The comorbid conditions that precipitate and maintain substance abuse for Latinas are different than those for Latinos; therefore, clinicians treating Latinas for substance abuse disorders need to be sensitive to specific issues unique to the Latina population • These unique conditions include, but are not limited to: • Being victims of sexual and/or physical assault • Having child-rearing obligations
RATIONALE• Sexual and/or physical assault • Substance abuse is a significant risk factor for male-to-female interpersonal violence (MFIPV) in the Latino/a population (Cunradi, Caetano, Clark, & Shafer, 1999; Gondolf, 1997; Lown & Vega, 2001) • In part due to conditions of extreme poverty, MFIPV is very prevalent in the Latino/a population: 20.7% of all U.S. fatalities due to MFIPV involve Latina victims and 24.1% of all U.S. murders due to MFIPV involve Latino perpetrators (Frye, El-Bassel, Gilbert, Rajah, & Christie, 2001; Zarza & Adler, 2008) • Adult trauma (e.g., MFIPV) is the most significant predictor of substance use and depression for Latinas (Newcomb & Carmona, 2004; Sullivan, Cavanaugh, Ufner, Swan, & Snow, 2009) • Therefore, it is likely that a significant proportion of U.S.-residing Latinas with substance abuse problems have been victims of sexual or physical assault at some point in their adult lives, and that this trauma is directly related to their substance abuse problems • It thus stands to reason that Latinas should have access to substance abuse treatment that addresses the impact and experience of trauma
RATIONALE• Child-rearing obligations • According to Latino/a gender roles, Latinas are responsible for child-rearing (Welland & Ribner, 2010) • Given that (1) a large number of Latino/as in the U.S. (including California) are living at the poverty level and (2) Latino/as generally tend to have large families (three or more children is typical), child-rearing tends to be challenging for U.S.-residing Latinas (Zabkiewicz & Schmidt, 2008; Zarza & Adler, 2008) • Due to a lack of trustworthy and affordable daycare services, Latina mothers often become economically dependent on Latino partners who may or may not be abusive, become welfare-dependent, or are forced to neglect their children in order to financially support them (Zarza & Adler, 2008) • U.S.-residing Latina mothers therefore have difficulty justifying spending time on their own mental, emotional, and physical health, which leads them to self-medicate with drugs and/or alcohol and to refrain from seeking treatment for the substance abuse problems that develop from that self-medicating (Zarza & Adler, 2008) • It thus stands to reason that Latinas should have access to substance abuse treatment that arranges for or provides adequate child care services
RATIONALE• Why should the government get involved? • The government is already involved! But not very efficiently or effectively • Criminal Justice System (Moore & Elkavich, 2008) • Instead of receiving adequate substance abuse treatment, non-violent racial/ethnic minority drug offenders in impoverished communities are being incarcerated – and incarceration is very expensive! • men and women of color (including Latino/as) compose 60% of the U.S. prison population and are much more likely to be arrested and prosecuted for drug use than are Caucasians • Incarceration removes Latino/a men, women and children from their families and communities and therefore actually increases the risk of substance abuse in the Latino/a population as a reaction to increased environmental stress (promotes weak family structure, moral ambiguity, economic hardship, anger and depression) • Upon release, incarcerated drug users are highly likely to reoffend (the prison environment reinforces antisocial and risky behavior)
RATIONALE• Why should the government get involved? (cont’d) • Criminal Justice System (Moore & Elkavich, 2008) (cont’d) • By funding incarceration rather than treatment, the government is actually fueling the substance abuse fire in Latino/a communities! • Given that Latinas are responsible for child-rearing in Latino/a communities, it is especially important that Latinas (particularly Latina mothers) not be incarcerated for non-violent drug-related offenses! • Essentially, the government is funding unnecessary incarceration at the expense of education and health services for substance abusing Latino/as • Welfare (Zabkiewicz & Schmidt, 2008) • Low-income substance abusing ethnic/racial minority women (including Latinas) make up a large portion of the California welfare population • These substance abusing women are much less likely to maintain steady employment and consequently are much less likely to get off welfare (and therefore are much more likely to continue draining government funds) than are women who don’t abuse substances • Essentially, the government is funding unnecessary welfare services at the expense of education and health services for substance abusing Latino/as
RATIONALE• Why should the government get involved? (cont’d) • Bottom Line: By not providing adequate substance abuse treatment for Latina residents, the California government is ultimately losing money and exacerbating the substance abuse problem in the California Latino/a population • Therefore, it is in the state of California’s best interest to provide Latina residents with affordable, accessible, and culturally sensitive substance abuse treatment
PROGRAM STRUCTURE• Key program components • Culturally competent clinicians • Bilingual (English and Spanish) and bicultural (Latina and American) or Latina females (Field & Caetana, 2010) • Clinicians are culturally responsive (Gallardo & Curry, 2009) • Clinicians have culture sensitivity (an awareness that all individuals have a culturally based schema through which they perceive and engage with the world) and culture specificity (a good understanding of the California Latina culture) • Clinicians fully understand and overtly acknowledge the culture-specific environmental stressors that California-residing Latinas struggle with on a daily basis (Gallardo & Curry, 2009), including: • Acculturative stress • Minority stress (due to discrimination, poverty, insecure identity formation, low social status, limited social support, and low educational attainment) • Gender-specific stresses (family obligations)
PROGRAM STRUCTURE• Key program components (cont’d) • Treatment is delivered in accordance with the central themes of Latino/a culture (Gallardo & Curry, 2009) • Confianza: trust • most important theme in the client-counselor relationship • can be established by the counselor’s demonstrating genuine concern and non-judgment of the client • Orgullo: pride/dignity • in the absence of confianza, Latinas view disclosure of personal problems to non-family members as losing face or disgracing their family • Personalismo: personal relationships with people are of primary importance • Instead of sticking to the “traditional” therapeutic hour, the counselor may extend the therapy time to take a walk with the client or meet the client in her home/community
PROGRAM STRUCTURE• Key program components (cont’d) • Central Latino/a themes (Gallardo & Curry, 2009) (cont’d) • Familismo: the central importance of the family • Counselor may emphasize the client’s family as a coping resource in therapy (may invite family to join counseling sessions, or may join family in celebrations so as to be considered a trustworthy friend) • Simpatia: importance of harmonious interpersonal relationships (confrontation/strife is avoided and dignity/kindness/honor are valued) • Latina client can consider simpatia in exploring how her substance abuse has compromised close relationships • Respeto: respect • a strength-based foundation is more effective for Latina clients than a pathology-based foundation
PROGRAM STRUCTURE• Key program components (cont’d) • Central Latino/a themes (Gallardo & Curry, 2009) (cont’d) • Espiritismo: spiritualism • If client indicates she finds comfort in religion, counselor may suggest that the client ask for spiritual aid in being open to the process of change • The counselor thus simultaneously emphasizes client’s responsibility for her own growth and encourages a healing process congruent with the client’s beliefs • The counselor should be open to including a Curandera or traditional healer in the counseling process if the client is reluctant to self-disclose due to orgulla
PROGRAM STRUCTURE• Program Agenda (Gallard & Curry, 2009) • Build the therapeutic alliance by adhering to aforementioned central cultural themes • Conduct culturally appropriate assessment services • Assess family history and cultural context (drug history, acculturation) • Screen for Intimate Partner Violence (IPV) and other sexual and/or physical assault/abuse • Obtain information about client’s law enforcement contact, personal/professional performance, social community, and role of spirituality and religion • Assess personal strengths • Intervention Services (on-site) • Group-oriented intervention services (include or consider the client’s family and community during the treatment process) (Gallardo & Curry, 2009) • Both individual and group therapy formats are offered, though due to cultural considerations both are more informal than “traditional” therapies
PROGRAM STRUCTURE• Program Agenda (cont’d) • Intervention Services (cont’d) • promote client’s awareness of how environmental factors have impacted her methods of coping (e.g., substance abuse) (Gallardo & Curry, 2009) • Collaboratively come up with attainable, culturally congruent personal/professional goals that utilize the client’s family and community support system (Gallard & Curry, 2009) • Teach client how to access/utilize her existing strengths to increase her ability to cope with environmental stressors without relying on substance use • Teach client skill-based stress-reduction and coping-enhancement strategies (Myers et al., 2009) • Promote strengthening of non-substance abusing social networks (Myers et al., 2009) • Encourage pursuit of higher education and provide culturally sensitive and economically accessible resources to help clients achieve educational goals (Newcomb & Carmona, 2004)
PROGRAM STRUCTURE• Program Agenda (cont’d) • Intervention Services (cont’d) • Help clients who have been victims of IPV or sexual/physical assault come to terms with their trauma and find ways to cope with that trauma that do not involve substance use, in accordance with the central cultural themes previously discussed (Lown & Vega, 2001; Newcomb & Carmona, 2004 ) • Referral and Other Services • On-site child care services run by experienced bilingual (English and Spanish) and bicultural (Latina and American) or Latina child caregivers • Referrals to off-site culturally competent child care services • Referrals to off-site culturally competent psychiatrists, medical doctors, social workers, and legal representatives • Referrals to off-site bilingual language, mathematics, writing, life-skills, and vocational tutors • Confidential referrals to off-site culturally competent male-to-female interpersonal violence (MFIPV) safehouses for women
PROPOSED PROGRAM FUNDING• Primary program funding • California Department of Mental Health Care Services (DMH) • Substance Abuse and Mental Health Services Administration (SAMHSA) Grant• Additional funding contributions • National Alliance for Hispanic Health • The California Endowment
REFERENCES• Cunradi, B.C., Caetano, R., Clark, C., & Shafer, J. (1999). Alcohol-related problems and intimate partner violence among White, Black, and Hispanic couples in the U.S. Alcoholism: Clinical and Experimental Research, 23, 1492–1501.• Field, C., & Caetano, R. (2010). The role of ethnic matching between patient and provider on the effectiveness of brief alcohol interventions with Hispanics. Alcoholism: Clinical and Experimental Research, 34(2), 262-271.• Frye, V., El-Bassel, N., Gilbert, L., Rajah, V., & Christie, N. (2001). Intimate partner sexual abuse among women on methadone. Violence and Victims, 16, 553-564.• Gallardo, M. E., & Curry, S. J. (2009). Shifting perspectives: Culturally responsive interventions with Latino substance abusers. Journal of Ethnicity in Substance Abuse, 8, 314-329.• Gondolf, E. (1997). Patterns of reassault in batterer programs. Violence and Victims, 12(4), 373–387.• Grella, C. E. (2008). From generic to gender-responsive treatment: Changes in social policies, treatment services, and outcomes of women in substance abuse treatment. Journal of Psychoactive Drugs, 5, 327- 343.• Lown, E. A., & Vega, W. A. (2001). Alcohol abuse or dependence among Mexican American women who report violence. Alcoholism: Clinical and Experimental Research, 25(10), 1479-1486.• Moore, L. D., & Elkavich, A. (2008). Who’s using and who’s doing time: Incarceration, the war on drugs, and public health. American Journal of Public Health, 98, 782-786.• Myers, H. F., Sumner, L. A., Ullman, J. B., Loeb, T. B., Carmona, J. V., & Wyatt, G. E. (2008). Trauma and psychosocial predictors of substance abuse in women impacted by HIV/AIDS. Journal of Behavioral Health Services & Research, 36(2), 233-246.
REFERENCES• Newcomb, M. D., & Carmona, J. V. (2004). Adult trauma and HIV status among Latinas: Effects upon psychological adjustment and substance use. AIDS and Behavior, 8(4), 417-428.• Nyamathi, A., & Vasquez, R. (1995). Impact of poverty, homelessness, and drugs on Hispanic women at risk for HIV infection. In A. Padilla (Ed.), Hispanic psychology: Critical issues in theory and research (pp. 213– 227). Thousand Oaks, CA: SAGE Publications.• Public Policy Institute of California. (2008). California’s future population. Retrieved from http://www.ppic.org/content/pubs/jtf/JTF_FuturePopulationJTF.pdf.• Substance Abuse and Mental Health Services Administration (SAMHSA). (2002). Results from the 2001 National Household Survey on Drug Abuse: Volume I. Summary of national findings (NHSDA series H -17, DHHS publication No. SMA 02–3758). Rockville, MD: U.S. Department of Health and Human Services.• Substance Abuse and Mental Health Services Administration. (2004). Results from the 2003 National Survey on Drug Use and Health: National findings. Retrieved November 25, 2006, from http://www.oas.samhsa.gov/nhsda/2k3nsduh/2k3Results.htm• Sullivan, T. P., Cavanaugh, C. E., Ufner, M. J., Swan, S. C., & Snow, D. L. (2009). Relationships among women’s use of aggression, their victimization, and substance use problems: A test of the moderating effects of race/ethnicity. Journal of Aggression, Maltreatment & Trauma, 18, 646-666.• Torres-Rivera, E., Wilbur, M. P., Phan, L. T., Maddux, C. D., & Roberts-Wilbur, J. (2004). Counseling Latinos with substance abuse problems. Journal of Addictions and Offender Counseling, 25, 26–42.• Welland, C., & Ribner, N. (2010). Culturally specific treatment for partner-abusive Latino men: A qualitative study to identify and implement program components. Violence and Victims, 25(6), 799-813.
REFERENCES• Zabkiewicz, D., & Schmidt, L. A. (2008). The mental health benefits of work: Do they apply to welfare mothers with a drinking problem? The Journal of Behavioral Health Services & Research, 36(1), 96-110.• Zarza, M. J., & Adler, R. H. (2008). Latina immigrant victims of interpersonal violence in New Jersey: A needs assessment study. Journal of Aggression, Maltreatment & Trauma, 16(1), 22-39.• Zarza, M. J., Ponsoda, V., & Carrillo, R. (2009). Predictors of violence and lethality among Latina immigrants: Implications for assessment and treatment. Journal of Aggression, Maltreatment & Trauma, 18, 1-16.
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