Cultural Considerations in AOD Treatment for African Americans

INTRODUCTION

As most people know, alcohol and other drug addiction have had a major impact on African Americans, destroying far too many black families and communities.

The short term relief one achieves from the use of alcohol and other drugs seduces many African Americans who are looking for a way out of the stress, frustration, pain, pressure and sense of hopelessness associated with continued oppression, the absence of opportunity, which has resulted in a culture wide condition known as PTSS - Post Traumatic Slavery Syndrome. (Dr. Joy De-Gruy-Leary, 2005)

The fast money associated with the illegal drug trade long seen as a way out of the poverty stricken ghettos of our nation has fueled the black-on-black, drug-related violence that is rampant in African American communities across the nation. In some black communities drug dealers are actually seen as heroes because of their flashy cars, jewelry and lifestyles. The gangster rap music so popular with our Black youth further glamorizes drug using and the drug dealing lifestyle; so much so that many young Blacks are anxious to make a career out of the drug business. (Centers and West, 1998)

The introduction of crack cocaine in the late 1980’s and the ensuing hysteria surrounding the crack epidemic has been particularly devastating to the African American community, as we saw sharp increases in violence, crime, prostitution, child abuse and neglect.

"It could be argued that addiction has been as effective as slavery in keeping African Americans oppressed, depressed and regressed."

Although there was no empirical evidence to support the concept of the crack baby, the on-going media campaign (in 1986, the cover of TIME magazine and more than 400 crack cocaine reports on NBC alone) served to manufacture public support for a criminal approach to the War on Drugs. This public policy is directly responsible for the 800% increase (since 1986) in the number of African American women behind bars, significantly higher sentencing laws for crack cocaine related arrests and subsequently more Blacks being in jail for longer periods of time. (Glenn, 2006; Boyd, 2004)

According to One in 100: Behind Bars in America 2008, a study released in January by the Pew Charitable Trusts - Public Safety Performance Project, more than one in every 100 adults in the United States is either in jail or prison. For African Americans those numbers are even higher with, 1 in 9 black males ages 20-34 and 1 in 100 black women ages 35-39 incarcerated (Bureau of Justice Statistics, 2006) making “the disparity in arrest rates alone one of the most devastating consequences of substance abuse among African Americans, affecting the abuser, their families and communities” (NIDA, 2003)

Considering that all of these issues continue to progress as addiction does, it is no wonder that substance abuse in the African American community and it’s related collateral consequences; homelessness, mental illness, HIV/AIDS and a three-fold increase in foster care costs, is one of the primary public health issues in this country.

Although there have been no large-scale empirical studies to examine the issue of cultural competency and substance abuse treatment for African Americans, the California Department of Alcohol and Drug Programs has adopted the Institute of Medicine model for inclusion in their Continuum of Services System re-design; acknowledging the importance of an ongoing commitment to institutionalize an appropriate set of practices and polices to ensure inclusion and respect of diversity in the delivery of culturally and linguistically appropriate services. (Howard, 2003; IOM, 2006; ADP, 2007)

Historically treatment programs have tried to fit everyone into a “one size fits all” model, failing to customize treatment modalities to accommodate the different cultural needs, experiences and beliefs of the individual client. The standard Twelve-Step Model developed by and for white, middle age men and used in most social model recovery programs, has resulted in poorer treatment outcomes for most minority groups, including women.

Treatment requires trust, honesty and self disclosure and if the client is unwilling or unable to do these things, the program will not be successful. Many African American clients have problems becoming engaged in the treatment process and are not comfortable talking opening and honestly about their genuine issues due to cultural norms that forbid “putting your business in the street”. Also, due to a history of oppression, discrimination, and racism, persons of color tend to have a healthy mistrust of bureaucratic systems and services provided by persons viewed to be the oppressor. (Sue & Sue, 1990)

Therefore, African Americans are either failing to successfully complete the program, or are being discharged for noncompliance. This is especially important when we consider that most African Americans gain access to treatment through the criminal justice (men) and/or child welfare system (women) and failure to successfully complete treatment often results in loss of family (parental rights), loss of livelihood, a felony conviction with a long jail sentence and/or a return to previous drug use.

Once convicted of a felony, he or she has a whole new set of obstacles to overcome. Some of the consequences of a felony conviction include not only the lifetime loss of the right to vote (in many states), but also the loss of many educational opportunities and social support services, as drug felons cannot obtain federal financial aid, food stamps, or public housing assistance.

There are also limited job options for drug felons as many employers will not hire an individual who answers yes to the question, “have you ever been convicted of a felony”, regardless of whether the person served his time. All of these obstacles combined are a set up for recidivism, and what we know about addiction is that a failed treatment experience often leads to relapse.

Unfortunately there are no concrete numbers on how many people who relapse never make it back for a second try at treatment, but we do know that the disease of addiction is so insidious and deadly that for many people the next time they use can be the last time they use. At the very least, a relapse or a poor treatment experience can extinguish the desire to be clean and sober. In my book, Relapse Prevention Counseling for African Americans, self image and hopes for the future were frequently impacted by the individuals perceptions of race; therefore it could be said that “The obstacle to engagement in treatment is not an absence of pain; it is an absence of hope”. (Quoted in White, Woll & Webber, 2003)

We, as a treatment industry need to ensure that the treatment we provide our clients affords them the best possible chance for success. We must continually strive to improve our ability to provide culturally competent services, delivered by trained and compassionate staff.

In doing so, we must offer resources, technical assistance and other training opportunities to our treatment teams; meet with decision makers at administrative levels to ensure that policies and systems are developed and implemented which allow African American clients to feel welcomed, understood, safe and cared for. (Bell, 1990)

Below, are some guidelines to consider when developing or evaluating a program serving African Americans. Each issue area is a significant component of a comprehensive, culturally competency treatment model.

Environment

The treatment environment should be welcoming to the African American client. It does not need to be in a Black neighborhood, but it should be easily accessible to the client (transportation is one of the top three reported barriers to treatment for women). It should aesthetically be made to feel comfortable and inclusive to the client, with photos, literature, artwork, etc. that portray African Americans in a healthy way.

There should be sufficient space for private and confidential consultation. The facility should be warm, clean and in good repair. Often times when a program caters to Black clients they are not as concerned with the upkeep of the environment and the space is not well maintained. Clients should not see the environment as punishing or demeaning but instead as a clean and safe place to heal.

Staff

Having a good staff is probably one of the most important components of an effective treatment program, as they provide the day-to-day clinical services and reflect the program’s philosophy in their work. The client will look to the staff for guidance, advice, support and leadership, so it is incredibly important that the staff be well trained, possessing a set of academic and interpersonal skills that allow them to understand and appreciate cultural differences, as the he interactions between the client and program staff can determine whether or not a client has a successful treatment experience. (SAMHSA, 1999)

African Americans have unique historical and contemporary experiences that come into play during the therapist/client relationship. Cultural differences between treatment providers and clients can hinder program efforts and client satisfaction, unless adjustments are made to accommodate the client’s values, behaviors and cultural traits. (Finn, 1994)

Although not required but certainly preferred, is that a program that treats African American clients should have some African Americans on the treatment team, as it helps the client to see someone of color represented on the staff roster. You don’t have to be Black to help a Black addict, but a multidisciplinary and multicultural team is most effective in providing substance abuse treatment. (Sue & Sue, 1999)

Staff should have cultural competency training, which includes an opportunity for them to identify their own cultural prejudices and biases. (SAMHSA, 1999) The program leadership should monitor the staff to assure that staff operates in a culturally sensitive manner. Staff should have clinical supervision as it relates to cultural issues and be given an opportunity to discuss and explore the cultural counter-transference issues that are certain to arise in any clinical environment. (Baker and Bell, 1999)

Staff should be screened and hired based on their expertise and their ability to work well with all clients. However, the African American client is highly sensitive to anything that resembles prejudice, discrimination and/or disrespect so all of the program staff, including clerical and administrative personnel need to be able to communicate to the client a warm, compassionate and accepting demeanor.

The Treatment Philosophy

The program’s treatment philosophy should embrace the idea that "one size does not fit all." Treatment should be individualized based on the specific clinical needs of each client regardless of race or ethnicity. Clients should be assessed at the beginning of their program to determine what clinical issues will be addressed during the course of treatment. Clients with culture-related issues should be given the opportunity to safely discuss their concerns.

The program’s philosophy should recognize that the African American client more likely than not, may have problems related to race that could interfere with their ability to benefit from treatment. For example, the client may have difficulty trusting or relating to people outside of his race, the client may have a culturally influenced sense of low self esteem or suspicion based on based on years of racial prejudice and societal injustices, the client may feel different and excluded from the rest of the community. The client may also have issues related to his or her living and social situation that pose a threat his ongoing recovery, These issues should always be considered when working with culturally diverse clients, including but not limited to Latinos, Asian-Americans, Pacific Islanders, and even the gay, lesbian and transgender client.

Therefore the program should make provisions in the day-to-day structure of the treatment to support the client in talking openly about their circumstances and processing any feelings or concerns. For an overview of actual dialogue between counselors and clients on this process, read Collaborative Efforts for Engaging African American and Euro-American Clients with Substance Abuse Counselors in Group Dialogue, Leitschuh, Lyles, Kayser and Budde, Illinois Counseling Association, 2002.

The Program Services and Levels of Care

Ideally, an effective treatment facility should provide a full range of services. In the best case scenario the program would offer or have access to the following core services:

• Free Intake Assessment
• One-on-One Counseling
• Intensive Out-Patient
• Residential Treatment
• Drug and Alcohol Awareness Classes (Prevention and Education)
• Case Management
• Aftercare

As mentioned earlier in this article, many African American clients come into treatment through the criminal justice system, or other social service-type agencies. Their freedom, livelihood and in some cases parental rights are dependent on them successfully completing the program. However, many of these clients do not meet the diagnostic criteria for substance dependence. Many are substance abusers, not addicts; but most treatment programs were developed to treat alcoholics and addicts. There is often not a level of care that addresses the needs of the substance abuser.

Clients are forced to identify themselves as addicts and alcoholics in the program and the 12 Step meetings they are mandated to attend. Some clients resist this labeling and are deemed unwilling and unmotivated. Others become “institutionally compliant” in order to “graduate” the program, but they never talk openly about their situation, their issues or their relationship with drugs. In both cases the client suffers and is likely to have a negative treatment outcome.

The appropriate treatment approach for these clients is often education and prevention rather than a full course of intensive addiction treatment. Programs should have the option of offering other, more clinically indicated interventions to increase the likelihood that clients are actually getting the care they need. Placing clients in the appropriate level of care and providing the appropriate clinical services increases the chances of a positive treatment outcome. (NIDA, 1999)

Aftercare and Follow-Up

The aftercare and follow-up plan is one of the most important aspects of treatment but unfortunately, one of the most overlooked. Often African American clients have multiple issues that pose a threat to their recovery, post discharge from treatment. Typical challenges include, high risk living situations, partners or family members that use, pressure from old friends to use, living in drug-infested neighborhoods, loss of spiritual connection, pending legal, employment and child custody issues, etc. A good program will develop a realistic discharge plan that provides a strategy for dealing with these concerns prior to the person being discharged.

Regular aftercare support groups or one-on-one sessions should also be made available to the client for a defined period of time, preferably at least one year post discharge. This allows the African American client to develop an ongoing relationship with the program at least through the difficult first few months of recovery. ADP’s Continuum of Services System, includes: support, monitoring and maintenance in the recovery component of the wheel, with proposed services to include a 1-800 number manned by trained relapse prevention specialists and the establishment of formal and information relationships and linkages with critical support systems, such as housing, employment, food assistance, etc.

In summary, the African American community is being devastated by alcohol and other drug addiction. All over the country, families, neighborhoods and communities are suffering because of addiction. The jails and institutions are full of Black people who have gotten caught up in the vicious cycle of addiction. Black children are packed in Child Protective Service systems, foster homes and juvenile halls, as a direct or indirect result of substance abuse and studies have shown that these children will most likely end up in the same situations as their parents without appropriate interventions. (Bernstein, 2007)

The problem is big, much bigger than we often care to admit as a society. However, there is a solution. We, as a treatment industry, can make a difference; helping to change lives by providing good, comprehensive, well thought out treatment. We can help African American clients by developing programs that work; programs that are sensitive to the fact that race is still a big part of our nation, and help African American clients address the unresolved racial issues that sometimes make it difficult for them to succeed in treatment and recovery.

We can step up to the plate and tackle these issues head on, by providing clients with a safe, supportive environment to deal with all of the issues that contribute to their addiction. In doing so, we can change the world, one life at a time.

Roland Williams is a nationally recognized consultant, author, trainer and speaker specializing in addiction relapse prevention, cross cultural counseling, and treatment program development. He is the Founder and Director of Free Life Enterprises and VIP Rccovery Coaching. He is the author of several books on African American treatment and recovery including the Relapse Prevention Workbook for African Americans and Relapse Warning Signs for African Americans.

Mr. Williams is a consultant and lead trainer for Terence Gorski’s CENAPS Corp., with whom he co-authored Relapse Prevention Counseling for African Americans Mr. Williams teaches addiction studies at several California universities, as well as the University of Utah at Salt Lake City and has recently traveled to Europe where he has worked in France, Italy and Holland. He has been assisting in the development one of the first abstinence-based treatment program in The Netherlands. For questions or comments, Roland can be reached at rolandwms@mac.com.

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