Cultural Considerations In Addiction Treatment
By Roland F. Williams, MA, Licensed Advanced Addiction Counselor (LAADC), Internationally Certified Addictions Counselor (ICADC), Nationally Certified Addiction Counselor Level II (NCAC II), Certified Drug and Alcohol Counselor Level II (CDAC II), Advanced Certified Relapse Prevention Specialist (ACRPS), Nationally Certified Substance Abuse Professional (SAP)
This article will help you be more effective, confident, and competent in working with clients from culturally different backgrounds. The following guidelines are useful to consider whenever you are working with a minority or culturally diverse group or individual; they are generic enough to be applied to any cross-cultural counseling situation. Take these recommendations to heart – many mistakes occur because of inadequate considerations of cultural concerns in addiction treatment.
Before you can assess any client it is important to examine and identify your own preconceived ideas about this particular group or individual. What has been your experience with this population? Have your experiences and/or views tainted your interaction style? Identifying your own prejudices makes it clearer when you are attempting to work with your client’s problems. After all, counselors’ issues often get confused as the client’s issues. The old adage, “If you can’t name it, you can’t tame it”, comes to mind. Most of us prefer to think of ourselves as ‘prejudice free’ or believe we’ve ‘worked through’ these issues; it somehow means something negative to admit that you are, in fact, the not-so-proud possessor of racist attitudes or beliefs.
In reality, we all have racism to certain degrees. Become aware of what feelings and attitudes really exist for you regarding Africans, Indians, Muslims, Jews, or any other culture different from your own – be careful and don’t allow yourself to be blind-sided by a surprise appearance of your own prejudice or racism during a therapy session. Certainly, it’s a form of countertransference that can be owned and managed.
Some issues to consider might be: How do you feel when a big black man walks into your office? What do you think of the slang that many blacks tend to use? How do you feel about the arrogance and sexism you sense from men of certain cultures? Do you find yourself stereo-typing certain groups or cultures? Do you tend to sit in judgment of different kinds of drugs users? For example, do you think less of heroin or crack addicts than you do of alcoholics or prescription drug abusers? Maybe some groups have been aggressive and rude to you, and you feel uncomfortable with them. Maybe you are somehow embarrassed or ashamed because of the oppression and poverty that some groups have endured. Are you willing to confront people from different cultures the same way you would of your own race? Do you find yourself talking differently to some cultures? For example, do you ‘talk down’ or patronize certain groups? Do you use racial slurs? Would you want someone of a different race to marry your sister, brother, or child? If not, why not?
These questions are designed to help identify your own issues that may be unresolved or even unrealized. Deciding what prejudices you actually own is the beginning of more effective cross-cultural counseling, putting you in a much better position to understand the differences between your agenda and the clients. You may also decide that your issues prevent you from being fair and effective and therefore choose to have someone else work with these clients. It is important to recognize that at times, this is appropriate; the primary concern is to always ensure clients’ get the best possible care, which is exactly what they deserve.
Racism does not always manifest itself in negative and abusive words and actions. Some cultures receive extra-favorable treatment from therapists who want to somehow express their solidarity and support for a specific culture’s cause. However, ‘special treatment’ is never in the best interest of the individual and can even be counterproductive in terms of their personal growth. Treating someone differently because you’ve determined this is necessary to address their individual clinical needs is certainly not the same as treating them differently because it somehow makes you feel better. Always examine your motivations whenever you feel a client is getting preferential treatment from you.
Just as all addicts aren’t the same, not all people of the same race or culture are the same. For example, it’s difficult to be sensitive to ‘black’ issues when they often appear totally different depending on the individual. I remember being in organizations where a black client would walk in, and automatically be referred to me. The idea was that we would be able to work better together because we were both black – in reality, there have been cases where the only thing we had in common was our race. All Indians, Africans, Asians and Europeans are not the same – even though individuals in each group share a racial heritage, they may have totally different cultural experiences and challenges. We must recognize that cultural experiences are so diverse that one can easily do more harm than good by trying to address the cultural needs of a whole race. Most cultural groups have completely different views and identity issues depending on what part of the world they’re from, their level of education, socio-economic background, complexion, and how they were raised.
Beware of generalizations and stereotyping. The best advice is to use good therapeutic skills. Develop a treatment plan that takes into account your client’s unique and specific clinical needs. In some cases, the client’s race will be more of an issue than in others. Not every person will have barriers that are created and nurtured by their ethnicity. With other clients, it will dominate the focus of your treatment.
A variation of the following model was made popular by Peter Bell and Jimmy Evans in their book “Counseling the Black Client: Alcohol Use and Abuse in Black America” (Hazelden, 1981). A helpful tool to determine treatment approaches for culturally diverse clients; it addresses how individuals adapt to dominant cultures and where they feel most comfortable. In viewing this model, it’s apparent that the same approach will not work for every client. We will look at three client types and show that the clinical needs for each client may be totally different. The client types listed below are not meant to be absolutes, merely brief examples of different coping styles. In these examples, I will use the term ‘dominant culture’ to represent the main culture that exists within your agency, community and/or majority client population.
* Has made no attempt to fit into the majority culture.
* May be described by some as a separatist and maybe even a racist.
* Might wear culturally identifiable garb and associate primarily with others from their own race and culture.
* Has little interest or desire to be accepted and approved of by the dominant culture.
* May often see cultures different from their own as the enemy or someone who doesn’t understand their issues.
* Feels much more comfortable with people of their own race and culture and avoids others.
* Distrusts and has difficulty relating with people outside of their race and culture.
This client type can be the most difficult for counselors to work with, and they might even be more difficult for a counselor from the same culture who is centered in the dominant culture (see the next client type). In dealing with this client, you might often see anger, resistance, and denial. They might excuse or explain their behavior by describing it as retaliation for racial oppression that their culture may have endured. They might demonstrate a sense of entitlement that causes power struggles, and be very distrustful of the counselor and their techniques. They might be resistant to taking responsibility for their addiction, instead blaming it on racism, prejudice and/or a lack of understanding. They can be controlling and antagonistic, and will most likely trigger any unresolved racial or cultural issues for the counselor.
* Does everything possible to fit in and be accepted by the dominant culture.
* May be described by some as not being true to their own culture and mimicking the dominant culture.
* Tries hard to gain the approval of friends from the dominant culture.
* Avoids contact with other members of his culture and has little connection to his own cultural community.
* Often sees other members of his race and culture as ‘the enemy’ and/or a source of shame and embarrassment.
* Has difficulty trusting other members of his own culture and usually feels ‘better than’ or ‘less than’.
* Often will adapt speech and mannerisms that mimic the dominant culture.
* May not like being reminded of being a member of his own race or culture.
This client type will prefer to work with a counselor from the dominant culture, and will get uncomfortable around others from their own race or culture. They will resist having their race be a topic of conversation and may feel superior to other members of their race/culture or even demonstrate strong racist views against their own race. They are usually articulate and well-educated with a sophisticated denial and rationalization system.
* Is able to function well in both cultures.
* Might sometimes feel bilingual or socially schizophrenic.
* Can speak the language of the dominant culture then go into their own community and switch to another language and mannerism.
* Feels a connection and loyalty to both worlds.
* Does not feel that being a member of their own race or culture requires exclusivity.
* Periodically feels pressure from both worlds to conform.
* Because of the ability to be in both cultures, will demonstrate the best and worst of each.
* Is often privy to conversations the separatist doesn’t hear.
* Is most likely to use a larger support system in recovery due to the exposure and comfort experienced in both cultures.
For this client, race will not be a primary focus of treatment. However, there is a possibility of feeling disconnected in both cultures. They might describe feeling like they’re in limbo between the two. Their ability to move from one culture to the next can be used as escapism in certain situations. For example, when hurt or pressured by his non-Asian friends, he can retreat to the Asian community or Asian ‘mannerisms’ for comfort and vice versa. This can be confusing and painful to the client and his friends. This client will expect to be treated as an individual and will resist stereotyping.
As tempting as it might be, don’t use your counseling session as an opportunity to learn more about another culture. Therapists often find themselves fascinated as their clients give them first-hand knowledge of the inner workings of their specific culture. Finding out what makes a person from a different culture ‘tick’ may be much more interesting than the treatment process. However, we must remember that the time spent with the client is their time; if you’re benefiting more than they are, something is very wrong. This isn’t to say that wanting to learn more about different cultures isn’t a good idea; just don’t use your clients as teachers or your counseling sessions as classrooms. Take workshops, read books, and spend time with your friends that are members of that culture or race. If you don’t have any friends from different races or cultures, reread the beginning of this article!
Sometimes the client may feel it’s their duty to teach you how their people think and feel. That is not the purpose of the session, and the client should be made aware of this. Again, the primary focus is the client and whether they are receiving what they need to achieve and maintain recovery.
This is a tricky one. Addicts often like to talk about anything other than what they need to do to recover. Many will find a million ways to divert the focus from the primary issue of addiction. Often they are looking for ways to avoid confrontation and feedback. Race is the perfect distraction. You may find that some clients want to talk about racial topics rather than the assignment they are working on, and when you touch on a hot issue they change the subject to a racial topic. Now here is the tricky part… when you refuse to talk about the cultural/racial complaints and instead insist on talking about the recovery assignments you might be labeled as insensitive and discounting. While honoring the cultural diversity of your client is important, you must remember that your primary purpose in addiction treatment is to help the client get clean and stay sober.
Any issue the client raises may be important. However, the questions you must ask are: How does this relate to the addiction? How has this contributed to their using? How is it going to prevent them from staying clean and sober? In the days of task-oriented, brief therapy and managed care, we don’t have the luxury of wasting sessions on issues that don’t relate directly to recovery. Gently remind the client that although you are interested in their views and opinions regarding race, you would be short-changing them if you didn’t bring the discussion back to the task at hand: how to get clean and stay sober.
Take a moment to rate your own clinical skills as a therapist. A ten means you believe you provide top-quality counseling in a compassionate and professional manner. A one indicates you need another job. I’ll bet you feel pretty good overall about the work you do and why shouldn’t you?
Can you work effectively with clients who feel depressed, have denial, or don’t trust you? Can you do conflict resolution and active listening? Are you familiar with chemical dependency and relapse prevention? Do you know how and when to confront a client? Can you read nonverbal communication? Can you facilitate a group? Can you do a lecture? Well, it sounds like you know your stuff.
Don’t minimize your own capabilities when working with a different culture. Don’t back down when you get accused of not knowing what you’re talking about. Don’t allow your own fears, insecurities, and self-doubt to cause you to abandon all your training. You don’t have to have walked in someone’s shoes to be able to help them. You don’t have to know all the inner workings of each culture in order to be effective. The most important description of a good therapist is: know what you’re taking about and care about your client. If you can communicate that to your clients, you’re in great shape. Remember, use your skills.
By reading this article you are already interested in cross-cultural counseling. You want to be more effective working with clients from different races and cultural backgrounds. You want to know as much as you can about the different cultures so you can provide better treatment. Well, by now you must have figured out that many cultures have a range of issues that are not only complicated, but also diverse. How can you possible study and learn enough to be prepared for the ‘type’ of client that might show up in your office? Trying to learn and understand the different cultural nuances amongst a racially diverse group of clients can be complicated. What about the Latino client? Is he Cuban, Puerto Rican or Mexican? First or second generation? What about the Middle Eastern client? Which country are they from? What part of the country? How about Asians or Pacific Islanders? And culture isn’t just race related. How much do you know about gay and lesbian issues? How about the different drugs people use? Do you know about the culture of people who smoke PCP versus people who smoke crack? Do you know about who uses ecstasy and goes to raves? Do you understand the difference between people who shoot heroin and those who smoke it? A bit overwhelming, isn’t it? Well, it certainly is. There is no way for any therapist to be knowledgeable about every culture that they might wind up working with, so what’s the answer?
Individualized treatment is the key. If you treat each of your clients as an individual with specific clinical needs, your treatment will be a success. You don’t need to be pregnant to work with a pregnant woman, and you don’t need to be black to work with a black client. However, you do need to avoid generalizing and stereotyping. You will see common issues that all addicts and alcoholics deal with, but they might be communicated or influenced differently based on cultural experience. If you create a truly individualized treatment plan, you will always be in a better position to provide professional, and competent care. At the end of the day, if the client leaves the session and feels you care about them and you know your job, you will be effective.