Substance use disorders (SUDs) affect various people around the world. There are many factors that contribute to people’s substance use, including gender, age, home environment, and family history; these subsequently affect their success in treatment. Race seems to be another important factor that affects success in SUD treatment. Specifically, minority populations in the United States have lower rates of treatment completion as compared with nonminorities. Research and data that explore this phenomenon will be discussed in this article.
What does success look like for individuals in SUD treatment? The word “success” can have different meanings, depending on who answers the question. According to Mignon, “treatment effectiveness is measured by a reduction in substance use and a reduction of accompanying problems” (2014, p. 1). Brown, Myers, Mott, and Vik state that success in treatment for any length of time—for example, three months, six months or one year—is classified as the significantly diminished use of alcohol or another substance that is correlated with a decrease in the negative behaviors associated with such use (1994, p. 62). All clinicians in the field of SUD treatment should be aware of how regulatory agencies and existing research define “success” for the treatment system in which they are working.
In the context of this article, the term “success” will be operationally defined as described above by Mignon (2014) and Brown et al. (1994): a reduction in substance use and its accompanying issues. Research on SUD treatment has a heavy adolescent focus, and there are many potential reasons for this: prevention programs that target adolescents, the fact that substance use typically begins during adolescent development, researchers who want to focus on early intervention and success, and more. Individuals who were twenty years old or younger when their SUD began and who are receiving services in SUD treatment have an increased chance of a higher severity of SUD-related problems within their families, behavioral problems, hostility toward others, antisocial traits, mood disturbance, and poor overall social functioning (Johnson, Cloninger, Roache, Bordnick, & Ruiz, 2000). There is a vast amount of literature that addresses the treatment of adolescents with SUDs (Zaso, Park, & Antshel, 2015), but the focus of this article will specifically be on the treatment of minority adolescents with SUDs.
SUD treatment is prevalent among both minority and nonminority adolescents. For this research, which addresses SUD treatment in the US, white adolescents will be considered nonminority adolescents, and African American, Latino, and American Indian/Alaskan Native (AI/AN) adolescents will be considered minority adolescents. Although there are many other minorities in the US, these three groups are the most prevalent in current research. Shih, Miles, Tucker, Zhou, and D’Amico (2010) have stated that Latinos and whites report higher lifetime and past use rates of alcohol use than Asian Americans and African Americans. Latino youths between the ages of twelve and seventeen years report the highest rate of marijuana use as compared with all other minority and nonminority populations (Shih et al., 2010).
Similarly, the National Institute on Drug Abuse (NIDA) found that 11.8 percent of AI/AN, 10.1 percent of Latino, 6.5 percent of African American, and 6.1 percent of white adolescents stated that they had used illegal drugs during the month before they were surveyed (2003, p. 34). One can see the differences in substance use rates between minority and nonminority youths. Although race may not be the only factor that contributes to substance abuse and SUD treatment success rates, its effect is still noticeable and warrants further exploration.
Much research has addressed the topic of adolescent substance abuse and treatment. Many of these studies have also investigated the effects of race on treatment success. The literature reviewed for this project was insightful and thorough. Adolescent SUDs and their treatment will continue to require further research. Looking at factors such as gender, socioeconomic status, family structure, family history, and environmental influences within the context of the SUD treatment of minority and nonminority adolescent groups will help to generate new ideas to increase treatment success among minority populations. The following paragraphs will demonstrate the intersectionality of race and successful SUD treatment.
Comparison of Treatment Completion Rates
Majority populations are large groups of individuals with shared traits within the population as a whole. In the US, the majority of the population is composed of white, English-speaking individuals who fall in the middle of the socioeconomic range. Therefore, white Americans will be the comparison majority population. SUD treatment program completion rates for whites in the United States are higher than the rates found for most minority populations, although Saloner and Lê Cook (2013) found higher rates among Asian Americans. Although treatment programs are successful for a significant percentage of the majority population, this article seeks to highlight the experiences of minority populations.
For the purposes of this article, minority populations are defined as the subgroups of the population that face disparities and systemic exclusion from the majority culture. The minority groups discussed in this paper include AIs/ANs, African Americans, and Latinos. Completion rates of SUD programs are lower for minority populations (Alegria, Carson, Goncalves, & Keefe, 2011). Research has shown that African Americans and Latinos are 3.5 to 8.1 percent less likely to successfully complete SUD treatment as compared with white Americans and that AIs/ANs are approximately 4.7 percent less likely to do so (Saloner & Lê Cook, 2013). Conversely, Asian Americans have at times been found to fare better than white Americans in terms of treatment completion (Saloner & Lê Cook, 2013). Further research needs to be conducted on the success rates of Asian Americans in the hopes of developing recommendations to improve the SUD treatment completion rates of other minority populations. As a result of the limited research in this area, the current research does not focus on SUD treatment among Asian American adolescents, even though they are a minority group within the US population.
Rationale from Existing Literature
An exploration of the literature demonstrates that there are effective SUD treatment programs for both majority and minority populations (Alegria et al., 2011). It has been suggested that the treatment itself is not affected by race or ethnicity if the treatment being evaluated is a quality, evidence-based form of care (Alegria et al., 2011). Furthermore, evidence has shown that the completion of SUD treatment correlates with the quality of the program or service (Alegria et al., 2011). The problems that influence the completion of these programs are found within the systems that affect health care and treatment. Existing literature illustrates that minority populations face discriminatory policies at the federal level, the health care system level, the provider level, and the environmental level (Alegria et al., 2011). These barriers lead to lower rates of SUD treatment completion for these minority populations as compared with white adolescents. Language serves as a further barrier to accessing treatment programs for non-English-speaking minority populations (Guerrero, Pan, Curtis, & Lizano, 2011).
In the US, there are few programs for Spanish-speaking populations and even fewer programs in alternate languages (Guerrero et al., 2011). Individuals who seek Spanish-language treatment must be able to travel long distances to receive services, and they have longer waitlists than white, English-speaking populations (Guerrero et al., 2011). Accessibility incorporates not only distance and language, but also economic ability. Housing issues and socioeconomic status are further barriers to successful access to and completion of SUD treatment programs (Saloner & Lê Cook, 2013). Systemic issues for minority populations result in less access to and lower rates of support during SUD treatment (Saloner & Lê Cook, 2013). To improve treatment completion rates for racial minority groups, aspects of their experiences within the health care system and the cultural system at large need to be examined.
Race is not the only indicator of SUD treatment completion rates; culture also greatly affects treatment considerations. Identified variables that describe the experience of minority populations are called “cultural variables” (Castro & Alarcón, 2002). Another rationale for disparities in rates of successful SUD treatment is the idea that the issue lies in the method of treatment. Treatment modalities do not currently recognize cultural variables and are therefore not able to form a full picture of the minority population experience (Castro & Alarcón, 2002). Only when treatment programs become increasingly culturally aware will this gap possibly begin to close. An awareness of racial and cultural disparities is key to increasing SUD treatment completion rates among minorities in the United States.
Treatment facilities use the sociocultural model to incorporate family and culture into SUD treatment programs. Many minority populations in the US experience something that White and Sanders call “cultural pain” (2008, p. 368), which is distress related to white power and privilege in this county. For minority populations in general, the “historical, political, economic, and sociocultural circumstances can also serve as etiological agents in the rise of [alcohol and drug] problems” (White & Sanders, 2008, p. 368). SUD treatment programs that include social context seem to be especially effective for the Latino population, because they address that population’s substance use in relation to the cultural context of being a Latino in the US (Lee et al., 2011). According to Lee et al. (2011), therapists need to take into consideration the environmental stressors that lead clients to abuse drugs or alcohol, because addressing those stressors can aid in treatment successes. A common theme in Latino culture is the idea of “familialism,” the importance of which reinforces the idea of incorporating the sociocultural model into treatment programs for these populations (Lee et al., 2011).
Like Latinos, African Americans also find this type of treatment useful, because “in communities of color, the individual, the family, and the community are inseparable. To wound one is to wound the other; to heal one is to heal all” (White & Sanders, 2008, p. 372). Similarly, AI/AN populations view substance use in two lights: they see it as both a characteristic of social cohesion and a symptom of social fragmentation and a lack of connectedness (Yuan et al., 2010). Culturally adapted models of mainstream modalities are purported to have success among AI/AN populations that struggle with SUDs (Yuan et al., 2010). The sociocultural model is able to incorporate these aspects into treatment and to relate the alcohol or drug use to clients’ individual selves, their families, and the community.
Lee et al. (2011) affirm the importance of considering sociocultural factors that may exacerbate clients’ drinking behaviors. In clinical settings, it is imperative that therapists recognize the social contextual features of clients’ drinking, which may not be accounted for by certain streamlined therapies. Unique sociocultural factors that minorities face include systematic discrimination and historical trauma, which stem from historical policies and procedures; examples include the systematic removal of AIs/ANs from their original lands and the enslavement of people of color (Dickerson, Brown, Johnson, Schweigman, & D’Amico, 2016). Adaptations of conventional motivational interviewing (MI) that include social contextual features as primary influences for clients’ presenting concerns can be beneficial for the treatment of minorities (Lee et al., 2011). AI/AN and Latino clients may face language barriers and challenges associated with discrimination, which can influence their substance use. Adapting MI to consider the social, economic, and political conditions that these clients face as both mediating factors for the clinical work and influencing factors for the SUDs is thought to enhance both therapeutic rapport and participation in treatment (Lee et al., 2011).
AI/AN youths who are between twelve and seventeen years old are believed to have the second-highest rates of illicit substance use and heavy drinking as compared with youths of any other racial or ethnic group in the US (Dickerson et al., 2016). More than half of AIs/ANs have stated that they live on nonreservation lands, although these statistics are somewhat questionable because they are self-reported (Dickerson et al., 2016). A significant risk factor that predisposes urban AIs/ANs to illicit substance use and drinking during adolescence is a perceived lack of a cohesive urban AI/AN community (Dickerson et al., 2016; Philip, Ford, Henry, Rasmus, & Allen, 2016).
The literature acknowledges that few SUD treatment modalities are tailored to nonmajority populations, least of all AI/AN populations. However, significant efforts have been made to adapt MI to AI/AN populations, including youth populations (Dickerson et al., 2016). Dickerson et al. (2016) consulted with tribal elders, individual adults who struggle with addictions, parents, and youth to develop the Motivational Interviewing and Culture for Urban Native American Youth (MICUNAY) intervention and prevention program. The MICUNAY program seeks to reduce substance use among youth by promoting physical, emotional, mental, and spiritual well-being as well as cultural identification; these are pieces of traditional AI/AN cultures that are often deemphasized among urban AIs/ANs who live in nonreservation areas (Dickerson et al., 2016). Focus groups of urban AI/AN youth indicated that community safety, lack of resources, and cultural identity contributed to substance use (Dickerson et al., 2016). Because the MICUNAY program was formulated in collaboration with tribal elders, parents, and youth, this approach to AI/AN youth addiction is a more holistic way to enhance cultural identity as a protective factor. This program is relatively new, so additional research among AI/AN clients is necessary to determine the effectiveness of the MICUNAY program for the prevention and treatment of SUDs.
Psychological Model: Social Learning Theory
There is not much research on the psychological model in relation to its use with the Latino and African American populations of the United States. However, studies have shown that typical MI does work for adolescents who are members of these populations (Gil, Wagner, & Tubman, 2004). Gil et al. (2004) also demonstrated that cognitive behavioral therapy and guided self-change produce positive effects as part of SUD treatment for African American and Latino adolescents.
The MICUNAY program for AI/AN youth emphasizes the impact that behavioral choices can have on mental health. In workshop segments that focus on the significance of choices, AI/AN youth are encouraged to consider the impact of substances on their brains. For instance, the workshop provides psychoeducation about how substance use can lead to impaired cognition, memory loss, and increased negative emotions (Dickerson et al., 2016). In other workshops, AI/AN youths are invited to discuss strategies for enhancing positive emotions without the use of substances (Dickerson et al., 2016). AI/AN cultures cherish their youth and encourage children and adolescents to learn from their parents, extended families, and elders. Programs such as MICUNAY can enhance the cultural identities of AI/AN youths and restore positive relationships among families so that adolescents can learn alternatives to substance use behaviors (Dickerson et al., 2016). Interventions that center on discussions about alternative behaviors to use to cope with negative conditions and emotions can provide youth with behavioral strategies that promote healthier choices.
The disease model, which is commonly used in the US, provides a pathological basis for SUDs (Saulnier, 1996). The concern is that, if addiction is labeled as a disease, those minority populations with high rates of SUDs will be considered diseased people, thereby leading all members of the minority group to be considered diseased (Gallardo & Curry, 2009). Another reason that the disease model has not been successful with minority populations is that these populations believe this pathological basis allows its members to use “the disease” as an excuse for their actions (Saulnier, 1996).
This model is not congruent with the needs of Latinos with SUDs, because the disease model alone does not focus on the whole lives and contexts of people (Gallardo & Curry, 2009). Therapists often use psychotherapy with the disease model, which also does not work for Latinos, because it does not address the sociocultural side of their addictions (Gallardo & Curry, 2009). There is not much research on the response of African Americans to the disease model of addiction and their reactions to this type of treatment.
AI/AN populations respond favorably to the disease model of treatment and treat SUDs with consideration of patients’ physical needs and other holistic features. The MICUNAY program promotes physical wellness as a method of substance use prevention and treatment. The program includes physical wellness activities, cooking lessons that incorporate ancestral ingredients and food, and psychoeducation about the impact that physical wellness has on people’s psychological, emotional, and spiritual well-being (Dickerson et al., 2016).
The biopsychosocial model seems to be the best fit for minority populations. It allows counselors to understand all of the facets of clients’ lives so that they may provide the most effective care to clients. As noted by Gallardo and Curry (2009) and White and Sanders (2008), it is important to include every part of patients’ ecosystems. As with the sociocultural model, when using the biopsychosocial model, counselors can use MI and adapt it to fit clients’ cultural needs (Gil et al., 2004). According to Gil et al., (2004), cognitive behavioral therapy and guided self-change can also be effective if the counselor incorporates cultural factors when creating the treatment plan. Many different current psychological and sociocultural techniques can work if they are modified to fit the culture of clients (White & Sanders, 2008), hence the desire for the biopsychosocial model. It is also important to inquire about “cultural mistrust” (Gil et al., 2004, p. 148) to understand whether issues involving American culture factor into patients’ SUDs.
Many Latinos develop mental illnesses as a result of the stress associated with moving to the US (Gallardo & Curry, 2009). Some of these individuals use alcohol and drugs to cope with the new culture and its associated stressors, which is why it is crucial to include the environment and context of clients in the chosen interventions (Gallardo & Curry, 2009). A form of culturally adapted MI that seems to work for Latinos and AI/ANs is the culturally adapted brief motivational interview (Lee et al., 2011, p. 319). According to Lee et al., counselors should ask clients about “historical and political experiences around immigration, context of migration, receptivity of the host community, the language barrier, and discrimination” (2011, p. 318) to integrate the contexts of clients into the cognitive behavioral therapy and the MI.
For Latinos, group therapy is often more effective than individual counseling, but it is still necessary to strengthen rapport with clients before clients are put into a group setting (Gallardo & Curry, 2009). Building rapport and understanding clients’ values are essential for biopsychosocial models to function effectively for minority clients, and the use of MI is one way to build rapport with Latinos (Lee et al., 2011). In Lee et al.’s 2011 study, minorities overall “responded favorably to the collaborative and nonjudgmental counselor attitudes, and appreciated being able to have a conversation while receiving helpful information about the effects of their drinking on their health” (p. 322). Lee et al. (2011) also reported that minority populations were satisfied when MI was used with cultural adaptations and when they received feedback regarding their treatment plan and goals.
Because many Latinos place significant value on family, it is necessary to include family members in SUD treatment when clients prefer to do so (Gallardo & Curry, 2009). Including the family allows counselors to gain the trust of clients and to better understand the context of their lives. There are many outside stressors that Latinos face that may at least partially cause them to turn to substance use, so the incorporation of family members into the treatment process can provide new insights into the daily stressors that affect clients and families (Gallardo & Curry, 2009). It can also be helpful to include family members in treatment to determine the types of support they can provide and the ways in which they can help clients recover (Lee et al., 2011). African Americans also find this model helpful, because it incorporates all aspects of clients’ lives. In the African American population, community and family are very important, and so family members should be included in the treatment plan for members of this population as well (White & Sanders, 2008). The AI/AN culturally adapted modalities make use of the concept of the medicine wheel when treating addiction; this encompasses wellness areas that include physical, psychological, emotional, and spiritual elements (Dickerson et al., 2016).
The spiritual model is known for its use in Twelve Step programs. According to Christine Saulnier (1996), Alcoholics Anonymous was started by straight white men and designed for middle class people. Saulnier (1996) also noted that the idea of “powerlessness” is central to the spiritual model used in such Twelve Step programs. In the past, the middle and upper classes used power to create change among minority populations (White & Sanders, 2008). These populations are marginalized and already feel powerless, so the spiritual model may negatively reinforce such feelings (Saulnier, 1996). White, middle-class, heterosexual men have power in terms of social status, access to resources, and opportunities for wellness, whereas many minority populations do not (Saulnier, 1996). This model’s stress on powerlessness usually just furthers the lack of power that minorities often feel.
Despite its use of the theme of powerlessness, the spiritual model has been effective for some Latinos. Latinos typically have a powerful “belief in spirits” called espiritismo (Gallardo & Curry, 2009, p. 323). This belief can be, and has been, harnessed in the spiritual model to promote recovery among Latinos. Latinos also value pride in themselves and their families, so telling people about their problems may make them feel like they are letting down or embarrassing their families; this feeling is related to the values of orgullo (pride) and machismo (honor; Gallardo & Curry, 2009).The spiritual model can be used to connect Latinos to their higher power; they may then view that higher power as a confidante.
There is little empirical evidence that the spiritual model is effective for African Americans in America. Specifically, Twelve Step programs have not been adjusted to address the needs of minority populations (Saulnier, 1996). According to Saulnier (1996), Twelve Step programs were created by people who do not understand the difficulties that African Americans face; these programs ignore the relationships among the social and political issues that African Americans deal with every day and how these issues relate to addiction. To be effective for African Americans, spiritual model programs would need to incorporate “an African-American worldview, lifestyle, behavior patterns, and problem-solving styles” into the treatment (Saulnier, 1996, p. 97). Although there is much evidence against the success of this model—and specifically against Twelve Step programs—with African Americans, there is also an aspect of such programs that can be effective for this population: “African-Americans have long focused on spiritual themes of personal salvation as a metaphor for emancipation of a people” (Saulnier, 1996, p. 114). This spirituality can be used to create a spiritual model that fits the needs of African Americans with SUDs.
As previously mentioned, Dickerson et al. (2016) developed the MICUNAY prevention and intervention program to addresses the spiritual component of treatment among AI/AN youth. One adaptation that this program includes is encouraging youth to think about their futures and to use prayer and cultural ceremonies to care for their spiritual needs instead of turning to substances (Dickerson et al., 2016). The program also provides education regarding the traditional ceremonial use of tobacco as opposed to its recreational use (Dickerson et al., 2016).
Like the spiritual models of addiction treatment, the moral models tend to place labels on substance use behaviors that imply that they are “good” or “bad,” “right” or “wrong.” Within AI/AN communities, some people believe that an SUD indicates that affected people are following the “Black Road”—making the moral choice to live a “bad” lifestyle—that often leads to misfortune (Dickerson et al., 2016). However, when AIs/ANs make healthier choices by reducing substance use and engaging in traditional cultural practices, they are following the “Red Road,” which can help steer them away from the negative effects of alcohol and drug use (Dickerson et al., 2016). Although these paths to recovery and wellness may seem spiritual to non-AIs/ANs, the associated beliefs imply that certain pathways and choices related to substance use are “right” or “wrong.” Not much research has yet been done regarding the effectiveness and use of the moral model with Latinos and African Americans.
Race is one of many factors that affect successful SUD treatment completion rates. Successful treatment completion depends on the quality of the program (Alegria et al., 2011). Because minority populations such as African Americans, Latinos, and AIs/ANs face discriminatory policies at every level of the health care system, it can be more difficult to place these individuals with agencies that could provide them with proper care, which would in turn result in higher treatment completion rates (Alegria et al., 2011). Each SUD treatment model looks different to each distinctive race and culture. It is important to recognize and incorporate clients’ cultures when working with adolescents of minority populations to achieve higher SUD treatment completion rates.
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