TIPS & TOPICS
Volume 6, No. 8
December 2008

In this issue
— SAVVY
— SKILLS
— SOUL
— STUMP THE SHRINK
— UNTIL NEXT TIME

Happy Holidays to you and your family. Welcome to all our new readers and welcome back to all who have been with us for a while.

SAVVY

Often when I am training on ASAM Patient Placement Criteria or co-occurring disorders or treatment planning, I am asked: “What about cultural issues?” Some workshop evaluations even stress this by asking participants to rate the speaker on how well they addressed and included cultural issues in the presentation. So here are some thoughts about cultural sensitivity and competence.

• When you are focused on person-centered, client-directed care, you will also want to be culturally sensitive and competent.

Firstly what do we mean by “culture”? Here’s one definition “Integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group.”

Source: Giachello 1995; Office of Minority Health 2001

What Cultural Competence is:

–> An interviewing skill and an awareness that individuals may be defined by a group in which they feel a part. This person may identify with a variety of cultural groups that span ethnicity, religious and spiritual affiliations, sexual orientation or identity, age etc.

–> A focus on a comprehensive picture and understanding of the person/family. In a therapeutic group composed of many different kinds of people, diversity considerations can take on added importance. We seek to understand people in the context of their unique upbringing and family and social influences. This promotes individualized treatment in ways most likely to speak to this individual.

–> A commitment to identify strengths/supports and develop a person-centered service plan. All individuals have unique characteristics. How people view themselves and how the dominant culture may view them are frequently different.

What Cultural Competence is not:

–> Not only for minority ethnic groups —
“Diversity” can mean any differences that distinguish an individual from others and which affects how an individual identifies himself, and how others identify him – age, gender, cultural background, sexual orientation, ability level, social class, education level, religious background, parental status and justice system involvement.

–> Is not a requirement to learn, inside and out, about every ethnic group—
The more you know about different cultures, the more you know what you don’t know. But the client is always to be considered the expert on what culture, ethnicity and gender identity means to them. So if you are actually interested in getting to know them, he/she can be your teacher, telling you about themselves, what’s important to them, not what you think from what you learned generically about a particular ethnic group.
–> Making assumptions about a person’s identity based on cultural stereotypes—
No one should be reduced to a single characteristic in an attempt to understand them. All people have multiple characteristics which define who they are. For example- An African-American raised in a fundamentalist Christian environment may be defined more by their religious cultural experiences than their ethnicity, vice versa or some mix.

References and Resources:

1. “Substance Abuse Treatment: Group Therapy” – Treatment Improvement Protocol Series No. 41 (2005) Consensus Panel Chair: Philip J. Flores, Ph.D.; Co-Chair: Jeffrey M. Georgi, M.Div. The Center for Substance Abuse Treatment. DHHS Publication No. (SMA) 05-3991 (Available from the National Clearinghouse on Alcohol and Drug Information.(800) 729-6686 or 301-468-2600. 800-487-4889 (TDD hearing impaired) 877-767-8432 (Hablamos Español). Ask for publication order number BKD507.)
Web: www.ncadi.samhsa.gov
Also Available: “Quick Guide for Clinicians Based on TIP 41, Substance Abuse Treatment: Group Therapy” (NCADI No. QGCT41)

2. Giachello, AL (1995): “Cultural diversity and institutional inequality” In: Adams, DL., ed. Health Issues for Women of Color: A Cultural Diversity Perspective. Thousand Oaks, CA: Sage Publications.
3. Office of Minority Health (2001): National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report. Washington, DC: Office of Minority Health

SKILLS

Addiction treatment has predominantly occurred in group settings. Increasingly mental health is balancing individual therapy with treatment in groups.

• Consider cultural and diversity issues in group treatment.Should the therapist/clinician wait for the client to raise issues of culture/ethnicity or raise the issue him/herself?

Should the therapist/clinician wait for the client to raise issues of culture/ethnicity or raise the issue him/herself?

If a group leader believes that cultural traditions might be a factor in a client’s participation in group or in misunderstanding among group members, the leader should check the accuracy of that perception with the client involved e.g., if a client is looking down and has little eye-contact with others, it may be depression, shyness, social skills or self esteem issues; or it may be cultural issues relating to expression of respect of authority.

How should culture/ethnicity be addressed when it does arise?

As group treatment proceeds, feelings of belonging to an ethnic or other cultural group can be intensified more than in individual therapy because, in a group process, the individual may engage many peers who are different, not just a single therapist who is different (TIP 41 page 44, Salvendy 1999). For example, an Asian client may become even more hesitant to speak up in a group where most members are Caucasian, more verbally assertive or outspoken. As the group leader is sensitive to the hesitancy of some cultures to speak up assertively, he/she can facilitate “equal opportunity” for participation.

What if the client denies the impact of culture/ethnicity in therapy?

You may have incorrectly assumed a cultural reason for certain behavior e.g., assuming that a patient’s reluctance to receive a blood transfusion is due to religious beliefs, when actually the person is just scared of pain and needles. Or you may be correct about a cultural issue, but are raising it prematurely with a client who is ambivalent about distinguishing himself from the dominant culture e.g., your attempts to reassure the client that being gay and speaking up about his homosexuality is safe in therapy, are met with adamant denial of any such sexual orientation.

How might culture/ethnicity influence the process in assessment, treatment planning and placement?

Group leaders should be aware of the possibility that group roles and values of some can be used positively to improve outcome, but can also conflict with treatment goals for others in the group e.g., a group composed partly of Southeast Asian refugees may give authority to older men in the group who may never be challenged, contradicted or disagreed. To do so would be to show disrespect. These older men can assist in group leadership. However, the opinions of female group members, particularly younger ones, might be ignored and a group leader should be able to compensate for this tendency.

How do you distinguish ethnicity issues from poor psychological functioning? e.g., one member of a certain ethnicity feels offended and devalued and another member does not – is one more paranoid than the other? How do you distinguish ethnicity issues from generational socio-economic status, role models and background?

The person’s reactions may arise from both cultural reasons and psychological functioning. For example, a client may indeed be experiencing some ethnic exclusion or devaluation. But in combination with that person’s low self esteem after years of childhood physical abuse, this is what most strongly accounts for the feelings of rejection.

Other examples of multiple characteristics that affect assessment and functioning – Hispanics/Latinos may be suspicious of rules and the people who enforce them. Group leaders consequently may be regarded as authority figures that unwittingly represent discrimination and encroachments on freedom. Women may hold emotional energy for men or nurture them.

References and Resources:

1. “Substance Abuse Treatment: Group Therapy” – Treatment Improvement Protocol Series No. 41 (2005) Consensus Panel Chair: Philip J. Flores, Ph.D.; Co-Chair: Jeffrey M. Georgi, M.Div. The Center for Substance Abuse Treatment. DHHS Publication No. (SMA) 05-3991 (Available from the National Clearinghouse on Alcohol and Drug Information.(800) 729-6686 or 301-468-2600. 800-487-4889 (TDD hearing impaired) 877-767-8432 (Hablamos Español). Ask for publication order number BKD507.)
Web: www.ncadi.samhsa.gov. Note pp 44-57.

2. Salvendy, JT (1999): “Ethnocultural considerations in group psychotherapy” International Journal of Group Psychotherapy 49(4):429-464.

SOUL

It’s gift giving (and getting) time—–time to get out your scissors, razor blades, buzz saws and other hardware tools to attempt to pry open those clear plastic packages clammed tightly shut. So close to the shiny new product inside! Yet so far from actually touching it!

Jeff Bezos, founder of Amazon.com, said: “I shouldn’t have to start each Christmas morning with a needle-nose pliers and wire cutters. But that is what I do: I arm myself, and it still takes me 10 minutes to open each package.” 6,000 other Americans feel the same way. They are the ones who each year end up in emergency rooms with injuries caused by stabbing and cutting open their purchases (Consumer Product Safety Commission).

The rest of the New York Times News Service article talked about companies including Amazon.com, Sony, Microsoft and Best Buy that have begun to create alternative, customer-friendly packaging that you can open without power tools.

Besides this being good news for the consumer part of me who likes getting new things in packages, it stirred some thoughts about our business. Of the 20.8 million people aged 12 years or older needing, but not receiving, treatment for illicit drug or alcohol use in the USA, 93.6% did not feel they needed treatment and therefore made no effort to access treatment. 6.4% did feel they needed treatment, but only 1.8% actually made an effort to access treatment (SAMHSA 2007 National Survey on Drug Use and Health).

For that 1.8% of people who made the effort to get into treatment, you know how hard it is to open the treatment package with waiting lists, funding and insurance obstacles, geographic access etc. Compared to accessing treatment, opening plastic packages is a piece of cake.

If you’ve shopped at Amazon.com over the years, you know how well they know the people they serve. They know what books I like and suggest other ones I might be interested in buying. They know I might need a map update for the Garmin GPS device I bought a year ago, and they let me know it’s on sale!

If you have an iPod and open up you iTunes music library, the Genius sidebar will tell you other music titles and artists that might suit your taste given the song you selected- and of course, want to sell it to you. But Steve Jobs and the Apple team certainly strive to make it easy for people to access their products and services.

Maybe we should get Jeff Bezos and Steve Jobs to help us attract people into recovery.

Happy holidays and have fun opening those packages….be safe and don’t drink, drug and drive.

STUMP THE SHRINK

Question

“Dear Dr Mee-Lee,

As a case manager for a court support program, I am curious as to what your thoughts are in relation to the brokerage model of case management for substance dependent individuals. At my place of work there is never a mention of the “Stages of Change” model or the application of “Motivational Enhancement” strategies in facilitating change for the individuals that utilize our service. Do you think these evidence-based approaches are inapplicable within the context of case management brokering of treatment? And if they are not, how best can I incorporate these approaches in my work, bearing in mind that my role is not a clinical one?”

Hanif Kamal
Case Manager, C.I.S.P.
Melbourne, Australia

DML Response

Hanif:
Glad you are getting TNT over there. Before changing anything you are doing, you would need to look at your own outcomes. Ask yourself if what you do is effective in increasing personal responsibility and accountability for safety of the public, decreasing legal recidivism, and the decreasing jail time. I assume this would be the kind of outcomes you’re aiming for in a court support program.

If you are not getting the kind of outcomes you want, or feel they could be improved, I suggest a greater emphasis on assessment of stage of change and engaging the client around the goals he/she wants. I presume they want to stay out of jail, get off probation or parole, or lighten their legal sentence.

Even if you’re not doing clinical work, I recommend a close tie-in between what you are doing with case management and what a counselor might do with motivational enhancement work. Define the client’s goal: for example, “stay out of jail”. Then collaborate as to what services you would need to broker for him/her to support that. If they need a safe place to live, away from drug users or dealers, then that would be important to broker.

However, if the client doesn’t even think they have a severe addiction, and doesn’t care who they live with, then finding them a safe and sober recovery-oriented place to live would not necessarily be effective. For someone still ambivalent about addiction and recovery, the case management focus would be different. You might coordinate with the counselor to track how successful (or not) the client is at avoiding more legal trouble if they still live and hangout with users and dealers. It would be premature to find a safe living environment for someone not interested in recovery.

David

Reader Response

Dear Dr Mee-Lee,

I think you really did shed light on a very important point, which relates to the goals that a service user might want to attain. Quite often, I work with clients who inform me that they do not want to be sentenced to prison, hence, their reason for coming in our program. Although they present with substance abusing issues, they show no willingness to engage in treatment for this. In this case, ‘not wanting to be sent to prison’ would clearly be the goal here. However, I usually tend to focus all my efforts on trying to address the substance-abusing problem rather than collaborating with the client to see how their goal/s could be achieved.

Hanif Kamal

DML Comment

Hanif had a light-bulb moment. It is a simple yet profound realization to recognize he was working on goals of no interest to the client, but of concern to him. Such a realization can bring stress relief, because now he doesn’t have to work harder than his client.

I am aware of Housing First initiatives which give people housing even if the person is not interested in treatment. That is an initiative in its own right and has its merits and effectiveness. In the example above however, I am referring to a client who does not embrace an addiction problem or recovery and who still wants to live with and hang out with drug users and dealers. To spend time cajoling him or her into safe, recovery supportive housing would be to push your agenda, and add work and stress to one’s case management efforts.

Until Next Time

Wishing you a safe holiday season and a healthy, successful 2009.

David