CHEMICAL DEPENDENCY TREATMENT PROGRAMS
AND OUTCOMES: CULTURAL COMPETENCY
Benet Ejay Guidera
B.A., California State University, Sacramento, 2009
Tina L. Everhart
B.A., California State University, Sacramento, 2009
PROJECT
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
SPRING
2011
CHEMICAL DEPENDENCY TREATMENT PROGRAMS
AND OUTCOMES: CULTURAL COMPETENCY
A Project
by
Benet Ejay Guidera
and
Tina L. Everhart
Approved by:
______________________________, Committee Chair
Maria Dinis, Ph.D., MSW
____________________________
Date
ii
Student: Benet Ejay Guidera and Tina L. Everhart
I certify that these students have met the requirements for format contained in the
University format manual, and that this project is suitable for shelving in the Library and
credit is to be awarded for the project.
, Graduate Coordinator
Teiahsha Bankhead, Ph.D., MSW
Date
Division of Social Work
iii
Abstract
of
CHEMICAL DEPENDENCY TREATMENT PROGRAMS
AND OUTCOMES: CULTURAL COMPETENCY
by
Benet Ejay Guidera
Tina L. Everhart
This paper is a collaborative effort between Tina Everhart and Benet Guidera. Benet
was the lead writer for chapter three of the project, while Tina was the primary writer
on chapter two. Both researchers worked equally on chapters one, four and five and all
the subsequent revisions of the five chapters. The purpose of this study was to better
understand the importance of cultural competence when treating individuals struggling
with substance abuse addiction and how that treatment affects outcomes. This was a
quantitative descriptive survey research design utilizing a convenient sampling method
of 49 substance abuse counselors. This study examined the relationship between
cultural competency in recovery programs and treatment outcomes. A statistically
significant relationship was found between positive treatment outcomes and the
agency’s utilization of bilingual interpreters when working with non-English speaking
iv
clients. No other statistically significant relationships emerged.
Future research is
important to understand culturally competent substance abuse treatment. Implications
for multi-level social work practice are discussed.
_____________________________, Committee Chair
Maria Dinis, Ph.D., MSW
_______________________
Date
v
ACKNOWLEDGMENTS
This project has been a labor of love and passion for the field of social work, and I
am a better person for it. Throughout this college journey, in those times when I was
challenged by life and it was hard to believe in myself, there I was in the unconditional
love of my husband Big Ed, the hearts of my sons Jake & Cole, and the spirit of my
college graduate predecessor, my mom Norma. I know what love is because of all of you.
Benet and I started out on this journey in graduate school as a team beginning the
first day of class. I never imagined at this point in my life that I would have met a
colleague & friend that I cherish this much. You, Tony & Alex have given me a soft
place to fall, by graciously sharing your home with me.
Throughout my education, during both BSW and MSW programs at CSUS, I am
acknowledging the professors from the CSUS Social Work dept: Maria Dinis, Ph.D.,
MSW, my thesis advisor, Susan Talamantes Eggman, Ph.D., MSW, my practice and
policy professor, and David Nyland, PhD., LCSW my theory professor who shares my
passion for the health and equal rights of LGBT persons & knowledge on all things
postmodern theory has to offer. All three of you have truly inspired me to move on and
continue my crusade with micro, mezzo and macro levels of Social Work.
I could not finalize my thoughts without recognizing their time, effort, education,
patience and caring compassion during my internship at National Association of Social
Workers’-CA. Janlee Wong, MSW, Executive Director, NASW-CA, has given me
opportunities to grow as a person and as a responsible caring citizen. Janlee is a dedicated
vi
person to the importance of ethical standards which includes social workers
responsibilities to cultural and ethnic diversity and strives to end discrimination,
oppression, poverty, and other forms of social injustice. Included, I am forever grateful,
in loving regards, for Rebecca Gonzales, Director of Government Relations and Political
Affairs, NASW-CA, who has mentored me towards social justice through advocacy,
social and political action, and policy development.
To my friend Brandy (Washington) Reaves I dedicate all the hard work,
commitment and perseverance one needs personally to being a loving mother and a
successful educated woman; all of which you have in your being. My last thoughts on
this matter I will leave for the love and life-long friendship I have with my friend Karen
Beaver-Wheat; I treasure your love and support.
It is because of all that I have acknowledged, that I will continue to advocate,
educate, and legislate on behalf of all social work issues, with special importance to the
LGBT people in our society. It was through the sweet strength of my son Jakob Phillips,
and the inspiration of living your truth from my friend Alan Rollins that I was propelled
into advocacy and social work to make this world more healthy and colorful. In order to
complete this research project, I was fortunate to receive from Ed and Cole a dose of their
enthusiasm and energy for life each day.
I dedicate this journey of cultural competence in Social Work to my grandmother
Josephine (Bonomi) Koll, an Italian immigrant who turned 90 years old during my thesis.
Tina
vii
I would like to thank Tina my partner, as this has been an incredible journey that I
could not have done it without her. Tina, you have been there for me in the most stressful
of times. Thank you for your commitment to this project. You have become a huge part
of my life and I look forward to spending time outside of graduate school with you.
Thank you to my family for supporting my educational pursuits. Tony, I must
thank you for being an amazing husband. For being my editor, sounding board, but
above all my champion. You always had words of wisdom and encouragement when I
needed it most. To Alexander my wonderful son, thank you for supporting me throughout
this journey. You both gave up time with me so that I could pursue my education.
Grandma and Grandpa G, thank you for your love and dedication. Without your help with
transportation and homework for your grandson, my Master’s degree would not have
been possible. Thank you so much for your love and support of me. To Mom and Papa
Phil thank you for encouraging me throughout my educational process. Mom, you always
told me growing up that I could achieve anything I set my mind to. Thank you for setting
such a great example.
Professor Maria Dinis, you have been an amazing thesis advisor. Your wisdom
and guidance in this process have proven to be invaluable. Thank you for your patience
when dealing with us throughout this project. Thank you for talking us off of the wall in
the most stressful of times. You rock! Lastly, this is accomplishment was as much for
you, Dad as it is for me. I love you and miss you.
Benet
viii
TABLE OF CONTENTS
Page
Acknowledgements ....................................................................................................... vi
List of Tables ................................................................................................................ xiii
Chapter
1. THE PROBLEM ...................................................................................................... 1
Introduction ....................................................................................................... 1
Statement of Collaboration ............................................................................... 2
Background of the Problem .............................................................................. 3
Statement of the Research Problem .................................................................. 7
Purpose of the Study ......................................................................................... 8
Research Questions ........................................................................................... 8
Theoretical Framework: Postmodernism .......................................................... 8
Application of Postmodernism: Relevance to Social Work ............................. 11
Definition of Terms........................................................................................... 13
Conceptual Definitions ........................................................................... 13
Operational Definitions........................................................................... 14
Assumptions...................................................................................................... 14
Justifications ..................................................................................................... 14
Delimitations ..................................................................................................... 16
Summary ........................................................................................................... 16
2. LITERATURE REVIEW ......................................................................................... 17
Introduction ....................................................................................................... 17
Historical Background Views on Substance Use in the United States ............. 18
A. A. “12-step” Model ...................................................................................... 23
Cultural Competence ........................................................................................ 25
California Substance Abuse and Crime Prevention Act (Prop 36) ................... 30
ix
New Alternatives (alternative methods) “Treatment Models” ......................... 32
Harm Reduction and Cognitive Behavioral Therapy Model ............................ 33
Gaps in the Literature........................................................................................ 36
Summary ........................................................................................................... 38
3. METHODS .............................................................................................................. 39
Introduction ....................................................................................................... 39
Research Question ............................................................................................ 39
Research Design................................................................................................ 39
Variables ........................................................................................................... 41
Conceptual and Operational Definitions of Study Variables ............................ 41
The Demographic Variables in Research Study ............................................... 43
Study Population ............................................................................................... 44
Sample Population ............................................................................................ 44
Instrumentation ................................................................................................. 44
Data Gathering Procedures ............................................................................... 45
Data Analysis .................................................................................................... 46
Protection of the Human Subjects..................................................................... 46
Summary ........................................................................................................... 47
4. RESULTS ................................................................................................................ 48
Introduction ....................................................................................................... 48
Research Question ............................................................................................ 48
Survey Responses ............................................................................................. 49
Dependent Variable .......................................................................................... 49
Treatment outcomes ................................................................................ 49
Independent Variables ...................................................................................... 49
Age .......................................................................................................... 50
Gender ..................................................................................................... 51
Race......................................................................................................... 52
x
Education ................................................................................................ 53
Religion ................................................................................................... 54
Years of practice in the field ................................................................... 55
Client’s age a factor in treatment outcomes ............................................ 56
The agency’s utilization of bi-lingual interpreters .................................. 57
Agency staff and gender barriers ............................................................ 58
Staff utilization of culturally related educational information ................ 59
Barriers to working with people of different races ................................. 60
Barriers to working with people of different religions ........................... 61
Agency staff discusses cultural issues .................................................... 62
Abstinence treatment outcomes and cultural competence ...................... 64
Court ordered into this treatment program because of cultural
competence ............................................................................................. 65
12-Step programs are successful with cultural competence ................... 66
Social model programs are successful with cultural competence ........... 67
Disease model programs are successful with cultural competence ........ 68
Summary ........................................................................................................... 69
5. DISCUSSION .......................................................................................................... 71
Introduction ....................................................................................................... 71
Summary ........................................................................................................... 71
Discussion ......................................................................................................... 72
Demographics ......................................................................................... 72
Treatment barriers ................................................................................... 74
Court ordered treatment .......................................................................... 75
Addressing cultural issues....................................................................... 76
Limitations ........................................................................................................ 78
Implications....................................................................................................... 79
Recommendations ............................................................................................. 80
xi
Conclusion ........................................................................................................ 81
Appendix A. Consent to Participate in Research .......................................................... 86
Appendix B. Chemical Dependency Treatment Programs and Outcomes: Cultural
Competency ............................................................................................ 88
References ..................................................................................................................... 93
xii
LIST OF TABLES
Page
1.
Table 1 Treatment and Responses ........................................................ 49
2.
Table 2 Treatment and Substance Abuse Counselors Age ................... 51
3.
Table 3 Treatment and Gender ............................................................. 52
4.
Table 4 Treatment and Race ................................................................. 53
5.
Table 5 Treatment and Education ......................................................... 54
6.
Table 6 Treatment and Religion ........................................................... 55
7.
Table 7 Treatment and Years in the Practice Field ............................... 56
8.
Table 8 Treatment and Client’s Age ..................................................... 57
9.
Table 9 Treatment and Utilization of Bi-lingual Interpreters ............... 58
10.
Table 10 Treatment and Gender Barriers .............................................. 59
11.
Table 11 Treatment and Utilization of Culturally Related Educational
Information ............................................................................ 60
12.
Table 12 Treatment and Staff Barriers with Different Races ............... 61
13.
Table 13 Treatment and Staff Barriers with Different Religions ......... 62
14.
Table 14 Treatment and Discussion of Cultural Issues ........................ 63
15.
Table 15 Treatment and Abstinence ..................................................... 65
16.
Table 16 Treatment and Court Ordered Treatment............................... 66
17.
Table 17 Treatment and 12-Step Programs .......................................... 67
18.
Table 18 Treatment and Social Model Programs ................................. 68
xiii
19.
Table 19 Treatment and Disease Model Programs ............................... 69
xiv
1
Chapter 1
THE PROBLEM
Introduction
Why do some individuals successfully complete substance abuse treatment
programs? Is cultural competence a component of treatment? For our society to
successfully accommodate minorities in substance abuse treatment programs, cultural
competency needs to be an integral piece among the way people perceive and accept
treatment in their communities for alcohol and other drugs addictions (Chao, 2010).
The authors of this research study have discovered throughout their careers that
there is frequently a lack of knowledge in how to provide culturally competent care in
substance abuse treatment programs. This research study will attempt to examine if a
clients cultural background and their religious beliefs and practices are being addressed
through substance abuse treatment programs. According to Rastogi and Wadhwa (2006)
family structure, cultural and religious values, gender, acculturation levels, and identity
issues contribute to substance use among Asian Indians in the United States. It is
important to assess and understand how these cultural issues can be barriers to clients
seeking the substance abuse treatment that is needed. Understanding the wide range of
cultures in this country may also help substance abuse programs to deliver better services
to meet the needs of ethnic minorities.
The alcohol/drug treatment needs of the individual ought to be customized to fit
the diversity of people living in the United States. Krestan (2000) indicates that our
society’s addiction treatment has been historically guided by two core ideas: power and
2
powerlessness. This US traditional addiction treatment model has evolved from Western
European cultures and the majority of addicts entering the treatment system will be
exposed to the hegemony of the twelve-step approach (Krestan, 2000).
Our nation is an ethnically and culturally diverse. According to the Bernstein and
Edwards at the US Census Bureau (2008) minorities are now roughly one-third of the US
population. Minorities are expected to become the majority by the year 2042. By the
year 2050, the nation is projected to be 54% minority. The population of Asian
American/Pacific Islanders in California has increased by more than 30% just in the last
decade (Bernstein & Edwards, 2008). Do our treatment programs and support groups
adequately address these different cultures and ethnic back grounds throughout our
country? The purpose of this study is to evaluate the need for alternative treatment
programs that address cultural diversity. With different ethnic groups come many
different religious and cultural beliefs. Our substance abuse treatment programs and
support groups throughout the country need to address the issue of cultural competency.
This chapter will focus on the background of the problem, statement of the
research problem, purpose of the study and research question. In addition, the theoretical
framework used to address the topic and definitions of terms used are defined. Finally
assumptions, justifications and delimitations are discussed.
Statement of Collaboration
This paper is a collaborative effort between Tina Everhart and Benet Guidera.
Benet was the lead writer for chapter three of the project, while Tina was the primary
writer on chapter two. Both researchers worked equally on chapters one, four and five
3
and all the subsequent revisions of the five chapters.
Background of the Problem
As America becomes increasingly diverse, we must incorporate other treatment
models of addiction to our repertoires. The problem dominating the most consumed “12
step model” of abstinence in which there are few other options is that it does not offer a
culturally competent program (Franklin, 2007). America has a wealth of opportunities to
engage with their citizens in a healthful productive life, by incorporating new alternatives
to Alcoholics Anonymous and their 12-step affiliates, or by enhancing the current
dominant discourse. Alternative rehabilitative programs beginning on a grass roots level
have faced the difficult challenge of gaining legitimacy. The 12-step model began on a
grass roots level, but has developed gradually to an institutional level, supported by the
medical model’s Diagnostic Statistics Manuel of mental disorders (lV), the judicial
system’s court mandates, and the religious Christian customs. Whites among ethnic
minorities may be practicing other religions, or alternative lifestyles that often dictate
different ideals on appropriations of alcohol and other drugs and its uses.
It is for this reasoning that there must be creations of other avenues for enhancing
family and/or individual therapy when alcohol and other drugs present itself to
problematic usage (Jennings, 1968). Jennings continues, “We must therefore direct our
attention to other cultural factors to find answers to the drug dilemma with the hope that
in discovering the cause we can also snake prescription for effective care” (p. 109). The
Western European settlers at one point in the history of the United States may have
viewed themselves as successful when working for the generalized constructed society
4
over the past several decades. Their puritan religious movement exemplified these beliefs
about abstinence to all mind altering drugs for recreational use (Berk, 2004). “Both the
Temperance Movement and Prohibition Era coincided with periods of intense religious
fervor in the US, when these religious revivals were steeped in Puritan moral codes
which in turn served as the basis for the underlying ideology of anti-liquor propaganda”
(Berk, 2004 & Rorabaugh, 1979, p. 37). Rorabaugh also informs us that during this
period in American history, the minimizing of alcohol consumption was not only
supported as a religious and moral issue, but the medical community became involved in
the campaign as well. This unequal distribution of power has been hard pressed to
accompany appropriate treatment to addiction with the continuing migration of
immigrants from around the world. The National Survey on Drug Use and Health report,
2002, statistics reflected the high occurrences of illicit drug use and alcohol abuse under
the “disease model” amid many underrepresented ethnic and cultural peoples that are in
need of such services. There must be a resolve to design a program that can be accessible
in other languages and free of intolerance to differing religious beliefs. California is an
intermingling of diverse cultures (Bernstein & Edwards, 2008).
Ethnic minorities are in large quantities a part of the make-up in our justice
system. One such entity is a great number of diverse participants in the Child Welfare
System. According to the Department of Health and Human Services (DHHS) Child
Welfare Training Institute (2011) substance misuse is a contributing factor for 35 to 80
percent of children involved in the Child Welfare System. The Judge will order guardians
into local agencies that invariably follow the Alcoholic Anonymous or Narcotics
5
Anonymous method manuals. Direct service providers are often well versed who have
only their own experiences with the 12-step model to emulate. Whether it is the
originating delegator to services or case managers for inpatient or outpatient treatment
requirements; they conjointly support the same model as truth.
In California we have taken it even a step further by offering those of drug related
crimes in criminal court the option for treatment in an A.A. or N.A. community/group
instead of incarceration in accordance to Proposition 36, The Substance Abuse and Crime
Prevention Act of 2000. Incarcerated individuals are offered more benefits if they attend
these group meetings as well. The 12-step model is exclusive to their teachings from a
book by its two Christian founders. A newly design model will not limit success on a
person’s religious beliefs in a “higher power” or “God” as the founders so clearly state. It
is our assumption that an alternative treatment protocol could have an equal success rate
of continuous participation by educating and effectively communicating diverse cultural
sensitivities. Therefore, by offering an alternative course to the 12- step model of therapy
to atheists or private practicing alternative lifestyles, it may empower the individual to
pay it forward in their own communities.
According to Volkow (2005) African Americans and Hispanics represent roughly
11 and 12 percent of the U.S. population and similar proportions of the drug-abusing
population. Volkow (2005) goes on to explain that of the injecting drug users diagnosed
with HIV African Americans account for 50 percent and Hispanics account for 23
percent. The U.S. Department of Health and Human Services, National Survey on Drug
6
Use and Health (NSDUH) reports the rates of current illicit drug use varied significantly
among the major racial/ethnic groups in 2002. The rate was highest among American
Indians/Alaska Natives (10.1 percent) and persons reporting two or more races (11.4
percent). Rates were 8.5 percent for whites, 7.2 percent for Hispanics, and 9.7 percent for
blacks. Asians had the lowest rate of substance abuse at 3.5 percent. Substance abuse
treatment programs that do not address cultural issues in treatment are doing a disservice
to their clients.
Within these minority groups, there are many differences that effect treatment. In
order to better serve minorities’ education and continuing education of substance abuse
counselors in regards to cultural competence could improve treatment outcomes. Client’s
culture directly impacts their level of engagement in services. Clients who come from a
very traditional background or have a low level of acculturation may be less likely to
engage in services (Castro & Alarcon, 2002). A client who’s religious affiliation is atheist
may be less likely to engage in 12-step self help groups. Substance abuse counselors
should also be aware of their own biases, and prejudices when treating clients from
various ethnic and racial backgrounds. In order to ensure positive treatment outcomes for
ethnic minority’s substance abuse, facilities need to recognize the different needs of their
clients. The treatment provided needs to recognize and make various treatment plans that
address the cultural needs of their clients.
In the past substance abuse treatment centers have taken a one size fits all
approach to treatment. Cliff (2005) explained that clients who are highly acculturated can
be treated similarly to traditional clients. She said that, "In contrast, Native clients who
7
have a strong connection with their Native identity and culture are more likely to respond
better to Nativized substance abuse treatment programs. A Nativized substance abuse
treatment program is a standard substance abuse treatment program that has been
culturally modified. Treatment typically includes social and coping skills training,
cognitive behavioral modification, AA (that has been culturally sensitized), relapse
education/prevention” (Cliff, 2005, p. 6). According to Campbell and Alexander (2002)
cultural competency training racial and ethnic matching between staff and clients, and
cultural competency training and language concordance may lead to better treatment
outcomes.
Statement of the Research Problem
When substance abuse counselors are guiding clients in their treatment, it is
important to know that cultural competence is addressed throughout the treatment
process. This study will attempt to address if there is a need for culturally competent
substance abuse programs. Cultural competence in substance abuse treatment programs
can have an effect on treatment outcomes. Staff who are continually educated in
culturally competent treatment strategies can improve their communication and level of
rapport with clients and in turn that can improve treatment outcomes. Addressing cultural
barriers with clients can open lines of communication and improve treatment outcomes.
Having bi-lingual counselors and interpreter services available can help break down the
language barriers that can hinder positive treatment outcomes. Substance abuse agencies
that offer alternative self help groups that are non-secular give client’s different options
for support groups. Having multiple treatment options available to clients can also
8
contribute to positive treatment outcomes. Therefore, there is a lack of information
regarding the role that cultural competence has on substance abuse treatment programs
and treatment outcomes.
Purpose of the Study
It is paramount for social workers to have a strong understanding of cultural
competence to be able to advocate for the needs of our clients. Lack of cultural
competence can hinder services that clients are receiving. The purpose of this study is to
quantitatively explore what the relationship is between culturally competency and
chemical dependency treatment outcomes. Results from this study will provide
counselors in the field of substance abuse with insight into whether this is an issue that
needs to be more thoroughly addressed throughout the course of treatment.
Research Questions
Is there a need for culturally competent recovery programs? What affect does
cultural competence have on substance abuse treatment outcomes? What kinds of
services are needed for treatment programs to be more culturally competent?
Theoretical Framework: Postmodernism
Postmodernism is anti-essentialist and anti-foundationalist because all knowledge
has the potential for change (Payne, 2005). It looks at exceptions of things you cannot
contain; things can be accepted if we do not follow a dominant discourse of established
norms (Nyland, 2010). Andersen and Collins (2007) describes essentialism by the
differences in women and men’s attributes; and that indeed men and women themselves
are inherently different. From this perspective, instead of focusing on their
9
commonalities, they were viewed as polar opposites. “Postmodern philosophers object to
binary categories and review them as one of many discourses, all of which should be seen
in political, historical, and social context” (Nuccio & Sands, 1992, p. 492). Essentialism
reduces people into objects by limiting human beings to a description, creating fixed
labels and stereotypes (Falk, 2001).
Modernism began during the 1500s, when scientific methods were developed,
which scientists believed would lead to all knowledge (Rosenau & Vaillancourt-Rosenau,
1992). Rosenau and Vaillancourt-Rosenau (1992) convey that the history of modernism
and positivism favors empirical evidence by studying and documenting the individual
using scientific methods of observation and data collection. “There are universal laws and
truths that can be uncovered through scientific discovery and that all phenomena can be
explained if these truths are discovered” (Roberts & Watkins, 2009, p. 273). These
“truths” guided their practice into believing that the same thing works for everyone.
Through these experiments and scientific methods, researchers were able to quantify their
studies. During these times of positivism, researchers supported fact over values and
disallowed diversity (Ritzer & Smart, 2001). These men believed that a person’s
perceptions and realities are inherent and therefore accepted their assumptions that
human behaviors are materials of science not ethics, or multicultural studies. Postmodern
social constructionists do not reject modernism but recognizes there are more ways; not
one reality, but allows several ways at looking at a person’s or institution’s problems and
solutions (Payne, 2005). Focusing implications and solutions directly within the
10
individual, one may become susceptible to stigmatization and isolation (Falk, 2001). Our
regimes of power continue to be held by religious, law and medical institutions.
Social constructionists value empirical research by incorporating current trends to
quantify their data, but also include quality and value. Postmodern theories are valued by
the ever evolving dynamics in societies, and are freely associated with individuals or
society’s behaviors and cognitions, (Schriver, 2004). Postmodernism recognizes that
there are many ways of thinking about knowledge and understanding; as it reflects on the
context of the social guidelines that are “of the current period in which we live”
(Schriver, 2004, p. 67). Obtained by current data, the US is growing in cultural diversity.
Our diverse population supports the need to separate problems from the individual, which
will allow us to be more culturally competent. Postmodern perspectives in relation to
social work, value diversity and a holistic approach to the health of an individual,
community, and worldly views; with emphasis on the theoretical knowledge of issues of
privilege, power or stratification (Payne, 2005).
Postmodernism deals with micro structures not just larger structures that see the
individual in terms of subjectivity (Rossiter, 2002). Our society is shaped by localized
history in which, everything is objective. “Clients cannot be treated as mere objects who
simply respond passively to professional subjectivities,” (Dominelli, 2002, p. 96).
Dominelli explains, “with regards to the client at the receiving end of these dynamics, if
the practitioner imposes power over relations that exclude the client from the decision
making processes, or delivers an unsatisfactory service, he or she has primarily lost their
own personal resources to draw upon,” (Dominelli, 2002, p. 95). Foucault examines
11
power as it is dispersed through social systems and manifested in micro-systems through
local forms (Chambon, Irving & Epstein, 1999). Chambon, Irving and Epstein (1999)
explains his thoughts about how language becomes our reality often through theory.
These assumptions masquerade as “truths.” In their truest form, Foucault reiterates that
knowledge and power are inextricably connected (Chambon, Irving & Epstein, 1999).
Our use of language shapes and directs our way of looking at and understanding the
world.
Application of Postmodernism: Relevance to Social Work
Social work seeks to make personal and societal changes through social
interactions (Payne, 2005). Social construction emphasizes the possibility of
effectiveness in social work, by understanding the meaning behind an action. Essentialist
consider race, gender, sexuality and class as fixed traits, not allowing differences between
individuals over time. To analyze race, gender, sexuality, and class form a social
constructionist and postmodern perspective establishes the connection between them, and
that none of these structural relationships operate alone (Anderson & Collins, 2007).
Anderson and Collins conclude that these are not individual or group characteristics; they
are the very structure of our society and are inter-sectional systems of inequality. Using
the social structural analysis, defines how complex, ever changing, and multidimensional
are these “systems of power.” Each of these categories has the commonality of being
socially constructed.
In these postmodern day times, in order to propagate more knowledge and power
within a growing multicultural society, we must provide individual clients with adequate
12
resourcing (Roberts & Watkins, 2009). This adequate resourcing includes culturally
competent treatment providers. The main predictor of change is the relationship between
social worker and the client not their biological predisposition (Huxley, Mohamad, Korer,
Jacob, Raval & Anthony, 1989). Treatment providers through cultural humility are then
able to enhance their client’s experience through the empowerment and strengths
perspectives. Dominelli maintains by acknowledging their client’s agency, and by
validating their client’s knowledge base as a source of expertise is “crucial to antioppressive practice” (Dominelli, 2002, p. 96). “Focusing on agency and strengths rather
than passivity and weaknesses to engage in a change-oriented relationship is one way of
achieving this objective in an empowering manner,” (Dominelli, 2002, p. 96). By
reducing power differentials as a result of individual interventions, will identify social
shortcomings, because “we are all shaped by cultural and community constructions,”
(Payne, 2005, p. 173).
The dominant discourse in American history on substance use, abuse and
treatment has derived from theology, law and medical institutions. It is important to
examine postmodern theory and how it developed out of essentialism and modernism.
The theoretical framework will allow us to comprehend the foundation of clinical and
socio-cultural evolution as it pertains to views on substance use, and the need to view the
complexity of substance abuse treatment within a multicultural society. This theoretical
framework will provide the history of how the dynamics have changed in the postmodern
era and how this shift in power may be applied to benefit local communities in regards to
the treatment of substance abuse. Our social work research project will examine these
13
growing needs by including the perceptions from treatment providers on the importance
of cultural competence in alcohol and drug treatment program’s outcomes in the United
States.
Definition of Terms
The following terms are used throughout this project and are relevant to cultural
competence, substance abuse, addiction, and treatment outcomes.
Conceptual definitions.
Cultural competence. involves responding respectfully and effectively to people
of all cultures, languages, classes, races, ethnic backgrounds, religions, and other
diversity factors in a manner that recognizes, affirms, and values the worth of individuals,
families, and communities and protects and preserves the dignity of each (NASW
Standards for Cultural Competence in Social Work Practice, Definitions, 2001).
Substance abuse. Substance abuse is continued use of a psychoactive drug
despite adverse consequences (Inaba & Cohen, 2007).
Addiction. A progressive disease process characterized by a loss of control over
use, obsession with use, continued use despite adverse consequences, denial that there are
problems, and a powerful tendency to relapse (Inaba & Cohen, 2007).
Treatment. The use of various techniques and therapies to change maladaptive
patterns of behavior and restore a client to full health (Inaba & Cohen, 2007).
Alcoholics anonymous. The first self-help alcoholism recovery group, founded in
1934 by Bill Wilson and Dr. Bob Smith; tens of thousands of chapters exist worldwide
(Inaba & Cohen, 2007).
14
12-step programs. Self-help groups based on Alcoholics Anonymous the twelve
steps of recovery. Their purpose is to change addicts’ thinking and behavior and enhance
their s spirituality (Inaba & Cohen, 2007).
Abstinence. The act of refraining from the use of alcohol and any other drug. It
also refers to stopping any other addictive behaviors, such as overeating and gambling
(Inaba & Cohen, 2007).
Harm Reduction. A tertiary prevention and treatment technique that tries to
minimize the medical and social problems associated with drug use rather than making
abstinence the primary goal (Inaba & Cohen, 2007).
Operational definitions.
Treatment success. The range of treatment success is a positive treatment
completion rate between 50-75 percent.
Assumptions
The assumptions to be considered in this study include: 1) Substance abuse is a
prevalent issue in the United States today. 2) Social workers have a professional
commitment to cultural competence. 3) Substance abuse treatment is a complex issue that
has many possible treatment factors that influence outcomes. 4) Substance abuse
counselors are the experts in treating substance abuse addictions.
Justification
The research may help others to understand the relationship between cultural
competency in recovery programs and treatment outcomes. In addition, information from
this study may help substance abuse counselors gain insight into their own knowledge
15
regarding the relationship between cultural competency in recovery programs and
treatment outcomes. This study may emphasize the need for awareness of cultural
competency in substance abuse treatment programs.
According to the National Association of Social Workers (NASW) code of ethics
(2008) clearly states that social workers’ have ethical responsibilities to clients section
1.05 Cultural Competency and Social Diversity of the code of ethics states that:
a) Social workers should understand culture and its function in human
behavior and society, recognizing the strengths that exist in all cultures. b)
Social workers should have a knowledge base of their clients’ cultures and
be able to demonstrate competence in provision of services that are
sensitive to clients’ cultures and differences among people and cultural
groups. c) Social workers should obtain information about and seek to
understand the nature of social diversity and oppression with respect to
race, ethnicity, national origin, color, sex, sexual orientation, gender
identity or expression, age marital status, political belief, religion,
immigration status, and mental or physical disabilities (p. 9-10)
This study fits well with the field of social work and the mission of social work
professionals. It addresses the need for cultural competence in substance abuse treatment
programs. This study focuses on the needs of clients in substance abuse treatment centers
and the availability of culturally competent services. Social workers and substance abuse
counselors need to be constantly assessing the needs of their clients and what is needed to
provide culturally competent services to clients.
16
Delimitations
This study does not include qualitative data to further explore in depth the cultural
competence and treatment outcomes of treatment facilities. This study is limited to one
substance abuse agency with two separate treatment facilities in the Sacramento,
California area that participated in the study. These facilities substance abuse counselors
may not be representative of all substance abuse counselors treating clients. This study
has a sample size of forty six substance abuse counselors and this sample size may not be
representative of all substance abuse counselors in the Sacramento area.
Lastly, this study does not include participation from actual clients of treatment
programs, but is based on feedback from substance abuse counselors at treatment
facilities.
Summary
Chapter one included an introduction, statement of collaboration, a background of
the problem, a statement of the research problem, a purpose of the study, hypothesis, and
theoretical frameworks. Chapter one contained conceptual and operational definitions of
the terms, assumptions, justifications, and delimitations of the project. Chapter two is a
review of the literature with sections covering history of substance abuse treatment,
treatment models, cultural competence, proposition 36, new alternatives in treatment, and
gaps in the literature. Chapter three is a description of the methodology. In chapter four,
the data obtained from the surveys is presented. Chapter five is a summary and an
analysis of the findings as well as the recommendations and implications for social work
practice and policy.
17
Chapter 2
LITERATURE REVIEW
Introduction
The United States is known as “the melting pot,” where people come from all
over the world to live together in our democratic Country. It is because we are a
multicultural society, in which programs need to hire multi-lingual staff and develop
educational opportunities to include cultural competency in order to accommodate more
people in their venture of recovery. Michael Paasche-Orlow (2004) asserts that
“Multiculturalism is the view that different cultures have different moral systems, and
postmodernism asserts that each person’s views have equal moral worth,” (p. 349). When
seeking treatment for substance abuse/addiction in the United States, a participant will
invariably be introduced to an abstinence group following the 12-step model. This is also
true when the courts become involved with one’s rehabilitation and recovery from
alcohol and other drugs (Peele, Bufe, Brodsky, & Horvath, 2000). Apanovitch (1998)
finds that, “the state runs the risk of ceding a large measure of control over its drunk
driving and prisoner rehabilitation policies to what is arguably a religious organization”
(p. 840). The state assumes the role of providing a constant flow of new client’s for
Alcoholics Anonymous (A. A.) and Narcotics Anonymous (N. A.), (Brodsky & Peele,
1991.)
This reviewed literature is made up of several subheadings. The first area is on the
historical background in how the United States has viewed substance use during the past
two hundred years. This includes definitions on the terms addictions and recovery. The
18
second area includes how Alcoholics Anonymous and the 12-step model, our dominant
discourse in the United States, derived since its inception. The third area focuses on the
legislation of proposition 36, court ordered treatment programs, and alternatives to
treatment which include cultural competence. Finally, gaps in the literature will also be
addressed.
Historical Background Views on Substance Use in the United States
Magnus Huss, a physician to Swedish kings, first coined the word “Alcoholism”
for the "disease of alcohol addiction" as part of a systematic study in 1848 (White, 2000).
In Sarah Tracy’s book, Alcoholism in America: from reconstruction to prohibition
(2005), she examines the evolution of terms used to describe habitual drunkenness
between 1870 and 1920; they began with “intemperance”, moved to “dipsomania” and
“inebriety” and evolved to the renowned diagnoses familiar to the twenty-first century as
“alcoholism” (p. 26). Sarah Tracy (2005), Director of The Project for Wellness and
Work-Life (PWWL) explains, “Intemperance references the most infamous language to
the promotion of the disease concept of inebriety” (p. 27). In American history, which
originated during the years of alcohol prohibition, she informs us that each of these labels
also represents an aspect of cultural assumptions about gender, class, ethnicity, heredity,
and personal responsibility. Tracy (2005) argues that the “disease model” of alcoholism
has always been complex to explain and it reflects different developments in medicine
and culture.
The disease model for addiction to foreign substances and its criteria is well
organized by The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
19
(Qureshi, Al-Ghamdy & Al-Habeeb, 2000). This serves as a diagnostic guide and source
of standardized naming system for purpose of assessing and treating both mental
disorders and addictive disorders. According to alcoholism and drug dependence
concepts in the DSM, Crowley, Helzer, Nathan, Schuckit and Woody (1991), defines
addiction in global terms: to establish such a diagnoses of addiction means for an
individual to consume enough amounts that would impair personal or social functioning,
health, or become required for daily functioning. The DSM states, “That a diagnosis is
the first step to treatment.”
The importance of diagnoses in current times has motivated more researchers to
gather evidence and implications of alcohol and other drug use. Wendy Rogers (2003)
explains that this is achieved through evidence based medicine (EBM) and evidence
based practice (EBP), by validating legitimate treatment options which are objectively
based through experiments. Both EBM and EBP create more operating and expense
power for professionals, and help construct policies for fair distribution of effective
interventions. When producing his own study, Felitti (2003) challenges the predisposition
and inherent origins of addiction. His findings indicated the major factor for these
shortcomings is “adverse childhood experiences that have not been healed through time
and that are overwhelmingly concealed from awareness by shame, secrecy, and social
taboo” (p. 10). Felitti’s (2003) findings of 17,000 middle class Americans supported early
psychoanalytical theories, which said that basic causes of addiction lie within us and our
interference with each other. Human beings have always been known to use psychoactive
substances for self medication, entertainment, and spiritual reasons (Breggin, 2003).
20
These are often taken out of cultural context when applied to our legislators across the
land merging the aspect of political and economic power.
The drug culture and a greater variety of drugs have changed the recovery model
since the 1960s-1970s. Group work on a grass roots level has since made its way as a
more equitable design treatment. This California Social Model, based on the twelve-step
program approach, has been absorbed into mainstream treatment for drug-dependent
individuals because of cost-effectiveness (Humphreys, 2002). This practice of self-help
also embraces mutual aid, compliments individual treatment and gives us more treatment
resources. In the Substance Abuse Position Statement, The American Psychiatric
Association (APA) (1980) concludes that clinicians must have the capability to provide
continuity care over time. These treatment plans must address the patient’s biological,
psychological, and social areas when referring them to both group and individual therapy.
The APA (1980) reiterates that the key treatment resource for these people includes
psychotropic medication, also group and individual treatment when significant
psychological and medical problems are associated with their substance abuse. They go
beyond their scope of expertise to specifically name a reputable brand without also
presenting alternatives, such as, community resources such as Alcoholics Anonymous
and Narcotics Anonymous (APA, Substance Abuse 1980).
Robin Room (1983) has support that the "disease model" or word disease for
alcoholism is too vague. Room looks at the "alcoholic movement" as socially constructed
and not at alcoholism as a "disease." The movement was supported by questions designed
by lay persons, specifically AA and not solely by the medical community. Yet this local
21
community model has been utilized to benefit statewide legislation and the medical
community throughout the Nation before it was recognized as evidenced based practice.
Legislation can be diverse which include legitimate alcohol/drug treatment options, the
legal age of a person who may consume or purchase alcoholic beverages, alcohol
advertising and marketing, along with the revenues created form the taxation on alcohol.
When comparing countries, the management and restrictions of use reflects on issues
which seem most relevant to different governments and societies. The most common
reports for countries who abstain from alcohol reported religious reasons. The
International Center for Alcohol Policies (ICAP), (2002), reports that “within the
countries reported, 40 specify a minimum legal drinking age” (p. 1). ICAP confirms that
the United States in more recent years has enacted federal law, The National Minimum
Drinking Age Act of 1984, in which all states comply with the 21 minimum age law. The
law supporters contend that their intentions are preventative in nature to avoid alcohol
related highway fatalities. The Kathryn Stewart Pacific Institute for Research and
Evaluation, 2002, reported that when other countries were asked about their ideals of this
particular strategy in the United States, they felt that raising the minimum of the purchase
age to 21 to be culturally unacceptable.
The United States government collects data in the hopes of sorting through rival
positions and conflicting data. Hanson states that when addressing alcohol policies, the
research is designed to promote the current temperance-oriented policy. This one-sided
research is of benefit to their objectives because it gets federal funding, a stamp of
approval from their majority Christian bi-partisan supporters, and the blanketing
22
dissemination of public information by the government regardless of its scientific merit,
(Hanson, 2009). David Hanson challenges federal agencies and officials by concluding
that they often present unreliable or misleading information about alcohol and drinking to
the public in their social marketing. He states that one such case, is their over inflated
reports in which the federal government equates estimates of “alcohol-related” traffic
fatalities with “drunk driving” creating an impression of widespread drunk driving that
isn’t factually supportable.
Since 1974, the World Health Organization (WHO) has collected data and written
reports on alcohol-related health issues and problems from a global, regional and country
perspectives in order to adopt preventive policies and programs. They also have a mission
to reduce drunk driving and the damage that it causes. WHO assembled again in May
2010 to launch The Global Status Report on Alcohol and Health, so that their health
ministry’s can use their information to support the developments and implementation of
new policies and interventions (Forward, 2011). Both the United States Department of
Justice and WHO reported that by raising the legal drinking age to 21, fatalities of
alcohol related motor vehicle accidents went down with underage minors. Yet the two
entities contradict themselves when reporting consumption data between European and
American Countries because of the difference in culture, in regards to their definition of
how they compare and define alcohol related impairments and consumption (Hansen,
WHO, 2009).
There are many factors that must be addressed when collecting current data which
are inclusive of social context, socioeconomic status, gender, age, and location, (Guerrini,
23
Gentili, & Guazzelli, 2006). More specifically to the young adults ages 16-20 in the
mentioned study were the differences in ideologies. The United States participant’s
beliefs on abstinence as opposed to the European‘s more moderate and liberal attitudes
on drinking and laws. WHO (2009), among other interested stakeholders are obtaining
reportable figures to not only benefit policy implications, but intervention and treatment
opportunities as well. “Four countries have a dedicated line item in their national budgets
for alcohol treatment,” (WHO, p. 53). The United States does not have a formal National
fiscal policy. However, implemented in 2001, California passed the Substance Abuse and
Crime Act (Proposition 36) which is a drug treatment and diversion program that usually
involves intervention, peer counseling and a referral to twelve-step program (Hser,
Teruya, Brown, Huang, Evans, & Anglin, 2006). Proposition 36 introduced an
unprecedented number of clients into licensed California’s drug treatment centers, most
established and notably referred to as Alcoholics Anonymous/Narcotics Anonymous.
A. A. “12-step” Model
Alcoholic Anonymous (A. A.) and the “12 step” treatment program was founded
by Bill Wilson and Dr. Bob Smith while living in Akron, Ohio in 1935 (Dick, 1998).
Great influence for these two white, middle-class men descended from The Oxford
Group. Dick B. examines The Oxford Group and their principles, which began in Eastern
Europe and then immigrated to the West to the Calvary Church in America. The Calvary
Church became the virtual American headquarters for the Oxford Group during the
1930s. One important step, a directly related approach used by Wilson and Smith from
the Oxford Group, was primarily based with the aim that those enrolled attain a life-
24
changing experience of God. Alcoholics’ Anonymous co-founder, Bill Wilson,
maintained that whether he was addressing thousands or witnessing to a peer over a cup
of coffee he frequently and straightforwardly made references about God (Hartigan,
2000). Bill believed, his Christian God was the source of the goodness and guidance
alcoholics could rely on to help them restore normalcy back into their lives. Although
A.A. and their affiliates using the 12-step program have not disclosed if they themselves
are a religious group, there is little doubt left that the 12-step approach to addiction
treatment has a strong spiritual component to its history and code of behaviors. Bill
Wilson (1953) reinforces such practices under several steps, most notably in “step three;
made a decision to turn our will and our lives over to the care of God”, and again in “step
five; admitted to God, to ourselves, and to another human being the exact nature of our
wrongs” (p. 34, 55). He establishes the importance of a belief system in “step 12; having
had a spiritual awakening as the result of these steps, we tried to carry this message to
alcoholics and to practice these principles in all our affairs” (Wilson, 1953, p. 106).
In relation to accepting diverse ideologies in treatment programs in the United
States, options are minimal because of A. A.’s large impact on our mainstream culture
(Mäkelä, et al., 1996). It is our understanding that the belief of separation between church
and state is creating even greater conflict regarding access to equitable services. One such
issue came to light, when a prisoner was court ordered to attend an Alcoholics
Anonymous meeting held within the institution. When he refused to attend due to
religious reasons and biases, he was given punitive consequences by the authorities in his
state prison. Upon repealing these orders, New York State’s highest court ruled that
25
Alcoholics Anonymous “engages in religious activity and religious proselytization”
(Barron, 1996). This higher Court ruling stated that prison officials at Shawangunk state
prison in Ulster County were wrong to penalize an inmate by not letting his eligibility for
a family reunion program move forward. Barron, June 12, 1996, also reported that the
appeals court voiced their dismay and said that the New York state prison had violated
David Griffin’s constitutional rights because of his long standing agnostic or atheist
views he has held since the 1950s. Unfortunately, States across the country are minimally
prepared for alternative drug recovery treatments which would remedy any biases. The
majority of the research for court ordered treatment programs continues to solely be
supporting Alcoholics Anonymous and Narcotics Anonymous.
Cultural Competence
When approaching any community based program with a one size fits all
approach to alcohol and drug rehabilitation, as previously cited with New York State’s
prison system, we run into ethical dilemmas. Michael Paasche-Orlow (2004) wrote,
“culturally competent care is a moral good that emerges from an ethical commitment to
autonomy and justice” (p. 349). In order to follow mandates which will remove barriers
of access to medical care and to eliminate health disparities, clinicians must be educated
on the “three essential principles of cultural competence, (1) acknowledgement of the
importance of culture in people’s lives, (2) respect for cultural differences, and (3)
minimization of any negative consequences of cultural differences,” (Paasche-Orlow, p.
347-348). Community based care and mutual aid groups are unique to their independent
participants and their surroundings. Community based participatory research (CBPR) is a
26
collaborative approach to address health problems that can improve and bring value to
social practices by tailoring them to access more clients in underserved or oppressed
areas (Minkler, 2005). CBPR is the approach and technique that we incorporated into this
study as an internal audit to assess how well this local community agency was addressing
the needs of its diverse clientele in Sacramento, CA.
In the past, diversity has been associated with the essential premise, that it is
absolutely necessary to equate diversity with race and ethnicity. “The United States is
undergoing a transition from a predominately white society rooted in Western European
culture to a global society composed of diverse racial and ethnic groups” (Kroanier &
Vander Zanden, 2002, p. 17). Race and/or ethnicity are no longer the only components in
a belief system of diversity. Postmodern theorists now define diversity as inclusive and
fluid, and without boundaries (Bloland, 1995). Included in the definition of diversity with
race and ethnicity are gender, sexual orientation, able-ism, nationality, geography,
religion, socioeconomic, education, age, and political affiliation. “Postmodernism, as an
approach to knowledge that moves us from the pre-modern when the church was the
ultimate authority, through the modern when scientific logic was the touchstone, to the
present when there is no ultimate authority for the way the world is perceived” (Wilson,
1997, p. 341).
Social work now drives towards balances in power through the empowerment
theories and the strengths perspective (Van Wormer, 2007). Therefore it is recognized
that individuals have a right to self-determination and to be the expert in their own lives.
To be more culturally competent we need to respect individuality and be inclusive with
27
diverse belief and behavioral systems. This view deconstructs the problems from the
individual and establishes its context by using culture as a valuable resource (Barnes,
2004). For instance, shame for particular cultures may be the reason a client will not
come to a communal meeting (Phelps & Scheff, 2004). This is often translated by the
courts and facilitating professionals, as being non-compliant in which they label this
person with contempt. An agency must gain the knowledge that once you label a client
“resistant” then you close space and limit available options (Poulin, 2004). By making
norms visible, it will give our clients’ options to operate more productively in their own
lives (Granovetter, 2004). Mark Granovetter also maintains that social relations are
closely linked to productivity and that group norms and cultures also shape skill and
productivity. Our ideals are the central story of a culture as it arises from assumptions
about what is normative, (An-Na’im, 1994). Abdullah An-Na’im (1994) continues,
“although clearly identifiable and distinguishable from each other, human cultures are
also characterized by their own internal diversity, propensity to change and mutual
influence” (p. 2).
Individuals learn to be culturally competent and are empowered through
education and self-determination to change cultural norms, such as segregation and
stratification (Dessirea, & Richardson, 2008). Gurin (2005) states that a diverse
community and an environment with diverse perspectives, has the benefits of breaking
these patterns and are better prepared for our pluralistic, democratic society. These
changes in perspectives may come about if they are perceived to be consistent within the
internal criteria of legitimacy of the dominant culture to be relevant to their needs. An-
28
Na’im (1994) further details, “that universality and cultural transformation derives from
the understanding that global cultural diversity reflects the dominance of certain norms
that are interpreted by each culture at a specific point in time” (p. 67).
People from every country in the world, have their own concepts and traditions
around the use of alcohol and other drugs. Many in the United States are driven to be
abstinent from mind altering substances and identify what constitutes as addiction.
Diverse groups may differentiate between drug use and abuse within their own
philosophies of consumption. Drug use does not discriminate when it comes to race,
culture, gender or ethnicity when compared to minority ethno-cultural subgroups and
main stream society (Adrian, 2002). According to the National Survey on Drug Use and
Health report (NSDUH, 2002), rates of current illicit drug use in 2002 varied
significantly among the major racial/ethnic groups. The report reflects substance
dependence and abuse. In the NSDUH report, the rate was highest among American
Indians/Alaska Natives 10.1% and those persons reporting two or more races (11.4%).
Other rates were reported for African Americans (9.7%), Caucasians (8.5%), and
Hispanics (7.2%). Asians had the lowest rate at (3.5%). The report stated that among
persons aged 12 years or older, males were more likely than females to receive treatment
for an alcohol or illicit drug problem in the past year. Regarding persons aged 12 or older
in 2002, the rates of alcohol or illicit drug treatment during the 12 months prior to the
interview were highest among American Indians/Alaska Natives at (4.8%), and followed
by African-Americans (2.2%) and persons reporting two or more races (2.1%). The
lowest rate of treatment usage was among Asians with (0.2%). Just as important, they
29
found substantial co-occurrence of serious mental illness with substance
dependence/abuse among these participants, with self medicating being an offending
factor.
When referencing the ecology of addiction in a multicultural society, Krestan
(2000) elaborates that pride; false pride and shame are concepts that must be viewed in a
multicultural context. Then to guide our treatment of addiction in the United States power
and powerlessness, and their dominant discourses, needs to be addressed as well. The
prevailing communication of power that the Europeans brought to America is “power
over” and included such ideals of moral superiority (Krestan, 2000). Foucault elaborates
on this traditional notion of power by examining its possible effects of norms to include
fear, perfection, hopelessness and judging others. Then Foucault argued that specific
practices are restricted to a narrow range of human possibilities, such can be applied to
A.A. and 12-step traditions (Chambon, 1999). Foucault does not separate language from
power; he asserts that it actually reproduces power, which then becomes a form of
convention and eventually a dominant discourse. These truths then become
institutionalized. Foucault believes it is crucial to critique and unmask so called “truths”.
Then these “truths” carry the potential for change since, “as soon as one can no longer
think things as one formerly thought them, transformation becomes quite possible”
(Schrag, 1999, p. 382).
Once addicts enter the treatment system, they will be initiated into the hegemony
of the 12-step program. Their approach begins with the belief that recovery begins by a
client admitting that they have powerlessness over a drug (Alcoholics Anonymous,
30
2010). In A.A. and supporting affiliates, “spirit” refers to a “higher power”. They are then
told to recite, "[We] admitted we were powerless over alcohol, that our lives have
become unmanageable" (Wilson, 2002, p. 59). This admission of powerlessness that AA
insists on is the first shift in power to unbridle their pride and to accept defeat from
something in which they have no control over. This particular model has gained rampant
support on an institutional level, often contradicting the values of postmodern
empowerment theories.
California Substance Abuse and Crime Prevention Act (Prop 36)
A greater power shift is enabled by shaping and enacting policies within the
legislator of California and across the Country that creates disciplinary and punitive
actions to be handed down to individuals by Courts when addressing alcohol and drug
related offenses. Community leaders and law enforcement officials are concerned when
an offender is arrested because of alcohol and/or drug problems and then returns to the
same neighborhood and environment without any type of intervention (CADA, 2009).
Agencies within these communities create an internal support system, for themselves and
their families. As a result of these findings, Counties in California have developed a
strong partnership between the treatment community and the courts (Uelmen,
Abrahamson, Appel, Cox & Taylor, 2002).
When a person is convicted of an offense related to addiction, the judge
commonly orders the person into one of two treatment programs: (1) Alcoholics
Anonymous (AA) or (2) to a Narcotics 12-step based group. Apanovitch (1998) states
that while AA has a commendable secular goal of helping alcoholics/addicts overcome
31
their disease; the dangers of state-imposed participation in these 12 step models may
channel potential believers to a religion. These persons are mandated by the court to
participate or face a less desirable alternative such as incarceration. The government
becomes dependent on that sole treatment provider in areas where there is no alternative
secular self-help programs to which offenders can be referred to or placed for treatment.
Proposition 36, The Substance Abuse and Crime Prevention Act of 2000 (SACPA)
won voter’s approval in the November 7, 2000, election. This proposition offers adults
convicted of nonviolent drug possession offenses the alternative to incarceration through
a drug treatment plan. Every county is authorized to contract with privately operated
agencies for the provision of Proposition 36 Drug Treatment Services, pursuant to Title 9
and 22 of the California Code of Regulations, Penal Code sections 1210 et seq. and
3063.1 and Health and Safety Code, sections 11750 et seq., 11991.6 and 11999.4 et seq.,
(West, 2010). According to the Judicial Council of California (2010), substance abuse
treatment falls on the jurisdiction of the County’s magistrate to order this alcohol/drug
rehabilitation through Proposition 36 at local private agencies. These agencies face
several obstacles during their operations to include compliance with local, state and
federal laws, staff and program development, and community relations (Alcohol and
Drug Policy Institute, 2010). The case study by Uelmen, Abrahamson, Appel, Cox and
Taylor (2002) notes that,
Everyone who commits a SACPA qualifying offense is entitled to treatment under
the law, regardless of race, ethnicity, gender or county of residence. By contrast,
independent government evaluators have criticized California’s drug courts for
32
admitting proportionally greater white offenders than persons of color, even
though persons of color comprise a disproportionately large percentage of the
low-level drug offender population eligible for drug court services (p.16)
The Evaluation of the Substance Abuse and Crime Prevention Act 2002 Report confirmed
that for each County and their SACPA stakeholders, implementation of the statue can be
difficult and need long term funding from all levels of government (Longshore, Evans,
Urada, Teruya, Hardy, Hser, Predergast, & Ettner, 2003). Longshore et al. claimed that
collaboration is critical to successful treatment outcomes, and “given stakeholders’
differing organizational cultures, philosophies, and priorities, their willingness to take the
time and make the effort to collaborate across agencies and build trusting relationships is
key” (p. 153).
New Alternatives (alternative methods) “Treatment Models”
Within the first few years of implementation of Prop 36, many local agencies
were surprised at the greater than anticipated number of diversion participants and the
severity of their addiction (Appel, Backes & Robbins, 2004). Many of these participants
had never received access to treatment before. Appel, Backes and Robbins (2004) shared
in their reaction paper, that given the “now-proven” success of treatment over
incarceration, we must make treatment a viable option to as many patients as possible
before they get caught up in the criminal justice system. The need for expansion of
services has been established whether a client is seeking help on their own, referred, or
court ordered. Appel, Backes and Robbins (2004) believes that the priorities going
forward must include not only continuation of SACPA funding, but also, “the
33
improvement and expansion of services to increase the likelihood of successful treatment,
and incentives for participation to encourage those who need treatment to opt in” (p.
1006). Current treatment models may include a medical/ disease model like AA or NA,
also referred to as a “12 step” program. Combining a multi-treatment design, with the
goal of moderation or abstinence is a Bio-Psycho-Social Model (Social Program Model).
Harm Reduction and Cognitive Behavioral Therapy Model
The improvement and expansion of services must include alternative treatment
models to accommodate the expanding cultural competence needs of California residents.
The assessment process needs to be met with proper treatment opportunities. For
example, people with a long history of alcohol and drug abuse, an in-patient residential
treatment facility is a better fit, than that which is most subsequently offered on an outpatient with limited visits as the treatment protocol. Many Californian community based
treatment centers have the need for specialized programs to include, bilingual services,
gender-specific services, and different age populations, including adolescents. “Most
youth treatment facilities utilize an adaptation of the adult 12-step modality which
includes attending A.A. and N.A. meetings,” (Kelly, Myers & Brown, 2002, p. 293).
Kelly, Myers and Brown (2002) professes the need for alternative models, due to the
overwhelming majority of professional private and public substance use disorder
treatment programs in the US being “self help” groups following the 12-step philosophy
and have an adolescent clientele. Gender research has shown that there were no gender
differences for drug use in general. Yet, drug of choice and an overall need for varied
services and support was greater and more complex for women (Pelissier & Jones, 2011).
34
They continue, “issues frequently mentioned in the literature along with alcohol and drug
treatment needs – victims of sexual abuse, vocational training, child care, and parenting –
are ones where a greater percentage of women have a problem more than men do” (p.
21). Bloom, Owen, & Covington, (2002) emphasize a multidimensional approach,
because, “all women, despite their racial, ethnic or social class backgrounds, have their
life experiences molded by the variable of gender” (p. 2).
The division between the moral and medical models of addiction has now a more
recent trend that has come to North America called The Harm Reduction Model, (Marlatt,
1998).
Marlatt informs us that harm reduction is also referred to as substance use
management. Reducing harmful consequences, reducing barriers to treatment,
making an assessment of harmful consequences, and what the clients is capable of
doing is the first step in what her refers to as a journey each addict must travel.
The harm reduction model is in direct opposition with treatment practices of
traditional substance-abuse professionals who insist abstinence as the only
acceptable goal. This new approach is that addicts can change their behavior
through the proper motivation and support, without coercion or incarceration.
With this approach of “meeting people where they are at,” allows for harm
reductionists allows them to be non-judgmental and encourages positive change
(p. 12-14)
Based on a comprehensive treatment philosophy and combined with motivational
interviewing, another treatment option is The Community Reinforcement Approach
35
(CRA). CRA combines lifestyle and social environment changes and may include,
pharmacotherapy, confrontational counseling and infliction of negative consequences. “In
order to overcome alcohol problems, it is important to rearrange the person’s life so that
abstinence is more rewarding than drinking, providing incentives for people to stop
drinking rather than punishment for continued drinking” ( p. 116-117). CRA is often
immersed in the 12-step philosophy with the goal of abstinence.
Along with the 12-step approach in which abstinence is the only acceptable
outcome, other approaches including harm reduction and motivational interviewing,
cognitive therapy, works with clients to set more flexible goals. The one co-occurring
theme to the different approaches in substance abuse treatment is the utilization of the
Stages of Change Model (SCM) and Motivational Interviewing (MI). The Transtheoretical Model AKA “stages of change” is a concept which has an approach that is
likened by the 12 step model. In addition, Harm Reduction consumers may go through
the stages of change multiple times with small changes (Thomas, 2009). The five stages
during the process of change are: 1) Precontemplation Stage, during which the idea of
change is not seriously considered. 2) Contemplation Stage, we contemplate the need for
change but have not taken any steps. 3) Determination Stage, we are determining to take
action, 4) Action Stage, action is initiated. 5) Maintenance Stage, action is maintained
over a period of time (several weeks); relapse is not a failure but considered normal and
part of discovery (DiClemenet, & Prochaska, 1982).
The beginning stage, precontemplation, includes the need for outreach to
underserved people with high-risk behaviors. Gayle Thomas believes that this initial
36
contact and engagement must begin by establishing trust to build a therapeutic alliance
with marginalized people due to homelessness, class and racial issues, gender issues and
sexual orientation issues. Norcross, Krebs and Prochaska (2010) states that the, “stage of
change assessment is straightforward and takes only a few minutes in the initial
therapeutic encounter, yet it has vital implications for guiding treatment method and
promoting therapy progress” (p. 144). Norcross et al. continues in regards to how people
navigate the first two stages, “change processes traditionally associated with the
experiential, cognitive, and psychoanalytic persuasions are most useful during the earlier
pre-contemplation and contemplation stages.” The Stages of Change Model works with
small or large behavior changes, with any populations and with any issues.
Gaps in the Literature
Across the field of substance abuse treatment, there has been no treatment method
proven to be universally effective for everyone (Inaba & Cohen, 2007). Although much
has been written on cultural competency in social work in recent years, cultural
competency in substance abuse treatment program outcomes has just begun to be
addressed. The research most often addressed the client’s who had successfully
completed the alcohol or other drug treatment program. Information about the clients was
gathered at the beginning of treatment and during the termination stage. The literature
most often did not account for consumers who were unsuccessful and/or dropped out of
treatment. The reasons for dropping from these programs may identify if there are
cultural competence barriers between treatment providers, their program and treatment
outcomes. There is limited literature related to cognitive and behavioral changing
37
strategies and models for addicted clients in regards to communication and relational
barriers between the client and the counselor. In addition, there was not any literature that
profiled demographic or educational level information pertaining to the mental health
providers or substance abuse counselors.
Other gaps in literature for the United States are treatment outcomes from
alternative models when compared to the dominant 12-step model. Our literature begins
to address this disparity by gathering information from counselors at an alcohol and drug
abuse recovery agency in Sacramento, CA that does not follow the traditional AA or NA
treatment protocol. Unique to our research was the focus on the treatment provider’s
personal demographic information and their perceptions of culturally relatable attributes
and needs of their participants. We have referenced the importance of the role that the
Professional has in the successful treatment outcomes for their clients, by learning their
personal culture, language and belief systems. Our research included the counselor’s
ethnicity, gender and religion.
This new research may educate us on provider’s perceptions and work experience,
as well as future training needs and how it relates to treatment outcomes. In this study,
some of the gaps maybe addressed through quantitative survey design that explored the
links between cultural competence in substance abuse treatment programs and treatment
outcomes. Substance abuse counselors were asked questions about treatment outcomes
and cultural competence. Questions were asked that explored counselor’s thoughts and
beliefs about social model programs, 12-step programs, continued cultural competency
training, religious barriers to treatment and language barriers to treatment.
38
Summary
In this chapter, relevant literature to this project was reviewed. The topics
discussed in this chapter included background on the United States views of substance
use, A. A. “12-step” model, cultural competence, California Substance Abuse and Crime
Prevention Act (proposition 36), new alternatives (alternative methods) “treatment
models”, and gaps in the literature. In the next chapter, the methods used to conduct the
study are described.
39
Chapter 3
METHODS
Introduction
This chapter will examine the research question, research design, methodology and
variables of this study. The population chosen to study, sample, and the measures taken
to ensure their safety and protection will also be discussed. The procedures for gathering
and analyzing the data, and the content of the questionnaire are also described. Finally, a
summarization of the information presented concludes this chapter.
Research Question
The purpose of this study was to better understand the importance of cultural
competence when treating individuals struggling with substance abuse addiction and how
that treatment affects outcomes. This study was designed to investigate the following
question: What is the relationship between cultural competency in recovery programs and
treatment outcomes?
Research Design
This is a quantitative descriptive survey research design. This study examines the
relationship between cultural competency in recovery programs and treatment outcomes.
This study was quantitative because the goal was to find a relationship between cultural
competence in recovery programs and treatment outcomes. Numerical values were
attached to the answers in order to statistically analyze the data collected rather than
observations or interviews. According to Rubin and Babbie (2008), description survey
research typically refers to characteristics of a population. Royse (2008) states that
40
quantitative descriptive research studies is concerned with the issue of representativeness
and samples should look much like the population in which they are drawn from.
Typically, quantitative data is obtained from a sample of people representative of the
study population. According to Royse (2008), one of the advantages of survey design is
that only a small random sample size is needed. Finding a large sample size of substance
abuse treatment facilities that were willing to participate in our survey was difficult. This
study’s purpose is to examine the cultural competency in recovery programs and
treatment outcomes.
Descriptive research often utilizes surveys. According to Neuman (1997),
researchers usually summarize the answers from a survey questionnaire into percentages,
tables, or graphs. In this study a written questionnaire was used ask substance abuse
counselors about their beliefs and opinions. Neuman (1997) explains that “surveys
produce quantitative information about the social world and describe features of people
or the social world” (p. 228). The survey used in this study asked many questions to
measure the variables in this study. Surveys usually measure many variables and they are
strongest when answers people give to questions measure variables (Neuman, 1997).
Survey research design has strengths and weaknesses. According to Rubin and
Babbie (2008), some of the strengths of survey research are that survey research gives the
researcher flexibility in analysis because various questions may be asked on one topic.
Surveys also allow multiple variables to be analyzed at one time (Rubin & Babbie, 2008).
Finally, survey research design according to Rubin and Babbie (2008) is a good method
for describing a population that is too large to observe directly.
41
Some of the weaknesses of survey research according to Rubin and Babbi (2008)
are that a survey may be superficial or artificial because a questionnaire may appear
standardized. Rubin and Babbi (2008) state that “survey research is generally weak on
validity and strong on reliability” (p. 385). Survey research was utilized in this study to
administer questionnaires to a sample of respondents selected from substance abuse
counselors. Despite the weaknesses of survey research design, it was best for this study
do describe the phenomena of cultural competency in recover programs and treatment
outcomes. The sample population in this study was demographically diverse and this
study analyzed important variables relating to cultural competency in recovery programs
and treatment outcomes
Variables
In this study, the dependent variable was treatment outcomes. The independent
variable was cultural competency in recovery programs.
The demographic variables in this study are: 1) age; 2) education level; 3) race; 4)
gender; 5) religion; and 6) years of practice in the field.
Conceptual and Operational Definitions of Study Variables
Agency and staff cultural competence. Substance abuse counselor’s perceptions
of culturally sensitive services in their agency. This variable is measured by giving the
substance abuse counselors statements regarding culturally sensitive services in their
agency and asking them to indicate whether they strongly agreed, agreed, disagreed, or
strongly disagreed with each statement. The statements were: 1) A client’s age is a factor
in treating them for substance abuse addictions; 2) A competent professional (five or
42
more years) in a direct practice setting, can work with any client; 3) An experienced
clinician (five or more years) in direct practice setting does not have a need for
continuing education-cultural competence training; 4) Agency staff utilizes bi-lingual
interpreters when working with non-English speaking clients; 5) Agency staff routinely
discusses barriers to working with people of different genders; 6) Agency staff utilizes
culturally related educational information during their client’s ongoing treatment; 7)
Agency staff routinely discusses barriers to working with people of different races; 8)
Agency staff routinely discusses barriers to working with people of different religions; 9)
Agency staff discusses cultural issues with clients throughout the treatment process; 10)
Agency displays and offers culturally diverse material in the lobby; 11) Agency refers
clients to community self help groups to achieve cultural competence; 12) Agency
considers abstinence as the only form of positive treatment outcome to achieve cultural
competence; 13) Client’s are court ordered into this facility’s drug treatment program
because we are known to have a cultural competence program component; 14) A client’s
drug of choice has an effect on a client’s treatment outcome; 15) Client’s motivation is
more predictive of success in treatment than the type of program itself; 16) 12-step
programs are successful because they are culturally competent; 17) Social model
programs are successful because they integrate culturally competent components; 18)
Disease model programs work because they integrate culturally competent components;
and 19) Some program components here are delivered by bi-lingual counselors.
Treatment outcomes. This variable is measured by giving the substance abuse
counselors a statement regarding the range of treatment success in their agency and
43
asking them to indicate whether they strongly agreed, agreed, disagreed, or strongly
disagreed with each statement. The statement was: 1) The range of treatment success is a
positive completion rate of 50 – 75%.
The Demographic Variables in Research Study
Age. The participant’s age is a variable measured by asking the participant to
choose between (less than 35 years old, or more than 35 years old.)
Level of education. The number of years the participant has received formal
education in a school setting. This variable was measured by asking the participant to
choose between (Some High School, High School or Some College, College Graduate.)
Race. Self reported race. This variable is measured by asking the participant to
choose between (Caucasian, African American, Hispanic, Asian, or Other,) in which the
participant could specify their identified race.
Gender. Self reported gender. This variable is measured by asking the participant
to choose between (Male, Female, or Other,) in which the participant could specify their
indentified gender.
Religion. Self reported religious denomination or sect. This variable is measured
by asking the participant to choose between (Catholic, Protestant, or Other,) in which the
participant could specify their particular religion.
Years of practice in the field. The number of years the participant has practiced in
the field as a substance abuse counselor. This variable is measured by asking the
participant to choose between (less than 5 years or more than 5 years).
44
Study Population
The study population included substance abuse counselors who were employed
with a substance abuse treatment facility in Sacramento, California. The population
surveyed included males and females from various ethnic backgrounds. All of the
participants were substance abuse counselors at an agency in Sacramento. The
participants were attending a weekly staff meeting at their participating agency. A total of
forty nine substance abuse counselors were surveyed.
Sample Population
The sample population was substance abuse counselors offering substance abuse
counseling at a treatment facility in Sacramento, California. Convenience purposive
sampling was used with this study. This sampling method is a non-probability sampling
design. It is utilized frequently in social work because other methods may not be feasible
for a particular type of study (Rubin & Babbi, 2008). According to Royse (2008), the
researcher uses non-probability sampling approaches to learn more detail about an issue
or problem that cannot be studied with probability sampling design methods. One of the
limitations of non-probability sampling is not knowing how closely the sample
population represents or resembles the “true” population being studied (Royse, 2008).
The sample size was forty nine substance abuse counselors. The response rate was ninety
four percent. The number of participants in the study was forty six.
Instrumentation
The survey used for the research contained a total of twenty-six questions (See
Appendix A). The first six questions were multiple choice and open-end, and dealt with
45
demographic information about the participants. The remaining twenty questions were
Likert scale types of questions that addressed cultural competency and treatment
outcomes. According to Rubin and Babbi (2008), often a Likert scale is used when the
researcher is determining the extent of a respondent’s attitude or particular beliefs. The
respondent is presented with a statement and then asked to indicate whether he or she
“strongly agrees,” “agrees,” “disagrees,” or “strongly disagrees.” According to Rubin and
Babbi (2008), Likert scaling is a measurement technique that is popular and extremely
useful.
Among the questions asked of respondents were basic demographics. Question
regarding substance abuse counselor’s perceptions of the range of treatment success in
their agency. The remainder of the survey consisted of questions concerning substance
abuse counselor’s perceptions of culturally sensitive services in their agency and
treatment outcomes.
Data Gathering Procedures
Data was collected from substance abuse counselors during their weekly staff
meeting. Prior to administering the survey, the researchers contacted the Director of the
substance abuse treatment programs and requested permission to attend their staff
meeting and administer the survey. The researchers then attended the staff meeting to
obtain consent and administer the survey.
When administering the survey, the researchers introduced themselves and the
survey. The researchers briefly explained the consent form and survey, and asked for
their participation, while emphasizing that participation was completely voluntary. The
46
researchers then passed out the consent forms and surveys. The participants spent
between ten and twenty minutes completing the consent form and survey. Upon the
completion of the survey or decision not participate in the survey, the researcher collected
the consent to participate forms and surveys. This way the researcher did not know who
had completed the survey and who had chosen not to participate. The completed surveys
and consent to participate forms were stored in separate envelopes to avoid any
identification of substance abuse counselors.
Data Analysis
All of the surveys were collected from the substance abuse counselors. The data
gathered was imputed into and analyzed by using the statistical package, PASW. The
researchers personally imputed the information into PASW for statistical testing and
analysis. Frequencies of the independent and dependent variables were analyzed. Crosstabulations and chi-square tests were also performed to compare the various independent
and dependent variables.
Protection of the Human Subjects
Prior to administering the survey, the Human Subjects Application was submitted
for approval to the California State University, Sacramento Division of Social Work
Committee for the Protection of Human Subjects. The survey was approved as “minimal
risk.”
Each participant of the study was given a consent form (See Appendix B). This
form explained the purpose of the survey, the procedures, risks, benefits, compensation,
and their right to withdraw from the study or to skip answering questions. The consent
47
form also indicated that confidentiality would be strictly upheld in order to protect their
privacy. The participants consented by signing or initialing the consent form.
Confidentiality was upheld by not collecting names or identifying information.
The completed consent forms were stored separately from the completed surveys in a
locked safe at the researcher’s home. The researchers and the researcher’s thesis advisor
were the only people who had access to the completed surveys during the completion of
the project. The data will be destroyed approximately one month after the project is filed
with Graduate Studies at California State University, Sacramento.
Summary
This chapter addressed the methods used in this research study. The research
design, study population and recruitment methods were described. This chapter also
examined the variables, the questionnaire, the data gathering procedures and data analysis
plan. The protection of human subjects was described in detail. The next chapter will
present the findings of the data analysis.
48
Chapter 4
RESULTS
Introduction
This chapter will analyze the results of this study. The research question will be
examined. Demographic characteristics of survey respondents will be presented as part of
each demographic variable. Survey responses to the dependant variable, treatment
outcomes will be presented. Response rates for all other variables will be presented.
Treatment outcomes will be compared with responses to each individual variable to
determine the presence of significantly statistic relationships. Analysis will include
frequencies of demographics and chi-square testing to explore relationships between
variables. A summary of the data presented will be included in this chapter.
This study attempts to investigate the relationship between cultural competency in
recovery programs and treatment outcomes. The data for this study was obtained through
a survey of substance abuse counselors offering substance abuse treatment at a treatment
facility in Sacramento, California.
Research Question
What factors contribute to cultural competence in substance abuse and treatment
outcomes? The factors being explored in this study are 1) demographic characteristics of
substance abuse counselors 2) substance abuse counselors attitudes and viewpoints of the
availability of culturally competent services 3) substance abuse counselor’s attitudes and
viewpoints of treatment success.
49
Survey Responses
A total of 49 substance abuse counselors were surveyed. Of those 49 substance
abuse counselors, a total of 46 completed the survey.
Dependent Variable
Treatment outcomes. The dependent variable in this study was the statement that
the range of treatment success is a positive completion rate of 50-75%. Substance abuse
counselors were asked this question on a scale ranging from 1 (strongly agree) to 4
(strongly disagree). To allow for meaningful statistical analysis, this variable was recoded into two response categories: (1) “agree,” which included all responses from agree
and strongly agree; and (2) “disagree,” which included all responses from disagree and
strongly disagree. Of the 45 respondents who answered this question, almost half (42.2%)
reported they agree with the definition of treatment outcomes as shown below in table 1.
Table 1
Treatment and responses
Successful Treatment Outcomes
Valid
Cumulative
Frequency Percent
Percent
Percent
Valid
Agree
19
41.3
42.2
42.2
Disagree
26
56.5
57.8
100.0
Total
45
97.8
100.0
Missing System
1
2.2
Total
46
100.0
Independent Variables
With the exception of age, gender and years of practice in the field, all of the
independent variables in this study were recoded after data collection to allow for more
50
accurate statistical analysis. For the non-demographic Likert scale questions, the fourpoint scale used in the survey was recoded into two categories. The response options of
“strongly agree” and “agree” were recoded into one “agree” category. The response
options of “disagree” and “strongly disagree” were recoded into one “disagree” category.
Each demographic variable that was recoded will be explained under the section of that
demographic variable.
Age. This category was comprised of two possible responses; less than 35 years
old with a total of 20 responses (43.5%); more than 35 years old with a total of 26
responses (56.5%). A total of 46 survey respondents answered this question.
Comparing substance abuse counselors who agreed with the definition of
treatment success across age groups, results showed that two-fifths (40%) of respondents,
less than 35 years old reported that they agreed with the definition of treatment success.
Among those age 35 years or older, almost half (44%) agreed with the definition of
treatment success (Table 2). Chi-square analysis was conducted and there were no
statistically significant findings.
51
Table 2
Treatment and Substance Abuse Counselors Age
Successful treatment * Age Crosstabulation
Age
Less than
35 years More than 35
old
years old
Successful Agree
Count
8
11
Treatment
% within Success
42.1%
57.9%
% within Age
40.0%
44.0%
% of Total
17.8%
24.4%
Disagree Count
12
14
% within Success
46.2%
53.8%
% within Age
60.0%
56.0%
% of Total
26.7%
31.1%
Total
Count
20
25
% within Success
44.4%
55.6%
% within Age
100.0%
100.0%
% of Total
44.4%
55.6%
Total
19
100.0%
42.2%
42.2%
26
100.0%
57.8%
57.8%
45
100.0%
100.0%
100.0%
Gender. Of the 45 responses to this question, two-fifths (40%) indicated they
were male, and three-fifths (60%) indicated they were female.
When analyzing substance abuse counselors who agreed with the definition of
treatment success across gender as a variable, half (50%) of the males reported they
agreed with the definition of treatment success. Among females, nearly two-fifths (37%)
agreed with the definition of treatment success. A greater percentage of male respondents
agreed with the definition of treatment success compared with female respondents,
though the largest group in the sample was female (Table 3). A chi-square test was
52
conducted with treatment outcomes and gender. There were no statistically significant
results in the analysis.
Table 3
Treatment and Gender
Successful Treatment outcomes * gender
Gender
Male Female
Successful Agree
Count
9
10
Treatment
% within Success
47.4%
52.6%
% within Gender
50.0%
37.0%
% of Total
20.0%
22.2%
Disagree Count
9
17
% within Success
34.6%
65.4%
% within Gender
50.0%
63.0%
% of Total
20.0%
37.8%
Total
Count
18
27
% within Success
40.0%
60.0%
% within Gender
100.0% 100.0%
% of Total
40.0%
60.0%
Total
19
100.0%
42.2%
42.2%
26
100.0%
57.8%
57.8%
45
100.0%
100.0%
100.0%
Race. A large majority of respondents’ over half, (56.8%) identified as
Caucasian. Over two-fifths (43.2%) of the respondents’ were grouped into the “race”
category of “other.” The variable was recoded to include a category of “All other races,”
and all non-Caucasian respondents were included in this category. There were a total of
44 responses to this question.
A cross tabulation was conducted comparing substance abuse counselors who
agreed with the definition of treatment success across the variable of race. Within the
Caucasian group of respondents, nearly half (48%) agreed with the definition of
53
treatment success. Among non-Caucasian respondents, less than two-fifths (36.8%)
indicated they agreed with the definition of treatment success (Table 4). Chi- square
analysis was conducted to explore relationships between the definition of treatment
success and race. No statistical significant results were obtained.
Table 4
Treatment and Race
Successful treatment * race Crosstabulation
Race
Caucasian Other
Successful Agree
Count
12
7
Treatment
% within Success
63.2% 36.8%
% within Race
48.0% 36.8%
% of Total
27.3% 15.9%
Disagree Count
13
12
% within Success
52.0% 48.0%
% within Race
52.0% 63.2%
% of Total
29.5% 27.3%
Total
Count
25
19
% within Success
56.8% 43.2%
% within Race
100.0% 100.0%
% of Total
56.8% 43.2%
Total
19
100.0%
43.2%
43.2%
25
100.0%
56.8%
56.8%
44
100.0%
100.0%
100.0%
Education. Over three-fifths (63.2%) of those who agreed with the definition of
treatment success had high school or some college. However, only 36.8% of college
graduates agreed (Table 5). This chi-square relationship was approaching
significance (p=.058).
54
Table 5
Treatment and Education
Successful treatment *education Crosstabulation
Education
High school
or some
College
college
graduate
Successful Agree
Count
12
7
Treatment
% within Success
63.2%
36.8%
% within Education
57.1%
29.2%
% of Total
26.7%
15.6%
Disagree Count
9
17
% within Success
34.6%
65.4%
% within Education
42.9%
70.8%
% of Total
20.0%
37.8%
Total
Count
21
24
% within Success
46.7%
53.3%
% within Education
100.0%
100.0%
% of Total
46.7%
53.3%
Total
19
100.0%
42.2%
42.2%
26
100.0%
57.8%
57.8%
45
100.0%
100.0%
100.0%
Religion. There were 40 respondents who answered this question. The religion
variable was also recoded into two new response categories: “Christian” represented
nearly three-fifths (57.5%) of the respondents; “Other,” totaling over two-fifths (42.5%).
Comparing treatment outcomes between the two categories beginning with the
“Christian” category, over two-fifths (43.5%) agreed with the definition of treatment
outcomes. Among “Other,” over two-fifths (41.2%) reported that they agreed with the
definition of treatment success. A higher percentage of respondents who identify with
Christianity indicated they agreed with the definition of treatment outcomes when
compared to those who had no religious affiliation (Table 6). Chi-square testing was
55
conducted with the definition of treatment outcomes versus different religious identity
categories, with no statistically significant findings emerging.
Table 6
Treatment and Religion
Successful treatment *Religion Crosstabulation
Religion
Christian Other
Successful agree
Count
10
7
Treatment
% within Success
58.8% 41.2%
% within Religion
43.5% 41.2%
% of Total
25.0% 17.5%
disagree Count
13
10
% within Success
56.5% 43.5%
% within Religion
56.5% 58.8%
% of Total
32.5% 25.0%
Total
Count
23
17
% within Success
57.5% 42.5%
% within Religion 100.0% 100.0%
% of Total
57.5% 42.5%
Total
17
100.0%
42.5%
42.5%
23
100.0%
57.5%
57.5%
40
100.0%
100.0%
100.0%
Years of practice in the field. A majority of respondents, (84.4%), indicated that
they had less than five years of practice in the field. Less than one-fifth (15.6%) of
respondents indicated they had been in the field for more than five years. Comparing
substance abuse counselors who agreed with the definition of successful treatment
outcomes across the two responses; it can be seen that among respondents in the first
category (less than five years), nearly half (44.7%) indicated they agreed with the
definition of successful treatment outcomes. For those respondents who had more than
five years in the practice field, nearly one-fourth (28.6%) indicated they agreed with the
56
definition of successful treatment outcomes (Table 7). Chi-square testing was conducted
to explore any relationship between successful treatment outcomes and the number of
years in the practice field. No statistically significant findings were discovered.
Table 7
Treatment and Years in the Practice Field
Successful treatment *years in the Field Crosstabulation
Years in Practice Field
Less than 5 More than 5
years
years
Successful agree
Count
17
2
Treatment
% within Success
89.5%
10.5%
% within Years in
44.7%
28.6%
Practice Field
% of Total
37.8%
4.4%
disagree Count
21
5
% within Success
80.8%
19.2%
% within Years in
55.3%
71.4%
Practice Field
% of Total
46.7%
11.1%
Total
Count
38
7
% within Success
84.4%
15.6%
% within Years in
100.0%
100.0%
Practice Field
% of Total
84.4%
15.6%
Total
19
100.0%
42.2%
42.2%
26
100.0%
57.8%
57.8%
45
100.0%
100.0%
100.0%
Client’s age a factor in treatment outcomes. The relationship between client’s
age and successful treatment outcomes was examined. Client’s age was explored to
determine if it was a factor in successful treatment outcomes when treating for substance
abuse addictions. Two-fifths of the respondents (40.0%) agreed with the definition of
treatment success or that a client’s age is a factor in treating their substance abuse
57
addiction. Over half (55.0%) who disagreed with the definition of treatment success also
disagreed that a client’s age is a factor in treating their substance abuse addiction (Table
8). Chi-square testing was conducted to explore any relationship between successful
treatment outcomes and age being a treatment factor. No statistically significant findings
were discovered.
Table 8
Treatment and Client’s Age
Successful treatment *client’s age Crosstabulation
Client’s age
Agree Disagree
Successful agree
Count
10
9
Treatment
% within Success
52.6%
47.4%
% within Age
40.0%
45.0%
% of Total
22.2%
20.0%
disagree Count
15
11
% within Success
57.7%
42.3%
% within Age
60.0%
55.0%
% of Total
33.3%
24.4%
Total
Count
25
20
% within Success
55.6%
44.4%
% within Age
100.0% 100.0%
% of Total
55.6%
44.4%
Total
19
100.0%
42.2%
42.2%
26
100.0%
57.8%
57.8%
45
100.0%
100.0%
100.0%
The Agency’s utilization of bi-lingual interpreters. This variable explored
respondents’ belief that: “Agency staff utilizes bi-lingual interpreters when working with
non-English speaking clients.” This variable was re-coded from a four-point Likert scale
format into a two- point scale. More than half (54.8%) of the participants agreeing with
the definition of treatment success used bi-lingual interpreters when working with nonEnglish speaking clients. More than four-fifths (85.7%) of those who disagreed with the
58
definition of treatment success did not use bi-lingual interpreters when working with nonEnglish speaking clients (table 9). The Chi-square test was statistically significant
(X²=6.502; df=1; p=.011).
Table 9
Treatment and Utilization of Bi-lingual Interpreters
Successful treatment *Bi-lingual Crosstabulation
Bi-lingual
Agree disagree Total
Successful agree
Count
17
2
19
Treatment
% within Success
89.5%
10.5% 100.0%
% within bi-lingual 54.8%
14.3% 42.2%
% of Total
37.8%
4.4% 42.2%
disagree Count
14
12
26
% within Success
53.8%
46.2% 100.0%
% within bi-lingual 45.2%
85.7% 57.8%
% of Total
31.1%
26.7% 57.8%
Total
Count
31
14
45
% within Success
68.9%
31.1% 100.0%
% within bi-lingual 100.0% 100.0% 100.0%
% of Total
68.9%
31.1% 100.0%
Agency staff and gender barriers. This variable assessed agreement with the
statement: “Agency staff routinely discusses barriers to working with people of different
genders.” This variable was recoded from a four-point Likert scale format into a twopoint scale. Nearly half of the respondents (48.6%) agreed with the definition of
treatment success; routinely discuss gender barriers when working with people of
different genders. More than four-fifths (87.5%) of those who disagreed with the
definition of treatment success did not discuss gender barriers when working with people
59
of different genders (Table 10). Chi-square testing was conducted to explore any
relationship between successful treatment outcomes and gender barriers. No statistically
significant findings were discovered. (2 cells had expected count less than 5. The
minimum expected count is 3.38).
Table 10
Treatment and Gender Barriers
Successful treatment* gender barrier Crosstabulation
Gender barriers
Agree
Disagree
Successful Agree
Count
18
1
Treatment
% within Success
94.7%
5.3%
% within Gender barriers
48.6%
12.5%
% of Total
40.0%
2.2%
Disagree Count
19
7
% within Success
73.1%
26.9%
% within Gender barriers
51.4%
87.5%
% of Total
42.2%
15.6%
Total
Count
37
8
% within Success
82.2%
17.8%
% within Gender barriers 100.0%
100.0%
% of Total
82.2%
17.8%
Total
19
100.0%
42.2%
42.2%
26
100.0%
57.8%
57.8%
45
100.0%
100.0%
100.0%
Staff utilization of culturally related educational information. This variable
assessed agreement with the statement; “Agency staff utilizes culturally related
educational information during their client’s on-going treatment.” This variable was
recoded from a four-point Likert scale format into a two-point scale. More than two-fifths
(44.1%) of the participants agreeing with the definition of treatment success utilized
culturally related educational information during their clients ongoing treatment. Three-
60
fifths (60.0%) of those who disagreed with the definition of treatment success did not
utilize culturally related educational information during their clients ongoing treatment
(Table 11). Chi-square testing was conducted to explore any relationship between
successful treatment outcomes and utilization of culturally related educational
information during a client’s ongoing treatment. No statistical significant findings were
discovered. (1 cell had expected count less than 5. The minimum expected count is
4.32).
Table 11
Treatment and Utilization of Culturally Related Educational Information
Success Treatment *cultural education Crosstabulation
Cultural Ed
Agree Disagree
Successful Agree
Count
15
4
Treatment
% within Success
78.9%
21.1%
% within cultural Ed
44.1%
40.0%
% of Total
34.1%
9.1%
Disagree Count
19
6
% within Success
76.0%
24.0%
% within Cultural Ed 55.9%
60.0%
% of Total
43.2%
13.6%
Total
Count
34
10
% within Success
77.3%
22.7%
% within Cultural Ed 100.0% 100.0%
% of Total
77.3%
22.7%
Total
19
100.0%
43.2%
43.2%
25
100.0%
56.8%
56.8%
44
100.0%
100.0%
100.0%
Barriers to working with people of different races. This variable explored
respondents’ belief that: “Agency staff routinely discusses barriers to working with
people of different races.” This variable was re-coded from a four-point Likert scale
61
format into a two-point scale. Two-fifths (40.6%) of the participants agreeing with the
definition of treatment success routinely discuss barriers to working with people of
different races. Over half (53.8%) of those who disagreed with the definition of treatment
success did not routinely discuss barriers to working with people of different races (Table
12). Chi-square testing was conducted to explore any relationship between successful
treatment outcomes and routinely discussing barriers to working with people of different
races. No statistically significant findings were discovered.
Table 12
Treatment and Staff Barriers with Different Races
Successful treatment * Race Barriers Crosstabulation
Race Barriers
Agree Disagree
Successful Agree
Count
13
6
Treatment
% within Success
68.4%
31.6%
% within Race Barriers 40.6%
46.2%
% of Total
28.9%
13.3%
disagree Count
19
7
% within Success
73.1%
26.9%
% within Race Barriers 59.4%
53.8%
% of Total
42.2%
15.6%
Total
Count
32
13
% within Success
71.1%
28.9%
% within Race Barriers 100.0% 100.0%
% of Total
71.1%
28.9%
Total
19
100.0%
42.2%
42.2%
26
100.0%
57.8%
57.8%
45
100.0%
100.0%
100.0%
Barriers to working with people of different religions. This variable assessed
agreement with the statement: “Agency staff routinely discusses barriers to working with
people of different religions.” The variable was recoded from the four-point Likert scale
62
format into a two-point scale. Nearly half (45.8%) of the participants agreed with the
definition of treatment success, discussed barriers to working with people of different
religions. Three-fifths (60.0%) of those who disagreed with the definition of treatment
success did not discuss barriers to working with people of different religions (Table 13).
Chi-square testing was conducted to explore any relationship between successful
treatment outcomes and routinely discussing barriers to working with people of different
religions. No statistically significant findings were discovered.
Table 13
Treatment and Staff Barriers with Different Religions
Successful treatment * Religion Barrier Crosstabulation
Religion Barrier
Agree Disagree
Success
Agree
Count
11
8
Treatment
% within Success
57.9%
42.1%
% within Religion Barrier 45.8%
40.0%
% of Total
25.0%
18.2%
Disagree Count
13
12
% within Success
52.0%
48.0%
% within Religion Barrier 54.2%
60.0%
% of Total
29.5%
27.3%
Total
Count
24
20
% within Success
54.5%
45.5%
% within Religion Barrier 100.0 100.0%
%
% of Total
54.5%
45.5%
Total
19
100.0%
43.2%
43.2%
25
100.0%
56.8%
56.8%
44
100.0%
100.0%
100.0%
Agency staff discusses cultural issues. This variable assessed agreement with
the statement: “Agency staff discusses cultural issues with clients throughout the
treatment process.” The variable was recoded from the four-point Likert scale format into
63
a two-point scale. Over one-third (36.7%) of participants agreed with the definition of
treatment success, agreed that staff routinely discussed cultural issues with clients
throughout the treatment process. Nearly half (46.2%) of those who disagreed with the
definition of treatment success did not discuss cultural issues with clients throughout the
treatment process (Table 14). Chi-square testing was conducted to explore any
relationship between successful treatment outcomes and routinely discussed cultural
issues with clients throughout the treatment process. Chi-square testing was conducted to
explore any relationship between successful treatment outcomes and routinely discussing
barriers to working with people of different races. No statistically significant findings
were discovered.
Table 14
Treatment and Discussion of Cultural Issues
Successful treatment * cultural issues Crosstabulation
Cultural issues
Agree Disagree
Successful Agree
Count
11
7
Treatment
% within Success
61.1%
38.9%
% within Cultural issues 36.7%
53.8%
% of Total
25.6%
16.3%
Disagree Count
19
6
% within Success
76.0%
24.0%
% within Cultural issues 63.3%
46.2%
% of Total
44.2%
14.0%
Total
Count
30
13
% within Success
69.8%
30.2%
% within Cultural issues 100.0% 100.0%
% of Total
69.8%
30.2%
Total
18
100.0%
41.9%
41.9%
25
100.0%
58.1%
58.1%
43
100.0%
100.0%
100.0%
64
Abstinence treatment outcomes and cultural competence. This variable
assessed agreement with the statement: “Agency considers abstinence is the only form of
positive treatment outcome to achieve cultural competence.” The variable was recoded
from the four-point Likert scale format into a two-point scale. Over half (54.5%) of
respondents’ agreeing with the definition of treatment success also agreed that the agency
considers abstinence as the only form of positive treatment outcome to achieve cultural
competence. Nearly two-thirds (63.6%) of those who disagreed with the definition of
treatment success did not agree that abstinence is the only form of positive treatment
outcome to achieve cultural competence (Table 15). Chi-square testing was conducted to
explore any relationship between successful treatment outcomes and abstinence being the
only form of positive treatment outcome to achieve cultural competence. No statistically
significant findings were discovered.
65
Table 15
Treatment and Abstinence
Successful treatment * Abstinence Crosstabulation
Abstinence
Agree Disagree
Successful agree
Count
6
12
Treatment
% within Success
33.3%
66.7%
% within Abstinence 54.5%
36.4%
% of Total
13.6%
27.3%
disagree Count
5
21
% within Success
19.2%
80.8%
% within Abstinence 45.5%
63.6%
% of Total
11.4%
47.7%
Total
Count
11
33
% within Success
25.0%
75.0%
% within Abstinence 100.0% 100.0%
% of Total
25.0%
75.0%
Total
18
100.0%
40.9%
40.9%
26
100.0%
59.1%
59.1%
44
100.0%
100.0%
100.0%
Court ordered into this treatment program because of cultural competence.
This variable assessed agreement with the statement: “Client’s are court ordered into this
facility’s drug treatment program because we are known to have a cultural competence
program component.” The variable was recoded from the four-point Likert scale format
into a two-point scale. Half (50%) of the participants agreeing with the definition of
treatment success also agreed that clients were court ordered into the treatment program
because it is known to have a cultural competence component. Over two-thirds (66.7%)
of those who disagreed with the definition of treatment success did not believe that
clients were court ordered into the treatment program (Table 16). Chi squared testing was
conducted and no statistically significant findings were discovered.
66
Table 16
Treatment and Court Ordered Treatment
Successful treatment *Court Ordered Crosstabulation
Court Ordered
Agree Disagree
Successful agree
Count
12
7
Treatment
% within Success
63.2%
36.8%
% within Court Ordered 50.0%
33.3%
% of Total
26.7%
15.6%
disagree Count
12
14
% within Success
46.2%
53.8%
% within Court Ordered 50.0%
66.7%
% of Total
26.7%
31.1%
Total
Count
24
21
% within Success
53.3%
46.7%
% within Court Ordered 100.0 100.0%
%
% of Total
53.3%
46.7%
Total
19
100.0%
42.2%
42.2%
26
100.0%
57.8%
57.8%
45
100.0%
100.0%
100.0%
12-Step programs are successful with cultural competence. This variable
assessed agreement with the statement: “12-step programs are successful because they
are culturally competent.” The variable was recoded from the four-point Likert scale
format into a two-point scale. Over two-thirds (66.7%) of participants agreeing with the
definition of treatment success also agreed that 12-step programs are successful because
they are culturally competent. Nearly two-thirds (63.2%) of those who disagreed with the
definition of treatment success did not believe that 12-step programs are successful
because they are culturally competent (Table17). Chi-square testing was conducted to
explore any relationship between successful treatment outcomes and 12-step program’s
cultural competence. No statistically significant findings were discovered.
67
Table 17
Treatment and 12-Step Programs
Successful treatment *12-Step Crosstabulation
12-Step
Agree Disagree
Successful agree
Count
4
14
Treatment
% within Success
22.2%
77.8%
% within 12-Step
66.7%
36.8%
% of Total
9.1%
31.8%
disagree Count
2
24
% within Success
7.7%
92.3%
% within 12-Step
33.3%
63.2%
% of Total
4.5%
54.5%
Total
Count
6
38
% within Success
13.6%
86.4%
% within 12-Step
100.0% 100.0%
% of Total
13.6%
86.4%
Total
18
100.0%
40.9%
40.9%
26
100.0%
59.1%
59.1%
44
100.0%
100.0%
100.0%
Social model programs are successful with cultural competence. This variable
assessed agreement with the statement: “Social model programs are successful because
they integrate culturally competent components.” The variable was recoded from the
four-point Likert scale format into a two-point scale. Nearly two-fifths (38.5%) of
participants agreeing with the definition of treatment success were in agreement that
social model programs were successful because they are culturally competent. Nearly
three-fifths (58.1%) of those who disagreed with the definition of treatment success did
not believe that social model programs are successful because they were culturally
competent (Table 18). Chi-square testing was conducted to explore any relationship
68
between successful treatment outcomes and social model program’s cultural competence.
No statistically significant findings were discovered.
Table 18
Treatment and Social Model Programs
Successful treatment *Social Model Crosstabulation
Social Model
Agree Disagree
Successful agree
Count
5
13
Treatment
% within Success
27.8%
72.2%
% within r Social
38.5%
41.9%
Model
% of Total
11.4%
29.5%
disagree Count
8
18
% within Success
30.8%
69.2%
% within Social Model
61.5%
58.1%
% of Total
18.2%
40.9%
Total
Count
13
31
% within Success
29.5%
70.5%
% within Social Model 100.0% 100.0%
% of Total
29.5%
70.5%
Total
18
100.0%
40.9%
40.9%
26
100.0%
59.1%
59.1%
44
100.0%
100.0%
100.0%
Disease model programs are successful with cultural competence. This
variable assessed agreement with the statement: “Disease model programs work because
they integrate culturally competent components.” The variable was recoded from the
four-point Likert scale format into a two-point scale. Over four-fifths (87.5%) of
participants agreeing with the definition of treatment success also agreed that disease
model programs were successful because they were culturally competent. Over twothirds (67.6%) of those who disagreed with the definition of treatment success did not
believe that disease model programs were successful because they were culturally
69
competent (Table 19). Chi-square testing was conducted to explore any relationship
between successful treatment outcomes and social model program’s cultural competence.
No statistically significant findings were discovered. (2 cells have expected count less
than 5. The minimum expected count is 3.38).
Table 19
Treatment and Disease Model Programs
Successful treatment *Disease Model Crosstabulation
Disease Model
Agree Disagree
Success
agree
Count
7
12
Treatment
% within Success
36.8%
63.2%
% within Disease Model 87.5%
32.4%
% of Total
15.6%
26.7%
disagree Count
1
25
% within Success
3.8%
96.2%
% within Disease Model 12.5%
67.6%
% of Total
2.2%
55.6%
Total
Count
8
37
% within Success
17.8%
82.2%
% within Disease Model 100.0% 100.0%
% of Total
17.8%
82.2%
Total
19
100.0%
42.2%
42.2%
26
100.0%
57.8%
57.8%
45
100.0%
100.0%
100.0%
Summary
This section presented an explanation of the data analysis procedures, including a
description of how the variables were recoded for statistical analysis. Descriptions of the
responses to demographic variables were provided, as well as an explanation of responses
to each survey variable. Responses to each variable and the dependent variable,
successful treatment outcomes, were analyzed in conjunction using chi-square analysis in
70
order to determine the presence of statistically significant relationships. Additionally,
frequency distribution was conducted on demographic variables to explore percentages.
71
Chapter 5
DISCUSSION
Introduction
This chapter will begin with a brief summarization of the most important findings
discovered in the study; those that were statistically significant and those that approached
significance. Also incorporated are those results that were unexpected even if not
statistically significant. A more in-depth discussion of the study results will also be
discussed. Limitations of the study will be included, and implications of the findings will
be addressed. This chapter will conclude with recommendations for further research, and
concluding summary.
Summary
The United States is made up of a multi-cultural society. For this reason more
research is needed in the area of substance abuse and culturally competent treatment. This
study’s purpose was to add to this knowledge by determining which of the factors
reviewed in the literature help substance abuse counselors and treatment centers achieve
cultural competence and positive treatment outcomes.
Among the 26 items included in the questionnaire, one was found to have a
statistically significant relationship with positive treatment outcomes. The variable with
the strongest statistical significance was the agencies utilization of bi-lingual interpreters
when working with non-English speaking clients. This is congruent with analysis by
Kelly, Myers and Brown (2002), which suggested that California community based
72
substance abuse treatment centers have the need for specialized programs to include bilingual services.
Two cross-tabulated variables of interest that approached significance were the
education level of those who agreed with the definition of treatment success. College
graduates were less likely to agree with our definition of treatment success, than those
who have high school or some college education.
Perhaps the most interesting finding, although it was not statistically significant,
was the percentage of participants who disagreed with the definition of treatment success.
According to our frequency distribution table, over half (57.8%) substance-abuse
counselors in this study disagreed with the definition of treatment success. Within those
that disagreed with the definition of treatment success, approximately seventy percent
were college graduates. The definition of treatment success as defined in this study: was
the statement, “range of treatment success was the positive completion rate of 50%75%.” This definition was provided by the treatment facility where the substance abuse
counselors work.
Discussion
Demographics. In terms of age, the majority of the respondents in this study were
more than 35 years old (56.5%). A similar percentage of substance abuse counselors in
each individual age bracket, less 35 years old (40%), and, over 35 years old (44%) agreed
with the definition of treatment success.
In regards to gender, a majority of treatment providers were female (60%). A
greater number of male respondents agreed with the definition of treatment success
73
(50%) compared with female respondents (37%), though the largest group in the sample
was female. In accordance to religion, more than half (57.5%) of the respondents in this
study identify as Christian. Worth mentioning was the number of providers that chose not
to answer this demographic data. Christian counselors were more likely to agree with the
definition of treatment success.
Reported years of practice in the field, the majority of substance abuse
counselors; (84.4%) indicated that they had less than five years of practice in the field. It
is the opinion of these two researchers of this project that the majority of the people, who
reported that they had less than five years of practice in the field, have recently been in
recovery themselves. According to SAMHSA, 2008, about half of the certified substance
abuse counselors are individuals in recovery themselves and/or have had family members
or close friends with a substance use disorder. A certificate in substance abuse counseling
may take only one year to complete. Treatment providers may work in the field with less
experience. Respondents that agreed with our definition of treatment success were more
likely to have less than five years of experience.
When reporting on the demographics of race, over half (56.8%) identified as
Caucasian. Following Caucasian in rank order, many participants responded to the
question by relating to more than one category. The affects of these responses by multicultural staff members led to the recoding and compilation of streamlining our
demographic variable into two definitive categories, one as Caucasian and the other as
All other Races for a more accurate statistical analysis. According to Campbell and
Alexander (2002), cultural competency training racial and ethnic matching between staff
74
and clients, and cultural competency training and language concordance may lead to
better treatment outcomes.
Treatment barriers. Race and/or ethnicity are no longer the only components in
a belief system of diversity. Included in the definition of diversity with race and ethnicity
are gender, sexual orientation, able-ism, nationality, geography, religion, socioeconomic,
education, age, and political affiliation (Bloland, 1995). Although no statistically
significant relationship was found in this study to support the ideas that gender, race and
religion are important components to a client’s successful treatment outcome. These
researchers believe that these maybe an important component of a success treatment plan.
When substance abuse counselors were asked if they routinely discussed barriers
to working with people of different genders, nearly half (48.6%) of the respondents that
agreed with the definition of treatment success, routinely discussed gender barriers when
working with people of different genders. More than four-fifths (87.5%) of those who
disagreed with the definition of treatment success did not discuss gender barriers when
working with people of different genders. Gender research has shown that there were no
gender differences for drug use in general. Yet, drug of choice and an overall need for
varied services and support was greater and more complex for women (Pelissier, &
Jones, 2011). Bloom, Owen, & Covington, (2002) emphasize a multidimensional
approach, because, “all women, despite their racial, ethnic or social class backgrounds,
have their life experiences molded by the variable of gender” (p. 2).
“The United States is undergoing a transition from a predominately white society
rooted in Western European culture to a global society composed of diverse racial and
75
ethnic groups” (Kroehler & Zanden, 2002, p. 17). According to the National Survey on
Drug Use and Health report (NSDUH, 2002), rates of current illicit drug use in 2002
varied significantly among the major racial/ethnic groups. Two-fifths (40.6%) of the
participants agreeing with the definition of treatment success routinely discussed barriers
to working with people of different races. Over half (53.8%) of those who disagreed with
the definition of treatment success did not routinely discuss barriers to working with
people of different races.
Nearly half (45.8%) of the treatment providers in this study agreed with the
definition of treatment success discussed barriers to working with people of different
religions. Three-fifths (60%) of those who disagreed with the definition of treatment
success did not discuss barriers to working with people of different religions. Religious
beliefs need to be assessed because of the wide use of self-help groups that have a
religious component and foundation. “According to Alcoholics Anonymous own
statistics, there are over 50,000 support groups with over 1.1 million members in the
United States,” (Apanovitch, 1998, p.786). These self-help groups have become the
dominant discourse and most consumed drug treatment model in America, one reason
being that they are a low or no cost treatment option. The California Social Model, based
on the twelve-step program approach, has been absorbed into mainstream treatment for
drug-dependent individuals because of cost-effectiveness (Humphreys, 2002).
Court ordered treatment. When a person is convicted of an offense related to
addiction, the judge commonly orders the person into one of two treatment programs: (1)
Alcoholics Anonymous (AA) or (2) to a Narcotics 12-step based group. Apanovitch
76
(1998) states that while AA has a commendable secular goal of helping alcoholics/addicts
overcome their disease; the dangers of state-imposed participation in these 12 step
models may channel potential believers to a religion. These persons are mandated by the
court to participate or face a less desirable alternative such as incarceration. Half (50%)
of participants agreeing with the definition of treatment of success also agreed that clients
were court ordered into the treatment program because it is known to have a cultural
competence component. Over two–thirds (66.7%) of those who disagreed with the
definition of treatment success did not believe that clients were court ordered into the
treatment program because they are known to have a culturally competent program.
Addressing cultural issues. A significant portion of the literature reviewed in
this study involved cultural competence as it relates to providers care of clients in
substance abuse treatment. Paasche-Orlow (2004) wrote, “culturally competent care is a
moral good that emerges from an ethical commitment to autonomy and justice” (p 349).
In order to follow mandates which will remove barriers of access to medical care and to
eliminate health disparities, clinicians must be educated on the “three essential principles
of cultural competence, (1) acknowledgement of the importance of culture in people’s
lives, (2) respect for cultural differences, and (3) minimization of any negative
consequences of cultural differences” (Paasche-Orlow, p. 347-348).
Three of the survey questions sought to explore what alcohol and drug treatment
counselors’ thoughts were in regards to 12 step programs, social model programs and
disease model programs, and their perceived success due to cultural competence. In our
study we made the statement that “12-step/social model/disease model programs are
77
successful because they are culturally competent.” More people in our study who agreed
with the definition of treatment success believed that 12-step programs and social model
programs are successful because they are culturally competent.
Opposing views were found in regards to the statement, “disease model programs
work because they integrate culturally competent components.” Nearly ninety percent of
those agreeing with the definition of treatment success also agreed that disease model
programs continued to be successful because they are culturally competent. This finding
in our study goes against our research in the literature that discusses the need for
alternative non-secular self-help groups. They have been criticized for their “cookie
cutter” approach in their recovery model; which did not address the multicultural issues
of their client’s. Kelly, Myers and Brown (2002) professed the need for alternative
models, due to the overwhelming majority of professional private and public substance
use disorder treatment programs in the United States being “self help” groups following
the 12-step philosophy.
When approaching any community based program with a one size fits all
approach to alcohol and drug rehabilitation, as previously cited with New York State’s
prison system, we run into ethical dilemmas (Paasche-Orlow, 2004). Community based
care and mutual aid groups must address the unique needs of their participants and their
surroundings. Research shows that these 12 step and social model programs have recently
been incorporating alternative program components that include non-religious affiliation
groups, multi-lingual groups and gender specific groups such as woman only and LGBT
78
groups in order to accommodate or fill in the gaps because they have been continuously
scrutinized for their lack of cultural competence.
Limitations
This study was limited in several areas that should be addressed in future research
that seeks to replicate and expand on these results. One issue in this study was the
instrument used to survey the participants was not standardized. No solution may be
available to this concept, as no instrumentation specific to the topic of cultural
competence and substance abuse treatment outcomes has yet been developed. The
development of such a tool could be a worthwhile focus of future research. Because the
instrument was not standardized, some of the questions were somewhat ambiguous in
spite of efforts by these researchers to create a clear and neutral questionnaire.
This study is limited by the small amount of research on alternative substance
abuse treatment for ethnic minorities and underserved populations. The majority of the
research for court ordered treatment programs continues to solely be supporting
Alcoholics Anonymous and Narcotics Anonymous. The evidence based practiced proven
method of treatment for substance abuse clients has been historically dominated by the
12-step model based in Christianity/Spirituality. This study presented the need for further
research from non-secular alternative drug treatment facilities. Liken to this research
which was administered to such an agency.
Another limitation was the fact that the substance abuse counselors surveyed were
recruited from one non-secular substance abuse agency in the Sacramento, CA area. The
sample size was (N=49). This sample size was too small for the researchers to generalize
79
the findings from the substance abuse counselor’s responses to the overall substance
abuse counselor population. In addition it is probable that this Agency is more likely to
have more progressive perceptions and beliefs in regards to cultural competence. In our
queries to gather and expand our sample size to provide more equitable research, there
was not one 12-step or social model program that would consent to participate in our
research project. Several substance abuse treatment agencies were contacted in the
greater Sacramento areas that were not willing to participate in a study that gauged their
provider’s perceptions of their level of cultural competence. Since this study only
explored one agency’s perceptions of cultural competence there may be more insight and
additional perspectives that were not captured adequately in this study.
Implications
The results of this study have important implications at the micro, mezzo and
macro levels of social work practice. At a micro level substance abuse counselors and
social workers can utilize the results of this study to support clients in their chemical
dependency treatment by continually addressing their multicultural needs. Additionally
substance counselors and social workers should look at the individual and should foster
empowerment and strength based theories.
At a mezzo level of practice substance abuse counselors and social workers can
learn from this study the need for their agency to provide for continuing education on
cultural competency and cultural humility. What can be learned from this study is the
importance of the role that their client’s families and communities culture plays in
seeking and engaging in treatment. According to Castro and Alarcon (2002) clients who
80
come from a very traditional background or have a low level of acculturation may be less
likely to engage in services.
Within a macro level of social work practice, this study highlights the needs for
more State mandates in legislation which would require substance abuse counselors and
social workers to have a two-year college degree or higher. These degrees may include
multicultural/ethnic studies and social work. When reporting the education levels of our
participants, our study found disparities between those who had a college degree and
those who did not. Out of the 24 participants with college degrees, (36.8%) agreed with
our definition of treatment success, whereas the 21 participants with a high school
diploma or some college, reported that (63.2%) agreed with the definition of treatment
success. These disparities may be accounted for by the gained knowledge through higher
education of the complexity of substance abuse in a multi-cultural society and the
utilization of the bio-psycho-social model.
Recommendations
For future research in this area, this researcher proposes several ideas that could
allow greater understanding of the importance of cultural competence in substance abuse
treatment outcomes, and fill in knowledge gaps left by this study.

An important addition to the research would be a longitudinal study which tracks
their attitudes, activities, and beliefs of client’s after they leave a treatment
facility’s program . Treatment success is difficult to gauge beyond the completion
of the program due to the lack of longitudinal studies.
81

Another important variable needing further exploration is the utilization and
availability of bi-lingual counselors in substance abuse treatment programs. This
variable resulted in a statistically significant relationship to the definition of
successful treatment outcomes.

Further studies could also address the higher educational needs and continuing
education of substance abuse providers.

Other studies could include comparison groups of 12-step model of treatment vs.
a non-secular model. Differences between the two groups could provide insights
to addressing the needs of our growing multi-cultural society in California.

Finally, development of a survey instrument with less ambiguous questions would
greatly enhance the quality of studies on the topic of cultural competence and
substance abuse treatment outcomes.
Conclusion
Cultural competence from providers in alcohol and drug abuse treatment and their
relationship to treatment outcomes is an important topic in contemporary American
society. In spite of the fact that the United States is known as “the melting pot,” where
people come from all over the world to live together in our democratic Country, there is a
small body of research about the topic that exists. The purpose of this study was to
increase this knowledge base and provide practical suggestions for substance abuse
treatment centers and social workers who are working within a multicultural society.
Although this study was conducted within the context of a non-secular treatment
program, the literature review demonstrates that the factors which affect cultural
82
competence in substance abuse treatment outcomes are likely to affect treatment
outcomes for the more widely used dominant discourses in substance abuse treatment.
Findings from this study suggest that two key factors can improve cultural competence
for substance abuse counselors and the relationships with their clients, and their client’s
treatment outcomes. These factors are: 1) an agency’s utilization of bi-lingual instructors
and 2) the need for substance abuse counselors to have a higher education including a
College degree, to gain the knowledge and theory based practices that must be addressed
when approaching the complexity of addiction.
The limitations of this study are that the substance abuse counselors surveyed
were recruited from one non-secular substance abuse agency in the Sacramento, CA,
limiting the amount of demographic diversity of respondents from other treatment
models. Additionally, this study is limited by the small amount of research on alternative
substance abuse treatment for ethnic minorities and underserved populations. The
majority of the research comes from court ordered treatment programs and continues to
be dominantly supporting Alcoholics Anonymous and Narcotics Anonymous. A further
limitation was the use of a non-standardized survey instrument, which may have affected
the accuracy of responses.
Further study should include longitudinal studies to explore variables over time.
Information about the clients was gathered by agency staff members at the beginning of
treatment and during the termination stage. The literature most often did not account for
consumers who were unsuccessful and/or dropped out of treatment. The reasons for
dropping from these programs may identify if there are cultural competence barriers
83
between treatment providers, their program and treatment outcomes. Further studies may
also include substance abuse treatment outcomes after a treatment facility incorporates a
cultural competence continuing education class and component for their counselors.
Other variables that need to be included are a cross-sectional study of cultural
competence in substance abuse treatment outcomes with secular and non-secular
treatment groups; as well as urban and rural needs assessments.
A hospitable environment can be arranged for a new treatment that will respect
different traditions and religions across cultures to become inclusive to Muslims, Taoists,
Buddhists, Ua Dabist, and Atheists alike, or other beliefs and their societal meanings to
substance use and co-occurring disorders. Another option may be created from the need
of minority groups to establish and comprise their own unique program that is understood
best by their community members. Native Americans will be able to apply their
community efforts, instead of the individual assumptions of the current Western medical
descriptions. The Asian and Pacific Islanders will be led by their own inference to gather
the proper tools in hopes that awareness will bring relief to ailing addictions and mental
health issues. This population was the least likely to engage in treatment and views
consumption of alcohol and other drugs differently. All religious and spiritual aspects
from the strictly enforced societal norms of the 12-step model will be left to worship and
be integrated by members outside of these parameters.
Because we have an ever increasing need for knowledge in our expanding
multicultural society in the United States, social workers and persons working within the
substance abuse/ addiction fields should inform themselves of the dynamics involved in
84
cultural competence as it relates to treatment outcomes. Failure to understand these
relationships may result unsuccessfully in the way people perceive, accept and retain
treatment in their communities for alcohol and other drug addictions. The findings of this
study should be utilized to engender further research and the subsequent dissemination of
research findings to the field of social work as well as other helping professions.
Continuing research in this area will assist social workers in addressing the cultural needs
of the diverse populous in our State and Country.
85
APPENDICES
86
APPENDIX A
Consent to Participate in Research
You are invited to participate in a research study that is being conducted by Tina
Everhart, and Benet Guidera, Master of Social Work students at the Division of Social
Work, California State University, Sacramento. This study will explore the relationship
between cultural competency in recovery programs and treatment outcomes.
Procedures:
After reviewing this form and agreeing to participate, you will be given a survey to
complete. The survey will take approximately 15 minutes to complete. The survey is
confidential and no names will be recorded. As a participant in the survey, you can
decide at any time not to answer any specific question, skip questions or to stop taking
the survey.
Risks:
The discussion of some of the topics on the survey may illicit some emotional responses
as you consider your knowledge level and the relationship between cultural competency
in recovery programs and treatment outcome. If needed, you can seek mental health
support services through El Hogar at 608 10th Street Sacramento, California 95814. They
can be reached at (916)441-2933. El Hogar provides mental health services for a sliding
fee scale. Sutter Counseling Center also offers mental health support for a sliding fee
scale. They are located at 855 Howe Ave. Suite 1, Sacramento, CA 95825. They can be
reached at (916)929-0808.
Benefits:
The research gained by completing this survey may help others to understand the
relationship between cultural competency in recovery programs and treatment outcomes.
In addition, by being part of this study you may gain insight into your own knowledge
regarding the relationship between cultural competency in recovery programs and
treatment outcomes.
Confidentiality:
All information is confidential and every effort will be made to protect your anonymity.
Your responses on the survey will be kept confidential. When the completed surveys are
collected, the consent forms will also be collected, but stored in separate envelopes, to
avoid any identification of participants. Information you provide on the consent form
will be stored separately from the completed surveys for the duration of the project. The
final research report will not include any identifying information. All of the data will be
87
reported in aggregate (summary) form only. All of the data will be destroyed
approximately one month (June of 2011) after the project is filed with Graduate Studies
at California State University, Sacramento.
Compensation:
Participants will not receive any kind of fiscal compensation.
Rights to Withdraw:
If you decide to participate in this survey, you can withdraw at any point. During the
survey you can elect not to answer questions or stop at any time.
If you have any questions you may contact the researchers, Benet Guidera (916) 8691025 or Tina Everhart (530) 559-3394.
Or, if you need further information, you may contact the researcher’s project advisor:
Maria Dinis, Ph.D., MSW
California State University, Sacramento
(916) 278-7161
dinis@csus.edu
I have read the descriptive information on the Research Participation cover letter. I
understand that my participation is completely voluntary. My signature or initials
indicate that I have received a copy of the Research Participation cover letter and I agree
to participate in the study.
Signature or Initials: ________________________________Date: __________________
Again, if you have any questions you may contact the researchers, Benet Guidera (916)
869-1025 or Tina Everhart (530) 559-3394.
Or, if you need further information, you may contact the researcher’s project advisor:
Maria Dinis, Ph.D., MSW
California State University, Sacramento
(916) 278-7161
dinis@csus.edu
88
APPENDIX B
Chemical Dependency Treatment Programs and Outcomes: Cultural Competency
The first set of questions asks for information for demographic purposes. Please mark or
circle the appropriate response.
A. What is your age?
1.
Less than 35 years old
2. More than 35 years old
B.
What is your education level?
1. Some High School
2.
High School or Some College
3. College Graduate
C.
What is your race?
1.
Caucasian
2. African American
3. Hispanic
4. Asian
5. Other Please Describe:______________________
D. What is your gender?
1.
Male
2. Female
3. Other
E. What is your religion?
1. Catholic
2. Protestant
3. Other, Please Describe:_____________________
F.
How many years have you practiced in this field?
1.
Less than 5 years
2. More than 5 years
89
The next set of questions asks for your level of agreement/disagreement based on the
scale of strongly agree to strongly disagree.
G. A client’s age is a factor in treating them for substance abuse addictions.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
H. A competent professional (five or more years) in a direct practice setting, can work with
any client.
Strongly Agree
1
I.
Disagree
3
Strongly Disagree
4
An experienced clinician (five or more years) in a direct practice setting does not have a
need for continuing education-cultural competence training.
Strongly Agree
1
J.
Agree
2
Agree
2
Disagree
3
Strongly Disagree
4
Agency staff utilizes bi-lingual interpreters when working with non-English speaking
clients.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
K. Agency staff routinely discusses barriers to working with people of different genders.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
L. Agency staff utilizes culturally related educational information during their client’s ongoing treatment.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
M. Agency staff routinely discusses barriers to working with people of different races.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
N. Agency staff routinely discusses barriers to working with people of different religions.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
90
O. Agency staff discusses cultural issues with clients throughout the treatment process.
Strongly Agree
1
P.
Agree
2
Disagree
3
Strongly Disagree
4
Agency displays and offers culturally diverse materials in the lobby.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
Q. Agency refers clients to community self help groups to achieve cultural competence.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
R. Agency considers abstinence as the only form of positive treatment outcome to achieve
cultural competence.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
S. Clients are court ordered into this facility’s drug treatment program because we are
known to have a cultural competence program component.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
T. A client’s drug of choice has an effect on a client’s treatment outcome.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
U. Client’s motivation is more predictive of success in treatment outcome than the type of
program itself.
Strongly Agree
1
V.
Agree
2
Disagree
3
Strongly Disagree
4
12-step programs are successful because they are culturally competent.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
W. Social model programs are successful because they integrate culturally competent
components.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
91
X. Disease model programs work because they integrate culturally competent
components.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
Y. The range of treatment success is a positive completion rate of 50 – 75%.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
Z. Some program components here are delivered by bi-lingual counselors.
Strongly Agree
1
Agree
2
Disagree
3
Strongly Disagree
4
92
REFERENCES
Adrian, M. (2002). A critical perspective on cross-cultural contexts for addiction and
multiculturalism: Their meanings and implications in the substance use field.
Substance Use & Misuse, 37(8-10), 853-900.
Alcoholics Anonymous. (2001). Alcoholics anonymous: The big book. (4th ed.). New
York: Alcoholics Anonymous World Services, Inc.
Alcohol and Other Drug Policy Institute. (2010). Training, Consultation and Technical
Assistance Services - BETA. Retrieved May 8, 2010, from
http://www.aodpolicy.org/tcta.htm.
American Psychiatric Association. (1980). Substance abuse: Position statement.
Retrieved April 5, 2010, from
http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRela
ted/PositionStatements/198005.aspx.
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental
Disorders. (4th ed.). Washington, DC: Author.
Amodeo, M., Jones, L. K. (1998).Using the AOD cultural framework to view alcohol
and drug issues through various cultural lenses. Journal of Social Work
Education, 34(3), (387-399).
An-Na’im, A. (1994). Cultural transformation and normative consensus on the best
interests of the child. International Journal of Law and the Family (8), 62-81.
Apanovitch, D., (February, 1998). Religion and rehabilitation: The requisition of god by
the state. Duke Law Journal,47(4), 785-852.
93
Appel, J., Backes, G., Robbins, J., (2004). California’s proposition 36: A success ripe for
refinement and replication. Drug Policy Alliance, 3(4), 1001-1009. Retrieved
May 10, 2010, from
http://www.drugpolicy.org/docUploads/CPP410_Appel_1st.pdf.
Babbie, E., & Rubin, A. (2008). Research Methods for Social Work (7th ed.). Belmont,
CA: Brooks/Cole.
Barnes, L., (2004). Concept paper: Culturally competent care. Paper presented at the
Consensus Building Meeting for the Culturally Competent Nursing Modules May
2004 (CCNM) project. Retrieved April 5, 2010, from
https://www.thinkculturalhealth.hhs.gov/Documents/CCNMConceptPaper_Barne
s.pdf.
Barron, J. (1996, June 12). Court lets inmate refuse alcohol program. The New York
Times.
Bernstein, R., & Edwards, T., (August, 2008). An older and more diverse nation by
midcentury. Retrieved March 5, 2010, from
http://www.census.gov/newsroom/releases/archives/population/cb08-123.html.
Berk, L., (2004). Temperance and prohibition era propaganda: A study in rhetoric
alcohol, temperance and prohibition. Brown University Library Center for
Digital Initiatives. Retrieved February 13, 2010, from
http://dl.lib.brown.edu/temperance/essay.html.
Bloland, H. G., (September, 1995). Postmodernism and higher education. Journal of
Higher Education, 66(5), 521-559.
94
Bloom, B., Owen, B., Covington, S., (2002). A theoretical basis for gender-responsive
strategies in criminal justice. Paper presented at the American Society of
Criminology Annual Meeting, Chicago, Illinois, November 2002. Retrieved June
1, 2010, from http://www.centerforgenderandjustice.org/pdf/6.pdf.
Breggin, P. R., (2003). Psychopharmacology and human values. Journal of Humanistic
Psychology, 43(2), 34-49.
Brodsky, A. & Peele, S. (November, 1991). AA Abuse. Reason, 34-39.
CADA. (2009). Court mandated treatment programs. Retrieved
on April 05, 2010, from http://cadasb.org/adult-services/court-mandatedprograms.aspx.
California penal code unabridged. (2010). California: Law Tech Publishing.
Campbell, C., & Alexander, J. (2002). Culturally competent treatment practices and
ancillary service use in outpatient substance abuse treatment. Journal of
Substance Abuse Treatment, 22(3), 109-119.
Castro, F. & Alarcon, E. (2002) Integrating cultural variables into drug abuse prevention
and treatment with racial/ethnic minorities. Journal of Drug Issues 32(3), 783810.
Chambon, A., Irving, A., Epstein, L. (1999). Foucault’s approach: Making the familiar
visible. New York. Columbia University Press.
Chao, A. (2010). Alcohol and other drugs services partners. Retrieved on May 05,
2010, from http://cchealth.org/groups/rhdi/aod.php.
95
Cliff, S. (2005). Culturally sensitive substance abuse treatment for native americans.
Retrieved on March 20, 2011, from http://www.wellbrietynci.
org/Publications/CulturallySensitiveSubAbuseTX.doc.
Cohen, M. B. & Graybeal, C.T., (2007). Using solution-oriented techniques in mutual aid
groups. Social Work with Groups, 30(4), 41-58.
Crowley, T. J., Helzer, J. E., Nathan, P. E., Schuckit, M. A. & Woody, G. E. (1991,
September 22). Evolution of the DSM diagnostic criteria for alcoholismDiagnostic and statistical manual of mental disorders. Alcohol health and
research world. Retrieved on April 5, 2010, from
http://www.accessmylibrary.com/article-1G1-12754641/evolution-dsmdiagnostic-criteria.html.
Department of Health and Human Services. (2002). National survey on drug use and
health: National findings. Retrieved on April 19, 2010, from
http://www.oas.samhsa.gov/nhsda/2k2nsduh/Results/2k2Results.htm#chap2.
Department of Health and Human Services. (2011). Co-occurring substance use disorder
and mental illness. Child Welfare Training Institute. Retrieved April 20, 2010,
from http://www.michiganchildwelfaretraining.com/News/tabid/70/prID/42/CoOccurring-Substance-Use-Disorder-and-Mental-Illness.aspx.
Dessirea, S. & Richardson, S. (2008). How culturally competent do we think we are as we
go into every persons world? Apparently not as much as we wish we were.
Unpublished manuscript. Retrieved on April 5, 2010, from
http://forest.huntington.edu/cccda/files/2009/05/tapp-cccda-manuscript-2008.pdf .
96
Dick B. (1998). The oxford group & alcoholics anonymous: A design for living that
works. (2nd ed.). Hawaii: Paradise Research Publications, Inc.
DiClemenet, C. C., & Prochaska, J. O. (1982). Self change and therapy change of
smoking behavior: A comparison of processes of change in cessation and
maintenance. Addictive Behavior, 7(2), 133-142.
Dominelli, L., (2002). Anti-Oppressive Social Work Theory and Practice. New York:
Palgrave Macmillan. Retrieved March 10, 2010, from
http://books.google.com/books?id=exvv_2qu_d8C&pg=PA96&lpg=PA96&dq=d
ominelli+2002+empowerment+strengths&source=bl&ots=CjpzDOG3nC&sig=9
OYa_ue-tqP7MrTbzrygeOpiLEA&hl=en&ei=QFuGTfPaIIPCsAOM_35AQ&sa=X&oi=book_result&ct=result&resnum=1&sqi=2&ved=0CBkQ6AEw
AA#v=onepage&q&f=false.
Falk, G., (2001). Stigma. New York: Prometheus Books.
Felitti, V. (2004). The Origins of Addiction: Evidence from the Adverse Childhood
Experiences Study. Retrieve on April 05, 2010, from
http://www.acestudy.org/files/OriginsofAddiction.pdf.
Franklin, K. (2007, September). Appellate court rules parolee cannot be forced into 12Step treatment. American Chronicle. Retrieved April 8, 2010, from
http://www.americanchronicle.com/articles/view/37344.
Granovetter, M. (2005). The impact of social structure on economic outcomes. The
Journal of Economic Perspectives 19(1), 33-50.
Guerrini, I., Gentili, C., & Guazzelli, M., (2006). Alcohol consumption and heavy
97
drinking: A survey in three Italian villages. Alcohol & Alcoholism 41(3), 336–
340. Retrieved June 3, 2010, from
http://alcalc.oxfordjournals.org/content/41/3/336.full.pdf+html.
Gurin, P. (2005). New research on the benefits of diversity in college and beyond:
An empirical analysis. Retrieved on December 11, 2009, from
http://www.diversityweb.org/Digest/Sp99/benefits.html.
Hanson, D. J. (2009). Alcohol Research and Statistics: Deceptive Reports. Alcohol
Problems and Solutions. Retrieved on February 24, 2011, from
http://www2.potsdam.edu/hansondj/Controversies/1098894305.html.
Hartigan, F. (2000). Bill W.: A biography of alcoholic’s anonymous cofounder Bill
Wilson. New York: Thomas Dunne Books.
Heather, N. & Stockwell, T. (Eds.). (2004). The Essential Handbook of Treatment and
Prevention of Alcohol Problems. England: John Wiley & Sons Ltd.
Hooker, J. (2009). Race and the politics of solidarity. New York: Oxford University
Press.
Hser, Y., Teruya, C., Brown, A., Huang, D., Evans, E., & Anglin, M., (2006, November
30). Research and practice: Impact of California’s Proposition 36 on the Drug
Treatment System: Treatment Capacity and Displacement. American Journal of
Public Health 97(1), 104-109. Retrieved January 19, 2010, from
http://ajph.aphapublications.org/cgi/reprint/AJPH.2005.069336v1.pdf.
Humphreys, K., (2002). Alcoholics anonymous and 12-step alcoholism treatment
98
programs: Recent developments in alcoholism. Behavioral Science, 16(3), 149164. Retrieved January 10, 2010, from
https://springerlink3.metapress.com/content/p7v245331g671287/resourcesecured/?target=fulltext.pdf&sid=ce2kopuiwsatbj45f4pkdpvb&sh=www.springerl
ink.com.
Inaba, D., & Cohen, W. (2007). Uppers downers and all arounders. Medford: CNS
productions Inc.
International Center for Alcohol Policies. (2002). Drinking age limits. Retrieved April
10, 2010, from
http://www.grsproadsafety.org/themes/default/pdfs/Drinking%20Age%20Limits.
pdf.
Jennings, G. (1968). American culture and drug use. Journal of the American Scientific
Affiliation 20, 104-114.
Judicial Council of California. (2010). Proposition 36 case law: Update. Retrieved on
April 05, 2010, from
http://www.courtinfo.ca.gov/programs/drugcourts/documents/prop36.pdf.
Kathryn Stewart Pacific Institute for Research and Evaluation. (1996). Environmentally
oriented prevention policies for young adults. Alcohol Policy X Paper, October 1:
p. 6.
Kelly, J., Myers, M., Brown, S., (2002). Adolescents affiliate with 12-step groups? A
multivariate process model of effects. Journal Of Studies On Alcohol 63(3), 293304.
99
Krestan, J. (2000). Bridges to recovery: Addiction, family therapy and multicultural
treatment. New York: The Free Press.
Kroehler, C. J., Zanden, V. W., J. & Hughes, M. (2002). Sociology: The core (6th ed.).
New York: McGraw-Hill. Kroanier, C. J. & Vander Zanden, J.W., 2002)
Longshore, D., Evans, E., Urada, D., Teruya, C., Hardy, M., Hser, Y. I., Predergast, M.,
& Ettner, S. (2003). Evaluation of the Substance Abuse and Crime Prevention
Act: 2002 Report. Retrieved June 5, 2010, from
http://www.uclaisap.org/Prop36/documents/Evaluation%20of%20the%20Substan
ce%20Abuse%20and%20Crime%20Prevention%20Act%202002%20Report.pdf.
Mäkelä, K., Arminen, I., Bloomfield, K., Eisenback-Stangl, I., Bergmark, K. H., Kurube,
N., Mariolini, N., Olafsdottir, H., Peterson, J. H., Phillips, M., Rehm, J., Room,
R., Rosenqvist, P., Rosovsky, H., Stenius, K., Swiatkiewicz, G., Woronowicz, B.
& Zielinski, A. (1996). Alcoholics Anonymous as a mutual-help movement: A
study in eight societies. Wisconsin: University of Wisconsin Press.
Markowitz, J. C. (2003). Depression in context: Strategies for guided action.
American Journal of Psychiatry 160, 1366.
Marlatt, G. A. (1998). Harm reduction: Pragmatic strategies for managing high-risk
behaviors (Eds.). New York: The Guilford Press.
Marlatt, G., A. (n.d.). Harm reduction therapy for addictions: Brief therapy for addictions
video series. Retrieved April 19, 2010, from
http://www.psychotherapy.net/video/marlatt-harm-reduction.
Marlatt, G. A. (2007). Harm Reduction. Paper presented at the Second National Harm
100
Reduction Conference November 2007. Retrieved January 10, 2010, from
https://www.onehealth.ca/r_alberta_nwt/video_conferences/E110112AHOA3.pdf.
Miller, W., Meyers, M. S. & Hiller-Strumhofel, S. (1999). The communityreinforcement approach. Alcohol Research and Health 23(2).
Minkler, M. (2005). Community-based research partnerships:
Challenges and opportunities. Journal of Urban Health: Bulletin of the New York
Academy of Medicine 82(2), ii3-ii12.
National Survey on Drug Use and Health NSDUH. (2002). Retrieved February 9, 2010,
from http://www.oas.samhsa.gov/nhsda/2k2nsduh/Results/2k2Results.htm#chap2.
National Association of Social Workers. (2001). NASW Standards for cultural
competence in social work practice. Retrieved April 30, 2010, from
http://www.naswdc.org/practice/standards/NASWCulturalStandards.pdf.
National Association of Social Workers (NASW). (2008). Code of Ethics. Washington
DC: NASW Press.
National Survey on Drug Use and Health (NSDUH). (2002). Illicit Drug Use. Retrieved
May 19, 2010, from
http://www.oas.samhsa.gov/nhsda/2k2nsduh/Results/2k2Results.htm#chap2.
National Institute On Drug Abuse. (2003). Drug use among racial/ ethnic
minorities. Department of Health and human services national institutes of health.
(NIH Publication No. 03-3888). Retrieved on April 5, 2010, from
http://www.drugabuse.gov/pdf/minorities03.pdf.
101
Neuman, L. (1997). Social research methods: Qualitative and quantitative approaches.
MA: Allyn &Bacon
NIDA Notes (2005). National institute of health NIDA the science of drug abuse and
addiction 19(6). Retrieved February 10, 2010, from
http://archives.drugabuse.gov/NIDA_notes/NNvol19N6/DirRepVol19N6.html.
Norcross, J., Krebs, P., & Prochaska, J. (2010). Stages of Change. Journal of Clinical
Psychology 67(2), 143-154. Retrieved December 28, 2010, from
http://onlinelibrary.wiley.com/doi/10.1002/jclp.20758/pdf.
Nunes-Dinis, M., C., (1989). A comparative study of alcohol problems and solutions:
Spain and Portugal. Unpublished master’s thesis, California State University,
Sacramento.
Nyland, David (2010, February 8). Theoretical bases of human behavior in the social
environment. Unpublished lecture notes, California State University, Sacramento.
Nyland, D. (2010). Lecture Foucault. March 3, 2010. CSUS
Orlandi, M. (Eds.), (1992). Cultural competence for evaluators: A guide for alcohol and o
ther drug abuse prevention practitioners working with ethnic/racial communities.
U.S. Department of Health and Human Services. (ERIC Document Reproduction
Service No. ED351387). Retrieved August 10, 2010, from
http://www.eric.ed.gov/PDFS/ED351387.pdf.
Paasche-Orlow, M. (2004, April). The ethics of cultural competence. Academic Medicine
79(4), 347-350.
102
Payne, M. (2005). Modern Social Work Theory (3rd ed.). New York: Palgrave
MacMillan.
Peele, S. (1991, November). AA Abuse. The Stanton Peele Addiction Website. Retrieved
September 5, 2010, from http://www.peele.net/lib/aaabuse.html
Peele, S., Bufe, C., Brodsky, A. & Horvath, T. (2000). Resisting 12-Step Coercion: How
to Fight Forced Participation in AA, NA, or 12-Step Treatment. Arizona: See
Sharp Press.
Pelissier, B. & Jones, N. (2011). A Review of Gender Differences among Substance
Abusers. Federal Bureau of Prisons. Retrieved April 8, 2010, from
http://www.bop.gov/news/research_projects/published_reports/drug_treat/oregend
er_differences.pdf.
Phelps, A. R. & Scheff, T. J. (2004). The challenge of bonding, shame and social death.
Paper presented at the International Center for the Study of Psychiatry and
Psychology October 2004. Retrieved September 3, 2010, from
http://batstar.net/drama/challnge.htm.
Poulin, P. (2004). On resistance: A response to Dr. Paul Hannig’s article, is there a
hole in your sole? International Primal Association. Retrieved on April 5, 2010
from http://primal-page.com/poulin.htm.
Qureshi, N. A., Al-Ghamdy, Y. S. & Al-Habeeb, T. A. (2000). Drug addiction: A general
review of new concepts and future challenges. Eastern Mediterranean Health
Journal(6)4, 723-733.
Rastogi, M. & Wadhwa, S. (2006). Substance abuse among asian indians in the
103
united states: a consideration of cultural factors in etiology and treatment.
Substance Use & Misuse, 41(9), 1239-1249.
Ritzer, G. & Smart, B. (2001). Handbook of Social Theory. CA: Sage Publications.
Roberts, A. & Watkins, J. (2009). Social Workers Desk Reference. New York: Oxford
Press.
Rogers, W. A. (2004). Evidence based medicine and justice: A framework for looking at
the impact of EBM upon vulnerable or disadvantaged groups. J Med Ethics 30(2),
141–145. Retrieved April 18, 2010, from
http://jme.bmj.com/content/30/2/141.full.pdf.
Room, R. (1983). Sociological aspects of the disease concept of alcoholism. Research
Advances in Alcohol and Drug Problems 7, 47-91. Retrieved April 30, 2010, from
http://www.robinroom.net/sociolog.pdf.
Rorabaugh, W.,(1979). The alcoholic republic: An American tradition. New York:
Oxford University Press.
Rosenau, P. & Vaillancourt- Rosenau. P. (1992). Post-modernism and the social
sciences: Insights, inroads, and intrusions. New Jersey: Princeton University
Press.
Royse, D. (2008). Research Methods in Social Work. California: Thomson Brooks/Cole.
Rubin, A. & Babbie, E. (2008). Research Methods for Social Work. California:
Thompson Brooks/Cole.
Schrag, F. (1999). Why foucault now? Journal of Curriculum Studies 31(4), 375-383.
Shriver, J. (2005). Human Behavior and the Social Environment: Shifting Paradigms in
104
Essential Knowledge for Social Work Practice (4th ed.). MA: Allyn & Bacon, Inc.
Substance Abuse and Mental Services Administration. (2008). What is substance abuse
treatment? A booklet for families. MD: DHHS Publication. Retrieved January 10,
2011, from
http://www.kap.samhsa.gov/products/brochures/pdfs/whatissatreatment_08r.pdf.
Thomas, G. (2003). Stages of change, a trans-theoretical model.
A Trans theoretical Model. Retrieved April 14, 2010, from
http://sexworkerswithoutborders.org/101s/harm-reduction-101/stages-of-changea-trans-theoretical-model/.
Tracy, S. (2005). Alcoholism in America from reconstruction to prohibition. Baltimore:
John Hopkins University Press.
Uelmen, G., Abrahamson, D., Appel, J., Cox, A., & Taylor, W. (2002). Substance abuse
and crime prevention act of 2000: Progress report. Drug Policy Alliance.
Retrieved June 1, 2010, from http://www.prop36.org/pdf/Prop36Report.pdf.
Van Wormer, K. (2007). Human behavior and the social environment, micro level:
individuals and families. New York: Oxford University Press.
Volkow, N. (2005). NIDA Addresses disparities in the impact of drug abuse and
addiction. National Institute of Health NIDA the science of drug abuse and
addiction 19(6). Retrieved April 19, 2010, from
http://archives.drugabuse.gov/NIDA_notes/NNvol19N6/DirRepVol19N6.html.
White, W. (2000) Addiction as a disease: Birth of a concept. Counselor, 1(1), 46-51, 73.
Retrieved April 20, 2010, from http://www.bhrm.org/papers/Counselor1.pdf.
105
Wilson, B. (1953). Twelve steps and twelve traditions. The A. A. Grapevine, Inc. and
Alcoholics Anonymous. New York: Alcoholics Anonymous Publishing. Retrieved
April 2, 2010, from http://www.guardureyes.com/GUE/PDFs/The%2012Steps%20and%2012%20traditions.pdf.
Wilson, G. (1997). A postmodern approach to structured dependency theory.
Journal of Social Policy26, 341-350.
Wood, S. (2007). The analysis of an innovative HIV-positive women's support group.
Social Work with Groups 30(3), 9-28.
World Health Organization (WHO). (2011). Global status report on alcohol and health.
Switzerland: WHO Press. Retrieved January 3, 2011, from
http://www.who.int/substance_abuse/publications/global_alcohol_report/msbgsru
profiles.pdf.