Cultural Issues in
Substance Abuse Treatment
Russell F. Lim, MD
Associate Clinical Professor
UC Davis School of Medicine
Department of Psychiatry &
Behavioral Sciences
rflim@ucdavis.edu
38th Semi-Annual Substance Abuse Research Consortium (SARC)
Meeting, Sacramento, CA, September 23, 2008
Agenda-1
 APA Practice Guidelines for the:
 Treatment of Patients with Substance Use
Disorders, 2nd ed., 2006
 Psychiatric Evaluation of Adults, 2nd ed., 2006
 Substance abuse in special populations
 The DSM-IV-TR Outline for Cultural
Formulation
 Ethnocultural Factors in Substance Abuse
Treatment, Straussner, 2001
Agenda-2
 TIP 40- Clinical Guidelines for the
Use of Buprenorphine in the
Treatment of Opioid Addiction,
2004
 TIP 42- Substance Abuse
Treatment for Persons With CoOccurring Disorders (COD), 2005
 TIP 47- Substance Abuse: Clinical
Issues in Intensive Outpatient
Treatment, 2006
General Assessment Principles:
Clinical Factors-1
 The number and type of substances used
 The individual's genetic vulnerability
for developing a substance use
disorder (s)
 The severity of the disorder, the rapidity
with which it develops, and the degree of
associated functional impairment (s)
 The individual's awareness of the disorder
as a problem
General Assessment Principles:
Clinical Factors-2
 The individual's readiness for change and
motivation to enter into treatment for the
purpose of change
 The associated general medical and
psychiatric conditions (either co-occurring or
induced by substance use)
 The individual's strengths (protective and
resiliency factors) and vulnerabilities
 The social, environmental, and cultural
context in which the individual lives
and will be treated
Characteristics of Substance
Abuse Disorders in Women-1
 Information on the natural history, clinical
presentation, physiology, and treatment of
substance use disorders in women is
limited.
 34% of all individuals with a substance
use disorder other than nicotine
dependence in the U.S.
 Women's low utilization of substance use
disorder treatment services may
be related to:
Characteristics of Substance
Abuse Disorders in Women-2
 Psychosocial and financial barriers
(e.g., lack of child care, lack of
health insurance) prevent many
women from seeking treatment.
 Women's perception of greater
social stigma associated with their
substance abuse.
Characteristics of Substance
Abuse Disorders in Women-3
 Higher prevalence than men of primary
co-occurring mood and anxiety
disorders that require psychiatric care.
 Many women with a substance use
disorder have a history of physical
and/or sexual abuse (both as children
and as adults).
 Poorer prognosis for medical sequelae
of alcohol abuse and
dependence in women.
Characteristics of Substance
Abuse Disorders in Women-4
 Alcohol-dependent women consume less
alcohol than men yet progress to late
stages of alcohol-related illness more
rapidly.
 Shorter time course to the initial
development of alcohol-related medical
morbidity than do men.
 Prevalence rates of alcohol-related
cirrhosis of the liver and cardiomyopathy
in women are twice that in men.
Characteristics of Substance
Abuse Disorders in Women-5
 Women frequently initiate cocaine and
opioid use in the context of a
substance-using partner and tend to
initiate use at a younger age than men.
 Tailoring the goals of treatment to meet
the needs of women improves
treatment outcomes for substanceusing women.
Characteristics of Substance Abuse
Disorders in Adolescents-1
 Alcohol and other psychoactive
substance use, abuse, and dependence
in children and adolescents presents a
serious public health problem in the US.
 Substance abuse is among the leading
causes of morbidity and mortality from
motor vehicle accidents, suicidal
behavior, violence, drowning, and
unprotected sexual activity.
Characteristics of Substance Abuse
Disorders in Adolescents-2
 Regional studies reveal that 7%-10% of
adolescents are in need of treatment for
substance use disorders.
 Dual diagnosis is common in most
adolescents with substance use disorders,
most often conduct disorder and/or major
depression, although ADHD, anxiety
disorders (social phobia and PTSD),
bipolar disorder, eating disorders, learning
disabilities, and axis II disorders.
Characteristics of Substance Abuse
Disorders in Adolescents-3
 Outcomes for adolescents appear to
be enhanced by the availability of
treatment that is developmentally
appropriate and peer oriented and
includes educational, vocational, and
recreational services.
 Family therapy also appears to have
benefit.
Characteristics of Substance Abuse
Disorders in Elderly Individuals-1
 Substance use disorders in elderly
individuals are often undiagnosed
and under-treated.
 Abuse of and dependence on
prescribed medications, particularly
benzodiazepines, sedative-hypnotic
medications, and opioids.
Characteristics of Substance Abuse
Disorders in Elderly Individuals-2
 Alcohol use disorders, whether an
extension of a long-standing disorder or
of later onset, are a major problem
among elderly individuals, particularly
those living alone.
 A large multi-site study (PRISM-E) has
shown that elderly primary care patients
screening positive for a substance use
disorder prefer to be treated within the
medical system, with integrated
treatment (Bartels SJ, 2004).
Characteristics of Substance Abuse
Disorders in Elderly Individuals-3
 VA patients age 54 years or older
who received specialized services
for elderly patients as part of a
treatment program were four times
more likely to complete the
program and remained in treatment
longer than those who received
conventional services. (Kofoed
LL,1987)
Characteristics of Substance Abuse
Disorders in Cultural Groups
 Treatment services that are culturally
sensitive and address the special
concerns of ethnic minority groups may
improve acceptance of, adherence to,
and, ultimately, the outcome of treatment.
 Current research suggests poorer
prognoses for ethnic and racial minorities
in conventional treatment programs,
although this may be accounted for by
socioeconomic group differences.
Alcohol Use
White
Ethnicity
Total
Hispanic- Cuban
Hispanic- Mexican
Native American
Hispanic- Puerto Rican
African American
Asian-Pacific Islander
68.9
66.4
65.7
63.7
63.7
59.5
55.4
53.2
Source: Office of Applied Studies,
Percentage SAMHSA, 1991-3
Alcohol Dependence
5.6
5.6
Hispanic- Mexican
Ethnicity
Native American
Total
3.5
African American
3.4
White
3.4
3
Hispanic- Puerto Rican
1.8
Asian-Pacific Islander
Hispanic- Cuban
0.9
Percentage
Source: Office of Applied Studies,
SAMHSA, 1991-3
Cocaine
5.2
Native American
3.9
3.7
3.1
2.5
2.4
Ethnicity
Hispanic- Mexican
Hispanic- Puerto Rican
African American
Total
White
Hispanic- Cuban
Asian-Pacific Islander
1.7
1.4
Source: Office of Applied Studies,
Percentage SAMHSA, 1991-3
Illicit Drugs
19.8
Native American
13.3
13.1
12.7
11.9
11.8
Ethnicity
Hispanic- Puerto Rican
African American
Hispanic- Mexican
Total
White
Hispanic- Cuban
Asian-Pacific Islander
8.2
6.5
Source: Office of Applied Studies,
Percentage SAMHSA, 1991-3
Need Treatment
7.8
Native American
Ethnicity
African American
Hispanic- Puerto Rican
Hispanic- Mexican
Total
Hispanic- Cuban
White
Asian-Pacific Islander
3.9
3.7
3.6
2.7
2.6
2.5
1.7
Source: Office of Applied Studies,
Percentage SAMHSA, 1991-3
Substance Abuse
Disorders:
Issues in Hispanic
Americans
Hispanic Americans-1
 Second largest ethnic group in USA
 Mexican-Americans, Puerto
Ricans, Cuban-Americans, and
immigrants from Central and South
American countries
 Heterogeneous
Hispanic Americans-2
 Emphasis on family
 Religious influences
 Tradition of folk healers
 Gender roles
 Styles of communication
Barriers to treatment
 Language
 Inability of staff to earn confianza
 Geographic
 Criminal justice system
 Lack of Hispanic physicians
 Lack of insurance
 Legal status
Treatment Issues
 Hispanics drop out of some types of
drug abuse treatment programs at
higher rates than Anglos (DeLeon,et al,
1992)
 Focus of treatment should emphasize
family values, cultural background
 Culturally appropriate assessment and
engagement is critical
 Therapeutic alliance is key
Effective substance abuse treatment
for Hispanics
 Involve extended family
 Use of folk healers
 Support of church
 Support of merchants, civic
organizations
 Respeto, dignidad, personalismo
Substance
Abuse
Disorders:
Issues in
African
Americans
African Americans
 Importance of religion and spirituality
 Extended family network
 Disproportional high rate of poverty
 Concerns about racial discrimination
 Concerns about privacy
African AmericansBarriers to Help Seeking
 Concerns about stigma
 Mistrust of health professionals
 Belief that prayer alone can heal
 Belief that suffering is a part of life for
Black people
 Criminal justice system
African AmericansAdequacy of Treatment Services-1
 Trust issues in therapeutic relationships
 Cultural sensitivity of care providers
 Ethnically appropriate assessment of
client behavior, symptoms and needs
Cultural Issues in Substance Abuse Treatment CSAT, 1999
African Americans-Adequacy of
Treatment Services-2
Additional services to consider (cont.)
 On site twelve-step programs attended by
members from the ethnic groups in the
area
 Employment of appropriate ethnic staff at
all levels
 Involvement of professional and
paraprofessional counselors from the
recovering community
Cultural Issues in Substance Abuse Treatment CSAT, 1999
Substance Abuse Disorders
in Asian Americans
Introduction to Asian Americans
 Many groups (43) and languages with
separate cultures- Heterogeneous
 Asian/Pacific Americans are one of the fastest
growing ethnic minority groups
 Major groups




Chinese
Filipino
Japanese
Korean
Southeast Asian
(Vietnamese, Cambodian,
Laotian, Hmong, Mien)
South Asian
 Substance abuse is under-reported due to
shame and stigma
Epidemiology
 Published data shows low incidence
 Lack of comprehensive data on many
groups-not included in many studies
 Heterogeneity makes drawing
conclusions difficult
 Language is a barrier
 Stigma and shame
Risk Factors
 Acculturation stress
 Increased freedom
 Alienation from parent culture
 Access to alcohol and drugs
 Traumatic experiences
 Personal losses; loss of supports
Assessment Issues
 Be familiar with the immigration
history of the group
 General knowledge-Cultural norms
 Specific knowledge-Migration
history
 Cultural consultation
 Delay screening of habits
Treatment Issues
 Know the cultural values
 Bilingual and bicultural staff
 Trauma issues in immigrants
 Awareness of shame and stigma
 Community based treatment
 Using culturally acceptable
treatment approaches
Substance Abuse Disorders:
Issues in American Indians
Sarah Penman, Buck Bear Heart, Lakota Nation, South Dakota, 1998
Historical and Sociocultural
Factors
Impact of Colonization
 Loss of knowledge and traditions
 Impact of disease from colonial contact
 Forced relocation from the land
 Removal of children from the family
Demographics-1
 Over 560 federally recognized
tribes
 Over 250 distinct languages among
tribes
 Most American Indians live in
Western States
 44% live in rural areas
Demographics-2
 (1997-99) 26% live in poverty
 Life expectancy 63.5 years
 Median age 27.8 years
 (1990 –01) population increased
22.4% to 2.5 million
Epidemiology-1
 5th leading cause of death chronic
liver disease and cirrhosis
( MMWR,CDC, 1994-96 )
 20% 12 – 17 yr olds illicit drug use
(SAMSHA Household Survey , 1999)
 Death rates due to alcoholism 7 x
greater then general population
 Suicide 1.5 x national rate
Epidemiology-2
 70% with lifetime alcohol disorder
and psychiatric disorder
(Robin et.al 1997)
 Fetal Alcohol Syndrome rate 3x
higher than for all other groups
2.97 per 1,000 births
(CDC , 1998)
 PTSD prevalence rate 2.75 x
higher than general population
(Kessler et al., 1995)
Surgeon General’s Recommendations
 Improve Access to Treatment
 VA/Tribal Outreach Projects-PTSD,
Depression, Substance Abuse highly comorbid. Natives teach Natives.
 Reduce Barriers to Care
 Tribal Health Programs
 Chapter Houses, Lodges
 Medicine Person/ Healers
 Sweat Lodge, Ceremonies
 Community Fairs, Pow Wow’s, Rodeo Circuit
 Denver Pow Wow – Eagle Lodge (Residential
Drug and Alcohol) sponsors dancers
& crafts booth
Characteristics of Substance
Abuse Disorders in GLBT
 Multiple studies do indicate increased
rates of drug use among gay and
bisexual sexually active men and lesbian
women compared with exclusively
heterosexual men and women, with a
prominence of cannabis and nicotine
dependence for both homosexual men
and lesbian women.
 Special therapeutic strategies have been
developed that target known regional
associations between sexual
orientation and substance abuse.
DSM-IV TR Outline for Cultural
Formulation
 Included in the text of the APA
Practice Guideline for the
Psychiatric Assessment of Adults,
2nd Edition, American Journal of
Psychiatry, June 2006 supplement
 Subject of the Clinical Manual of
Cultural Psychiatry edited by
Russell F. Lim, MD, APPI, 2006
DSM-IV TR Outline for Cultural
Formulation
A. Cultural identity of the individual
B. Cultural explanations of the
individual’s illness
C. Cultural factors related to
psychosocial environment and
levels of functioning
DSM-IV TR Outline for Cultural
Formulation
D. Cultural elements of the
relationship between the individual
and the clinician
E. Overall cultural assessment for
diagnosis and care
A. Cultural identity of the individual
 Ethnicity
 Race
 National origin/Indigenous culture
 Migration/acculturation/bi-culturality
 Language (s)
 Age
 Gender
 Sexual orientation
Cultural identity—Think widely
 Religious/spiritual beliefs &
practices
 Socioeconomic status
 Political orientation
 Geographic location
 Disabilities
 Other aspects of identity, such as
vocation
Can health disparities be caused by the
clinician’s poor understanding of the
patient’s culture?
 Clinicians can prematurely close on and
make assumptions about the person’s
cultural identity, then make erroneous
assessments, diagnosis and treatment
plans.
VERSUS
 Clinicians will enhance rapport and the
therapeutic relationship by being
respectful to the whole person including
his/her cultural identity for improved
adherence.
B. Cultural expressions and
explanations of illness-1
 Idioms of distress
 Meaning and perceived severity of
symptoms in relation to the norms
of the cultural reference group
B. Cultural expressions and
explanations of illness-2
 Culture-Bound Syndromes
 Explanatory model (s)- cultural
healing rituals
 Treatment pathway(s)—history and
expectations (professional and
popular sources of care)
C. Cultural factors related to
psychosocial environment and levels of
functioning
 Stressors and social supports
 Religion and kin networks
Culturally related strengths and
supports: Personal strengths (Pamela
Hays, 2007)
 Culturally-related knowledge and
practical skills
 Culture-specific beliefs that help one
cope
 Respectful attitude toward the natural
environment
 Commitment to helping one’s own
group
 Wisdom from experience
Culturally related strengths and
supports: Environmental conditions
 An altar in one’s home or room to honor
deceased family members and ancestors
 A space for prayer and meditation
 Foods related to cultural preferences
(cooking and eating)
 Pets
 A gardening area
 Access to outdoors for subsistence or
recreation
Recommended References
Hays P. Addressing Cultural Complexities in
Practice, 2nd ed. Washington, DC: APA
Press, 2007
Josephson A, Peteet J (eds.). Handbook of
Spirituality and World Views in Clinical
Practice. Washington, DC: APPI, 2004
McGoldrick M, et al (eds.). Ethnicity and
Family Therapy, 3rd ed. New York: Guilford
Press, 2005
D. Cultural elements of the
relationship between the
individual and the clinician
 Intra-ethnic and inter-ethnic
transference/counter-transference
 Clinical methods
 Mental status exam
1. Understand the cultural identity of
the clinician through self-reflection.
 Be aware of and understand one’s
own personal and professional
identity development.
 Be aware of biases and limitations
of knowledge and skills that might
affect the clinical encounter.
2. Compare the cultural identity of the
patient to that of the clinician.
 Compare the cultural identity variables for
similarities and differences.
 Go beyond a categorical approach to
understanding of self-construal of identity.
 Factor in the context of the clinical
encounter.
 Look for problems in the clinical
encounter, assessment and treatment that
might arise from similarities and
differences.
3. Assess the cultural elements of
the relationship in an ongoing
way.
 Rapport and respect
 Dealing with stigma and shame
 Empathy
 Communication, verbal and non-verbal
 Transference and counter-transference
 Involvement with significant others,
community organizations
E. Overall cultural assessment
for diagnosis and care
 Culturally congruent treatment plan
 Cultural consultants
 Diagnosis- Category fallacy vs.
cultural relativism
Differential diagnosis: The goal
is a more accurate diagnosis.





Axis I and II psychopathology
-Age, gender, cultural considerations
Cultural phenomena
Cultural idiom of distress
Culture-Bound Syndrome
Sign or symptom of
psychopathology Sign or symptom
of a V code diagnosis
Differential diagnosis: Issues
 Misdiagnosis due to:
 Cultural idioms of distress, explanatory
models, treatment pathways
 Inadequate relationship to gather history
 Clinician bias,stereotyping, clinical
uncertainty
 Prevalence may vary by culture/gender.
 Misdiagnosis can lead to mis-treatment.
 Course and outcome may vary by
culture/gender.
Treatment planning-1
 Process
 Negotiate and manage a treatment plan
to maximize adherence/compliance
 Content
 Biological
 Psychological
 Sociocultural
Treatment planning-2
 Biological
 Medication pharmacodynamics and
pharmacokinetics may vary due to:
 Genetics related to race/ethnicity
 Diet
 Environment
 Interaction with herbal medications
 Medication adherence/compliance strategies
 Medication combined with other biological
approaches such as acupuncture?
Treatment planning-3
 Psychotherapy
 Patient/family expectations and goals
 “Be the Tiger Balm oil at the first interview.”
-Evelyn Lee, Ed D
 Family vs. individual vs. group
 Supportive vs. Cognitive-Behavioral vs.
Insight-oriented
 What cultural modifications in therapy would
help?
 What therapist characteristics would
facilitate/hinder treatment?
Treatment planning-4
 Sociocultural Approaches
 Utilize cultural strengths when possible
such as:
 Family
 Spiritual/religious beliefs/practices
 Work with other systems of care such as:
 Primary care
 Faith organizations and leaders
Ethnocultural Factors in Substance
Abuse Treatment, Straussner, 2001
 Six sections, twenty chapters
 Assessment
 Specific Populations
 African
 Native American & Latino
 European
 Middle Eastern
 Asian
TIP 40- Clinical Guidelines for the Use
of Buprenorphine in the Treatment of
Opioid Addiction, 2004
 The presence of certain life circumstances
or co-morbid medical or psychosocial
conditions warrant special attention during
the evaluation and treatment of opioid
addiction with buprenorphine.
 Pregnant women, adolescents, geriatric
patients, patients under the jurisdiction of
the criminal justice system, and healthcare
professionals who are addicted
TIP 42- Substance Abuse Treatment for
Persons With Co-Occurring Disorders
(COD), 2005- Homeless
 Address the housing needs of clients.
 Help clients obtain and maintain housing.
 Address real-life issues in addition to
housing, such as children, healthcare
needs, legal and pending criminal justice
issues, Supplemental Security
Insurance/entitlement applications.
 Work closely with shelter workers and
other providers of services to the
homeless.
TIP 42- Substance Abuse Treatment for
Persons With COD, 2005-Community
Treatment
 Recognize special service needs.
 Give positive reinforcement for small
successes and progress.
 Clarify expectations regarding response to
supervision.
 Use flexible responses to infractions.
 Provide ongoing monitoring of symptoms.
 Design highly structured activities.
 Give concrete directions.
TIP 42- Substance Abuse Treatment for
Persons With COD, 2005- Adaptations
for Women-1
 Identify and build on each woman's
strengths.
 Avoid confrontational approaches –
Instead, use supportive interventions in
the early stages of treatment.
 Teach coping strategies, based on a
woman's experiences, with a willingness
to explore the woman's individual
appraisals of stressful situations.
TIP 42- Substance Abuse Treatment for
Persons With COD, 2005- Adaptations
for Women-2
 Arrange to meet the daily needs of
women, such as childcare and
transportation.
 Have a strong female presence on staff.
 Promote bonding among women.
 Develop programs for both women &
children.
TIP 42- Substance Abuse Treatment for
Persons With COD, 2005 Adaptations
for Women-3
 Offer program components that help
women reduce the stress associated with
parenting, and teach parenting skills.
 Provide interventions that focus on
trauma and abuse.
 Foster family reintegration and build
positive ties with the extended/kinship
family.
TIP 47- Substance Abuse: Clinical
Issues in Intensive Outpatient
Treatment, 2006
 Many assumptions and approaches
used in intensive outpatient treatment
(IOT) programming were developed for
and validated with middle-class,
employed, adult men.
 Chapter 9: the justice system
population, women, people with cooccurring mental disorders, and
adolescents and young adults.
TIP 47- Substance Abuse: Clinical
Issues in Intensive Outpatient
Treatment, 2006: Chapter 10
 Review of current research that supports
the need for individualized treatment that
is sensitive to the client's culture
 Principles in the delivery of culturally
competent treatment services
 Topics of special concern, including
foreign-born clients, women from other
cultures, and religious considerations
 Clinical implications of culturally
competent treatment
TIP 47- Substance Abuse: Clinical
Issues in Intensive Outpatient
Treatment, 2006: Chapter 10
 Sketches of diverse client populations,
including
 Ethnic groups (Af AM, As AM, Hisp., NA)
 Persons with HIV/AIDS
 Lesbian, gay, and bisexual (LGB) populations
 Older adults and Persons with physical and
cognitive disabilities
 Rural and Homeless populations
 Resources on culturally competent
treatment for various populations
Conclusions
 Cultural competence is critical in
assessment and treatment
 DSM-IV-TR Outline for Cultural Formulation
 Ethnic groups are heterogeneous
 Cultural consultation-cultural norms
 General and specific cultural knowledge
 Engage the family and the community
 Treatment must be in the cultural context of
the patient and his or her values
and belief systems
Questions?
Internet Links
 APA Practice Guideline for the Treatment of Patients with Substance
Use Disorders, 2nd edition, 2006
(http://www.psychiatryonline.com/content.aspx?aID=141079)
 APA Practice Guideline for the Psychiatric Evaluation of Adults, 2nd
edition, 2006
(http://www.psychiatryonline.com/pracGuide/pracGuideTopic_1.aspx)
 TIP 40- Clinical Guidelines for the Use of Buprenorphine in the
Treatment of Opioid Addiction, 2004
(http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.72248)
 TIP 42- Substance Abuse Treatment for Persons With Co-Occurring
Disorders, 2005
(http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.74073)
 TIP 47- Substance Abuse: Clinical Issues in Intensive Outpatient
Treatment, 2006
(http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.88658)
Clinical Manual
Contact Information:
Russell F. Lim, MD
Associate Clinical
Professor
2230 Stockton Blvd.
Sacramento, CA
95817
rflim@ucdavis.edu
916-734-5070 x
60190
Fax 916-875-1086