Cultural Considerations in SUD Treatment for African Americans

I want to preface this article by acknowledging there is no single type or description of a Black or African American person, we are very different depending on our upbringing, lifestyle and personal experience. I don’t want to stereotype and I don’t want you to do so either. These are my personal and professional observations that apply to many but not all African Americans.

As most people know, alcohol and other drug addictions have had a major impact on the African American community, destroying far too many Black families and communities. I grew up on the southside of Chicago and my once thriving neighborhood now looks like a war-zone, where it is not safe to walk the streets. The transformation is due largely to the massive drug problem and all the things that ripple from that, such as gangs, violence, poverty, incarceration, overdoses, etc.

In regards to substance abuse, the short term relief one achieves from the use of alcohol and other drugs seduces many African Americans who are looking for a way out of the stress, frustration, pain, pressure and sense of hopelessness associated with decades of continued systemic oppression, the perceived absence of equal opportunity, which has resulted in a culture wide condition known as PTSS – Post Traumatic Slavery Syndrome. (Dr. Joy De-Gruy-Leary, 2005)

The fast money associated with the illegal drug trade long seen as a way out of the poverty-stricken ghettos of our nation has fueled the Black-on-Black, drug-related violence that is rampant in African American communities across the nation. In some Black communities drug dealers are actually seen as heroes because of their flashy cars, jewelry, and lifestyles. I remember in 1986 in Oakland, California after Felix Mitchell, a then very popular drug dealer was killed in prison, he was given a traffic stopping, Rolls Royce and horse drawn funeral procession down San Pablo Ave fit for a king.

The gangster rap music, so popular with our Black youth, further glamorizes drug using and the drug dealing lifestyle; so much so that many young Blacks are anxious to make a career out of the drug business. (Centers and West, 1998)

The so-called opioid epidemic that we are hearing so much about now and even the proliferation of fentanyl is not new to the Black Community. There has been an opioid epidemic in the Black Community since the 1960s, most notably heroin (Greene, 2018). Fentanyl was also present in the 1980s, and its impact was tragically felt, as evidenced by my best friend’s death from a fentanyl overdose in 1981. Moreover, the introduction of crack cocaine in the late 1980s and the ensuing hysteria surrounding the crack epidemic had a particularly devastating effect on the African American community. The crack epidemic led to sharp increases in violence, crime, prostitution, child abuse, and neglect, deeply affecting the well-being of Black families and communities (Alexander, 2012).
Interestingly, I suggest that the classification of an epidemic often varies based on the demographics affected. When drug-related issues predominantly affect urban, low-income, minority communities, they might not receive the same level of attention and aggressive policy response as when these problems begin to impact more affluent, predominantly white suburban areas (Dawkins, 2020). The disparity in the response to drug epidemics based on race and socioeconomic status is a critical issue that demands attention and reconsideration of current drug policies and public health approaches.

Although there was no empirical evidence to support the concept of the “crack baby”, the on-going media campaign (in 1986, the cover of TIME magazine and more than 400 crack cocaine reports on NBC alone) served to manufacture public support for a criminal approach to the 1970’s War on Drugs. This public policy is directly responsible for the 800% increase (since 1986) in the number of African American women behind bars, significantly higher sentencing laws for crack cocaine related arrests and subsequently more Blacks being in jail for longer periods of time (Glenn, 2006; Boyd, 2004).

According to One in 100: Behind Bars in America 2008, a study released in January by the Pew Charitable Trusts – Public Safety Performance Project, more than one in every 100 adults in the United States is either in jail or prison. For African Americans those numbers are even higher with, 1 in 9 Black males ages 20-34 and 1 in 100 black women ages 35-39 was incarcerated (Bureau of Justice Statistics, 2006) making “the disparity in arrest rates alone one of the most devastating consequences of substance abuse among African Americans, affecting the abuser, their families and communities” (NIDA, 2003), There was time in the 1990’s where it was reported that there were more Black men in prison than in college (Lewin, 1991; Western & Pettit, 2000).

Substance abuse in the African American community and its associated collateral consequences, including homelessness, mental illness, crime, and increased foster care costs, have emerged as one of the most significant public health challenges in the United States (Herbeck et al., 2015; SAMHSA, 2019; Williams et al., 2017). As addiction continues to escalate, these issues also progress, creating a complex web of challenges that disproportionately affect African American individuals and communities.

Although there have been no large-scale empirical studies to examine the issue of cultural competency and substance abuse treatment for African Americans, the California Department of Alcohol and Drug Programs has adopted the Institute of Medicine model for inclusion in their Continuum of Services System re-design; acknowledging the importance of an ongoing commitment to institutionalize an appropriate set of practices and policies to ensure inclusion and respect of diversity in the delivery of culturally and linguistically appropriate services. (Howard, 2003; IOM, 2006; ADP, 2007), I actually worked on the task force to adapt the CLAS Model to SUD treatment.

Historically treatment programs have tried to fit everyone into a “one size fits all” model, failing to customize treatment modalities to accommodate the different cultural needs, experiences and beliefs of the individual client.

Treatment requires trust, honesty and self-disclosure, and if the client is unwilling or unable to do these things, the program will not be successful. Many African American clients have problems becoming engaged in the treatment process and are not comfortable talking opening up about their genuine issues due to cultural norms that forbid “putting your business in the street”, coupled with an assumption that the provider and the non-Black clients won’t and don’t understand or relate to them. Also, due to a history of oppression, discrimination, and racism, persons of color tend to have an understandable mistrust of bureaucratic systems and services provided by persons viewed to be the oppressor (Sue & Sue, 1990).

Therefore, African Americans are either failing to successfully complete the program, or are being discharged for noncompliance at higher rates. This is especially important when we consider that most African Americans gain access to treatment through the criminal justice (men) and/or child welfare system (women) and failure to successfully complete treatment often results in loss of family (parental rights), loss of livelihood, a felony conviction with a long jail sentence, and/or a return to previous drug use.
Once convicted of a felony, he or she has a whole new set of obstacles to overcome. Some of the consequences of a felony conviction may include not only the lifetime loss of the right to vote (in many states), but also possibly the loss of many educational opportunities and social support services, as drug felons may not be able to obtain federal financial aid, food stamps, or public housing assistance.

There are also limited job options for drug felons as many employers will not hire an individual who answers yes to the question “have you ever been convicted of a felony”, regardless of whether the person served his time. All of these obstacles combined are a set up for recidivism, and what we know about addiction is that a failed treatment experience often leads to relapse. Unfortunately, there are no numbers on how many people who relapse never make it back for a second try at treatment, but we do know that the disease of addiction is so insidious and deadly, that for many people the next time they use can be the last time they use. At the very least, a relapse or a poor treatment experience can extinguish the desire to be clean and sober. In my book, Relapse Prevention Counseling for African Americans, self-image and hopes for the future were frequently impacted by the individuals’ perceptions of race. Therefore, it could be said that “the obstacle to engagement in treatment is not an absence of pain; it is an absence of hope” (Quoted in White, Woll & Webber, 2003).

We, as a treatment industry, need to ensure that the treatment we provide our clients affords them the best possible chance for success. We must continually strive to improve our ability to provide culturally competent services, delivered by trained and compassionate staff.

In doing so, we must offer resources, technical assistance and other training opportunities to our treatment teams; meet with decision makers at administrative levels to ensure that policies and systems are developed and implemented which allow African American clients to feel welcomed, understood, safe and cared for (Bell, 1990).

Below are some guidelines to consider when developing or evaluating a program serving African Americans. Each issue area is a significant component of a comprehensive, culturally competency treatment model.

Environment

The treatment environment should be welcoming to the African American client. It does not need to be in a Black neighborhood, but it should be easily accessible to the client (transportation is one of the top three reported barriers to treatment for women). It should aesthetically be made to feel comfortable and inclusive to the client, with photos, literature, artwork, etc. that portray African Americans in a healthy way.

There should be sufficient space for private and confidential consultation. The facility should be warm, clean, and in good repair. Often times when a program caters to Black clients, they are not as concerned with the upkeep of the environment and the space is not well maintained. Clients should not see the environment as punishing or demeaning, but instead as a clean and safe place to heal.

Staff

Having a skilled and dedicated staff is paramount in ensuring the effectiveness of a treatment program, as they play a pivotal role in providing day-to-day clinical services and embodying the program’s guiding principles (SAMHSA, 1999). Clients rely on the staff for guidance, support, and leadership, making it essential for the staff to be well-trained and equipped with both academic knowledge and interpersonal skills to comprehend and embrace cultural diversity. The interactions between the clients and program staff can significantly influence the success of a client’s treatment experience.

African Americans have unique historical and contemporary experiences that come into play during the therapist/client relationship. Cultural differences between treatment providers and clients can hinder program efforts and client satisfaction, unless adjustments are made to accommodate the client’s values, behaviors, and cultural traits (Finn, 1994).

Although not required, but certainly preferred, is that a program that treats African American clients should have some African Americans on the treatment team, as it helps the client to see someone of color represented on the staff roster. You don’t have to be Black to help a Black addict, but a multidisciplinary and multicultural team is most effective in providing substance abuse treatment (Sue & Sue, 1999).

Staff should have cultural competency training, which includes an opportunity for them to identify their own cultural prejudices and biases (SAMHSA, 1999). The program leadership should monitor the staff to assure that staff operates in a culturally sensitive manner. Staff should have clinical supervision as it relates to cultural issues and be given an opportunity to discuss and explore the cultural counter-transference issues that are certain to arise in any clinical environment (Baker and Bell, 1999).

Staff should be screened and hired based on their expertise and their ability to work well with all clients. However, the African American client is highly sensitive to anything that resembles prejudice, discrimination, and/or disrespect, so all of the program staff, including clerical and administrative personnel, need to be able to communicate to the client a warm, compassionate, and accepting demeanor.

The Treatment Philosophy

The program’s treatment philosophy should embrace the idea that “one size does not fit all”. Treatment should be individualized based on the specific clinical needs of each client regardless of race or ethnicity. Clients should be assessed at the beginning of their program to determine what clinical issues will be addressed during the course of treatment. Clients with culture-related issues should be given the opportunity to safely discuss their concerns.

The program’s philosophy should recognize that the African American client more likely than not, may have problems related to race that could interfere with their ability to benefit from treatment. When working with culturally diverse clients, it is essential to acknowledge and address the unique challenges they may face, such as difficulties in trusting or relating to people outside of their race, culturally influenced low self-esteem, suspicion due to historical racial prejudice, and feelings of being different and excluded from the community (Leitschuh, Lyles, Kayser, & Budde, 2002). Additionally, issues related to their living and social situations can significantly impact their ongoing recovery. These considerations are relevant for a broad range of culturally diverse clients, including Latinos, Asian-Americans, Pacific Islanders, as well as gay, lesbian, and transgender clients.

To create a supportive environment for these clients, treatment programs should incorporate provisions in their day-to-day structure that encourage open discussions about clients’ circumstances and feelings. This approach enables clients to process their concerns and emotions effectively, fostering a more inclusive and therapeutic atmosphere.

The Program Services and Levels of Care

Ideally, an effective treatment facility should provide a full range of services. In the best-case scenario, the program would offer or have access to the following core services:

• Free Intake Assessment
• One-on-One Counseling
• Intensive Out-Patient
• Residential Treatment
• Drug and Alcohol Awareness Classes (Prevention and Education Case Management)
• Relapse Prevention
• Aftercare

As mentioned earlier in this article, many African American clients come into treatment through the criminal justice system, or other social service-type agencies. Their freedom, livelihood, and in some cases parental rights, are dependent on them successfully completing the program. However, many of these clients do not meet the diagnostic criteria for substance dependence. Many are substance abusers, not addicts; but most treatment programs were developed to treat alcoholics and addicts. There is often not a level of care that addresses the needs of the substance abuser.

Clients are forced to identify themselves as addicts and alcoholics in the program and the 12 Step meetings they are mandated to attend. Some clients resist this labeling and are deemed unwilling and unmotivated. Others become “institutionally compliant” in order to “graduate” the program, but they never talk openly about their situation, their issues or their relationship with drugs. In both cases the client suffers and is likely to have a negative treatment outcome.

The appropriate treatment approach for these clients is often education and prevention rather than a full course of intensive addiction treatment. Programs should have the option of offering other, more clinically indicated interventions to increase the likelihood that clients are actually getting the care they need. Placing clients in the appropriate level of care and providing the appropriate clinical services increases the chances of a positive treatment outcome. (NIDA, 1999)

Aftercare and Follow-Up

The aftercare and follow-up plan is a crucial aspect of treatment that deserves greater attention. For African American clients, in particular, successful recovery post-discharge from treatment is often hindered by multiple challenges. These challenges may include high-risk living situations, exposure to partners or family members who still use substances, peer pressure from old friends, residing in drug-infested neighborhoods, a loss of spiritual connection, and unresolved legal, employment, and child custody issues, among others (SAMHSA, 2017).

To enhance the chances of sustained recovery, a comprehensive and realistic discharge plan should be developed within the treatment program. This plan must address each client’s unique concerns and provide effective strategies for navigating these challenges upon discharge. By proactively tackling these issues, the program can better support African American clients as they transition back into their daily lives and communities.

Regular aftercare support groups or one-on-one sessions should also be made available to the client for a defined period of time, preferably at least one year post discharge. This allows the African American client to develop an ongoing relationship with the program at least through the difficult first few months of recovery. ADP’s Continuum of Services System, includes: support, monitoring and maintenance in the recovery component of the wheel, with proposed services to include a 1-800 number manned by trained relapse prevention specialists and the establishment of formal and information relationships and linkages with critical support systems, such as housing, employment, food assistance, etc.

In summary, alcohol and other drug addiction have had a devastating impact on the African American community. Across the nation, families, neighborhoods, and communities are bearing the brunt of addiction’s effects. A significant number of Black individuals find themselves caught in a vicious cycle of addiction, leading to their incarceration or involvement in institutions. As a consequence, Black children are disproportionately placed in Child Protective Service systems, foster homes, and juvenile halls, with substance abuse being a direct or indirect factor in these circumstances. Studies indicate that without appropriate interventions, these children are at a higher risk of following a similar path as their parents (Bernstein, 2007).

The problem is big, much bigger than we often care to admit as a society. However, there is a solution. We, as a treatment industry, can make a difference; helping to change lives by providing good, comprehensive, well thought out treatment. We can help African American clients by developing programs that work; programs that are sensitive to the fact that race is still a big part of our nation, and help African American clients address the unresolved racial issues that sometimes make it difficult for them to succeed in treatment and recovery.

In 12 Step meetings, there is a common phrase often heard: “focus on the similarities rather than the differences.” While I understand and agree with this sentiment, it is also crucial to acknowledge and verbalize the differences, particularly when working with clients. Engaging in an open dialogue about these differences can be a valuable part of the therapeutic process. As a counselor, it is essential to ask the client directly, “Let’s acknowledge our differences, let’s talk about them, and let’s work together to find ways to address them effectively so that you can receive the help and support you deserve.”

We can step up to the plate and tackle these issues head on, by providing clients with a safe, supportive environment to deal with all of the issues that contribute to their addiction. In doing so, we can change the world, one life at a time.

Bibliography

• Baker, F.M. and Bell, C.C., Issues in the psychiatric treatment of African Americans. Psychiatric Services, 50, 3, 362-368, 1999
• Bell, P. et.al. Developing chemical dependency services for black people. Institute on Black Chemical Abuse, 1990
• Bernstein,M. All Alone in the World: Children of the Incarcerated, New Press, 2007
• Bowser, B.P., Bilal, R. Drug Treatment Effectiveness: African American culture in recovery. Journal of Psychoactive Drugs, 33 (4) 391-402, 2001
• Boyd, S. From Witches to Crack Moms, Women, Drug Law and Policy 208-09, 2004
• Brach, C., & Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review, 57 (Supplement1), 181-217, 2000
• Bureau of Justice Statistics, Prison and Jail Inmates at Midyear 2006
• California Department of Alcohol & Drug Programs, Continuum of Services System Re-Engineering Task Force, Phase II Report, 2007
• Centers, N.L., & Weist, M.D. Inner city youth and drug dealing: a review of the problem. Journal of Youth and Adolescence, 27, 37, 395-411, 1998
• Cross T.L., Bazron, B.J., Dennis, K.W. & Issacs, M.R. Towards a culturally competent system of care, Volume 1. A monograph on effective services for minority children who are severely emotionally disturbed. (CSSAP TA Center, Washington DC), Georgetown University, Child Development Center, 1989
• De-Gruy-Leary, J. Post Traumatic Slave Syndrome: America’s Legacy of Enduring Injury and Healing, Uptone Press, 2005
• Finn, P. Addressing the needs of cultural minorities in drug treatment. Journal of Substance Abuse Treatment, 11, 4, 325-337, 1994
• Glenn, J. The Birth of the Crack Baby and the History that “Myths” Make, Journal of Health Politics, Policy and Law, October 2006
• Howard, D.L., LaVeist, T.A. & McCaughrin, W.C. The Effect of social environment on treatment outcomes in outpatient substance mis-use treatment organizations: Does race really matter? Substance Use and Mis-Use, 31 (5), 617-638, 1996
• Howard, Daniel L., Culturally competent treatment of African American clients among a national sample of outpatient substance abuse treatment units, Journal of Substance Abuse Treatment 24, 89-102, 2003
• Institute of Medicine (IOM), Improving the Quality of Health Care for Mental and Substance-Use Conditions, 2006
• Leitschuh, G., Lyles, J., Kayser, L. and Budde, K. Collaborative Efforts for Engaging African-American and Euro-American Clients with Substance Abuse Counselors in Group Dialogue, Eastern Illinois University, Illinois Counseling Association, November 2002
• Lewin, T. (1991, December 22). More Black Men Are in Prison Than in College, Report Says. The New York Times. https://www.nytimes.com/1991/12/22/us/more-black-men-are-in-prison-than-in-college-report-says.html
• National Institute on Drug Abuse (NIDA), Principles of Drug Addiction Treatment, 1999
• Substance Abuse and Mental Health Services Administration (SAMHSA) – Center for Substance Abuse Treatment (CSAT), Cultural Issues in Substance Abuse Treatment, 2000
• Substance Abuse and Mental Health Services Administration (SAMHSA) – Center for Substance Abuse Treatment (CSAT), Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of Professional Practice – TAP 21, 2002
• Sue, D.W., & Sue, D. Counseling the culturally different: Theory and practice (2nd ed.). New York: John Wiley & Sons, 1990
• The Pews Charitable Trusts – Public Safety Performance Project, One in 100: Behind Bars in America 2008
• Virginia, Department of Mental Health, Mental Retardation and Substance Abuse Services, Current Literature Reviews for Substance Abuse Professionals, October 2003
• Williams, Roland – Relapse Prevention for African Americans, 2007

Roland Williams

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Roland Williams is a nationally recognized consultant, author, trainer and speaker specializing in addiction, relapse prevention, cross cultural counseling, and treatment program development.

He has provided counseling and consulting services to individuals and treatment facilities worldwide, including Switzerland, Holland, France, Dominican Republic, Italy, Thailand, Japan, Russia, Switzerland, India the Philippines and the United Kingdom. Roland has worked with impaired healthcare and legal professionals since 1991. He is the author of The Relapse Prevention Workbook for African Americans, Relapse Prevention Textbook for African Americans and Relapse Warning Signs for African Americans and Recovery is a Verb. Mr. Williams the CEO and Director of Training for the Gorski CENAPS Corp., Mr. Williams has taught addiction studies at several California Universities. For questions or comments, Roland can be reached at roland@rolandwilliamsconsulting.com

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