Engaging African Americans with SUDs in Treatment

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Evidence indicates that client engagement is among the most important evidence-based practices (Duncan, Miller, & Sparks, 2004). You could be a master therapist with expertise in motivational interviewing (MI), cognitive behavioral therapy (CBT), mindfulness meditation, and acceptance and commitment therapy (ACT), and if you cannot keep clients engaged in treatment, your expertise matters little.

Research reveals that African Americans seeking addiction treatment have higher dropout rates than the general population (Sanders, 2013). This column focuses on strategies to engage African American clients in addiction treatment. Topics discussed includes pretreatment engagement, engagement within the first few minutes of contact, and engagement within the first few counseling sessions.

Pretreatment Engagement

In terms of pretreatment engagement, it can be helpful for addiction service providers to ask themselves a range of questions regarding their program, including:

Has our staff been trained in cultural competence with a specific focus on counseling African Americans with substance use disorders (SUDs)?
Does our staff reflect some of the diversity of populations served?
What do the pictures on the walls at the agency and magazines in waiting room say about who is welcomed at the agency? For example, years ago an African American radio station interested in an agency providing counseling services for their radio personalities toured the agency where I worked to see if our agency was a good fit to provide such services. The CEO of that radio station took a look of the pictures on our walls and said, “No African Americans on the wall, no contract!”
When clients visit our agencies, do they expect to see images that reflect their backgrounds? Do they see these images?

Engagement Within the First Few Minutes of Contact

Nearly half of clients seeking outpatient counseling miss their second session (Duncan et al., 2004). This suggests the need for quick engagement. Below are some suggestions which may be helpful in your work with African American clients.

A Warm Greeting

In seminars I ask participants if they have ever worked with a receptionist with a negative attitude. Their laughter indicates that this might be a common experience. It is explained to the audience that receptionists are the most vulnerable to depersonalization, a unique aspect of burnout which allows one to detach from those receiving organizational services. Depersonalization is often caused by having a large caseload or a great deal of contact with the public. Everyone who walks through the agency’s door and who calls the agency are a part of the receptionists’ caseload.

A warm greeting received by African Americans seeking recovery can be perceived by clients as meaning that they are welcome there. It is important for programs to make sure they provide necessary support to receptionists in order for them to keep their customer service high.

A Short Wait

While there may be good reason to keep clients sitting long in the waiting room, a short wait says to clients in general, and African American clients specifically, that we value them and their time.

An Inviting and/or Attractive Waiting Room

This says to clients, “You’re important.” While this may seem unimportant, many African Americans report having customer service experiences in the broader community that says, “You are not important.”

Counselor Hospitality

When greeted by counselors in the waiting room, a sincere smile, positive service energy, a handshake, eye contact, and a tour of the agency can go a long way towards facilitating rapport before the first session with clients. This hospitality says to African American clients, who may have often experienced poor customer service in the broader community, that they are valued here.

Engagement Within the First Few Counseling Sessions

Engagement during the first few sessions is important in order to retain clients in treatment. Engagement strategies with African American clients includes:

Utilize a Strength-Based Approach

A strength-based approach involves asking questions like the following:

“What are your strengths?”
“What do you do well?”
“How did you survive that?”
“What have you learned from what you have gone through?”
“Which of your experiences have taught you the most about your own experiences?”

In addition, a strength-based approach with African American clients indicates that your work together with not be guided by deficits or negative stereotypes.

Have Respect for Culture

Asking African American clients questions like, “How do you view this challenge from your cultural perspective” or “How are challenges like this addressed from your cultural perspective?” can go a long way towards sending the message of cultural respect.

Be Aware of Microaggressions

Microaggressions are intentional or unintentional slights which, if unaddressed, can rupture the clinical relationship (Sue & Sue, 2012). For example, telling African American clients they “speak good English” could be perceived by clients to mean that you do not expect African Americans to speak “good English.” Paying attention to body language and facial expressions as we interact with clients will give us a clue as to how our words are affecting them.

Should we detect client discomfort based upon our words, a simple statement such as, “You looked uncomfortable when I said that” can begin the process of repairing damage, along with listening to their responses. A proactive way to deal with microaggressions is to let clients know early in the counseling relationship that you will try to pay attention to how your words affect them and that you are open to feedback if you say anything offensive.

Give Clients a Voice in the Treatment Plan

While this is important in all clinical relationships, having a voice in the treatment plan can send a signal to African American clients that you see them as equals. This is important as African Americans have fought for equality for decades.

Elicit Feedback

Receiving regular feedback at the end of each session allows you to continue to assure that the client voice is an important part of the work. This may be particularly helpful in cross-cultural work with African American clients as it provides continuous opportunities for input and to incorporate different world views.

Have Materials that Respect Culture

This involves assuring that literature, videos, and audiovisual materials used in treatment reflects a range of cultural experiences, including African American culture.

Conclusion

As the field of addiction treatment continues to evolve, we are in the position as a field to tailor services to the unique needs of clients served with an openness to incorporating client uniqueness and differences into recovery programming. I hope these suggestions help to build greater rapport and have more successful outcomes with the African American clients you serve.

Mark Sanders, LCSW, CADC, is an international speaker and consultant in the behavioral health field. He is the author of five books and curator of the online Museum of African American Addictions Treatment and Recovery. The online museum provides articles, webinars, videos, expert interviews, and other information geared towards helping providers work effectively with African Americans with SUDs. You can visit the museum at www.museumofafricanamericanaddictionsrecovery.org.

References

Duncan, B. L., Miller, S. D., & Sparks, J. A. (2004). The heroic client: A revolutionary way to improve effectiveness through client-directed, outcome-informed therapy. New York, NY: Jossey-Bass.
Sanders, M. (Ed.). (2013). Substance use disorders in African American communities: Prevention, treatment, and recovery. New York, NY: Routledge.
Sue, D. W., & Sue, D. (2012). Counseling the culturally diverse: Theory and practice (6th ed.). Hoboken, NJ: John Wiley and Sons.

Mark Sanders LCSW, CADC

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Mark Sanders, LCSW, CADC, is an international speaker in the behavioral health field whose presentations have reached thousands throughout the United States, Europe, Canada, and the Caribbean Islands. He is coauthor of Recovery Management and author of Relationship Detox: How to Have Healthy Relationships in Recovery. He has had two stories published in the New York Times best-selling book series, Chicken Soup for the Soul. His most recent book is entitled, Slipping through the Cracks: Intervention Strategies for Clients with Multiple Addictions and Disorders. He is a lecturer at the University of Chicago and conducts private practice.