Principles of Substance Abuse Treatment

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A central doctrine in the drug treatment of Hispanic Americans is the need to match the patient to the most appropriate form of care. Unfortunately, the "one-size-fits-all" approach to substance abuse treatment is still evident in many clinics throughout the United States. These treatment agencies often lack Spanish-speaking, culturally competent staff who understand and are sensitive to the particular cultural characteristics of their patients. Because it is frequently not possible to have a bilingual and bicultural therapist available, the therapist assigned to a Hispanic patient should be at least knowledgeable and understanding of Hispanic cultural values and beliefs. The ability of the therapist to effectively integrate the value systems of the Hispanic individual and of United States society as they relate to the substance abuse problems of the patient is crucial. It is equally vital to be on guard against making assumptions of the patient's needs and potential response to treatment on the basis of blanket cultural generalizations that may not be warranted. Thus, those particular cultural values that apply to the patient's own subgroup and the personal qualities of the patient must be taken into consideration.

One of the best examples of tailoring a particular therapy to a specific Hispanic subgroup has been the work of Szapocznik and Kurtines (1989), who successfully used their strategic structural-systems engagement to treat drug use in Cuban Americans and their families. Szapocznik's approach is cultur ally sensitive because it strengthens the role of parents in the traditionally hierarchical Hispanic family and because it is well suited to address problems of intergenerational conflict that arise from migration and acculturation (Rio et al. 1990). The functioning extended family is portrayed as a source of strength and a preventer of drug use, whereas the fragmented or dysfunctional family is described as a source of disruption and demoralization that leads to drug use (Rio et al. 1990).

When the Hispanic patient first presents to the treatment provider, it is highly recommended that the issue of confidentiality be explained to the patient's full satisfaction. The objective is to engender as much trust as possible in the clinical setting and promote therapeutic disclosure. Scores of Hispanics may have been exposed to regimes in their countries of origin that involved limited freedoms and considerable surveillance, resulting in their having little trust in institutions. To foster the honest communication of sensitive material, the therapist must be nonjudgmental about the patient's drug use and convey respect, empathy, and a sense of equality at all times. This nonjudgmental approach by the clinician is immensely important because it is often the most influential of all the factors affecting the Hispanic patient's decision to remain in treatment. Many Hispanics are extremely reticent to seek treatment because of the shame society attaches to being a drug user, particularly if they live in areas of the United States where anti-immigrant xenophobia has crossed over into anti-Hispanic sentiment. Research (Delgado and Hume-Delgado 1993) has indicated that Hispanics often ascribe to a nondisease, or moral, model of addiction wherein the drug user is stigmatized and labeled as lacking in moral fortitude or having a "weak character." For these reasons, it is understandable that the Hispanic patient can often be exquisitely sensitive to any indication that the clinician may be passing judgment on his or her drug use.

Because of the additional culturally based stigma experienced by the substance-abusing Hispanic female, and the special treatment needs (e.g., pregnancy) of women, employment of female staff is clearly indicated, whenever possible. Also, at the first meeting with the Hispanic patient, the clinician should inquire about the specific Hispanic subgroup to which the patient belongs. This shows respect for the uniqueness of the patient's culture and enhances rapport. Ultimately, any intervention that improves the alliance between the patient and the clinician is extremely valuable when the highly charged topic of substance abuse is the focus of discussion.

In working with the Hispanic substance abuser, it has been found efficacious to focus on the "here and now" in therapy, based on the assumption that this is more consistent with cultural expectations and with the realities of those Hispanics in deprived socioeconomic circumstances. The clinician may find it helpful to engage the patient in therapy that is pragmatic, catalytic, and problem solving in its orientation. A cognitive-behavioral (Beck et al. 1993) approach, in particular, fulfills many of these characteristics and has proven to be effective when tailored to relapse prevention. The cognitive approach helps to reduce the intensity and frequency of the urges to use drugs by modifying the underlying erroneous thinking and maladaptive beliefs. A particular challenge in therapy is redirecting Hispanic substance abusers into the preventive mode of thinking in relation to their drug use, when many are in the survival mode because of economically disadvantaged situations. Another major challenge for the clinician is to not overemphasize the significance of the disease model of addiction when educating the Hispanic patient about the addiction process. The danger is that the patient may feel predestined to continue with his or her alcohol or drug use, especially if he or she already has a strong degree of fatalism as part of his or belief system. The clinician must inform his or her patient that although he or she may have a predisposition or heightened vulnerability to substance abuse, he or she is certainly not predestined to become addicted to drugs. This therapeutic approach empowers the Hispanic patient to assume a strong measure of responsibility for the drug use and not abdicate the role as an active participant in treatment and recovery.

A point of considerable contention when a Hispanic patient initially presents for an evaluation of substance use is to what extent an actual alcohol or drug problem exists. To accurately answer this question and not risk alienating the patient, the clinician must thoroughly review with the Hispanic individual the criteria for making this determination. Many in the addiction field have realized that clinicians cannot solely rely on measures of quantity and frequency of drug use to diagnose abuse or dependence. Some clinicians may overrely on these measures and neglect other criteria that are more salient in determining whether a substance use problem exists. The clinician should emphasize to Hispanic patients that the sine qua non for a drug use problem is a loss of control that is best demonstrated by the patient's continuing to use of a drug even though using creates significant life problems. The ability of certain Hispanic patients to intermittently curtail or discontinue their drug use, only to eventually start again, also is often erroneously interpreted by the patient as signifying that "there is really not a problem." The clinician must educate the Hispanic patient that this pattern simply represents the chronic, relapsing nature of the addiction process and that it most assuredly indicates that treatment is necessary.

A significant proportion of clinicians treating substance abuse believe that alcohol- and drug-related problems frequently develop because of an individual's attempt to self-medicate a psychiatric condition. However, a careful review of the literature by Schuckit (Brown and Schuckit 1988; Schuckit and Hesselbrock 1994) indicated that about 60%-70% of the people who develop serious alcohol or drug problems do not have a major preexisting psychiatric disorder. Their substance abuse is actually the primary disorder and often leads to the development of secondary psychiatric symptoms. If this appears to be the case after taking a careful history and delineating the temporal sequence of symptoms in a patient, it is helpful to inform the patient that symptoms of depression or anxiety may be temporary and disappear on their own with abstinence. Note, however, that certain psychiatric diagnoses in Hispan-ics, especially posttraumatic stress disorder, often are associated with a significant degree of self-medication with alcohol and drugs. All patients must therefore be followed up once they achieve abstinence to ensure that their psychiatric symptoms remit. If symptoms remain, a psychiatric assessment is certainly warranted. It is also judicious for the clinician to inquire whether the patient has been given any medications by friends or relatives who may have sought to help relieve the patient's distress by sharing their own supply. This is a very culturally sanctioned practice among many Hispanics but may seriously complicate the patient's substance abuse treatment if the provider is unaware. Many medications that have significant abuse potential, such as diazepam, can be obtained without a prescription in some countries in Latin America and may lead to unsupervised and indiscriminate use in the United States.

As stated earlier in the chapter, Hispanic women may underreport their alcohol use because of the austere cultural proscriptions they face when drinking. Clinicians must stress to all Hispanic female drinkers of childbearing age, whether known to be pregnant or not, that there is no known safe level of alcohol consumption during pregnancy and that they should abstain completely if possible. Some are tragically unaware that although they may deliver apparently healthy babies without physical signs of fetal alcohol syndrome, myriad neuropsychiatric problems are attributable to gestational alcohol intake, such as speech and language delays, learning disabilities, and emotional instability, which sometimes do not become evident until well after birth. It is helpful for clinicians to present balanced points of view to their Hispanic patients when the media sensationalize a particular drug issue. For example, the past media reports of low to moderate alcohol ingestion reducing cholesterol levels usually have failed to emphasize to the public that such benefits are far outweighed by the colossal health problems that can arise from alcohol abuse. In a similar vein, the favorable publicity recently generated for marijuana because of its medically approved uses has caused many Hispanics to perceive it as harmless.

Now is an opportune time to return to a discussion of the catastrophic association of substance abuse and AIDS and the ramifications for clinicians treating these high-risk Hispanics. When substance abuse, especially injection drug use, is added to inadequate access to health care and the often deplorable socioeconomic conditions faced by Hispanics, it is evident why this population has been so severely and disproportionately affected by the AIDS epidemic. Research (National Center for Health Statistics 1989) has consistently shown that Hispanics are the least knowledgeable of all racial/ethnic groups about AIDS, HIV transmission, and methods of prevention, whereas a definite correlation has been found between years of education and the perceived risk of HIV infection. Hispanics are at higher risk than other groups for HIV infection because of increased rates of injection drug use and greater sharing of needles and drug paraphernalia (Friedman et al. 1986). In addition, the natural disdain for needles that may serve as a deterrent in many cultures may be tempered significantly in certain Hispanic populations in which use of needles to administer antibiotics and vitamins to family members is not uncommon (Marin and Marin 1989). Several studies (Stimson et al. 1990) funded by the Centers for Disease Control and Prevention in the United States and others abroad have provided strong evidence that the availability of clean needles in needle-exchange programs reduces the rate of HIV transmission among those who inject drugs and does not increase the rate of injection drug use. It is clear that the ban on many needle-exchange programs and methadone maintenance programs is less the result of a scientific analysis of these interventions and more the result of uninformed officials engaging in vitriolic rhetoric to advance their political agendas. Government officials and politicians remain loath to endorse any AIDS prevention strategy that may be viewed as sanctioning illicit drug use. The often-heard but ill-advised drug enforcement mantra, "We don't want to send the wrong message," is far removed from the reality that needle-exchange programs do not increase the rate of injection drug use and do save lives by reducing HIV transmission. Although these programs are not sufficient by themselves, they are certainly an improvement over other methods of preventing HIV transmission in the drug injecting population. It is crucial that clinicians treating substance abuse in Hispanics realize that needle-exchange programs also may serve as the initial entry point of a patient into a drug treatment program and be a vehicle for disseminating vital information about risk reduction. The need to improve access to treatment was borne out by a National Institute on Drug Abuse study (National Drug and Alcoholism Treatment Unit Survey 1991), which showed that about 45% of Hispanic intravenous drug users have never been in treatment. The consequences of denying needle-exchange and methadone mainte nance programs to the exceptionally vulnerable Hispanic population are potentially cataclysmic.

In concluding this discussion of HIV transmission in the Hispanic population, it should not be lost on clinicians that the use of any drugs, regardless of whether injected or not, can result in HIV infection by leading to other high-risk behaviors. When other factors that adversely affect the Hispanic person's immune function, such as poverty, malnutrition, and poor access to health care, are also considered, we can appreciate why Hispanics are such a susceptible population and have an augmented risk of HIV infection.

Clinicians also must have an open mind toward the use of nontraditional treatments that could prove successful in certain cases. One example is the use of acupuncture in treating opiate and cocaine addiction. Acupuncture has gained wide acceptance in Latin America and Europe, but until recently, its use in the United States has been limited to certain large centers. Although there is skepticism about its efficacy because it has been difficult to conduct controlled clinical trials, acupuncture should certainly remain an option for the motivated Hispanic patient. It may prove particularly beneficial in the Hispanic individual who has failed other treatment modalities or has a history of a good response to acupuncture in his or her country of origin.

Clinicians working with recidivistic Hispanic patients must realize how important alcohol or drugs have become in their patients' lives. This can assuage the clinician's frustration when treating a patient prone to relapse and assist that clinician in continuing to work constructively toward his or her patient's recovery.

The following brief case report illustrates some of the more salient issues in treating substance abuse in the Hispanic patient.

Mr. S, a 37-year-old Mexican American unemployed construction worker, conversant mostly in Spanish, was referred to the Family Treatment Center by his wife for excessive drinking and difficulty in getting along with the other members of the family. According to his wife, Mr. S had become increasingly irritable, argumentative, and depressed and had begun to drink alcohol frequently and in large amounts in the weeks following the loss of his job.

At the outset of therapy, Mr. S was reluctant to discuss the difficulties at home, stating often that "anyone else out of work would also be having a rough time" and that he was entitled to drink to cope with his disappointment. The therapist empathized with the problems Mr. S was facing but was clear in the first meeting that to derive any benefit from therapy, Mr. S would have to refrain from all alcohol use. The therapist acknowledged the challenging nature of this task and stated that he would wholeheartedly support Mr. S in his struggle to achieve abstinence. He impressed on Mr. S that his problem with alcohol was not a sign of weakness but a disease that he could recover from. The therapist helped Mr. S understand that drinking was exceedingly detrimental to his daily functioning and impeded his effectiveness as the head of the family. This allowed Mr. S to counteract derision from friends, maintain his dignity, and remain invested in treatment.

In the initial sessions, the therapist allowed Mr. S wide latitude and considerable time to describe his expectations of treatment. Following this, a detailed accounting of Mr. S's alcohol use and its effect on his functioning was obtained. Mr. S agreed to pursue additional treatment for his alcohol abuse but vehemently opposed a referral to a Spanish-speaking AA group on the grounds that he was not "religious" and had felt uncomfortable with the AA doctrine that he was "powerless" over alcohol. He stated that his preference was to learn how he could help himself and not feel dependent on others to maintain his sobriety. After further discussion, the therapist believed that a referral to a Spanish-speaking Rational Recovery Systems group might be a better match for Mr. S's belief system.

The therapist then referred Mr. S to a seminar at the treatment center that focused on dealing with unemployment and searching for a new job. Soon after attending the seminar, Mr. S was able to discuss some of his other stressors in therapy. He admitted feeling that he had "let down" his family because he was not able to contribute financially and expressed particular shame after friends joked that his wife, who was a seamstress, was "supporting" him. He also was unable to continue sending money to his mother in Mexico, which had always been a great source of pride for him. After several weeks, Mr. S further confided that having to depend on his three children to translate into Spanish had always caused him to feel weak and "not in charge," exacerbating his sense of helplessness.

As therapy progressed, Mr. S gradually began to view treatment as less stigmatizing and more helpful. This was partially accomplished by the therapist's successfully reducing Mr. S's resistance to admitting that he had lost control of his drinking without impugning his manhood. The therapist guided Mr. S in refocusing on the fact that by seeking assistance and acknowledging his problems, Mr. S was also helping his family to get through this difficult period. The therapist was able to successfully appeal to Mr. S's sense of machismo by promoting the reality that by abstaining from alcohol, Mr. S was actually reinforcing his position as the head of the family.

In the later stages of treatment, the therapist was able to help Mr. S challenge some of the distorted cognitions relating to his alcohol abuse, including his grossly exaggerated sense of the number of men who drank alcohol to cope with stress. Mr. S came to realize that several individuals in his neighborhood were experiencing economic hardship but had not resorted to drinking. He was more open to other suggestions for improving his situation, including enrolling in an English as a second language class to increase his English-speaking ability and, thereby, also improve his self-esteem because of a reduced reliance on his children to translate.

Near the termination of his therapy and with Mr. S's consent, the therapist invited Mrs. S to help her better understand the principal issues associ-

ated with Mr. S's drinking. The therapist also used the opportunity to educate her about alcoholism and discuss ways that she could support her husband in his sobriety. A few days after this meeting, Mr. S continued his job search and decided to apply for unemployment benefits, which he had previously refused to do because of feeling ashamed.

The above case report illustrates some key points that are useful in understanding specific dynamics in working with substance-abusing Hispanic patients. A major task for the therapist was addressing Mr. S's view that his alcohol use was simply an adaptive response to being unemployed. The key to the therapist's success was eventually leading Mr. S to recognize and deal with his alcohol use as an issue independent of the loss of his job. The therapist was able to advance the process by which Mr. S assumed responsibility for his drinking, which led to his patient experiencing a more sanguine sense of the future. The empathic, nonjudgmental, and comprehensive approach used by the therapist greatly enhanced communication with his patient and led to a satisfactory outcome. This case also shows the tremendous importance ascribed to employment in the Hispanic culture and how the therapist's sensitivity to this issue laid the foundation for a trusting alliance and allowed him to effectively engage the patient in a discussion of his alcohol abuse.

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