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9: Multicultural Treatment Considerations in Corrections

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    Chapter 9 - Multicultural Treatment Considerations in Corrections46

    Key Learning Objectives:

    • Be able to identify the importance of providing culturally specific treatment to offenders in a correctional setting.
    • Identify key issues in treating offenders based on their ethnicity.
    • Understand the “Stages of Change” in offender rehabilitation.
    • Identify the importance of case management with an understanding of race and culture in offender rehabilitation.

    9.1 - Culturally Responsive Evaluation and Treatment Planning

    This section offers correctional staff guidance in providing and facilitating culturally responsive interviews, assessments, evaluations, and treatment planning. Correctional professionals: prison guards, correctional counselors, probation officers, parole agents and others involved in the rehabilitation of offenders have a dual role when dealing with offenders. On one hand, they must protect the community/institution and ensure the offender complies with court orders. However, in order to also aid the offender in rehabilitation, they must develop a rapport with the offender. This is often a difficult role to balance; however, it is best to describe this as an authoritative relationship similar to parent/child relationship. Correctional professionals can provide the best treatment services when the offender is receptive to the officer’s guidance. This section provides direction on how officers can develop rapport while maintaining professionalism.

    Image result for cdcr treatment

    Figure 9.1 Diagram of California Department of Corrections and Rehabilitation Program budget funding. Image is in the public domain.

    Step 1: Engage Offender

    The initial contact with the offender is vital for success. Often times they stand on the far side of a yet-to- be-established therapeutic relationship. At the outset of treatment, offender can feel scared, vulnerable, and uncertain about whether treatment will really help. They may even be ambivalent that you are there to help them and only intend to catch them doing wrong. To engage the offender, the correctional professional should try to establish rapport and set the tone of the interaction. It is important to provide the expectations and requirements of treatment, so they understand what to do and how to act. It is also important to provide possible consequences of non-compliance. Some offenders feel that a single violation will result in incarceration or additional days. So, when they fail, or even a minor misstep occurs, they give up. It’s important to let them know that not all failures will result in custody sanctions.

    Step 2: Familiarize Offender and Their Families with Treatment and Evaluation Processes

    Behavioral health treatment facilities located in prisons and in the community maintain their own culture (i.e., the treatment milieu). Correctional professionals, counselors, and agency administrators can easily become accustomed to this culture and assume that offenders are used to it as well. However, offenders are typically new to treatment language or jargon, program expectations and schedules, and the intake and treatment process. Unfortunately, offenders from diverse racial and ethnic groups can feel more estranged and disconnected from treatment services when staff members fail to educate them and their families about treatment expectations or when the offenders are not walked through the treatment process, starting with the goals of the initial intake and interview. By taking the time to acclimate offenders and their families to the treatment process, correctional professionals, counselors and other behavioral health staff members tackle one obstacle that could further impede treatment engagement and retention among racially and ethnically diverse offender.

    Step 3: Endorse Collaboration in Interviews, Assessments, and Treatment Planning

    Most offenders are unfamiliar with the evaluation and treatment planning process and how they can participate in it. Often times they just expect to be told what to do or suffer a sanction if they fail to comply. However correctional professionals are now engaging offenders and making them part of the treatment process. This is often a bit strange for offenders who often resent authority and don’t trust officers. Again, this is why the initial meeting with offenders are vital. Establishing a quasi-parental role that provides structure and support is important. It is also necessary for the offender to provide personal information, so the case plan is accurate. Some offenders may view the initial interview and evaluation as intrusive if too much information is requested or if the content is a source of family dishonor or shame. Other offender may resist or distrust the process based on a long history of racism and oppression. Still others feel inhibited from actively participating because they view the counselor as the authority or sole expert.

    Image result for california prison treatment programs

    Figure 9.2 Inmate substance abuse treatment. Bureau of Prison photo. Image is in the public domain.

    Step 4: Integrate Culturally Relevant Information and Themes

    By exploring culturally relevant themes, correctional professionals can more fully understand their offender and identify their cultural strengths and challenges. For example, a Korean woman’s family may serve as a source of support and provide a sense of identity. At the same time, however, her family could be ashamed of her and respond to her treatment as a source of further shame because it encourages her to disclose personal matters to people outside the family. The following section provides a brief overview of suggested strength-based topics to incorporate into the intake and evaluation process.

    Immigration History

    Immigration history can shed light on offender’s support systems and identify possible isolation or alienation. Some immigrants who live in ethnic enclaves have many sources of social support and resources. By contrast, others may be isolated, living apart from family, friends, and the support systems extant in their countries of origin. Culturally competent evaluation should always include questions about the offender’s country of origin, immigration status, length of time in the United States, and connections to his or her country of origin. Ask American-born offender about their parents’ country of origin, the language(s) spoken at home, and affiliation with their parents’ culture(s). Questions like these give the correctional professional important clues about the offender’s degree of acculturation in early life and at present, cultural identity, ties to culture of origin, potential cultural conflicts, and resources. Specific questions should elicit information about:

    • Length of time in the United States, noting when immigration occurred or the number of generations who have resided in the United States.
    • Frequency of returns and psychological and personal ties to the country of origin.
    • Primary language and level of English proficiency in speaking and writing.
    • Psychological reactions to immigration and adjustments made in the process.
    • Changes in social status and other areas as a result of coming to this country.
    • Major differences in attitudes toward alcohol and drug use from the time of immigration to now.

    Step 5: Gather Culturally Relevant Collateral Information

    An offender who needs behavioral health treatment services may be unwilling or unable to provide a full personal history from his or her own perspective and may not recall certain events or be aware of how his or her behavior affects his or her well-being and that of others. Collateral information—supplemental information from sources other than the offender—can be derived from family members, medical and court records, probation and parole officers, police reports, community members, and others. Collateral information should include culturally relevant information obtained from the family, such as the organizational memberships, beliefs, and practices that shape the offender’s cultural identity and understanding of the world.

    As families can be a vital source of information, correctional professionals are likely to attain more support by engaging families earlier in the treatment process. Although interactions with family members are often limited to a few office or field visits, the families of racially and ethnically diverse offenders tend to play a more significant and influential role in offender’s participation in treatment. Consequently, special sensitivity to the cultural background of family members providing collateral information is essential. Families, like offenders, cannot be easily defined in terms of a generic cultural identity (Congress 2004; Taylor et al. 2012). Even families from the same racial background or ethnic heritage can be quite dissimilar, thus requiring a multidimensional approach in understanding the role of culture in the lives of offender and their families.

    Step 6: Select Culturally Appropriate Screening and Assessment Tools

    Correctional professionals and service providers should be able to use assessment and screening information in culturally competent ways. This section discusses several instruments and their appropriateness for specific cultural groups. Correctional professionals should continue to explore the availability of mental health and substance abuse screening and assessment tools that have been translated into or adapted for other languages.

    Step 7: Determine Readiness and Motivation for Change

    Offender enter treatment programs at different levels of readiness for change. Even offenders who appear to be willing to engage in treatment could have been pushed into it by external pressures to accept treatment before reaching the action stage. (For example, wanting to earn credit for early release, or going to treatment just to avoid incarceration.) These different readiness levels require different approaches. The strategies involved in motivational interviewing can help correctional professionals prepare culturally diverse offender to change their behavior and keep them engaged in treatment. To understand motivational interviewing, it is first necessary to examine the process of change that is involved in recovery.

    Stages of Change

    Prochaska and DiClemente’s (1984) classic transtheoretical model of change is applicable to culturally diverse populations. This model divides the change process into several stages:

    • Precontemplation. The offender does not see a need to change. For example, a offender at this stage who abuses substances does not see any need to alter use, denies that there is a problem, or blames the problem on other people or circumstances.
    • Contemplation. The offender becomes aware of a problem but is ambivalent about the course of action. For instance, a person struggling with anger issues recognizes that the anger and violence has affected his or her life and thinks about getting help but remains ambivalent on how he/she may do this.
    • Preparation. The offender has determined that the consequences of his or her behavior are too great, and that change is necessary. Preparation includes small steps toward making specific changes, such as when a person who is overweight begins reading about wellness and weight management. The offender still engages in poor health behaviors but may be altering some behaviors or planning to follow a diet.
    • Action. The offender has a specific plan for change and begins to pursue it. In relation to substance abuse, the offender has engaged in a drug assessment prior to becoming abstinent from alcohol and drugs.
    • Maintenance. The offender continues to engage in behaviors that support his or her decision. For example, an offender with prior domestic violence issues follows a daily relapse prevention plan that helps him or her assess warning signs of an angry or violent episode and reminds him or her of the importance of engaging in help-seeking behaviors to minimize the severity of an episode.

    Progress through the stages is nonlinear, with movement back and forth among the stages at different rates. It is important to recognize that change is not a one-time process, but rather, a series of trials and errors that eventually translates to successful change. For example, people who are dependent on substances often attempt to abstain several times before they are able to acquire long-term abstinence.

    Image result for motivation for change

    Figure 9.3 Lead people effectively not efficiently. Airforce Global Strike Command. Image is in the public domain.

    Motivational Interviewing

    Motivational interventions assess a person’s stage of change and use techniques likely to move the person forward in the sequence. Miller and Rollnick (2002) developed a therapeutic style called motivational interviewing, which is characterized by the strategic therapeutic activities of expressing empathy, developing discrepancy, avoiding argument, rolling with resistance, and supporting self-efficacy. The counselor’s major tool is reflective listening and soliciting change talk.

    This nonconfrontational, offender-centered approach to correctional interviews differs significantly from traditional correctional interviews in several ways, creating a more balanced relationship. In this dialog, it’s not about telling the offender what to do, it’s about letting the offender come to the conclusion he or she needs to make changes in their lives. Motivational interviewing is a highly successful technique that take time to master. However, once successful in this technique, the correctional professional becomes a much better communicator. A wise statement was made – “You can lead a horse to water, but you can’t make him drink.” This can be true for offenders. We can provide the offender treatment resources, but until he or she decides it’s important to them, they will not be successful.

    Step 8: Provide Culturally Responsive Case Management

    Offenders from various racial, ethnic, and cultural populations participating in behavioral health services may face additional obstacles that can interfere with or prevent access to treatment and ancillary services, compromise appropriate referrals, impede compliance with treatment recommendations, and produce poorer treatment outcomes. Obstacles may include immigration status, lower social economic status, language barriers, cultural differences, and lack of or poor coverage with health insurance.

    Proper case management provides a single professional contact through which offender’s gain access to a range of services. The goal is to help assess the need for and coordinate social, health, and other essential services for each offender. Case management can be an immense help during treatment and recovery for a person with limited English literacy and knowledge of the treatment system. Case management focuses on the needs of individual offender and their families and anticipates how those needs will be affected as treatment proceeds. The correctional professional at times advocates for the offender, easing the way to effective treatment by assisting the offender with critical aspects of life (e.g., food, childcare, employment, housing, legal problems).

    Step 9: Incorporate Cultural Factors into Treatment Planning

    The cultural adaptation of treatment practices is a burgeoning area of interest, yet research is limited regarding the process and outcome of culturally responsive treatment planning in behavioral health treatment services for diverse populations. How do correctional professionals and prisons/jails respond culturally to the diverse needs of offenders in the treatment planning process? How effective are culturally adaptive treatment goals? Typically, programs that provide culturally responsive services approach treatment goals holistically, including objectives to improve physical health and spiritual strength (Howard 2003). Newer approaches stress implementation of strength-based strategies that fortify cultural heritage, identity, and resiliency.

    Treatment planning is a dynamic process that evolves along with an understanding of the offender’ histories and treatment needs. Foremost, correctional professionals should be mindful of each offender’s linguistic requirements and the availability of interpreters. Correctional professionals should be flexible in designing treatment plans to meet offender specific criminogenic needs and, when appropriate, should draw upon the institutions and resources of offender’ cultural communities. Culturally responsive treatment planning is achieved through active listening and should consider offender’s values, beliefs, and expectations. Offender’s health beliefs and treatment preferences (e.g., purification ceremonies for Native American offender) should be incorporated in addressing specific presenting problems. Some people seek help for psychological concerns and substance abuse from alternative sources (e.g., clergy, elders, social supports). Others prefer treatment programs that use principles and approaches specific to their cultures. Correctional professionals can suggest appropriate traditional treatment resources to supplement clinical treatment activities.

    In sum, clinicians need to incorporate culture-based goals and objectives into treatment plans and establish and support open offender–counselor dialog to get feedback on the proposed plan’s relevance. Doing so can improve offender’s engagement in treatment services, compliance with treatment planning and recommendations, and treatment outcomes, thereby reducing recidivism and reducing new crime.

    9.2 – Introduction to Correctional Counseling for Races

    Culture is a primary force in the creation of a person’s identity. Correctional professionals who are culturally competent are better able to understand and respect their offenders’ identities and related cultural ways of life. This section proposes strategies to engage offenders of diverse racial and ethnic groups (who can have very different life experiences, values, and traditions) in treatment. The major racial and ethnic groups in the United States covered in this section are African Americans, Asian Americans (including Native Hawaiians and other Pacific Islanders), Latinos, Native Americans (i.e., Alaska Natives and American Indians), and White Americans. In addition to providing epidemiological data on each group, this section discusses salient aspects of treatment for these racial/ethnic groups, drawing on clinical and research literature. This information is only a starting point in gaining cultural knowledge as it relates to behavioral health. Understanding the diversity within a specific culture, race, or ethnicity is essential; not all information presented in this chapter will apply to all individuals. The material in this chapter has a scientific basis, yet cultural beliefs, traditions, and practices change with time and are not static factors to consider in providing services for offenders, families, or communities.

    Although these broad racial/ethnic categories are often used to describe diverse cultural groups, the differences between two members of the same racial/ethnic group can be greater than the differences between two people from different racial/ethnic groups (Lamont and Small 2008; Zuckerman 1998). It is not possible to capture every aspect of diversity within each cultural group. Correctional professional workers should acknowledge that there will be many individual variations in how people interact with their environments, as well as in how environmental context affects behavioral health. However, to provide a framework for understanding many diverse cultural groups, some generalizations are necessary; thus, broad categories are used to organize information in this chapter. Correctional professionals are encouraged to learn as much as possible about the specific populations they serve.

    9.3 - Treatment for Black Americans

    According to the 2010 U.S. Census definition, African Americans or Blacks are people whose origins are “in any of the black racial groups of Africa” (Humes et al. 2011, p. 3). The term includes descendants of African slaves brought to this country against their will and more recent immigrants from Africa, the Caribbean, and South or Central America (many individuals from these latter regions, if they come from Spanish-speaking cultural groups, identify or are identified primarily as Latino). The term “Black” is often used interchangeably with African American, although sometimes the term “African American” is used specifically to describe people whose families have been in this country since at least the 19th century and thus have developed distinct African American cultural groups. “Black” can be a more inclusive term describing African Americans as well as more recent immigrants with distinct cultural backgrounds.

    Beliefs About and Traditions Involving Substance Use

    In most African American communities, significant alcohol or drug use may be socially

    unacceptable or seen as a sign of weakness (Wright 2001), even in communities with limited resources, where the sale of such substances may be more acceptable. Overall, African Americans are more likely to believe that drinking and drug use are activities for which one is personally responsible; thus, they may have difficulty accepting alcohol abuse/dependence as a disease (Durant 2005).

    Mental and Co-Occurring Disorders

    A number of studies have found biases that result in African Americans being over

    diagnosed for some disorders and underdiagnosed for others. African Americans are less likely than White Americans to receive treatment for anxiety and mood disorders, but they are more likely to receive treatment for drug use disorders (Hatzenbuehler et al. 2008). In one study evaluating post-traumatic stress disorder (PTSD) among African Americans in an outpatient mental health clinic, only 11 percent of offenders had documentation referring to PTSD, even though 43 percent of the offenders showed symptoms of PTSD (Schwartz et al. 2005). Black immigrants are less likely to be diagnosed with mental disorders than are Blacks born in the United States (Burgess et al. 2008; Miranda et al. 2005b).

    African Americans are more likely to be diagnosed with schizophrenia and less likely to be diagnosed with affective disorders than White Americans, even though multiple studies have found that rates of both disorders among these populations are comparable (Baker and Bell 1999; Bresnahan et al. 2000; Griffith and Baker 1993; Stockdale et al. 2008; Strakowski et al. 2003). African Americans are about twice as likely to be diagnosed with a psychotic disorder as White Americans and more than three times as likely to be hospitalized for such disorders. These differences in diagnosis are likely the result of clinician bias in evaluating symptoms (Bao et al. 2008; Trierweiler et al. 2000; Trierweiler et al. 2006). Clinicians should be aware of bias in assessment with African Americans and with other racial/ethnic groups and should consider ways to increase diagnostic accuracy by reducing biases. For an overview of mental health across populations, refer to Mental Health United States, 2010 (SAMHSA 2012a).

    In some African American communities, incidence and prevalence of trauma exposure and PTSD are high, and substance use appears to increase trauma exposure even further (Alim et al. 2006; Breslau et al. 1995; Curtis- Boles and Jenkins-Monroe 2000; Rich and Grey 2005). Black women who abuse sub- stances report high rates of sexual abuse (Ross-Durow and Boyd 2000). Trauma histories can also have a greater effect on relapse for African American offenders than for offenders from other ethnic/racial groups (Farley et al. 2004). There are few integrated approaches to trauma and substance abuse that have been evaluated with African American offenders, and although some have been found effective at reducing trauma symptoms and substance use, the extent of that effectiveness is not necessarily as great as it is for White Americans (Amaro et al. 2007; Hien et al. 2004; SAMHSA 2006).

    Treatment Patterns

    African Americans may be less likely to receive mental health services than White Americans. In the Baltimore Epidemiologic Catchment Services Area study conducted during the 1980s, African Americans were less likely than White Americans to receive mental health services. However, at follow-up in the early 1990s, African American respondents were as likely as White Americans to receive such services, but they were much more likely to receive those services from general practitioners than from mental health specialists (Cooper-Patrick et al. 1999). Stockdale et al. (2008) analyzed 10 years of data from the National Ambulatory Medical Care Survey; they found significant improvements in diagnosis and care for mental disorders among African Americans in psychiatric settings between 1995 and 2005, but they also found that disparities persisted in the diagnosis and treatment of mental disorders in primary care settings. Fortuna et al. (2010) suggest that persistent problems exist in the delivery of behavioral health services, as evidenced by lower retention rates for treating depression.

    Even among people who enter substance abuse treatment, African Americans are less likely to receive services for CODs. A study of administrative records from substance abuse and mental health treatment providers in New Jersey found that African Americans were significantly more likely than White Americans to have an undetected co-occurring mental disorder, and, if detected, they were significantly less likely than White Americans or Latinos to receive treatment for that disorder (Hu et al. 2006). Among persons with substance use disorders and co-occurring mood or anxiety disorders, African Americans are significantly less likely than White Americans to receive services (Hatzenbuehler et al. 2008). African Americans who do receive services for CODs are more likely to obtain them through substance abuse treatment programs than mental health programs (Alvidrez and Havassy 2005).

    African Americans are over represented among people who are incarcerated in prisons and jails (for review, see Fellner 2009), and a substantial number of those who are incarcerated (64.1 percent of jail inmates in 2002) have substance use disorders (Karberg and James 2005) and mental health problems (SAMHSA 2012a). However, according to Karberg and James 2005), African Americans with substance dependence disorders who were in jail in 2002 were less likely than White Americans or Latinos to participate in substance abuse treatment while under correctional supervision (32 percent of African Americans participated compared with 37 percent of Latinos and 45 percent of White Americans). In the 2010 TEDS survey, African Americans entering treatment were also less likely than Asian Americans, White Americans, Latinos, Native Hawaiians/Pacific Islanders, or American Indians in the same situation to be referred to treatment through the criminal justice system (SAMHSA, CBHSQ 2012). Notwithstanding, African Americans are more likely to be referred to treatment from criminal justice settings rather than self-referred or referred by other sources (Delphin-Rittmon et al. 2012)

    Beliefs and Attitudes About Treatment

    According to 2011 NSDUH data, African Americans were, next to Asian Americans, the least likely of all major ethnic and racial groups to state a need for specialized substance abuse treatment (SAMHSA, CBHSQ 2013a). Still, logistical barriers may pose a greater challenge for African Americans than for members of other major racial and ethnic groups. For example, 2010 NSDUH data regarding individuals who expressed a need for substance abuse treatment but did not receive it in the prior year indicate that African Americans were more likely than members of other major ethnic/racial groups to state that they lacked transportation to the program or that their insurance did not cover the cost of such treatment (SAMHSA 2011a). African Americans experience several challenges in accessing behavioral health treatment, including fears about the therapist or therapeutic process and concerns about discrimination and costs (Holden et al. 2012; Holden and Xanthos 2009; Williams et al. 2012).

    Longstanding suspicions regarding established healthcare institutions can also affect African Americans’ participation in, attitudes toward, and outcomes after treatment (for review, see Pieterse et al. 2012). Historically, the mental health system has shown bias against African Americans, having been used in times past to control and punish them (Boyd-Franklin and Karger 2012; Jackson 2003). After controlling for socioeconomic factors, African Americans are significantly more likely to perceive the healthcare system as poor or fair and significantly more likely to believe that they have been discriminated against in healthcare settings (Blendon et al. 2007). Attitudes toward psychological services appear to become more negative as psychological distress increases (Obasi and Leong 2009). In many African American communities, there is a persistent belief that social and treatment services try to impose White American values, adding to their distrust of the treatment system (Larkin 2003; Solomon 1990).

    Treatment Issues and Considerations

    African American offenders generally respond better to an egalitarian and authentic relationship with counselors and other correctional professionals (Sue 2001). Paniagua (1998) suggests that in the initial sessions with African American offenders, correctional professionals should develop a collaborative offender–counselor relationship. Correctional professionals should request personal information gradually rather than attempting to gain information as quickly as possible, avoid information-gathering methods that offenders could perceive as an interrogation, pace the session, and not force a data-gathering agenda (Paniagua 1998; Wright 2001). Correctional professionals must also establish credibility with offenders (Boyd-Franklin 2003).

    Next, correctional professionals should establish trust. Self- disclosure can be very difficult for some offenders because of their histories of experiencing racism and discrimination. These issues can be exacerbated in African American men whose experience of racism has been more severe or who have had fewer positive relationships with White Americans (Reid 2000; Sue 2001). Correctional professionals, therefore, need to be willing to address the issue of race and to validate African American offenders’ experiences of racism and its reality in their lives, even if it differs from their own experiences (Boyd-Franklin 2003; Kelly and Parsons 2008). Moreover, racism and discrimination can lead to feelings of anger, anxiety, or depression. Often, these feelings are not specific to any given event; rather, they are pervasive (Boyd-Franklin et al. 2008). Correctional professionals should explore with offenders the psychological effects of racism and develop approaches to challenge internal negative messages that have been received or generated through discrimination and prejudice (Gooding 2002).

    Family therapy

    African American offenders appear more likely to stay connected with their families through- out the course of their addiction. For instance, Bourgois et al. (2006) reported that in comparing African American and White American individuals who injected heroin, African Americans appeared to be more likely to maintain contact with their extended families. Some research also suggests that African Americans with substance use disorders are more likely to have family members with histories of substance abuse, suggesting an even greater need to address substance abuse within the family (Brower and Carey 2003).

    Strong family bonds are important in African American cultural groups. African American families are embedded in a complex kinship network of biologically related and unrelated persons. Hence, correctional professionals should be willing to expand the definition of family to a more extended kinship system (Boyd-Franklin 2003; Hines and Boyd-Franklin 2005). Offenders need to be asked how they define family, whom they would identify as family or “like family,” who resides with them in their homes, and whom they rely on for help. Hines and Boyd-Franklin (2005) discuss the importance of both blood and nonblood kinship networks for African American families. To build a support network for African American offenders, correctional professionals should start by asking offenders to identify people (whether biological kin or not) who would be willing and able to support their recovery and then ask offenders for permission to contact those people and include them in the treatment process.

    Group therapy

    Because of the communal, cooperative values held by many African Americans, group therapy can be a particularly valuable component of the treatment process (Sue and Sue 2013b). A strong oral tradition is one of many forms of continuity with African tradition maintained in the African American experience; therefore, speaking in groups is generally acceptable to African American offenders. How- ever, Bibb and Casimer (2000) note that Black Caribbean Americans can be less comfortable with the group process, particularly the requirement that they self-disclose personal problems to people who are relative strangers. African Americans seem less likely to self- disclose about the past in group settings that include non-Hispanic Whites (Johnson et al. 2011; Richardson and Williams 1990). Consequently, groups composed only of African Americans can be more beneficial. Homogenous African American groups can also be good venues for offenders to deal with systemic problems, such as racism and lack of economic opportunities in the African American com- munity (Jones et al. 2000).

    Mutual-help groups

    A variety of mutual-help groups are available for African Americans entering recovery from substance use and mental disorders. However, most of the literature focuses on 12-Step groups, including Alcoholics Anonymous (AA) and Narcotics Anonymous. Some find that the 12-Step approach warrants careful consideration with African Americans, who can find the concept of powerlessness over substances of abuse to be too similar to experiences of powerlessness via discrimination. Additionally, the disease concept of addiction presented in 12-Step meetings can be difficult for many African Americans (Durant 2005). In some instances, the Black community has changed the mutual-help model for substance use and mental health to make it more empowering and relevant to African American participants. For additional information on the 12 Steps for African Americans, visit Alcoholics Anonymous World Services (AAWS), AA for the Black and African American Alcoholic, available online ( pdf/products/p-51_CanAAHelpMeToo.pdf).

    Relapse prevention and recovery

    African Americans appear to be responsive to continuing care participation and recovery activities associated with substance use and mental disorders, yet research is very limited. According to NESARC data (Dawson et al. 2005), African Americans in recovery from alcohol dependence were more than twice as likely as White Americans to maintain abstinence rather than just limiting alcohol consumption or changing drinking patterns. In another study analyzing the use of continuing care following residential treatment in the U.S. Department of Veterans Affairs care system, African American men were significantly more likely than White Americans to participate in continuing care (Harris et al. 2006). Other research evaluating continuing care for African American men who had been mandated to outpatient treatment by a parole or probation office found that participants assigned to a continuing care intervention were almost three times as likely to be abstinent and five times less likely to be using any drugs on a weekly basis during the 6-month follow-up period compared with those who did not receive continuing care (Brown et al. 2004).

    In evaluating appropriate relapse prevention strategies for African American offenders, Walton et al. (2001) found that African American offenders leaving substance abuse treatment reported fewer cravings, greater use of coping strategies, and a greater belief in their self-efficacy. However, they also expected to be involved in fewer sober leisure activities, to be exposed to greater amounts of substance use, and to have a greater need for continuing care services (e.g., housing, medical care, assistance with employment). Walton notes that these findings could reflect a tendency of African American offenders to underestimate the difficulties they will face after treatment; they report a greater need for resources and greater exposure to substance use, but they still have a greater belief in their ability to remain free of substances. Although an individual’s belief in coping can have a positive effect on initially managing high-risk situations, it also can lead to a failure to recognize the level of risk in a given situation, anticipate the consequences, secure resources and appropriate support when needed, or engage in coping behaviors conducive to maintaining recovery. Correctional professionals can help offenders practice coping skills by role-playing, even if offenders are confident that they can manage difficult or high-risk situations.

    9.4 - Counseling for Asian Americans, Native Hawaiians, and Other Pacific Islanders

    Asian Americans, per the U.S. Census Bureau definition, are people whose origins are in the Far East, Southeast Asia, or the Indian subcontinent (Humes et al. 2011). The term includes East Asians (e.g., Chinese, Japanese, and Korean Americans), Southeast Asians (e.g., Cambodian, Laotian, and Vietnamese Americans), Filipinos, Asian Indians, and Central Asians (e.g., Mongolian and Uzbek Americans). In the 2010 Census, people who identified solely as Asian American made up 4.8 percent of the population, and those who identified as Asian American along with one or more other races made up an additional 0.9 percent. Census data includes specific information on people who identify as Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and “other Asians.” The largest Asian populations in the United States are Chinese Americans, Filipino Americans, Asian Indian Americans, Korean Americans, and Vietnamese Americans. Asian Americans overwhelmingly live in urban areas, and more than half (51 percent) live in just three states New York, California and Hawaii. (Hoeffel et al. 2012).

    Not all people with origins in Asia belong to what is commonly conceived of as the Asian race. Some Asian Indians, for example, self- identify as White American. For this reason, among others, correctional professionals should be careful to learn from their Asian American offenders how they identify themselves and which national heritages they claim. Correctional professionals should recognize that offenders who appear to be Asian may not necessarily think of themselves primarily as persons of Asian ancestry or have a deep awareness of the traditions and values of their countries of origin. For example, Asian orphans who have been adopted in the United States and raised as Americans in White American families may have very little connection with the cultural groups of their biological parents (St. Martin 2005). Correctional professionals should not make generalizations across Asian cultures; each culture is quite distinct.

    Little literature on substance use and mental disorders, rates of co-occurrence, and treatment among Asian Americans focuses on behavioral health treatment for Native Hawaiians and Pacific Islanders; thus, a text box at the end of this section summarizes available information.

    Beliefs About and Traditions Involving Substance Use

    Within many Asian societies, the use of intoxicants is tolerated within specific contexts. For example, in some Asian cultural groups, alcohol is believed to have curative, ceremonial, or beneficial value. Among pregnant Cambodian women, small amounts of herbal medicines with an alcohol base are sometimes used to ensure an easier delivery. Following childbirth, similar medicines are generally used to increase blood circulation (Amodeo et al. 1997). Some Chinese people believe that alcohol restores the flow of qi (i.e., the life force). The written Chinese character for “doctor” contains the character for alcohol, which implies the use of alcohol for medicinal purposes.

    Some Asian American cultural groups make allowances for the use of other substances. Marijuana, for instance, has been used medicinally in parts of Southeast Asia for many years (Iversen 2000; Martin 1975). However, some Asian Americans tend to view illicit substance use and abuse as a serious breach of acceptable behavior that cannot readily be discussed. Nonetheless, there are broad differences in Asian cultures’ perspectives on substance use, thus requiring correctional professionals to obtain more specific information during intake and subsequent encounters.

    Acknowledging a substance abuse problem often leads to shame for Asian American offenders and their families. Families may deny the problem and inadvertently, or even intentionally, isolate members who abuse substances (Chang 2000). For example, some Cambodian and Korean Americans perceive alcohol abuse and dependence as the result of moral weakness, which brings shame to the family (Amodeo et al. 2004; Kwon-Ahn 2001).

    Substance Use and Substance Use Disorders

    According to the 2012 NSDUH, Asian Americans use alcohol, cigarettes, and illicit substances less frequently and less heavily than members of any other major racial/ethnic group (SAMHSA 2013d). However, large surveys may undercount Asian American substance use and abuse, as they are typically conducted in English and Spanish only (Wong et al. 2007b). Despite the limitations of research, data suggest that although Asian Americans use illicit substances and alcohol less frequently than other Americans, substance abuse problems have been increasing among Asian Americans. The longer Asian Americans reside in the United States, the more their substance use resembles that of other Americans. Excessive alcohol use, intoxication, and substance use disorders are more prevalent among Asians born in the United States than among foreign-born Asians living in the United States (Szaflarski et al. 2011). Among Asian Americans who entered substance abuse treatment between 2000 and 2010, methamphetamine and marijuana were the most commonly reported illicit drugs (SAMHSA, CBHSQ 2012). Methamphetamine abuse among Asian Americans is particularly high in Hawaii and on the West Coast (OAS 2005a). As with other racial and ethnic groups, numerous factors—such as age, birth country, immigration history, acculturation, employment, geographic location, and in- come—add complexity to any conclusions about prevalence among specific Asian cultural groups. Asian Americans who are recent immigrants, highly acculturated, unemployed, or living in Western states are generally more likely than other Asian Americans to abuse drugs or alcohol (Makimoto 1998). For example, according to the National Latino and Asian American Study (NLAAS), Asians who are more acculturated are at greater risk for prescription drug abuse (Watkins and Ford 2011).

    Despite rates of substance use disorders among Asian Americans having increased over time, research has regularly found that, of all major racial/ethnic groups in United States, Asian Americans have the lowest rates of alcohol use disorders (Grant et al. 2004; SAMHSA 2012b). This phenomenon has typically been explained in part by the fact that some Asians lack the enzyme aldehyde dehydrogenase, which chemically breaks down alcohol (McKim 2003). Thus, high levels of acetaldehyde, a byproduct of alcohol metabolism, accumulate and cause an unpleasant flushing response (Yang 2002). The alcohol flushing response primarily manifests as flushing of the neck and face but can also include nausea, headaches, dizziness, and other symptoms.

    Mental and Co-Occurring Disorders

    Overall, health and mental health are not seen as two distinct entities by Asian American cultural groups. Most Asian American views focus on the importance of virtue, maturity, and self-control and find full emotional expression indicative of a lack of maturity and self-discipline (Cheung 2009). Given the potential shame they often associate with mental disorders and their typically holistic worldview of health and illness, Asian Americans are more likely to present with somatic complaints and less likely to present with symptoms of psychological distress and impairment (Hsu and Folstein 1997; Kim et al. 2004; Room et al. 2001; U.S. Department of Health and Human Services [HHS] 2001; Zhang et al. 1998), even though mental illness appears to be nearly as common among Asian Americans as it is in other ethnic/racial groups. In 2009, approximately 15.5 percent of Asians reported a mental illness in the past year, but only 2 percent reported past-year occurrence of serious mental illness (SAMHSA 2012a). Asian Americans have a lower incidence of CODs than other racial/ethnic groups because the prevalence of substance use disorders in this population is lower. In the 2012 NSDUH, 0.3 percent of Asian Americans indicated co-occurring serious psychological distress and substance use disorders, and 1.1 percent had some symptoms of mental distress along with a substance use disorder—the lowest rates of any major racial/ethnic group in the survey (SAMHSA 2013c).

    Considerable variation in the types of mental disorders diagnosed among diverse Asian American communities is evident, although it is unclear to what extent this reflects diagnostic and/or self-selection biases. For example, Barreto and Segal (2005) found that Southeast Asians were more likely to be treated for major depression than other Asians or members of other ethnic/racial groups; East Asians were the most likely of all Asian American groups to be treated for schizophrenia (nearly twice as likely as White Americans). Traumatic experiences and PTSD can be particularly difficult to uncover in some Asian American offenders. Although Asian Americans are as likely to experience traumatic events (e.g., wars experienced by first-generation immigrants from countries such as Vietnam and Cambodia) in their lives, their cultural responses to trauma can conceal its psychological effects. For instance, some Asian cultural groups believe that stoic acceptance is the most appropriate response to adversity (Lee and Mock 2005a,b).

    Treatment Patterns

    Treatment-seeking rates for mental illness are low among most Asian populations, with rates varying by specific ethnic/cultural heritage and, possibly, level of acculturation (Abe-Kim et al. 2007; Barreto and Segal 2005; Lee and Mock 2005a,b). Asian Americans who seek help for psychological problems will most likely consult family members, clergy, or traditional healers before mental health professionals, in part because of a lack of culturally and linguistically appropriate mental health services available to them (HHS 2001; Spencer and Chen 2004). However, among those Asian Americans who seek behavioral health treatment, the amount of services used is relatively high (Barreto and Segal 2005).

    Beliefs and Attitudes About Treatment

    Compared with the general population, Asian Americans are less likely to have confidence in their medical practitioners, feel respected by their doctors, or believe that they are involved in healthcare decisions. Many also believe that their doctors do not have a sufficient under- standing of their backgrounds and values; this is particularly true for Korean Americans (Hughes 2002). Even so, Asian Americans, especially more recent immigrants, seem more likely to seek help for mental and substance use disorders from general medical providers than from specialized treatment providers (Abe-Kim et al. 2007). Many Asian American immigrants underuse healthcare services due to confusion about eligibility and fears of jeopardizing their residency status (HHS 2001).

    As with other groups, discrimination, acculturation stress, and immigration and generational status, along with language needs, have a large influence on behavioral health and treatment-seeking for Asian Americans (Meyer et al. 2012; Miller et al. 2011). The NLAAS found that although rates of behavioral health service use were lower for Asian Americans who immigrated recently than for the general population, those rates increased significantly for U.S.-born Asian Americans; third- generation U.S.-born individuals’ rates of service use also were relatively high (Abe-Kim et al. 2007). Of those Asian Americans who had any mental disorder diagnosis in the prior year, 62.6 percent of third-generation Americans sought help for it in the prior year compared with 30.4 percent of first-generation Americans.

    Overall, Asian Americans place less value on substance abuse treatment than other population groups and are less likely to use such services (Yu and Warner 2012). Niv et al. (2007) found that Asian and Pacific Islanders entering substance abuse treatment programs in California expressed significantly more negative attitudes toward treatment and rated it as significantly less important than did others entering treatment. Seeking help for substance abuse can be seen, in some Asian American cultural groups, as an admission of weakness that is shameful in itself or as an interference with family obligations (Masson et al. 2013). Among 2010 NSDUH respondents who stated a need for substance abuse treatment in the prior year but did not receive it, Asian Americans were more likely than members of all other major racial/ethnic groups to say that they could handle the problem without treatment or that they did not believe treatment would help (SAMHSA 2011c). Combining NSDUH data from 2003 to 2011 NSDUH, Asian Americans who needed but did not receive treatment in the past year were the least likely of all major ethnic/racial groups to express a need for such treatment (SAMHSA, CBHSQ 2013c).

    Treatment Issues and Considerations

    It is important for correctional professionals to approach presenting problems through offenders’ culturally based explanations of their own issues rather than imposing views that could alter their acceptance of treatment. In Asian cultural groups, the physical and emotional aspects of an individual’s life are undifferentiated (e.g., the physical rather than emotional or psychological aspect of a problem can be the focus for many Asian Americans); thus, problems as well as remedies are typically handled holistically. Some Asian Americans with traditional backgrounds do not readily accept Western biopsychosocial explanations for substance use and mental disorders. Correctional professionals should promote discussions focused on offenders’ understanding of their presenting problems as well as any approaches the offenders have used to address them. Subsequently, presenting problems need to be reconceptualized in language that embraces the offenders’ perspectives (e.g., an imbalance in yin and yang, a disruption in chi (Lee and Mock 2005a,b). It is advisable to educate Asian American offenders on the role of the counselor/therapist, the purpose of therapeutic interventions, and how particular aspects of the treatment process (e.g., assessment) can help offenders with their presenting problems (Lee and Mock 2005a,b; Sue 2001). Asian American offenders who receive such education participate in treatment longer and express greater satisfaction with it (Wong et al. 2007a).

    As with other racial/ethnic groups, Asian American offenders are responsive to a warm and empathic approach. Correctional professionals should realize, though, that building a strong, trusting relationship takes time. Among Asian American offenders, humiliation and shame can permeate the treatment process and derail engagement with services. Thus, it is essential to assess and discuss offender beliefs about shame (see the “Assessing Shame in Asian American Offenders” advice box on the next page). In some cases, self-disclosure can be helpful, but the counselor should be careful not to self-disclose in a way that will threaten his or her position of respect with Asian American offenders.

    Theoretical Approaches and Treatment Interventions

    Some Asian cultural groups emphasize cognitions. For instance, Asian cultural groups that have a Buddhist tradition, such as the Chinese, view behavior as controlled by thought. Thus, they accept that addressing cognitive patterns will affect behaviors (Chen 1995). Some Asian cultural groups encourage a stoic attitude toward problems, teaching emotional suppression as a coping response to strong feelings (Amodeo et al. 2004; Castro et al. 1999b; Lee and Mock 2005a,b; Sue 2001). Treatment can be more effective if providers avoid approaches that target emotional responses and instead use strategies that are more indirect in discussing feelings (e.g., saying “that might make some people feel angry” rather than asking directly what the offender is feeling; Sue 2001).

    Asian Americans often prefer a solution-focused approach to treatment that provides them with concrete strategies for addressing specific problems (Sue 2001). Even though little research is available in evaluating specific interventions with Asian Americans, clinicians tend to recommend cognitive–behavioral, solution-focused, family, and acceptance commitment therapies (Chang 2000; Hall et al. 2011; Iwamasa et al. 2006; Rastogi and Wadhwa 2006; Sue 2001). Asian American offenders are likely to expect that their correctional professionals take an active role in structuring the therapy session and provide clear guidelines about what they expect from offenders. CBT has the advantages of being problem focused and time limited, which will likely increase its appeal for many Asian Americans who might see other types of therapy as failing to achieve real goals (Iwamasa et al. 2006). Although specific data on the effectiveness of CBT among Asian Americans is not available, there is some research indicating that CBT is effective for treating depressive symptoms in Asians (Dai et al. 1999; Fujisawa et al. 2010). In China, a Chinese Taoist version of CBT has been developed to treat anxiety disorders and was found to be effective, especially in conjunction with medication (Zhang et al. 2002).

    Family Therapy

    Some Asian Americans, particularly those who are less acculturated, prefer individual therapy to group or family interventions because it better enables them to save face and keep their privacy (Kuramoto 1994). Some offenders may wish to enter treatment secretly so that they can keep their families and friends from knowing about their problems. Once treatment is initiated, correctional professionals should strongly reinforce the wisdom of seeking help through statements such as “you show concern for your husband by seeking help” or “you are obviously a caring father to seek this help.”

    The norm in Asian families is that “all problems (including physical and mental problems) must be shared only among family members”; sharing with others can cause shame and guilt, exacerbating problems (Paniagua 1998, pp. 59–60). Correctional professionals should expect to take more time than usual to learn about offenders’ situations, anticipate offender needs for reassurance in divulging sensitive information, and frame discussions in a culturally competent way. For example, correctional professionals can assure offenders that discussing problems is a step toward resuming their full share of responsibility in their families and removing some of the stress their families have been feeling.

    Group Therapy

    Group therapy may not be a good choice for Asian Americans, as many prefer individual therapy (Lai 2001; Sandhu and Malik 2001). Paniagua (1998, p. 73) suggests that “group therapy...would be appropriate in those cases in which the offender’s support system (relatives and close friends) is not available and an alternative support system is quickly needed.” Some Asian Americans participating in group therapy will find it difficult to be assertive in a group setting, preferring to let others talk. They can also abide by more traditional roles in this context; men might not want to divulge their problems in front of women, women can feel uncomfortable speaking in front of men, and both men and women might avoid contradicting another person in group (especially an older person). It may not make sense to Asian American offenders to hear about the problems of strangers who are not part of their community.

    Asian Americans are likely to be motivated to work for the good of the group; presenting group goals in this framework can garner active participation. Still, in group settings and in other instances, Asian American offenders may expect a fair amount of direction from the group leader. Chen (1995) described leader- ship of a culturally specific therapy group for Chinese Americans, noting that offenders expect a group leader to act with authority and give more credence to his or her expertise than to other group members. If members of the group belong to the same Asian American community, the issue of confidentiality will loom large, because the community is often small. Asian cultural groups generally appreciate education in more formal settings, so psychoeducation groups can work well for Asian Americans. It is possible for a psychoeducational group with Asian American participants to evolve comfortably into group therapy.

    Mutual-help Groups

    According to 2012 NSDUH data, Asian Americans were less likely than other racial and ethnic groups to report the use of mutual-help groups in the past year (SAMHSA 2013d). Mutual-help groups can be challenging for Asian Americans who find it difficult and shaming to self-disclose publicly. The degree of emotion and candor within these groups can further alienate traditional Asian American offenders. Furthermore, linguistically appropriate mutual-help groups are not always available for people who do not speak English. Highly acculturated Asian Americans may perceive participation in mutual-help groups as less of a problem, but nevertheless, Asian Americans can benefit from culture-specific mutual-help groups where norms of interpersonal interaction are shared. Asian American 12-Step groups are available in some locales. It is important for correctional professionals to assess offender attitudes toward mutual-help participation and find alternative strategies and resources, including encouragement to attend without sharing (Sandhu and Malik 2001).

    Although they are not mutual-help groups in the traditional sense, mutual aid societies and associations are important in some Asian American communities. Some mutual aid societies have long histories and have provided assistance ranging from financial loans to help with childcare and funerals. The Chinese have family associations for people with the same last name who share celebrations and offer each other help. Japanese, Chinese, and South Asians have specific associations for people from the same province or village. For some Asian American groups, such as Koreans, churches are the primary organizational vehicles for assistance. These social support groups can be important resources for Asian American offenders, their families, and the behavioral health agencies that provide services to them.

    Relapse Prevention and Recovery

    Little research has evaluated relapse prevention and recovery promotion strategies specifically for Asian Americans. However, issues involving shame can make the adjustment to abstinence difficult for Asian offenders. Correctional professionals should take this into account and address difficulties that can arise for offenders with families who have shame about mental illness or substance use disorders. To date, there are no indications that standard approaches are unsuitable for Asian American offenders.

    9.5 - Counseling for Hispanics and Latinos

    The terms “Hispanic” and “Latino” refer to people whose cultural origins are in Spain and Portugal or the countries of the Western Hemisphere whose culture is significantly influenced by Spanish or Portuguese colonization. Technically, a distinction can be drawn between Hispanic (literally meaning people from Spain or its former colonies) and Latino (which refers to persons from countries ranging from Mexico to Central and South America and the Caribbean that were colonized by Spain, and also including Portugal and its former colonies); this TIP uses the more inclusive term (Latino), except when research specifically indicates the other. The term “Latina” refers to a woman of Latino descent.

    Latinos are an ethnic group rather than a racial group; Latinos can be of any race. According to 2010 Census data, Latinos made up 16 percent of the total United States population; they are its fastest growing ethnic group (Ennis et al. 2011). Latinos include more than 30 national and cultural subgroups that vary by national origin, race, generational status in the United States, and socioeconomic status (Padilla and Salgado de Snyder 1992; Rodriguez-Andrew 1998). According to Ennis et al. (2011), of Latinos currently living in the United States (excluding Puerto Rico and other territories), Mexican Americans are the largest group (63 percent), followed by Central and South Americans (13.4 percent), Puerto Ricans (9.2 percent), and Cubans (3.5 percent).

    Beliefs About and Traditions Involving Substance Use

    Attitudes toward substance use vary among Latino cultural groups, but Latinos are more likely to see substance use in negative terms than are White Americans. Marin (1998) found that Mexican Americans were significantly more likely to expect negative consequences and less likely to expect positive outcomes as a result of drinking than were White Americans. Similarly, Hadjicostandi and Cheurprakobkit (2002) note that most Latinos believe that prescription drug abuse could have dangerous effects (85.7 percent), that individuals who abuse substances cause their whole families to suffer (81.4 percent), and that people who use illicit drugs will participate in violent crime (74.9 percent) and act violently toward family members (78.9 percent). Driving under the influence of alcohol is one of the most serious substance use problems in the Latino community.

    Other research suggests that some Latinos hold different alcohol expectancies. When comparing drinking patterns and alcohol expectancies among college students, Velez-Blasini (1997) found that Puerto Rican participants were more likely than other students to see increased sociability as a positive expectancy related to drinking and sexual impairment as a negative expectancy. Puerto Rican participants were also significantly more likely to report abstinence from alcohol. In another study comparing Puerto Ricans and Irish Americans, Puerto Rican participants who expected a loss of control when drinking had fewer alcohol-related problems, whereas Irish Americans who expected a loss of control had a greater number of such problems (Johnson and Glassman 1999). The authors concluded that “losing control” has a different cultural meaning for these two groups, which in turn affects how they use alcohol.

    For many Latino men, drinking alcohol is a part of social occasions and celebrations. By contrast, solitary drinking is discouraged and seen as deviant. Social norms for Latinas are often quite different, and those who have substance abuse problems are judged much more harshly than men. Women can be perceived as promiscuous or delinquent in meeting their family duties because of their substance use (Hernandez 2000). Amaro and Aguiar (1995) note that the heavy emphasis on the idealization of motherhood contributes to the level of denial about the prevalence of substance use among Latinas. Women who use injection drugs feel the need to maintain their roles as daughters, mothers, partners, and community members by separating their drug use from the rest of their lives (Andrade and Estrada 2003), yet research suggests that substance abuse among women does not go unrecognized within the Latino community (Hadjicostandi and Cheurprakobkit 2002).

    Among families, Latino adults generally show strong disapproval of alcohol use in adolescents of either gender (Flores-Ortiz 1994). Adults of both genders generally disapprove of the initiation of alcohol use for youth 16 years of age and under (Rodriguez-Andrew 1998). Long (1990) also found that even among Latino families in which there has been multigenerational drug abuse, young people were rarely initiated into drug abuse by family members. However, evidence regarding parental substance use and its influence on youth has been mixed; most studies show some correlation between parental attitudes toward alcohol use and youth drinking (Rodriguez- Andrew 1998). For instance, research with college students found that family influences had a significant effect on drinking in Latinos but not White Americans; the magnitude of this effect was greater for Latinas than for Latino men (Corbin et al. 2008).

    Substance Use and Substance Use Disorders

    According to 2012 NSDUH data, rates of past-month illicit substance use, heavy drinking, and binge drinking among Latinos were lower than for White Americans, Blacks, and Native Americans, but not significantly so (SAMHSA 2013d). The same data showed that 8.3 percent of Latinos reported past- month illicit drug use compared with 9.2 percent of White Americans and 11.3 percent of African Americans. Although data are available from a number of studies regarding Latino drinking and drug use patterns, more targeted research efforts are needed to unravel the complexities of sub- stance use and the many factors that affect use, abuse, and dependence among subgroups of Latino origin (Rodriguez-Andrew 1998). For example, some studies show that Latino men are more likely to have an alcohol use disorder than are White American men (Caetano 2003), whereas others have found the reverse to be true (Schmidt et al. 2007). Disparities in survey results may reflect varying efforts to develop culturally responsive criteria (Carle 2009; Hasin et al. 2007). The table in Exhibit 5-2 shows lifetime prevalence of substance use disorders among Latinos based on immigration status and ethnic subgroup (Alegria et al. 2008a).

    Among diverse Latino cultural groups, different patterns of alcohol use exist. For example, some older research suggests that Mexican American men are more likely to engage in binge drinking (having five or more drinks at one time; drinking less frequently, but in higher quantities) than other Latinos but use alcohol less frequently (Caetano and Clark 1998). There are also differences regarding the abuse of other substances. Among Latinos entering substance abuse treatment in 2006, heroin and methamphetamine use were especially high among Puerto Ricans and Mexican Americans, respectively. Other research has found that Puerto Ricans are more likely to inject drugs and tend to inject more often during the course of a day than do other Latinos (Singer 1999).

    Patterns of substance use are also linked to gender, age, socioeconomic status, and acculturation in complex ways (Castro et al. 1999a; Wahl and Eitle 2010). For instance, increased frequency of drinking is associated with greater acculturation for Latino men and women, yet the drinking patterns of Latinas are affected significantly more than those of Latino men (Markides et al. 2012; Zemore 2005).

    Age appears to influence Latino drinking patterns somewhat differently than it does for other racial/ethnic groups. Research indicates that White Americans often “age out” of heavy drinking after frequent and heavy alcohol use in their 20s, but for many Latinos, drinking peaks between the ages 30 and 39. Latinos in this age range have the lowest abstention rates and the highest proportions of frequent and heavy drinkers of any age group (Caetano and Clark 1998). In the same study, Latino men between 40 and 60 years of age had higher rates of substance use disorders than men in the same age group across other racial/ethnic populations.

    Latino youth appear to start using illicit drugs at an earlier age than do members of other major ethnic/racial groups. Cumulative data from 28 years of the Monitoring the Future Study show Latino eighth graders as having higher rates of heavy drinking, marijuana use, cocaine use, and heroin use than African or White Americans in the same grade. Among youth in grade 12, the rates of use among Latino and White American students are more similar, but Latinos still had the highest rates of crack cocaine and injected heroin use (Johnston et al. 2003).

    Patterns of substance use and abuse vary based on Latinos’ specific cultural backgrounds. Among Latinos, rates of past-year alcohol dependence were higher among Puerto Rican and Mexican American men (15.3 percent and 15.1 percent, respectively) than among South/Central American or Cuban American men (9 percent and 5.3 percent, respectively). Among Latinas, past-year alcohol dependence rates were significantly higher for Puerto Rican women (6.4 percent) than for Mexican American (2.1 percent), Cuban American (1.6 percent), or South/Central American (0.8 percent) women (Caetano et al. 2008).

    Mental and Co-Occurring Disorders

    As with other populations, it is important to address CODs in Latino offenders, as CODs have been associated with higher rates of treatment dropout (Amodeo et al. 2008). There are also reports of diagnostic bias, suggesting that some disorders are under reported and others are overreported. Minsky et al. (2003) found that, at one large mental health treatment site in New Jersey, major depression was over diagnosed among Latinos, especially Latinas, whereas psychotic symptoms were sometimes ignored. Among Latinos with CODs, other mental disorders preceded the development of a substance use disorder 70 percent of the time (Vega et al. 2009).

    Treatment Patterns

    Barriers to treatment entry for Latinos include, but are not limited to, lack of Spanish- speaking service providers, limited English proficiency, financial constraints, lack of culturally responsive services, fears about immigration status and losing custody of children while in treatment, negative attitudes toward providers, and discrimination (Alegria et al. 2012; Mora 2002). Among all ethnic/racial groups included in the 2010 NSDUH, Latinos were the most likely to report that they had a need for treatment but did not receive it because they could not find a program with the appropriate type of treatment or because there were no openings in programs that they wished to attend, which may reflect a lack of linguistically and/or culturally appropriate services (SAMHSA 2011c). They were about twice as likely to state the former and four times as likely to state the latter as members of the group that was the next most likely to make such statements.

    A significant problem prohibiting participation in substance abuse treatment among Latinos is the lack of insurance coverage to pay for treatment. In SAMHSA’s 2010 NSDUH, 32 percent of Latinos who needed but did not receive substance abuse treatment in the past year reported that they lacked money or insurance coverage to pay for it compared with 29.5 percent of White Americans and 33.5 percent of African Americans (SAMHSA 2011c). Other national surveys also found that Latinos with self-identified drinking problems were significantly more likely than either White Americans or African Americans to indicate that they did not seek treatment because of logistical barriers, such as a lack of funds or being unable to obtain childcare (Schmidt et al. 2007).

    Latinos with substance use disorders are about as likely to enter substance abuse treatment programs as White Americans (Hser et al. 1998; Perron et al. 2009; Schmidt et al. 2006). Latinos tend to enter treatment at a younger age than either African Americans or White Americans (Marsh et al. 2009). There are also significant differences in treatment-seeking patterns among Latino cultural groups. For example, Puerto Ricans who inject heroin are much more likely to participate in methadone maintenance and less likely to enter other less-effective detoxification programs than are Dominicans, Central Americans, and other Latinos (Reynoso-Vallejo et al. 2008). The researchers note, however, that this could be due partially to the fact that Puerto Ricans, compared with other Latinos, have a greater awareness of treatment options.

    Beliefs and Attitudes About Treatment

    In general, Latino attitudes toward health care are shaped by a lack of access to regular quality care, including inability to afford it. DeNavas-Walt et al. (2006) found that Latinos are less likely to have health insurance (32.7 percent were uninsured in 2005) than either non-Latino White Americans (11.3 percent were uninsured) or African Americans (19.6 percent were uninsured). They are also less likely to have had a regular place to go for conventional medical care (Schiller et al. 2005). Lack of knowledge about available services can be a major obstacle to seeking services (Vega et al. 2001). In their review, Murguia et al. (2000) identified several factors that influence the use of medical services, including cultural health beliefs, demographic barriers, level of acculturation, English proficiency, accessibility of service providers, and flexibility of intake procedures; they found that many Latinos only seek medical care for serious illnesses.

    Research on substance abuse indicates that Latinos who use illicit drugs appear to have relatively unfavorable attitudes toward treatment and perceive less need for treatment than do illicit drug users among every other major ethnic and racial group but Native Americans (Brower and Carey 2003). However, in the 2011 NSDUH, Latinos were more likely than White Americans, African Americans, or Asian Americans to indicate that they had a need for substance abuse treatment in the prior year but did not receive it (SAMHSA 2012b). Other studies have found that Latinos with substance use disorders are about as likely to enter substance abuse treatment programs as other racial and ethnic groups (Hser et al. 1998; Perron et al. 2009; Schmidt et al. 2006). Latinos who receive substance abuse treatment also report less satisfaction with the services they receive than White or African Americans (Wells et al. 2001). Even when receiving a level of substance abuse treatment services comparable to those received by White and African Americans, Latinos are more likely to be dissatisfied with treatment (Tonigan 2003).

    Treatment Issues and Considerations

    Latino offenders’ responsiveness to therapy is influenced not only by correctional professional and program characteristics, but also by individual characteristics, including worldview, degree of acculturation, gender orientation, religious beliefs, and personality traits. As with other cultural groups, efforts to establish clear communication and a strong therapeutic alliance are essential to positive treatment outcomes among Latino offenders. Foremost, correctional professionals should recognize the importance of—and integrate into their counseling style and approach—expressions of concern, interest in offenders’ families, and personal warmth (person- alismo; Ishikawa et al. 2010).

    Correctional professionals need to be educated about culturally specific attributes that can influence participation and clinical interpretation of offender behavior in treatment. For instance, some Latino cultural groups view time as more flexible and less structured; thus, rather than negatively interpreting the offender’s behavior regarding the keeping of strict schedules or appointment times, correctional professionals should adopt scheduling strategies that provide more flexibility (Alvarez and Ruiz 2001; Sue 2001). However, correctional professionals should also advise Latino offenders of the need to take relevant actions with the aim of arriving on time for each appointment or group session. Correctional professionals should try to avoid framing noncompliance in Latino offenders as resistance or anger.

    Because some research has found that Latinos have higher rates of treatment dropout than other populations (Amaro et al. 2006), programs working with this population should consider ways to improve retention and out-comes. Treatment retention issues for Latinos can be similar to those found for other populations (Amodeo et al. 2008), but culturally specific treatment has been associated with better retention for Latinos (Hohman and Galt 2001). Research evaluating ethnic matching with brief motivational interventions also found more favorable substance abuse treatment outcomes at 12-month follow-up when offenders and providers were ethnically matched (Field and Caetano 2010).

    Available literature and research highlight four main themes surrounding general counseling issues and programmatic strategies for Latinos, as follows:

    • Socializing the offender to treatment: Latino offenders are likely to benefit from orientation sessions that review treatment and counseling processes, treatment goals and expectations, and other components of services (Organista 2006).
    • Reassurance of confidentiality: Regardless of the particular mode of therapy, correctional professionals should explain confidentiality. Many Latinos, especially undocumented workers or recent immigrants are fearful of being discovered by authorities like the United States Citizenship and Immigration Services and subsequently deported back to their countries of origin (Ramos-Sanchez 2009).
    • Offender–counselor matching based on gender: To date, research does not provide consistent findings on offender–counselor matching based on similarity of Latino ethnicity. How- ever, offender–counselor matching based on gender alone appears to have a greater effect on improving engagement and abstinence among Latinos than it does for offenders of other ethnicities (Fiorentine and Hillhouse 1999).
    • Offender–program matching: Matching offenders to ethnicity-specific programs appears to improve outcomes for Latinos. Takeuchi et al. (1995) found that only 68 percent of Mexican American offenders in programs that had a majority of White American offenders returned after the first session compared with 97 per- cent in those programs where the majority of offenders were Mexican American.
    Family Therapy

    Family therapy is often recommended for treating Latinos with substance use disorders (Amaro et al. 2006; Barón 2000; Hernandez 2000). Although there is little research evaluating the effectiveness of family therapy for adults, both multidimensional family therapy (Liddle 2010) and brief strategic family therapy (Santisteban et al. 1997; Santisteban et al. 2003; Szapocznik and Williams 2000) have been found to reduce substance use and improve psychological functioning among Latino youth. The term familismo refers to the centrality of the family in Latino culture and can include valuing and protecting children, respecting the elderly, preserving the family name, and consulting with one another before making important decisions. As highlighted in the case study of a Puerto Rican offender on the next page, correctional professionals must consider the potentially pivotal roles families can play in supporting treatment and recovery. Latino families are likely to have a strong sense of obligation and commitment to helping their members, including those who have substance use disorders. Even so, the level of family support for people who have substance use or mental disorders varies among Latinos depending on country of origin, level of acculturation, degree of family cohesion, socioeconomic status, and factors related to substance use (Alegria et al. 2012). For example, Reynoso-Vallejo et al. (2008) concluded that significantly higher rates of homelessness found among people from Central American countries who injected heroin compared with other Latinos could stem from lower levels of tolerance for injection drug use among their families.

    Group Therapy

    Little information is available concerning Latinos’ preferences in behavioral health services, but a study evaluating mental health treatment preferences for women in the United States found that Latinas were significantly more likely to prefer group treatment (Nadeem et al. 2008). According to Paniagua (1998), the use of group therapy with Latino offenders should emphasize a problem-focused approach. Group leaders should allow members to learn from each other and resist functioning as a content expert or a representative of the rules of the system. Otherwise, members could see group therapy as oppressive. Facilitators in groups consisting mostly of Latino offenders must establish trust, responsibility, and loyalty among members. In addition, acculturation levels and language preferences should be assessed when forming groups so that culturally specific or Spanish-speaking groups can be made available if needed.

    Mutual-help Groups

    Findings on the usefulness of 12-Step groups for Latino offenders are inconsistent. Membership surveys of AA indicate that Latinos comprise about 5 percent of AA membership (AAWS 2012). Latinos who received inpatient treatment were less likely to attend AA than White Americans (Arroyo et al. 1998). Rates of mutual-help participation among people with drug use disorders are also lower for Latinos (Perron et al. 2009). Language can present a barrier to mutual-help group participation for Spanish-speaking Latinos; however, Spanish-language meetings are held in some locations. Correctional professionals should consider the appropriateness of 12-Step participation on a case-by-case basis (Alvarez and Ruiz 2001). For example, Mexican American men who identify with attitudes of machismo can feel uncomfortable with the 12-Step approach. Concern about divulging family issues in public can cause hesitation to address substance- related problems in public meetings.

    For Latinos who do participate in 12-Step programs, findings suggest higher rates of abstinence, degree of commitment, and level of engagement than for White American participants (Hoffman 1994; Tonigan et al. 1998). For some Latinos, 12-Step groups can appeal to religious and spiritual beliefs. Hernandez (2000) suggests that mutual-help groups composed solely of Latinos make it easier for participants to address the cultural context of substance abuse. Some Latino 12- Step groups do not hold that substance abuse is a biopsychosocial problem, instead conceptualizing the disorder as a weakness of character that must be corrected. Hoffman (1994) studied Latino 12-Step groups in Los Angeles and observed that, in addition to a more traditional form of AA, there were groups that practiced terapia dura (i.e., rough therapy), which often uses a confrontational approach and endorses family values related to machismo (e.g., by reinforcing that overcoming substance abuse rather than drinking is manly). However, these groups were not overly welcoming of female members and gay men. In such cases, gay Latino men and Latinas can benefit from attending 12-Step groups that are not culturally specific or that do not use terapia dura.

    Relapse Prevention and Recovery

    There are no substantial studies evaluating the use of relapse prevention and recovery promotion with Latinos, yet literature suggests that they would be appropriate and effective for this population (Blume et al. 2005; Castro et al. 2007). Overall, Latinos can face somewhat different triggers for relapse relating to acculturative stress or the need to uphold particular cultural values (e.g., personalismo, machismo; Castro et al. 2007), which can lead to higher rates of relapse among some Latino offenders. For example, in a study of relapse patterns among White American and Latino individuals who used methamphetamine, Brecht et al. (2000) found that Latino participants relapsed more quickly than White American participants.

    Data are lacking on long-term recovery for Latinos. Given the many obstacles that block accessibility to treatment for Latinos, continuing care planning can benefit from greater use of informal or peer supports. For example, White and Sanders (2004) recommend the use of a recovery management approach with Latinos. They point to an early example of the East Harlem Protestant Parish’s work, which helped Puerto Rican individuals recovering from heroin dependence connect to social clubs and religious communities that sup- ported recovery. Latinos use community and family support in addition to spirituality to address mental disorders (Lynch and Hanson 2011; Molina 2001). Castro et al. (2007) also note that family support systems can be especially important for Latinos in recovery.

    9.6 - Counseling for Native Americans

    There are 566 federally recognized American Indian Tribes, and their members speak more than 150 languages (U.S. Department of the Interior, Indian Affairs 2013a); there are numerous other Tribes recognized only by states and others that still go unrecognized by government agencies of any sort. According to the 2010 U.S. Census (Norris et al. 2012), the majority (78 percent) of people who identified as American Indian or Alaska Native, either alone or in combination with one or more other races, lived outside of American Indian and Alaska Native areas. Approximately 60 percent of the 5.2 million people who identified as American Indian or Alaska Native, alone or in combination with one or more other races, reside in urban areas (Norris et al. 2012). The category of Alaska Natives includes four recognized Tribal groups— Alaskan Athabascan, Aleut, Eskimo, and Tingit-Haida—along with many other independent communities (Ogunwole 2006).

    Native Americans who belong to federally recognized Tribes and communities are members of sovereign Indian nations that exist within the United States. On lands belonging to these Tribes and communities, Native Americans are able to govern themselves to a large extent and are not subject to most state laws—only to federal legislation that is specifically designated as applying to them (Henson 2008). Although health care (including sub- stance abuse treatment) is provided to many Native Americans by Indian Health Services (IHS), Tribal governments do have the option of taking over those services. Correctional professionals working with these populations should remember that Native Americans, by virtue of their membership in sovereign Tribal entities, have rights that are different from those of other Americans; this distinguishes them from members of other ethnic/racial groups.

    American Indians live in all 50 states; the states with the largest populations of American Indians are Oklahoma, California, and Arizona. The 2000 Census allowed people to identify, for the first time, as a member of more than one race. Of persons who checked two or more races, nearly one in five indicated that they were part American Indian or Alaska Native (U.S. Census Bureau 2001a,b).

    Beliefs About and Traditions Involving Substance Use

    Few American Indian Tribes and no Alaska Natives consumed alcoholic beverages prior to contact with non-Native people, and those who did used alcohol primarily for special occasions and ceremonies. Most Tribes first encountered the use of alcohol when they encountered European settlers and traders. Because of this lack of experience with alcohol, few Native Americans had a context for drinking besides what they learned from these non-Natives, who at the time drank in large quantities and often engaged in binge drinking. Although patterns of alcohol consumption in the mainstream population of the United States changed over time, they remained relatively the same in the more isolated Native American communities. According to an NSDUH report on American Indian and Alaska Native adults, binge drinking continues to be a significant problem for these populations. Both binge drinking and illicit drug use is higher among Native Americans than the national average (30.2 percent versus 23 percent and 12.7 percent versus 9.2 percent, respectively; SAMHSA 2013d).

    American Indian drinking patterns vary a great deal by Tribe. Tribal attitudes toward alcohol influence consumption in complicated ways. For example, in Navajo communities, excessive drinking was acceptable if done in a group or during a social activity. However, solitary drinking (even in lesser amounts) was considered to be deviant (Kunitz et al. 1994). Kunitz et al. (1994) observed that during the 1960s, binge drinking was acceptable among the Navajo during public celebrations, whereas any drinking was considered unacceptable among the neighboring Hopi population, wherein regular drinkers were shunned or, in some cases, expelled from the community. Hopi individuals who did drink tended to do so alone or moved off the reservation to border towns where heavy alcohol use was common. The ostracism of Hopi drinkers seemed to lead to even greater levels of abuse, given that there were much higher death rates from alcoholic cirrhosis among the Hopi than among the Navajo.

    Native American recovery movements have often viewed substance abuse as a result of cultural conflict between Native and Western cultures, seeing substances of abuse as weapons that have caused further loss of traditions (Coyhis and White 2006). To best treat this population, substance abuse treatment providers need to expand their perspectives regarding substance abuse and dependence and must embrace a broader view that explores the spiritual, cultural, and social ramifications of substance abuse (Brady 1995; Duran 2006; Jilek 1994).

    Substance Use and Substance Use Disorders

    According to 2012 NSDUH data, American Indian and Alaska Native peoples have the highest rates of substance use disorders and binge drinking (SAMHSA 2013d). Although rates of substance abuse are high among Native Americans, so too are rates of abstinence. American Indians and Alaska Natives are more likely to report no alcohol use in the past year than are members of all other major racial and ethnic groups (OAS 2007). The American Indian Services Utilization and Psychiatric Epidemiology Risk and Protective Factors Project (AI-SUPER PFP) also found that rates of lifetime abstinence from alcohol for American Indians in the study were significantly higher than lifetime abstinence rates among the general population (Beals et al. 2003). Data on alcohol consumption also show that Alaska Natives are significantly more likely to abstain than are other Alaskans (Wells 2004).

    The most common pattern of abusive drinking among American Indians appears to be binge drinking followed by long periods of abstinence (French 2000; May and Gossage 2001). A similar pattern is seen among Alaska Natives (Seale et al. 2006; Wells 2004). As an example, the Urban Indian Health Institute (2008) found that binge drinking was significantly more common among the Native American population (with 21.3 percent engaging in binge drinking in the prior 30 days compared with 15.8 percent of non- Native Americans) and that, among those who drank, 40.7 percent of Native American participants engaged in binge drinking compared with 26.9 percent of non-Natives.

    In addition to alcohol, methamphetamine and inhalant abuse are major concerns for a number of Native American communities. Nonetheless, there are considerable regional differences in patterns and prevalence of drug use (Miller et al. 2012). According to the National Congress of American Indians (2006), 74 percent of Tribal police forces ranked methamphetamine as the drug causing the most problems in their communities. Methamphetamine abuse can be even more serious for Native Americans living in rural areas than for those in urban areas, but it is also a serious problem for growing numbers of American Indians, especially women, entering treatment in urban areas (Spear et al. 2007).

    American Indians and Alaska Natives are more likely to report having used inhalants at some time during their lives, but use tends to peak in 8th grade and then decrease (Miller et al. 2012). In some Native American communities (e.g., on the Kickapoo reservation in Texas), inhalants have been a major drug of abuse for adults as well as youth. During the early 1990s, about 46 percent of the adult population on that reservation were thought to abuse inhalants (Fredlund 1994). Although more recent data are not available, reports from the area suggest that inhalant abuse remains a significant problem (Morning Star 2005).

    Mental and Co-Occurring Disorders

    According to the 2012 NSDUH, 28.3 percent of American Indians and Alaska Natives report having a mental illness, with approximately 8.5 percent indicating serious mental illness in the past year (SAMHSA 2013c). Native Americans were nearly twice as likely to have serious thoughts of suicide as members of other racial/ethnic populations, and more than 10 percent reported a major depressive episode in the past year. Common disorders include depression, anxiety, and substance use.

    As with other groups, substance use disorders among Native Americans have been associated with increased rates of a variety of different mental disorders (Beals et al. 2002; Tann et al. 2007; Westermeyer 2001). The 2012 NSDUH revealed that 14 percent of Native Americans reported both past-year substance use disorders and mental illness. Among those who reported mental illness, nearly 5 percent reported several mental illnesses co-occurring with substance use disorders (SAMHSA 2013c).

    Native American communities have experienced severe historical trauma and discrimination (Brave Heart and DeBruyn 1998; Burgess et al. 2008). Studies suggest that many Native Americans suffer from elevated exposure to specific traumas (Beals et al. 2005; Ehlers et al. 2006; Manson 1996; Manson et al. 2005), and they may be more likely to develop PTSD as a result of this exposure than members of other ethnic/racial groups. PTSD comparison rates taken from the AI-SUPER PFP study and the National Comorbidity Study show that 12.8 percent of the Southwest Tribe sample and 11.5 percent of the Northern Plains Tribe sample met criteria for a lifetime diagnosis of PTSD compared with 4.3 percent of the general population (Beals et al. 2005). Trauma histories and PTSD are so prevalent among Native Americans in substance abuse treatment that Edwards (2003) recommends that assessment and treatment of trauma should be a standard procedure for behavioral health programs serving this population. For example, Native American veterans with substance use disorders are significantly more likely to have co-occurring PTSD than the general population of veterans with substance use disorders (Friedman et al. 1997).

    Treatment Patterns

    Despite a number of potential barriers to treatment (Venner et al. 2012), Native Americans are about as likely as members of other racial/ethnic groups to enter behavioral health programs. According to data from the 2003 and 2011 NSDUH (SAMHSA, CBHSQ 2012), Native Americans were more likely to have received substance use treatment in the past year than persons from other racial/ethnic groups (15.0 percent versus 10.2 percent). Other studies indicate that about one-third of Native Americans with a current substance use disorder had received treatment in the prior year (Beals et al. 2006; Herman-Stahl and Chong 2002). The 2012 NSDUH reported that approximately 15 percent of Native Americans received mental health treatment (SAMHSA 2013c).

    Native Americans were least likely of all major ethnic/racial groups to state that they could not find the type of program they needed and were the next least likely after Native Hawaiians and other Pacific Islanders to state that they did not know where to go or that their insurance did not cover needed treatment. Among Native Americans who identified a need for treatment in the prior year but did not enter treatment, the most commonly cited reasons for not attending were lack of transportation, lack of time, and concerns about what one’s neighbors might think (SAMHSA 2011c).

    The same research also found that Native Americans were somewhat more likely than the general treatment-seeking population to enter residential programs. Native Americans were more likely to enter treatment as a result of criminal justice referrals than were White Americans or African Americans: 47.9 percent of American Indians and Alaska Natives entering public treatment programs in 2010 were court-ordered to treatment compared with 36.6 percent of White Americans and 36.4 percent of African Americans (SAMHSA, CBHSQ 2012). The lack of recognition of special needs and knowledge of Native American cultures within behavioral health programs may be the main reasons for low treatment retention and underuse of help-seeking behaviors among Native Americans (LaFromboise 1993; Sue and Sue 2013e).

    Beliefs and Attitudes About Treatment

    Duran et al. (2005) evaluated obstacles to treatment entry among American Indians on three different reservations; most frequently mentioned were the perception that good-quality or suitable services were unavailable and the perceived need for individuals to be self-reliant. They also found social relationships to be extremely important in overcoming these barriers. Jumper-Thurman and Plested (1998) reported that focus groups of American Indian women listed mistrust as one of the primary barriers for seeking treatment. This is due, in part, to the women’s belief that they would encounter people they knew among treatment agency staff; they also doubted the confidentiality of the treatment program.

    Treatment Issues and Considerations

    Each Tribe and community will likely have different customs, healing traditions, and beliefs about treatment providers that can influence not only willingness to participate in treatment services, but also the level of trust offender have for providers. Correctional professionals and other behavioral health workers must develop ongoing relationships within local Native American communities to gain knowledge of the unique attributes of each community, to show investment in the community, and to learn about community resources (Exhibit 5- 3). Identifying and developing resources within Native communities can help promote culturally congruent relationships. To provide culturally responsive treatment, providers need to understand the Native American offender’s Tribe; its history, traditions, worldview, and beliefs; the dimensions of its substance abuse problem and other community problems; the incidence of trauma and abuse among its members; its traditional healing practices; and its intrinsic strengths. Providers who work with Native Americans but do not have an understanding of their cultural identity and acculturation patterns are at a distinct disadvantage (Ponterotto et al. 2000).

    Native Americans often approach the beginning of a relationship in a calm, unhurried manner, and they may need more time to develop trust with providers. Concerns about confidentiality can be an important issue to address with Native American offender, especially for those in small, tightly knit communities. For providers, it is very important to make clear to offender that what they say to the counselor will be held in confidence, except when there is an ethical duty to report. Native American cultural groups generally believe that health is nurtured through balance and living in harmony with nature and the community (Duran 2006; Garrett et al. 2012).

    They also, for the most part, have a holistic view of health that incorporates physical, emotional, and spiritual elements (Calabrese 2008), individual and community healing (Duran 2006; McDonald and Gonzalez 2006), and prevention and treatment activities (Johnston 2002). For many, culture is the path to prevention and treatment. However, not all Native Americans have a need to develop stronger connections to their communities and cultural groups. As Brady (1995) cautions, culture is complex and changing, and a return to the values of a traditional culture is not always desired. An initial inquiry into each offender’s connection with his or her culture, cultural identity, and desire to incorporate cultural beliefs and practices into treatment is an essential step in culturally competent practice. When appropriate, providers can help facilitate the offender’s reconnection with his or her community and cultural values as an integral part of the treatment plan. In addition, treatment providers need to adapt services to be culturally responsive. In doing so, outcomes are likely to improve not only for Native American offender, but for all offender within the program. Fisher et al. (1996) modified a therapeutic community in Alaska to incorporate Alaska Native spiritual and cultural practices and found that retention rates improved for White and African American offender as well as Alaska Native offender participating in the program.

    In working with Native American offender, providers should be prepared to address spirituality and to help offender access traditional healing practices. Culturally responsive treatment should involve community events, group activities, and the ability to participate in ceremonies to help offender achieve balance and find new insight (Calabrese 2008). Stronger attachment to Native American cultural groups protects against substance use and

    abuse; therefore, strengthening this connection is important in substance abuse treatment (Duran 2006; Moss et al. 2003; Spicer 2001; Stone et al. 2006).

    Family Therapy

    Family involvement in treatment leads to better outcomes for Native Americans at the time of discharge from treatment (Chong and Lopez 2005). Research also suggests that family and community support can have a significant effect on recovery from substance use disorders for this population (Jones- Saumty 2002; Paniagua 1998). Family therapy can be quite helpful and perhaps even essential for American Indian offender (Coyhis 2000), especially when other social supports are lacking (Jones-Saumty 2002).

    American Indians place high value on family and extended family networks; restoring or healing family bonds can be therapeutic for offender with substance use disorders. Moreover, Native American offenders are sometimes less motivated to engage in “talk therapy” and more willing to participate in therapeutic activities that involve social and family relationships ( Joe and Malach 2011). Treatment approaches should remain flexible and include offender’s families when appropriate. Correctional professionals should be able to recognize what constitutes family, family constellations, and family characteristics. The Native American concept of family can include elders, others from the same clan, or individuals who are not biologically related. In many Tribes, all members are considered relatives. Families can be matrilineal (i.e., kinship is traced through the female line) and/or matrilocal (i.e., married couples live with wife’s parents).

    Group Therapy

    Although researchers and providers once viewed group therapy as ineffective for American Indian offenders (Paniagua 1998), opinion has shifted to recognize that, when appropriately structured, group therapy can be a powerful treatment component (Garrett 2004; Garrett et al. 2001; Trimble and Jumper- Thurman 2002). Garrett (2004) notes that many Native American Tribes have traditional healing practices that involve groups; for many of these cultural groups, healing needs to occur within the context of the group or community (e.g., in talking circles). Thus, if properly adapted, group therapy can be very beneficial and culturally congruent. It is important, however, to determine Native American offender’s level of acculturation before recommending Western models of group therapy, as less acculturated Native offender are likely to be less comfortable with group talk therapy (Mail and Shelton 2002). Group therapy for Alaska Natives should also be non- confrontational and focus on offender’s strengths.

    Group therapy can incorporate Native American traditions and rituals to make it more culturally suitable. For example, the talking circle is a Native tradition easily adapted for behavioral health treatment. In this tradition, the members of the group sit in a circle. An eagle feather, stone, or other symbolic item is passed around, and each person speaks when he or she is handed the item. Based on a review of the literature, Paniagua (1998) recommends that providers using group therapy with Native American offender:

    • Earn support or permission from Tribal authorities before organizing group therapy.
    • Consult with Native professionals.
    • If group members consent, invite respected Tribal members (e.g., traditional healers or elders) to participate in sessions.
    Mutual-help Groups

    Native American peoples have a long history of involvement in mutual-help activities that predates the 12-Step movement (Coyhis and White 2006). Depending on acculturation, availability of a community support network, and the nature of their presenting problems, Native American offenders may be more likely to solicit help from significant others, extended family members, and community members. Contemporary manifestations of Native American mutual-help efforts include adaptations of the 12 Steps (Exhibit 5-4) and of 12-Step meeting rituals and practices (Coyhis and White 2006). Another modified element of the 12 Steps is use of a circular, rather than a linear, path to healing. The circle is important to American Indian philosophy, which sees the great forces of life and nature as circular (Coyhis 2000). In addition, staff members of the White Bison program have also rewritten the AA “Big Book” from a Native American perspective (Coyhis and Simonelli 2005). The principles of the 12 Steps, which involve using the group or community to provide support and motivation while emphasizing spiritual reconnection, appeal to many Native Americans who see treatment as social in nature and who view addiction as a spiritual problem.

    The Native American Wellbriety movement is a modern, indigenous mutual-help program that has its roots in 12-Step groups but incorporates Native American spiritual beliefs and cultural practices (Coyhis and Simonelli 2005; Coyhis and White 2006; White Bison, Inc. 2002; also see Although the Wellbriety movement is popular with many Native Americans in recovery, a considerable number also continue to participate in traditional 12-Step groups. In the AI- SUPER-PFP, 47 percent of Northern Plains Tribe respondents and 28.8 percent of South- west Tribe respondents with a past-year substance use disorder reported 12-Step group attendance in the prior year (Beals et al. 2006). Mohatt et al. (2008b) found that more Alaska Natives in recovery reported participation in 12-Step groups than in substance abuse treatment. In Venner and Feldstein’s (2006) re- search with American Indians in recovery, 84 percent of respondents had attended some mutual-help meetings.

    Relapse Prevention and Recovery

    Despite limited data on long-term recovery for Native Americans who have substance use disorders, a few studies have found high rates of relapse following substance abuse treatment (see review in Chong and Herman-Stahl 2003). White and Sanders (2004) recommend that long-term recovery plans for Native Americans make use of a recovery management rather than a traditional continuing care approach. Such an approach emphasizes the use of informal recovery communities and traditional healing approaches to provide extended monitoring and support for Native Americans leaving treatment.

    Researchers have conducted interviews with both American Indians (Bezdek and Spicer 2006) and Alaska Natives (Hazel and Mohatt 2001; Mohatt et al. 2008; People Awakening Project 2004) who have achieved extended periods of recovery. Bezdek and Spicer (2006) identified two key tasks for American Indians entering recovery. First, they need to learn how to respond to family and friends who drank with them and to those who supported their recovery. Next, they have to find new ways to deal with boredom and negative feelings. By accomplishing these tasks, Native offenders can build new social support systems, develop effective coping strategies for negative feelings, and achieve long-term recovery. The People Awakening Project found that, among Alaska Natives who had a substantial period of recovery, the development of active, culturally appropriate coping strategies was essential (e.g., distancing themselves from friends or family who drank heavily, getting involved in church, doing community service, praying; Hazel and Mohatt 2001; Mohatt et al. 2008; People Awakening Project 2004).

    9.7 - Counseling for White Americans

    According to the 2010 U.S. Census definition, White Americans are people whose ancestors are among those ethnic groups believed to be the original peoples of Europe, the Middle East, or North Africa (Humes et al. 2011). The racial category of White Americans includes people of various ethnicities, such as Arab Americans, Italian Americans, Polish Americans, and Anglo Americans (i.e., people with origins in England), among others. Many Latinos will also identify racially (if not ethnically) as White American. Non-Latino White Americans constitute the largest racial group in the United States (making up 63.7 percent of the population in the 2010 Census; Mather et al. 2011).

    White Americans, like other large ethnic and cultural groups, are extremely heterogeneous in historical, social, economic, and personal features, with many (often subtle) distinctions among subgroups. Perhaps because White Americans have been the majority in the United States, it is sometimes forgotten how historically important certain distinctions between diverse White American ethnic heritages have been (and continue to be, for some). Conversely, many White American people prefer not to see themselves as such and instead identify according to their specific ethnic background (e.g., as Irish American). For similar reasons, certain cross-cutting cultural issues (see Chapter 1) like geographic location, sexual orientation, and religious affiliation are important in defining the cultural orientations of many White Americans.

    Beliefs About and Traditions Involving Substance Use

    Historically, use of alcohol was accepted among White/European cultural groups because it provided an easy way to preserve fruit and grains and did not contain bacteria that might be found in water. Over time, the production and consumption of alcohol became an often-integral part of cultural activities, which can be seen in the way some White cultural groups take particular pride in national brands of alcoholic beverages (e.g., Scotch whisky, French wine; Abbott 2001; Hudak 2000). A number of European cultural groups (e.g., French, Italian) traditionally believed that daily alcohol use was healthy for both mind and body (Abbott 2001; Marinangeli 2001), and for others (e.g., English, Irish), the bar or pub was the traditional center of community life (O’Dwyer 2001). Despite some variations in cultural attitudes toward appropriate drinking practices, alcohol has been and remains the primary recreational substance for Whites in the United States. Predominant attitudes toward drinking in the United States more closely reflect those of Northern Europe; alcohol use is generally accepted during celebrations and recreational events, and, at such times, excessive consumption is more likely to be acceptable.

    Typically, White European cultural groups accept alcohol use as long as it does not interfere with responsibilities, such as work or family, or result in public drunkenness (Hamid 1998). However, among certain groups of White Americans (usually defined by religious beliefs), the use of alcohol or any other intoxicant is considered immoral (van Wormer 2001). These religious beliefs, combined with concerns about the effects of problematic drinking patterns (especially among men in the frontier; White 1998), became the impetus for the early 19th-century creation of the Temperance Movement and culminated in the passing of the 18th Amendment to the United States Constitution, which enacted Prohibition. Although the Temperance Movement is no longer a major political force, belief in the moral and social value of abstinence continues to be strong among some segments of the White American population.

    Illicit drug use, on the other hand, has historically been demonized by White American cultural groups and seen as an activity engaged in by people of color or undesirable subcultures (Bonnie and Whitebread 1970; Hamid 1998; Whitebread 1995). For example, White Americans typically link drug use to perceived threat of crime—particularly crimes perpetrated by people of color (Hamid 1998; Whitebread 1995). Attitudes have changed over time, but White American cultural groups continue to enforce strong cultural prohibitions against most types of illicit drug use. At the same time, White Americans are often more accepting of prescription medication abuse and less likely to perceive prescription medications as potentially harmful (Hadjicostandi and Cheurprakobkit 2002).

    Despite illicit drug use now being as common among White Americans as people of color, White Americans still tend to perceive drug use as an activity that occurs outside their families and communities. In a 2001 survey, only 54 percent of White Americans expressed concern that someone in their family might develop a drug abuse problem compared with 81 percent of African Americans (Pew Research Center for the People and the Press 2001). In the same survey, White Americans expressed less concern about drug abuse in their neighborhoods than did other racial and ethnic groups. However, in terms of seeing drugs as a national problem, White Americans and other racial and ethnic groups are in closer agreement. Perhaps as a result of this misperception about the prevalence of drug use in their homes and communities, White American parents are less likely to convey disapproval of drug use to their children than African American parents (National Center on Addiction and Substance Abuse 2005) and much more likely than Latino or African American parents to think that their children have enough information about drugs (Pew Research Center for the People and the Press 2001).

    There are also differences in how White Americans, Latinos, and African Americans perceive drug and alcohol addictions. White Americans are less likely than African Americans, but more likely than Latinos, to state that they believe a person can recover fully from addiction (Office of Communications 2008). However, White Americans are more likely than African Americans to indicate that substance use disorders should be treated as diseases (Durant 2005).

    Substance Use and Substance Use Disorders

    According to 2012 NSDUH data, rates of past-year substance use disorders were higher for White Americans than for Native Hawaiians, other Pacific Islanders, and Asian Americans; rates of current alcohol use were higher than for every other major ethnic/racial group (SAMHSA 2013d). Alcohol has traditionally been the drug of choice among White Americans of European descent; however, not all European cultural groups have the same drinking patterns. Researchers typically contrast a Northern/Eastern European pattern, in which alcohol is consumed mostly on week- ends or during celebrations, with that of Southern Europe, in which alcohol is consumed daily or almost daily but in smaller quantities and almost always with food. The Southern European pattern involves more regular use of alcohol, but it is also associated with less alcohol-related harm overall (after controlling for total consumption; Room et al. 2003). The pattern of White Americans typically follows that of Northern and Eastern Europe, but individuals from some ethnic groups maintain the Southern European pattern.

    White Americans, on average, begin drinking and develop alcohol use disorders at a younger age than African Americans and Latinos (Reardon and Buka 2002). White Americans are more likely to have their first drink before the age of 21 and to have their first drink before the age of 16 than members of any other major racial/ethnic group except Native Americans (SAMHSA 2011c). Some data suggest that White Americans begin using illicit drugs at an earlier age than African Americans (Watt 2008) and that the mean age for White Americans who inject heroin has decreased (Broz and Ouellet 2008).

    White Americans who use heroin are less likely than people who use heroin from all other major racial/ethnic groups except African Americans to have injected the drug (SAMHSA 2011c). White Americans are also more likely than members of other major racial/ethnic groups, except Native Hawaiians and other Pacific Islanders (for whom estimates may not be accurate), to have tried ecstasy. Except for Native Americans (some of whom may use the hallucinogen peyote for religious purposes), they are also more likely than other racial/ethnic groups to have tried hallucinogens (SAMHSA 2011c). Research confirms that prescription drug misuse is more common among White Americans than African Americans or Latinos (Ford and Arrastia, 2008; SAMHSA 2011c), and they are more likely to have used prescription opioids in the past year and to use them on a regular basis.

    Comparative studies indicate that White Americans are more likely than all other major racial/ethnic groups except Native Americans to have an alcohol use disorder (Hasin et al. 2007; Perron et al. 2009; Schmidt et al. 2007). White Americans are at a greater risk of having severe alcohol withdrawal symptoms (such as delirium tremens) than are African Americans or Latinos with alcohol use disorders (Chan et al. 2009). So too, White Americans are more likely than African Americans or Latinos to meet diagnostic criteria for a drug use disorder at some point during their lives (Perron et al. 2009). Overall, substance use disorders vary considerably across and within non-European White American cultural groups. For example, rates of substance abuse treatment admissions in Michigan from 2005 suggest that substance use disorders may be considerably lower for Arab Americans than other White Americans (Arfken et al. 2007).

    Mental and Co-Occurring Disorders

    About 20 percent of White Americans reported some form of mental illness in the past year, and they were more likely to have past-year serious psychological distress than other population groups excluding Native Americans (SAMHSA 2012a).

    White Americans appear to be more likely than Latinos or Asian Americans to have CODs (Alegria et al. 2008a; Vega et al. 2009) and more likely to have concurrent serious psychological distress and substance use disorders (SAMHSA 2011c). White Americans with CODs are also more likely to receive treatment for both their substance use and mental disorders than are African Americans with CODs (Alvidrez and Havassy 2005; Hatzenbuehler et al. 2008), but they are perhaps less likely to receive treatment for their substance use disorder alone (Alvidrez and Havassy 2005). White Americans are more likely to receive family counseling and mental health services while in substance abuse treatment and less likely to have unmet treatment needs (Marsh et al. 2009; Wells et al. 2001). In addition, White Americans are significantly less likely than Latinos or African Americans to believe that antidepressants are addictive (Cooper et al. 2003).

    The most common mental disorders among White Americans are mood disorders (particularly major depression and bipolar I disorder) and anxiety disorders (specifically phobias, including social phobia, and generalized anxiety disorder; Grant et al. 2004b). Among White Americans, these disorders are more prevalent than in any other ethnic/racial groups save Native Americans (Grant et al. 2005; Hasin et al. 2005). For example, rates of a lifetime diagnosis of generalized anxiety disorder are about 40 percent lower for African Americans and Latinos than for White Americans and about 60 percent lower for Asian Americans (Grant et al. 2005). A similar pattern exists for major depressive disorder (Hasin et al. 2005).

    Treatment Patterns

    White Americans are more likely to receive mental health treatment or counseling than other racial/ethnic groups (SAMHSA 2012b). White Americans are more likely than African Americans to receive substance abuse treatment services from a private physician or other behavioral health or primary care professional (Perron et al. 2009). Among White American offenders entering substance abuse treatment programs in 2010, alcohol (alone or in conjunction with illicit drugs) was most often the primary substance of abuse, followed by heroin and cannabis. However, findings are inconsistent concerning the relative frequency with which White Americans enter substance abuse treatment. Some studies have found that White Americans are more likely to receive needed behavioral health services than both African Americans and Latinos (Marsh et al. 2009; Wells et al. 2001). In contrast, other studies have found that African Americans with an identified need are somewhat more likely to enter treatment for drug use disorders and about as likely to receive treatment for alcohol use disorders when compared with White Americans (Hatzenbuehler et al. 2008; Perron et al. 2009; SAMHSA, CBHSQ 2012; Schmidt et al. 2006).

    Beliefs and Attitudes About Treatment

    White Americans appear to be generally accepting of behavioral health services. They have better access to health care and are more likely to use services than people of color, but this varies widely based on socioeconomic status and cultural affiliation. Most treatment services have historically been developed for White American populations, so it is not surprising that White Americans are more likely than other racial/ethnic groups to be satisfied with treatment services (Tonigan 2003).

    Still, attitudes differ among certain cultural subgroups of White Americans. For example, Russian immigrants from the former Soviet Union have a longstanding distrust of mental health systems and hence may avoid substance abuse treatment (Kagan and Shafer 2001). Other groups who have a strong family orientation, such as Italian Americans or Scotch-Irish Americans, might avoid treatment that asks them to reveal family secrets (Giordano and McGoldrick 2005; Hudak 2000).

    According to 2010 NSDUH data regarding people who recognized a need for substance abuse treatment in the prior year but did not receive it, White Americans were more likely than members of other major racial/ethnic groups to state that it was because they had no time for treatment, that they were concerned what their neighbors might think, that they did not want others to know, and/or that they were concerned about how it might affect their jobs (SAMHSA 2011c). Other research confirms that White Americans are significantly more likely to avoid treatment due to fear of what others might think or because they are in denial (Grant 1997). White Americans may also have different attitudes toward recovery, at least regarding alcohol use disorders, than do members of other ethnic/racial groups. According to NESARC data on people who met criteria for a diagnosis of alcohol dependence at some point during their lives, White Americans were more likely than African Americans, Latinos, or other non- Latinos to have achieved remission from that disorder but were also less likely than African Americans or other non-Latinos (but not Latinos) to currently abstain from drinking, as opposed to being in partial remission or drinking without symptoms of alcohol dependence (Dawson et al. 2005).

    Treatment Issues and Considerations

    Most major treatment interventions have been evaluated with a population that is largely or entirely White American, although the role of White American cultural groups is rarely considered in evaluating those interventions. For example, as Straussner (2001) notes, “the paradox of writing about substance abusers of European background is that they are a group that is believed to be the group for whom the traditional alcohol and other drug treatment models have been developed, and yet they are a group whose unique treatment needs and treatment approaches have rarely been explored” (p. 165). Very few evaluations of treatment strategies and interventions (whether based on research or clinical observation) have taken into account ethnic and cultural differences among White American offenders, and therefore it is generally not possible to make culturally responsive recommendations for specific subgroups of White Americans.

    Culturally responsive treatment for many White Americans will involve helping them rediscover their cultural backgrounds, which sometimes have been lost through acculturation and can be an important part of their long- term recovery. Giordano and McGoldrick (2005) note that ethnic identity and culture can be more important for some White Americans “in times of stress or personal crisis,” when they may want to “return to familiar sources of comfort and help, which may differ from the dominant society’s norms” (p. 503). Appendix B provides information on instruments for assessing cultural identification. For an overview of challenges in maintaining mental health, access to health care, and help-seeking among White Americans, see Downey and D’Andrea (2012).

    Family Therapy

    In White American families, individuals are generally expected to be independent and self-reliant; as a result, families in therapy can have trouble adjusting to work that focuses more on communication processes than specific problems or content (McGill and Pearce 2005). Van Wormer (2001) notes that many White Americans need help addressing communication issues. In family therapy, useful approaches include those that encourage open, direct, and nonthreatening communication.

    There is no singular description that fits White American families within or across ethnic heritages, and there is no approach that is effective for all White Americans in family therapy (Hanson 2011). Hierarchical families, such as German American families, may expect the correctional professional to be authoritative, at least in the initial sessions (Winawer and Wetzel 2005), although a more egalitarian German American family might not respond well to such imperatives. In the same vein, one offender of French background could readily accept direct and clear therapeutic assignments that contain measurable goals (Abbot 2001), whereas another French American offender may value counseling that is more process oriented. Thus, it is imperative to assess the cultural identification of offenders and their families, along with the treatment needs that best match their cultural worldviews.

    In some White American families, there is a longstanding culture of drinking. Attempts at abstinence can be perceived by family members as culturally inappropriate. In other families, there is deep denial about alcohol abuse or dependence, especially when talking about substance use to those outside the family. For example, some Polish American families can be resistant to the idea that drinking is the cause of family problems (Folwarski and Smolinski 2005) and sometimes believe that to admit an alcohol problem, especially to someone outside the family, signals weakness.

    Group Therapy

    Standard group therapies developed for mental health and substance abuse treatment programs have generally been used and evaluated with White American populations.

    Mutual-help Groups

    Mutual-help groups, of which AA is the most prevalent, have a largely White American membership (AAWS 2008; Atkins and Hawdon 2007). In a 2011 survey, 87 percent of AA members indicated their race as White (AAWS 2012). In research with largely White populations, AA participation has been found to be an effective strategy for promoting recovery from alcohol use disorders (Dawson et al. 2006; McCrady et al. 2004; Moos and Moos 2006; Ritsher et al. 2002; Weisner et al. 2003). Other mutual-help groups, such as Self-Management and Recovery Training, Secular Organizations for Sobriety/Save Our Selves, and Women for Sobriety, also have predominately White American membership and are based on Western ideas drawn from psychology (Atkins and Hawdon 2007; White 1998).

    The appeal of mutual-help groups among White Americans rests on the historical origins of this model. The 12-Step model was originally developed by White Americans based on European ideas of spirituality, faith, and group interaction. Although the model has been adopted worldwide by different cultural groups (White 1998), the 12-Step model works especially well for White ethnic groups, including Irish Americans, Polish Americans, French Americans, and Scotch- Irish Americans, because it incorporates Western cultural traditions involving spiritual practice, public confession, and the use of anonymity to protect against humiliation (Abbott 2001; Gilbert and Langrod 2001; Hudak 2000; McGoldrick et al. 2005; Taggart 2005).

    PinIn addition to mutual-help groups for substance abuse, numerous recovery support groups, Internet resources, Web-based communities, and peer support programs are available to promote mental health recovery.

    Pin It! Mental Health Resources

    Click here to explore the many resources are available through the National Alliance on Mental Illness.

    Relapse Prevention and Recovery

    Factors that promote recovery for White Americans include the learning and use of coping skills (Litt et al. 2003; Litt et al. 2005; Maisto et al. 2006). Even though some research suggests that White Americans are less likely to use coping skills than African Americans (Walton 2001) and have lower levels of self- efficacy upon leaving treatment (Warren et al. 2007), the development of these skills and of self-efficacy is important in managing relapse risks and in maintaining recovery. Correctional professionals may offer psychoeducation on the value of coping strategies, specific skills to manage stressful situations or environments, and opportunities to practice these skills during treatment. Some coping skills or strategies may be more important than others in managing high-risk situations, but research suggests that greater use of a variety of coping strategies is more important than the use of any one specific skill (Gossop et al. 2002).

    Social and family supports are also important in maintaining recovery and preventing re- lapse among White Americans (Laudet et al. 2002; McIntosh and McKeganey 2000; Rumpf et al. 2002). Other important factors include continuing care, the development of substitute behaviors (i.e., reliance on healthy or positive activities in lieu of substance use), the creation of new caring relationships that do not involve substance use, and increased spirituality (Valliant 1983). Valliant (1983) and others (e.g., Laudet et al. 2002; McCrady et al. 2004; Moos and Moos 2006) conclude, based on research with mostly White participants, that mutual-help groups often play an important role in maintaining recovery.


    Correctional professionals have a difficult role in the law enforcement continuum. They must provide offenders with rehabilitative services and provide for the safety and security of the community. This dual role is challenging and requires an understanding of culture, gender, religion and socioeconomic status to be effective. This will aid officers to build a rapport with offenders to develop a professional, therapeutic relationship. This section was designed to give correctional professionals a greater understanding of how race and culture can impact the treatment process. Many times, offenders are required to engage in treatment. They may be unresponsive to treatment because they have a different cultural perspective. The information provide in this chapter allows correctional professional to explore whether the lack of involvement may be a cultural misunderstanding. It can also guide correctional professional on how to improve outcomes through different approaches.

    In this chapter, we learned about treatment of offenders specific to their ethnicity. This is an important consideration when conducting case management services with offenders because not all offenders can be treated the same. Unique cultural experiences need to be considered so treatment services are effective.

    During this chapter, we discussed in great detail specific issues in dealing with rehabilitation and ethnicity. For this activity, pretend you are a counselor in a prison and the following offenders present these issues. What is your case plan? Support your answer with information from the chapter.

    person with megaphone

    Act It Out! Case Manager Assignment

    Case #1 – A 36-year-old African American woman is on your caseload. She has been in treatment for substance abuse but doesn’t feel as if it is helping her. She states she still has sudden panic attack at visiting. She has a volatile relationship with her husband and after visits, she states she feels “amped” up for several days after his visits. What do you recommend?

    Case #2 – A 45-year-old Native American man is set for discharge soon. He has a supportive family and will return to the reservation. What is your discharge plan? What services to set up for him for re-entry to the community? Make sure to support your answer with information from the readings.

    Case #3 – A 21-year-old Hispanic male routinely shows up late for treatment sessions. Once at the session, he participates and is actively engaged in the materials. He indicates he feels the sessions are valuable. How do you address the tardiness, as it is distracting to the other participants? Explain why he may be acting this way.

    Case #4 – A 40-year-old white woman is having difficulties with her treatment program. She is an alcoholic and in prison for a DUI in which she killed a family member. Her relationship with her family is strained. She feels she must abstain from drinking when she is released from prison, however all of her family members drink socially. How do you prepare her for transition?

    This page titled 9: Multicultural Treatment Considerations in Corrections is shared under a CC BY license and was authored, remixed, and/or curated by Dave Wymore & Tabitha Raber.