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.