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).

In 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.

Conclusion

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.

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?