Comprehensive care for the African-American client

Alcohol and other drug addiction have had a major impact on African-Americans, destroying far too many black families and communities. The short-term relief one achieves from the use of alcohol and other drugs seduces many African-Americans who are looking for a way out of the stress, frustration, pain, pressure, and sense of hopelessness associated with oppression and the absence of opportunity.

The fast money associated with the illegal drug trade, long seen as a way out of the poverty-stricken ghettos of our nation, has fueled the black-on-black, drug-related violence that is rampant in African-American communities across the nation. The gangster rap music so popular with our black youth further glamorizes drug use and the drug-dealing lifestyle—so much so that many young blacks are eager to make a career out of the drug business.1

The introduction of crack cocaine in the late 1980s and the ensuing hysteria surrounding the crack “epidemic” was particularly devastating to the African-American community, as we saw sharp increases in violence, prostitution, and child abuse/neglect. Although there was no empirical evidence to support the concept of the “crack baby,” the ongoing media campaign served to manufacture public support for a criminal approach to the War on Drugs.

This public policy is directly responsible for an 800% increase since 1986 in the number of African-American women behind bars, disparate sentences for crack-related offenses, and more blacks being in jail for longer periods of time.2,3 One in nine black males ages 20 to 34 is incarcerated.4

It is no wonder, then, that substance abuse in the African-American community and its collateral consequences of homelessness, mental illness, HIV/AIDS, and soaring foster care costs represents one of the primary public health issues in this country.

Although there have been no large-scale empirical studies to examine the issue of cultural competency in substance use treatment for African-Americans, there are signs of progress. The California Department of Alcohol and Drug Programs has adopted the Institute of Medicine model for inclusion in the redesign of its service system, acknowledging the importance of the commitment to institutionalize appropriate practices to ensure inclusion and respect of diversity in the delivery of services.5,6

Treatment requires trust, honesty, and self-disclosure, and if the client is unwilling or unable to do these things the program will not succeed. Many African-American clients have problems becoming engaged in the treatment process and are not comfortable talking openly about their genuine issues because of cultural norms that forbid “putting your business in the street.” Also, due to a history of oppression, discrimination, and racism, persons of color tend to have a healthy mistrust of bureaucratic systems and services provided by persons viewed to be the oppressor.7

Therefore, African-Americans are either failing to complete programs successfully or are being discharged for noncompliance. This is especially important when we consider that most African-Americans gain access to treatment through the criminal justice and/or child welfare system, and failure to complete treatment often results in loss of parental rights, loss of livelihood, a felony conviction with a long stay behind bars, and/or a return to previous drug use.

While there are no concrete numbers on how many people who relapse never make it back for a second try at treatment, we do know that the disease of addiction is so insidious and deadly that for many people the next time they use could be the last time they use. At the very least, a relapse or a poor treatment experience can extinguish the desire to be clean and sober. We in the treatment industry need to ensure that the treatment we provide affords clients the best possible chance for success. We must continually strive to improve our ability to provide culturally competent services delivered by trained and compassionate staff.

In doing so, we must offer resources, technical assistance, and other training opportunities to our treatment teams. We must meet with decision-makers at administrative levels to ensure that policies and systems that allow African-American clients to feel welcomed, understood, safe, and cared for are developed and implemented.

In the development or evaluation of programs serving African-Americans, the issue areas described below should be considered significant components of a comprehensive, culturally competent treatment model.

Environment

The treatment environment should be welcoming to the African-American client. A program does not need to be located in a black neighborhood, but it should be easily accessible to the client (transportation is one of the top three reported barriers to treatment for women). It should aesthetically be made to feel inclusive to the client, with photos, literature, artwork, etc., that portray African-Americans in a healthy way.

There should be sufficient space for confidential consultation. The facility should be warm, clean, and in good repair. Oftentimes when a program caters to black clients it is not as concerned with the upkeep of the environment. Clients should see the environment not as demeaning, but as a clean and safe place to heal.

Staff

Having a good staff is one of the most important components of an effective treatment program, as it reflects the program's philosophy in its day-to-day work. The client will look to the staff for advice, support, and leadership, so it is incredibly important that staff members be well-trained and possess a set of academic and interpersonal skills that allow them to understand and appreciate cultural differences.

African-Americans have unique historical and contemporary experiences that come into play in the therapeutic relationship. Cultural differences between treatment providers and clients can hinder client satisfaction, unless adjustments are made to accommodate the client's values, behaviors, and cultural traits.8

It is not required but certainly preferred that a program treating African-American clients have some African-Americans on the treatment team, as it helps the client to see someone of color represented on the staff roster. You don't have to be black to help a black addict, but a multidisciplinary and multicultural team is most effective in providing substance use treatment.7

Staff members should have cultural competency training, which includes an opportunity for them to identify their own cultural biases. Program leaders should monitor the staff to ensure that it operates in a culturally sensitive manner. Staff members should have clinical supervision as it relates to cultural issues and should be given an opportunity to discuss and explore the cultural counter-transference issues that are certain to arise in any clinical environment.9

Staff members should be screened and hired based on their expertise and their ability to work well with all clients. However, the African-American client is highly sensitive to anything that resembles prejudice, discrimination, and/or disrespect, so all program staff—including clerical and administrative personnel—need to be able to communicate to the client in a warm, compassionate, and accepting demeanor.

Treatment philosophy

The program's treatment philosophy should embrace the idea that “one size does not fit all.” Treatment should be individualized based on the specific clinical needs of each client regardless of race or ethnicity. Clients should be assessed at the beginning of their program to determine what clinical issues will be addressed during treatment. Clients with culture-related issues should be given the opportunity to discuss their concerns safely.

The program should recognize that the African-American client more likely than not will have problems related to race that may interfere with his/her ability to benefit from treatment. Therefore, the program should make provisions in the day-to-day treatment structure to support the client in talking openly about his/her circumstances and processing any feelings. The publication Collaborative Efforts for Engaging African-American and Euro-American Clients with Substance Abuse Counselors in Group Dialogue offers an overview of actual dialogue in this process.10

Levels of care

Ideally, an effective treatment facility should provide a full range of services. In the best-case scenario the program would offer or have access to the following core services:

• Free intake assessment;

• One-on-one counseling;

• Intensive outpatient treatment;

• Residential treatment;

• Drug and alcohol awareness classes (prevention and education);

• Case management; and

• Aftercare.

Many African-American clients come into treatment through the criminal justice system or via a social service agency, but a good number of them do not meet the diagnostic criteria for substance dependence. Many have substance abuse problems but not an addiction, yet most treatment programs are designed to treat alcoholics and addicts.

Clients are forced to identify themselves as addicts and alcoholics in the program and the 12-Step meetings they are mandated to attend. Some resist this labeling and are deemed unwilling and unmotivated. Others become “institutionally compliant” in order to “graduate” the program, but they never talk openly about their situation or their relationship with drugs. In either scenario, the client is likely to have a negative treatment outcome.

The appropriate treatment approach for these clients is often education and prevention rather than a full course of intensive treatment. Programs should include the option of other more clinically indicated interventions to increase the likelihood that clients are actually getting the care they need.

Aftercare and follow-up

The aftercare and follow-up plan is one of the most important yet most overlooked aspects of treatment. Often African-American clients have multiple issues that pose a threat to their long-term recovery, including high-risk living situations; partners or family members who use; loss of spiritual connection; ongoing legal, employment, and child custody issues; etc. A good program will develop a realistic discharge plan that provides a strategy for dealing with these concerns.

Regular aftercare support groups or one-on-one sessions should be made available to the client for a defined period of time, preferably at least one year post-discharge. This allows the African-American client to develop an ongoing relationship with the program at least through the difficult first few months of recovery.

Conclusion

The African-American community is being devastated by alcohol and other drug addiction. Jails and institutions are full of black people who have gotten caught up in addiction's cycle. Black children are packed in child protective service systems, foster homes, and juvenile halls as a direct or indirect result of substance abuse.

The problem is big—much bigger than we often care to admit as a society. However, there is a solution. We as a treatment industry can make a difference—helping to change lives by providing comprehensive, well thought-out treatment. We can help African-American clients by developing programs that work, programs that are sensitive to the fact that race still constitutes a major issue in our nation. We can help African-American clients address the unresolved racial issues that sometimes make it difficult for them to succeed in treatment and recovery.

We can tackle these issues head-on by providing clients with a safe, supportive environment in which to deal with all of the issues that contribute to their addiction. In doing so, we can change the world one life at a time.

He is a NAADAC member. His e-mail address is rolandwms@mac.com, and his Web site is https://www.rolandwilliamsconsulting.com.

References

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5. California Department of Alcohol and Drug Programs. Continuum of Services System Re-Engineering Task Force, Phase II Report, 2007. Available at https://www.adp.state.ca.us/COSSR/pdf/Phase_II_Report.pdf.
6. Institute of Medicine. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, D.C.:National Academies Press; 2006.
7. Sue DW, Sue D. Counseling the Culturally Different: Theory and Practice (Second Ed.). Hoboken, N.J.:John Wiley and Sons; 1990.
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9. Baker FM, Bell CC. Issues in the psychiatric treatment of African Americans. Psychiatr Serv 1999; 50:362-8.
10. Leitschuh G, Lyles J, Kayser L, et al.Collaborative efforts for engaging African-American and Euro-American clients with substance abuse counselors in group dialogue. Illinois Counsel Assoc Quarterly 2002 November.