Culturally Competent Substance Abuse Nursing
The road back from addiction is arduous—for those in the grips of the addiction, of course, but also for the people around them, including their health care providers. Though prescribed manners of treatment exist, every journey to recovery is unique, every substance abuser takes his or her own path. Why should it matter, then, if nurses and other health care practitioners take into consideration the patient’s culture and background? In short, because understanding patients on a more personal level through familiarity with their cultural and social mores can lead to more effective substance abuse treatment.
“The general argument is that through cultural competence, providers can enhance the therapeutic alliance, which may lead to high client engagement,” says Erick Guerrero, Ph.D., M.A., B.A., an assistant professor at the University of Southern California and licensed clinical therapist. “Research supports the notion that deep and effective cross-cultural training, translation of material, and use of translators are associated with better engagement outcomes in [substance abuse treatment].”
The solutions start simple, such as cross-cultural education for all providers, particularly managers and administrators, perhaps provided on an annual basis. A straightforward adjustment toward culturally congruent care is providing adequate translation services. For example, it’s hard to refute the instant improvement in communication when pairing Spanish-speaking practitioners with Spanish-speaking patients. In a recent study, Guerrero and his colleagues examined the effects of cultural and linguistic competence in Latinos’ mandated substance abuse treatment (published in the August 2012 edition of Substance Abuse Treatment, Prevention, and Policy). Their study of 5,150 first-time Latino participants in court-mandated treatment programs revealed that the culturally congruent practice of providing Spanish language translation services increased participants’ odds of completing the treatment, notably amongst a population with a high risk of abandoning the treatment.
And, as cultural competence often results in more efficient, effective patient care, it not only benefits patients but potentially administrative bottom lines. So what are some of the other benefits of implementing culturally competent care, and how can nursing teams treating those struggling with substance abuse provide it? Guerrero and several experts in substance abuse treatment share their insights regarding culturally competent care below.
How does cultural competence improve the delivery of substance abuse care?
Roland: “In my experience over the last 40 years in nursing—and in particular over the last 20 years working in the field of addictions—patients who feel accepted, heard, understood, and validated for their strengths tend to do better in treatment. Clinicians who are aware of and knowledgeable about the diversity of cultures and subcultures that exist in the U.S. are in a better position to accurately assess, communicate, and individualize treatment. I believe that when people feel understood and supported within the context of their values and beliefs, treatment outcomes are better. Culturally sensitive clinicians aid the psychological and emotional well-being of their patients and, in so doing, will help foster and nourish a healthier self esteem, especially in substance abusers, who are generally filled with a lot of guilt and shame. Cultural competence should be incorporated into health care training and practice in order to maximize the opportunity for constructive change and recovery.”
Chandler & Degner: “Nurses need to have the ability to understand the cultural differences each substance abuse/ dependent person presents and must hone skills to correctly interpret non-verbal, verbal, and physical cues appropriately. Therefore, cultural competence training in serving substance abuse/dependent consumers is imperative to improve treatment delivery.”
How might nurses improve the cultural competence of their substance abuse care?
Chandler & Degner: “Nurses can improve their cultural competence and understand the culture in which substance abuse/ dependent populations exist daily. The substance abuser/dependent person will not focus on their substance(s) of choice but rather focus on the accompanying affective symptoms (depression, mood swings, anxiety, etc.). Hence, the outcome of working with this client may actually be perpetuating their addictive process.
There are specific cultural aspects of substance abuse/dependence in different populations as well. An example would be a Caucasian substance-abusing male as opposed to a Hispanic male. The very aspect of entering a treatment episode has different cultural barriers for each of these clients. Understanding these cultural differences will enhance motivational interviewing and will place the client at ease. What we view sometimes as resistance is attributable many times to cultural norms of the individual we are serving. Other cultural factors including religion, folk ways, family life, values, and so forth need to be considered when working with and providing medication to the client.”
Guerrero: “Continuing education [is needed] in areas of cultural and linguistic diversity, as well as in the complexity of substance use and other co-occurring disorders. Informally, service providers benefit from personal and professional interactions with people and contexts that are from other cultural and linguistic backgrounds. These interactions, coupled with a nuanced understanding of the complexity of culture and language in mental health and provider client interaction, may provide nurses with the necessary ‘cultural intelligence’ to effectively engage minority clients. It is through the therapeutic alliance that we service providers have the greatest impact on clients’ attitudes about change.”
Roland: “Nurses can improve the cultural competence of their substance abuse care by ongoing education both academically and experientially. For example, nurses can advocate for regular in-service trainings about this subject on their jobs. Also, state and national organizations can offer conferences and panel discussions that could include minorities in order to get feedback on how we can improve in this area. Nurses working in addictions with minority patients have the opportunity to ask them directly for suggestions on how to improve our treatment specifically for them.”
Spanswick: “Each program tends to treat different problems but all professionals should try to take advantage of cultural competency classes offered by qualified professionals. Areas of cultural sensitivity include understanding different ethic backgrounds, the GLBTQ (Gay, Lesbian, Bisexual, Transsexual, and Questioning) community, and sensitivity surrounding economic status and class. Especially important is for practitioners to understand transference and countertransference issues so that they can try to be consciously aware of their relationship with the client and use tools to create a positive therapeutic join with the client and minimize the risk of clients leaving treatment. It is also extremely important to understand the current drug culture and trends. The most common issues regarding transference are anger and resentment towards the entitlement and denial of early stage addicts in recovery.”
What administrative steps can outpatient clinics adopt to deliver more culturally competent care?
Guerrero: “Quality assurance protocols need to go beyond checklists and rely on existing program evaluation tools to assess the level of cultural competence of their program. That information can inform a strategic plan to invest in areas of need (training, diversity, etc.)”
Chandler & Degner: “Administration is challenged with the opportunity to provide cultural diversity trainings for staff as well as education on alternate delivery methods. In-services training needs to be continual and learning needs to be focused on the various cultural aspects of all encountered aspects of client culture, including races, religion, sexual orientation, age group, etc. While we all cannot be experts, exposure to education over time can provide a broader base of overall cultural diversity within an agency.”
Roland: “Actively recruiting more diversity within the staff and administration is one way to help bridge the gap. Another suggestion is administrations could fund programs about substance abuse that will help educate as well as interest students in urban communities in this particular field of health care.”
Spanswick: “The best administrative step is using the skill of leading by example—administrators should be involved in training just as much as the treatment staff.”
What are some of the barriers to providing culturally competent substance abuse care?
Guerrero: “Individual providers face significant challenges to improve their cultural intelligence and culturally competent care, if they are limited to a monocultural life and professional environment. But the responsibility to develop a culturally competent health care extends beyond individual providers; managers and policy makers are responsible for developing adequate policy and organizational incentives for providers to engage in cross cultural training, implement evidence-based culturally responsive practices, and to track client outcomes. Substance abuse treatment providers are generally ill-prepared to implement new practices, including translation services, family based protocols, recruitment of diverse staff, cross-cultural training, etc.
In my research, I found that the major barriers to implement culturally responsive care are leaders and staff attitudes about the effectiveness of culturally competent practices and resources necessary to implement such practices. Interestingly, implementing such practices is not cost-prohibited; most programs have resources to translate material, prioritize hiring of diversity, or modify treatment protocols to include families in the treatment process. It is just not a priority until leaders support it or funding entities require it.”
Chandler & Degner: “The greatest barrier that exists in providing culturally competent health care is to be able to respond in an empathetic and supportive way to the client who presents for treatment. Many times it is our own fear of our knowledge base as it pertains to cultural differences. Training and education are key in meeting the demands and serving a more diverse population.”
“Another barrier, particularly in rural settings, is the lack of exposure to a more diverse consumer population. This, however, does not preclude those within the helping profession in these areas from exposure to a culturally diverse client base. . . . [We] need to educate ourselves and do what we can to understand emerging populations.
Additionally, the substance abuse/dependent population is ever changing, including the substances abused, the manner in which substances are abused, the background of users, etc. Referrals from businesses in the city as well as rural areas provide challenges for us to become better equipped and knowledgeable in understanding how to serve these many diverse populations and their very specific needs.”
Roland: “As an African American I can speak directly to some of the barriers that I know exist. There is a double stigma of being an addict and also being black in a predominately white culture where racism still persists. There is also—although I think this is changing somewhat—a stigma within the black community itself against getting psychiatric and addiction care. Many believe that giving one’s life to the Lord and going to church is all one needs for healing. . . . Other barriers are economic, as some people can’t take the time off from their jobs for treatment. Others, particularly women, may be hindered because of childcare issues. Homelessness and lack of adequate transportation or the money to travel to treatment facilities is also a problem. While some of these are barriers to health care in general, treatment programs may need more funding to hire clinicians willing to work evenings to facilitate groups and family meetings.”
Spanswick: The lack of diversity in hiring and organizational ‘group think’ and culture, which tend to be self-reinforcing of a singular cultural sensitivity—it’s important to try and join with clients from where they are at the point of admission.”
What resources or readings can you recommend to nurses wishing to improve the substance abuse care they provide their patients?
Guerrero: “For practice-oriented material, check with National Center for Cultural Competence website.”
Chandler & Degner: “The American Society of Addiction Medicine (ASAM) Patient Placement Criteria is a great resource. ASAM has provided substance abuse professionals with criteria that assist nurses in discerning the correct level of intervention needed for their patients.”
Roland: “A good article that I would recommend is ‘Cultural Competency: Its Impact on Addiction Treatment and Recovery’ from Resource Links, Volume 7 Issue 2.”
How has the delivery of care changed over the past 10 years and what work remains to be done?
Chandler & Degner: “The cultural diversity training presented 10 years ago was more cursory compared to today. Changes in population(s) served has driven a need for a more culturally aware and culturally competent staff. Population(s) across the U.S., both in the heartland and on our coasts, have changed drastically during the past 10 years.
Even though every year we go through training on the topic of understanding cultural diversity, it does not meet the needs of the ever-changing consumer populations. We are more challenged to be knowledgeable about the cultural heritage of patients and how it impacts their care, now more than ever before. Because of the culturally diverse populations in rural communities and larger cities especially, we must improve our understanding of what the specific populations’ needs are and also change the way we provide treatment to ensure that we are responding to these more culturally diverse populations in the most effective way.”
Roland: “I think that awareness has definitely increased. There are more books, articles, and trainings on the subject. Years ago, this wasn’t even talked about. Mandatory trainings on the subject of cultural competence need to be implemented in health care institutions. Patients who are not part of the mainstream culture need to be asked how we can help improve in this area. Then these suggestions need to be implemented.”
Spanswick: “The field is constantly evolving and the types of drugs and the culture changes. I would say that the biggest change in the last 10 years is the use of prescription opiates and crystal meth, which has required clinicians to use more family-based education as to what is and what is not a drug that is likely to become one that carries more danger. It is appalling how many ‘drug addicts’ become accidental abusers of prescribed medication—this is something we see too often at KLEAN Treatment Center.
As a field we are just beginning to understand addiction and how the brain works. As science progresses, I believe the medical models will become much more sophisticated and will dominate the field. Culturally we have made huge strides in the past 50 years but there is always room for more understanding, especially as cultures are constantly evolving. Most importantly we need to constantly remind ourselves that every client is different, all have unique issues, and it is the primary relationship between clinician and client that can produce the greatest outcomes in the long term.”
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