Cultural diversity in the US emerged due to many historical and political reasons. These reasons did not depend on the will and desires of people who fall out of the cohort. In the 60s of the 20th century, the first movements appeared that protected the civil and human rights of diverse groups that make up American society. Throughout the mid-1970s and late 1990s, African Americans, Mexican Americans, Native Americans, women, and LGBTQ people formed communities to support each other and fight discrimination in US society, which meant that an active and responsible role was assigned for several centuries exclusively for white men. During the 17th and 20th centuries, the rights of immigrants from many countries in Europe, Latin America, Asia, and the Middle East, were perceived as optional, provided with the goodwill of ‘real’ US citizens. However, this approach has long been outdated and was deemed unacceptable due to the active position of the oppressed groups. In psychological practice, including addiction counseling, the situation based on the privilege of white men is ineffective, given the great variety of social problems and circumstances with which people who seek help from consultants struggle. This paper aims to discuss the importance of multicultural competence in addiction counseling and explain how issues of race may impact the quality of medical and psychological help received by racial and ethnic minorities.
Reasons for Discrimination in Counseling
Despite the declared democratic values, discrimination in the United States is widespread, especially in providing social services to the population. Although health care is a privately paid and expensive service for most people, not everyone gets the same quality of care. During the first 200 years of US independence, most of the country’s universities “did not accept women, and only a few accepted men of color” (“Multicultural counseling,” 2021, par. 4). As a result, most therapists were white males who do not represent the diverse American society. According to the latest census, 60.4% of whites, 18.3% of Hispanics, 13.4% of African Americans, and 5.9% of Asians live in the US, whereas, according to the APA, in 2015, 86% of psychologists in the US were white, 5% Asian, 5% Hispanic, and 4% African American (“Multicultural counseling,” 2021). Differences in mentality and life experience due to racial and ethnic differences between patients and therapists hinder effective psychological therapy, including addiction counseling.
Notably, the most common problems associated with discrimination in the United States are systemic racism, ableism, and religious differences. Ableism refers to discrimination against people with disabilities, “including disabilities resulting from a genetic disease or physical injury” (“Multicultural counseling,” 2021, par. 6). Religious differences are often a prerequisite for discrimination when therapists subconsciously or consciously insist that Christianity is the only correct religion and treat alternative value systems and religious views with disapproval or disrespect.
Racism in Addiction Counselling
Historical evidence suggests that the United States has a long history of racial intransigence that has been ingrained in society for hundreds of years. Systemic racism is widespread, as well as everyday racism when discrimination is expressed in a series of seemingly insignificant differences in perception that have a cumulative effect destroying the psyche and self-assessment of people. Systemic racism is made evident by annual statistics showing that non-white people receive health services of different quality and have lower access to services. Representatives of the non-white race are more likely to end up in prison and a less favorable financial position due to a combination of social and socio-economic factors, including prejudice. Often, racial differences are the cause of substance abuse or homelessness.
Skewes & Blume (2019) confirm the devastating impact of racism on the health and well-being of American Indians. Scientists emphasize the effects of racism on the use of psychoactive substances by this group. Skewes & Blume (2019) argue that, according to epidemiological studies, among the Alaska Natives and American Indians, there is higher morbidity and mortality due to drug and alcohol use. Therefore, scientists claim the need for immediate intervention, including adopting cultural measures and introducing new cultural approaches to treatment and counseling.
Skewes & Blume (2019) conducted a study with 25 key community informants from a border reservation in Montana. They discussed the causes of “substance use problems and barriers to recovery on the reservation” (Skewes & Blume, 2019, p. 88). Even though the researchers did not ask questions about discrimination, the participants stated that the stress caused by racism is a crucial factor influencing the decision to use psychoactive substances. One participant said that “oppression is the overarching umbrella for all drug and alcohol-related illnesses” (Skewes & Blume, 2019, p. 88). Other reasons cited were the historical trauma of colonization and racial stress as predictors of addiction. The researchers concluded that addiction treatment counseling and interventions must consider determinants of health such as racial discrimination.
Results from a study by Richards et al. (2020) show that “occupational status and demographic variables are important predictors of attitudes toward addiction” (p. 218). Demographic characteristics impacted physicians’ behavior during treatment and influenced the adolescents’ drug addiction treatment refusal. Therefore, scholars recommend widespread training in multicultural counseling practices to reduce stigma. Beckerman & Fontana (2019) emphasize that scientists need to pay more attention to drug courts as a particular phenomenon in the American justice system. The scholars note that programs for clients subjected to legal inducement through drug courts must be culturally sensitive. In particular, special attention should be paid to African American female offenders that have a drug addiction. According to scholars, traditional compulsory treatment is not effective enough for these populations. At the same time, approaches that consider cultural differences are more effective in retaining patients.
Racism in Addiction Treatment
Addiction counseling is not the only area where discrimination is widespread and cultural diversity is under-observed. Mennis et al. (2019) recognized several trends in SUD treatment that were indicative of racial discrimination. Scientists noted that “African Americans and Hispanics take outpatient SUD treatment longer than whites” (Mennis et al., 2019, p. 158). The researchers found that African Americans and Hispanics had a lower treatment completion rate and more prolonged treatment. Mennis et al. (2019) specifically state that the likelihood of completion of therapy is reduced under the influence of economic, cultural, potentially discriminatory factors and access to medical services. These same indicators lead to an increase in the duration of treatment before completion. Therefore, scholars recommend paying particular attention to the unique problems faced by minorities, as this can affect the patient outcomes and increase the quality of the provided services.
DeKock (2020) notes that cultural competence helps to reduce disparities in drug abuse treatment among ethnic minorities and migrants. The scientist conducted a review of the existing academic literature on the topic and identified several key research areas. The scientist analyzed 41 studies and determined that the cultural competence concept is unique in the United States and originated here. Then the idea was adopted in medical institutions on other continents (DeKock, 2020). It was also found that problems with cultural competence usually arise between the client and the health care provider.
Researchers note that problems in treating substance use patients from various ethical backgrounds and migrant patients arise at the service level due to language, trauma, and shame issues. Concerns are also present in the relationship between the patient and the service provider. They are associated with non-compliance with ethical requirements, discomfort, mistrust of the supplier, fears of violation of confidentiality, worldview differences, and counter-transference (DeKock, 2020). Therefore, most of the authors call for consideration of whether physicians and health care providers are culturally competent enough and how cultural competence relates to general approaches to treatment. Equally important is the assessment of access to treatment among migrants and racial and ethnic minorities. This review demonstrates complete academic consensus regarding discrimination and racism in the provision of SUD counseling.
Matsuzaka & Knapp (2020) also recognize discrimination and racism in counseling patients with substance use disorder (SUD). Scientists emphasize that people of color experience additional barriers to participation in treatment and successful completion of treatment and lower treatment satisfaction rates due to racism and discrimination. Therefore, scholars recommend exploring the cultural competencies of drug dependence treatment counselors, given that they are often susceptible to beliefs associated with systemic racism. Academics state that the institutions where counseling services are provided are a source of socialization within the framework of systemic racism.
It means that the problem should be resolved by providing training for consultants and reviewing medical institutions’ compliance with generally accepted ethical requirements and legislation. Therefore, the scholars summarize that there is a need to “implement an anti-racist framework for drug addiction treatment” (Matsuzaka & Knapp, 2020, p. 567). This study is of particular value as the authors speak directly about the problems of systemic racism in institutions.
Pagano et al. (2018) examined discrimination and treatment inequality based on race or ethnicity among tobacco-addicted patients. The scientists noted that tobacco use is widespread among patients undergoing SUD. After interviewing 1,840 clients in 24 tobacco addiction treatment programs, the researchers found that tobacco use was more common among white people than African Americans and Hispanics. According to the study, Hispanics and African Americans “were less likely to smoke daily, smokeless tobacco or e-cigarettes” (Pagano et al., 2018, p. 9). The two groups reported more smoking cessation attempts and consumed more menthol. Hispanics also showed greater interest in quitting smoking during treatment for SUD. At the same time, African Americans received more advice and services to quit smoking during treatment.
These results suggest that African Americans and Hispanics show a higher level of awareness in the treatment of addiction and thus have a higher potential in SUD treatment. This positive trend is important when evaluating treatment outcomes, which are often worse than those of the white race. Therefore, this study suggests that there are even more significant problems associated with discrimination and systemic and daily racism than it might seem at first glance. Notably, getting more advice and services on smoking cessation among African Americans may indicate successful policies to tackle inequalities in health care provision and successful addiction prevention. Pagano et al. (2018) conclude that the study’s findings support the need for a continued policy of providing advice and services on tobacco cessation among African Americans and Hispanics, including during treatment for SUD. Scientists also note the need for increased interest in tobacco cessation during SUD treatment among white patients.
Racism in Addiction Interventions and Assessment
Racism in addiction interventions and assessment is an equally common problem. This issue requires approaches related to ensuring the implementation of practices of cultural competence, including medical education and a systemic approach at the level of medical institutions, which often suffer from entrenched systemic racism. Alegria (2018) notes that collaborative decision-making in interventions and assessment is a promising practice that will help to level racism and discrimination. According to the scholar, joint decision-making leads to better treatment outcomes because the patient and doctor work as partners when discussing decisions. This practice requires that physicians acquire the skills to involve the patient in the decision-making process. Alegria (2018) notes differences in patients from ethnic and racial minorities who express less participation. These patients are less likely to show concern, trust, or seek information, which is an obstacle to better patient and treatment outcomes.
Ethical and Legal Factors in Culturally Diverse Addiction Counseling
The most important law that protects the rights of racial and ethnic minorities is the Civil Rights Act of 1964, which covers many areas of social participation, including in the medical field. However, legislation needs to be expanded to more clearly encompass health services and describe existing types of discrimination and racism, including day-to-day and systemic racism. In 1964, the law was passed to protect civil rights in general and aimed primarily at ending segregation and ensuring equal voting and political representation opportunities. The law describes the requirements for equal access to public accommodations and ensures nondiscrimination in federally assisted programs. Under its influence, the Americans with Disabilities Act of 1990 was passed. Society needs additional legislation to provide for liability for discriminatory behavior, including in the provision of medical advice.
Ethical standards are less binding and therefore fail to ensure due respect for the rights of racial and ethnic minorities. Nonetheless, codes of ethics provide a suitable basis for future laws. The NAADAC Code of Ethics of 2021 reminds healthcare providers of the need to acquire knowledge, skills and develop personal sensitivity to demonstrate cultural competence in consulting patients (“Code of Ethics,” 2021). In particular, the code has sections on Ethical Framework for Counseling and Ethical Framework for Interaction, which require healthcare professionals to demonstrate a range of qualities, practices, and knowledge. The areas of concern include respect, cultural humility, personal beliefs, heritage, credibility, roles, methodologies, advocacy, special needs, and cultural needs.
Scientists emphasize the importance of emotional intelligence in the development of practices related to cultural competence. Smith (2020) conducted a study that showed that emotional intelligence is positively associated with cultural empathy. Cultural humility is considered no less important in providing culturally competent counseling. Tirado & Hilert (2019) state that the cultural humility approach is beneficial in leading counseling groups for women in the criminal justice system. Thanks to their unique experience, the authors developed a cultural humility framework that consultants can further apply when working with racial and ethnic minorities. Remarkably, according to the authors, cultural humility led to “empowering and mutually beneficial counselor-client relationships across differences in power and privilege” (Tirado & Hilert, 2019, p. 82). The results of this study can be beneficial in the development of educational programs for consultants and their acquisition of cultural competence.
Importance of the Multicultural Competence
Many universities today prescribe work internships in multicultural communities for psychology students. This approach helps broaden the horizons of physicians. Sensitive cultural and racial experiences are often the cause of addiction and substance abuse, which is mentioned in many scientific studies. Moreover, when receiving counseling, for example, when referring to addiction treatment or receiving a diagnosis, patients face discrimination, which exacerbates their psychological problems. Therefore, multicultural counseling and multicultural competence are essential components of effective community outreach.
Multicultural competence involves providing multicultural counseling, which becomes possible after therapists undergo special training and master specific skills. Multicultural factors include race, ethnicity, geographic origin, religion and belief system, gender, sexual self-determination, disability, and financial security. The systems of values and priorities also differ in groups, when some patients may prioritize career and raising children, while others – family life and integration into the community. Multicultural counselors can provide services in schools, private practice, or as social workers.
Multicultural counseling is a highly effective tool in providing consulting services for patients with addiction from diverse cultural backgrounds. The official representative for multicultural consultants is the Association for Multicultural Counseling and Development (AMCD), created by APA in 1972 with the aim of “recognizing human diversity and the multicultural nature of our society, identifying and working to eliminate conditions that create obstacles to the individual development of marginalized populations” (“Multicultural counseling,” 2021, par. 5). The organization creates training programs and provides guidelines for working with patients from diverse backgrounds, including patients with addiction. The AMCD is an official body that protects the interests of patients with addiction discriminated against at all levels, including in the home environment and when receiving medical services. ACMD tackles the harm of old ways of providing advice and inclusion.
Thus, the importance of multicultural competence in addiction counseling was discussed, and explanations were provided on how issues of race may impact the quality of medical and psychological help received by ethnic and racial minorities. Cultural competence, or multicultural competence, is an essential element in medical counseling, including addiction counseling. Members of ethnic and racial minorities are systematically discriminated against, as evidenced by many studies. The only way to overcome these limitations is by adopting multicultural competence among the broadest circle of medical services providers. Redefining deep-rooted racial and ethnic prejudices will help reduce discrimination and improve the lives and self-esteem of ethnic minorities. Given that discrimination is often the cause of addictive behavior, cultural competence is critical in substance use treatment, assessment, and intervention practices.
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