Introduction to the Proceedings for the Conference: Culturally Based Substance Abuse Treatment for American Indians/Alaska Natives and Latinos

Although it is generally accepted that substance abuse treatment programs and approaches for minority clients that are not culturally based would have limited effectiveness, there is great variance in what constitutes cultural relevance. For example, many extant treatment models are limited by more surface or superficial cultural mismatches between the program, providers, and clients (e.g., language/translation problems; not being able to establish a basic rapport with a client from a different cultural background). In addition, the larger paradigm of the treatment approaches (e.g., 12 Steps, etc.)--which is largely guided by Western assumptions--may be limited in more fundamental ways (e.g., not reaching “deep structure” changes; Resnicow, et al., 2000) if applied to certain ethnic minority clients. As a result, there has been increasing interest in incorporating into mental health and substance abuse-specific treatments culturally relevant interventions for US minority clients whose lifestyle and cultural orientation are strongly anchored to non-Western perspectives. Descriptions of some of these unique, culturally-based intervention modalities have been presented, but few studies have examined how these interventions have been adapted as promising or as evidence-based forms of “best practice.”

The following selected papers in this collection are from presentations given at the conference, Culturally Based Substance Abuse Treatment for American Indians/Alaska Natives and Latinos, which was held April 17 – 19, 2006, in Tucson, Arizona. The purpose of this conference was to provide a forum for therapists, researchers, policy makers and community leaders to discuss the kinds of culturally relevant interventions that are promising or best practices in the treatment of substance abuse for many American Indians, Alaska Natives, and Latinos. Because of the geography of the conference, major emphasis was placed on southwestern tribal and Chicano/a and Mexican responsive programs and approaches, although we contend that many of the programs and approaches would have much broader relevance to other indigenous peoples, including Latino subgroups (e.g., Puerto Rican, Cuban, Dominican, Central American, South American decent) and other groups where the impact of colonization by a more dominant group has had lasting cultural and socioeconomic effects.

The conference objectives, based on the questions raised by the conference planning committee, were as follows:

1. To discuss the problem of addiction in a cultural context;

2. To share information about the use of different cultural interventions by American Indian/Alaska Native counselors and by Latino counselors in the treatment of substance abuse in their respective populations;

3. To discuss historical trauma as a factor in alcohol abuse and as a basis for the use of cultural interventions in the treatment of alcohol abuse/polysubstance abuse;

4. To discuss gender issues in the treatment of alcohol abuse with specific emphasis on the use of cultural interventions;

5. To discuss the policy implications (e.g., reimbursement issues) of the use of culturally based interventions in the treatment of substance abuse; and

6. To provide epidemiological information about current rates of alcohol abuse among American Indian and Latino populations.

The conference planning committee also suggested that a Proceedings of the conference be prepared for publication, and eight seminal papers were requested and submitted. The following discussion presents a context for these papers by providing a brief overview of the history and development of some of the culturally-based substance abuse treatment approaches incorporated into treatment plans for American Indian/Alaska Native and Latino clients in recovery.

Use of traditional culture in the treatment and prevention of substance abuse problems in American Indians/Alaska Natives

Stratton et al. (1978), Thomas, 1981, and May (1986) have observed that those American Indians who are either assimilated, are traditional, or belong to communities with strict social norms about drinking are at lowest risk for substance abuse and alcohol related problems. Conversely, Ferguson (1976), French and Hornbuckle (1980), and May (1982) have all concluded that the American Indians who are highest risk for substance abuse problems are those who are “marginalized” with respect both to their traditional cultures and to mainstream culture.

Researchers have defined the “marginalized” as those native persons who are the victims of “cross cultural” or “acculturation stresses,” i.e., victims of the cross cultural conflicts between Euro-American norms and American Indians customs and traditions (Mail, 1980; May, 1982; Schaefer, 1981). Mail (1980) has observed that this cross cultural conflict combined with what historically has been a lack of tolerance by mainstream society for differences in cultural perspectives, makes it difficult for American Indians to be bicultural in American society. The consequences for American Indians of this cross-cultural stress are anomie, cultural disruption, social disintegration, poor self-image (shame), and a sense of powerlessness and helplessness, all of which contribute to the high rates of substance abuse in this population (May, 1977; Jilek, 1981).

Based in part on this notion that cross cultural stresses contribute to alcoholism, the fundamental premise behind culturally based treatment interventions for American Indian and Alaska Native clients is that restoring a culturally centered sense of self and instilling a sense of pride in one’s heritage and spiritual traditions will provide a protective mechanism or barrier against further abuse of alcohol or drugs (Young, 1992). This use of traditional American Indian/Alaska Native cultural interventions as part of the treatment process to restore a sense of self and of cultural pride has a long history (Abbott, 1998). The earliest such programs have been the nativistic movements such as the Longhouse religion of Handsome Lake, which sought to suppress use of alcohol by reviving Iroquoise traditions (Jilek, 1994), and the Indian Shaker movement established by John and Mary Slcoum (Slagel & Weibel-Orlando, 1986). Both movements have been called reformative nativism (Voget, 1956) because they emphasized both a return to traditional behaviors as well as an accommodation with the values of the dominant culture. What may be the best known of the nativistic movements is the Native American Church, which is a syncretist group that combines traditional American Indian and Christian concepts with a peyote ritual that originated in Mexico as a part of the healing process (LaBarre, 1964; Albaugh & Anderson, 1988).

Other traditional interventions more recently incorporated into treatment plans include the talking circle (Manson, Walker, & Kivlahan, 1987) and the Sweat Lodge (Hall, 1983; Jilek, 1994; Manson et al., 1987). Both are “pan-Indian” i.e., although these two cultural approaches have traditionally been used by a number of tribes, today they have also been adapted by a number of urban Indian programs that include clients from many different tribes, some of whom did not traditionally have talking circles nor conducted sweats. Frequently, the talking circles and sweats are conducted in the clinics by traditional healers, who also provide counseling if requested by the clients.

Although some tribal treatment programs have also incorporated various traditional pan-Indian healing modalities such as talking circles and sweats, the staff at these clinics may also refer clients to ceremonial specialists (Hammerschlag, 1988). In many cases, native communities have developed their own specific programs. For instance, an Inupiat program at Kotezebue, Alaska, established by the Maniilaq Association, is an example of a program developed by community elders to combat the problem of drug and alcohol abuse by having the elders of the community guide the development of a treatment program that incorporates a number of traditional values and activities (Jilek, 1994). A similar program conducted in the Yukon-Kuskokwin Delta of southwest Alaska incorporated traditional activities such as hunting, chopping wood, and gathering medicinal plants as part of the treatment program (Capers, 2003).

A number of tribal programs have attempted to combine western treatment approaches such as Alcoholics Anonymous (AA) with native traditions. One of the successful community based programs which used this approach was the model developed by the Alkali Lake tribe in Canada, which successfully eliminated alcohol as a community problem (95% dry). The program was based on an “Indianized” version of AA, and although the program was successful at Alkali Lake, it has not been successfully replicated in other communities (Womack 1996).

The use of the twelve step AA model has an interesting history in Indian country. Because the philosophy of AA is based on a Christian, Eurocentric world view, one would have expected resistance to its use in Indian country, particularly in programs that use traditional cultural interventions. However, AA is flexible enough that it can be adapted to fit the needs and world views of people from other cultures (Womack, 1996). In a review of some of the adaptations of AA by Indian groups, Womack (1996) notes that these programs frequently eliminate obvious Christian overtones, particularly references to God and to good and evil, and also, with a few exceptions (See Jilek-Aall, 1981), most American Indian and Alaska Native programs do not include the “confessional approach” used in non-Indian AA meetings. Womack (1996) reports that the urban based AA meetings for American Indians/ Alaska Natives that she witnessed in Tucson, Arizona, and in Seattle Washington, included family (children and other relatives) as part of the meeting, incorporated some traditional spirituality as part of the program, and were generally more informal and loosely organized compared to non-Indian AA meetings.

The AA model has also been adapted and modified by a number of non-tribal treatment programs designed specifically for American Indians and Alaska Native clients in recovery. Two such programs are White Bison, Inc., in Colorado Springs, and Sobriety through the Sacred Pipe, a prison based program. White Bison also incorporates a number of pan-Indian spiritual traditions as part of its twelve step programs, and Sobriety Through the Sacred Pipe has incorporated a variety of Plains Indian traditions into its AA model (Womack, 1996).

Some of the treatment programs have also recently begun to look at substance abuse treatment in the context of historical trauma theory (Duran & Duran, 1995; Brave Heart, 2004). In an attempt to understand the widespread use of alcohol and illicit drugs among American Indians and Alaska Natives, these researchers hypothesize that trauma that includes the suppression or destruction of indigenous culture may result in emotional and psychological injury that is transmitted intergenerationally, resulting in unresolved grief, depression, low self-esteem, and anger. The resulting emotional injury in turn leads to self-destructive behaviors that include drug and alcohol abuse. Thus treatment for a client in recovery from substance abuse who has experienced historical trauma involves helping the client to reconnect with his/her cultural roots as an integral part of the healing process (Brave Heart, 2004; Whitbeck, Chen, Hoyt, & Adams, 2004). For those who accept historical trauma as a primary cause of substance abuse, this treatment approach provides further justification for incorporating cultural approaches and interventions into the clients treatment plan.

Central to historical trauma theory as well as to other culturally based interventions and therapies is the belief that most non-Indians are not sensitive to current socioeconomic conditions in Indian country or to cultural perspectives of American Indians/Alaska Natives (Young, 1992). As noted earlier, the justification for using cultural interventions administered by a native therapist is the belief that a major cause of alcohol and drug abuse is the loss of American Indian and Alaska native identity and sense of self as a result of the cultural clash between Native culture and the culture of the dominant society. For Indians, culture and traditional spirituality are interrelated and inseparable. As a result, many reservation programs and some urban programs that include Indian clients use Native counselors and paraprofessionals in the belief that only someone who is native will have the “cultural competency” to understand and be able to relate to the spiritual, socioeconomic, and cultural background of these clients (Young, 1992).

While few therapists would dispute the importance and need for using traditional and culturally based interventions as a part of the treatment process, nevertheless a need exists to systematically evaluate the efficacy of these approaches. Such evaluations would be extremely difficult to implement but are absolutely critical to establishing these approaches as “best practices.”

Use of cultural interventions for Latino clients with substance abuse problems

Our review of the literature and extant field-based drug and alcohol abuse treatment programs for Latino and Mexican American clients indicates that few employ indigenous approaches to healing. Despite the paucity of these types of culturally based programs, there has been substantial attention to whether programs for substance abuse treatment are more broadly culturally relevant to Latinos. For instance, Arroyo and colleagues (2003) evaluated the AA 12-step facilitation therapy relative to two other treatment modalities and found that the AA approach was less effective in reducing long term alcohol abuse among Latinos than among non-Latino Whites. In response to a call for culturally relevant materials for Latino clients, the SAMHSA within the United States Department of Health and Human Services, the leading national funder of substance abuse treatment, publishes documents, manuals, and promising programs with linguistic and cultural competence for Latino clients (SAMHSA, 2007).

Additionally, there has been movement within the larger mental health field to consider such issues as ethnic or cultural matching of therapists to clients. Generally the results of such an approach have been mixed. There is some evidence that such approaches have led to improved retention and outcomes, but other studies have shown negative effects (Carvajal & Granillo, 2008), potentially because issues of class, education, gender, and acculturation were not fully considered. Generally therapy with Latinos is enhanced if the client perceives the therapist as being culturally compatible with him/her--but whether the client and therapist use the same pan ethnic label (both identify in part or whole as “Latino”) is an ineffective way to encourage this.

Cultural competency reflects the degree a counselor or therapist is adequately knowledgeable about the client’s culture. However, cultural “competence” implies that providers can study a particular culture to a certain level, which if achieved, enables them competently to treat an individual from that culture. However as a counselor would never assume to know all there is about a client, he/she should not assume they have a complete understanding of a culture or an individual’s cultural context--both of which are fluid and frequently non-obvious (Arredondo & Rosen, 2007). Furthermore, one may have a significant knowledge base about a particular culture, but that does not mean cultural ascriptions of what an individual client is experiencing are accurate. Rather than a “cultural competence” model, where a set knowledge base about culture is assumed, the best way to learn about a Latino client’s cultural context and acculturative experience is from the client him/herself. Paying close attention to subtleties and an individual’s cultural context within therapy has been termed by some researchers as cultural naiveté (Dych & Zayas, 1995). This reflects humility and respectfulness towards a person’s unique, culturally influenced, spaces without practioner anxiety or self-consciousness. Data do suggest that immigrant and/or minority clients care more about a clinician’s attitude and reassurance and that he/she will be treated respectfully than they care about the clinician’s skills or perceived knowledge of the client’s culture (see Carvajal & Granillo, 2008). Thus therapy may be beneficial for the client if the clinician is more focused on being culturally responsive. This reflects a high degree of openness in addition to a strong foundation of culturally-relevant knowledge, and clients who have had experience with a culturally responsive clinician report higher levels of satisfaction, increased trust and self-disclosure, and decreased rates of attrition (see Burkhard, et al., 2006; Gallardo & Curry, this issue).

While substance abuse treatment approaches should be informed from broader mental health and counseling modalities for Latinos (see Gallardo & Curry; Vasquez; this issue), there have also been scholars who have developed or articulated the need for more Latino-cultural values within substance abuse-specific treatment programs. For instance Szapocznik and colleagues (2002), consistent with the Latino cultural value of familismo, have central to their intervention modality family process and family communication. Also, Castro and colleagues (2007) have discussed cultural resilience, which includes an understanding of the sociocultural and political reasons underlying substance abuse disparities, as a promising theme on which to develop substance abuse treatment programs. Additionally, de la Rosa and colleagues (2005) have outlined the basis for understanding the need for addressing cultural, familial, and environmental contexts influencing Latino clients while addressing the substance abusing Latino’s recovery. With regard to substance abuse prevention among youth, enhancing protective factors such as cultural pride in response to discrimination and enhancing collectivism/community engagement may reinforce substance abuse deterrence (Edwards & Romero, 2008; Romero et al., 2007).

In addition to efforts to make substance abuse treatment programs more effective through addressing specific cultural values (e.g., familismo) and general principles of cultural responsiveness, there may also be an important role for indigenous paradigms of healing. For instance, clients of Mexican descent may use curanderas, and Latinos of Caribbean and Central America descent may turn to various non-traditional healers. Programs should therefore consider including such healers (see Garrardo and Curry, this issue). Further, there is increasing recognition of greater common linguistic (e.g., Nahua) and cultural connections among the indigenous persons within the Americas (see Estrada, this issue). For example, the largest membership unit within the National Association of Chicano and Chicano Studies (2008) is the indigenous caucus, which reveals the importance of many Mexican Americans of increasingly recognizing, understanding, and enhancing their indigenous cultural influences. It should also be noted that the Caribbean Studies Association (2008) regularly includes work recognizing indigenous and African cultural influences. Thus treatment modalities more common to Native American substance abuse treatment programs, such as the use of sweats and talking circles, may be increasingly relevant to various Latino persons who strongly identify with their indigenous roots.

The Proceedings

The following papers given at the conference touch on a number of these themes. The first two papers address the epidemiology of substance among American Indians/Alaska Natives and among Latinos in order to provide a comprehensive perspective of the problem based on available data. The third and fourth papers analyze the importance of using culture in treatment and prevention programs for American Indians/Alaska Natives. The fifth and sixth papers discuss the importance of taking a cultural appropriate approach to providing treatment to Latinos for substance abuse, and the seventh raises the interesting question of whether historical trauma is a factor in the mental health of some Mexican Americans. The eighth and final paper provides a comprehensive review of these issues when providing treatment to minority female clients in recovery from substance abuse.

Epidemiology of Substance Abuse among American Indians, Alaska Natives and Latinos

A number of epidemiological studies of substance abuse among American Indians/Alaska Natives have been conducted over the past decades for specific tribes and for specific urban American Indian/Alaska Native populations. In their paper, Some Thoughts about the Epidemiology of Alcohol and Drug Use among American Indian/Alaska Native Populations, Joe and Young look at IHS and SAMHSA data on substance use and mortality. Their goals include an effort to understand why American Indians/Alaska Natives have the highest mortality rates of any population group from alcohol abuse when the data indicates that rates of drinking are highest among Whites compared to all other population groups. The authors also provide an overview of the rates of illicit substance use (cocaine, marijuana, methamphetamine, etc.) among American Indians/Alaska Natives based on published data and offer some recommendations for further research.

Lipsky and Caetano, in their paper Epidemiology of Substance Abuse among Latinos, provide an overview of disparities and trends in substance abuse in US Latino adults using various general population studies. Most of the data reported on were collected via SAMHSA, the National Institute on Drug Abuse (NIDA) and the National Institute on Alcoholism and Alcohol Abuse (NIAAA), the major US federal agencies addressing these issues. Among Latinos groups, Mexican Americans tend to show the highest levels of alcohol abuse and dependence, although typically these rates are less than the rates in non-Latino whites. Within Latinos, men and women who are less acculturated consistently report higher alcohol consumption and more alcohol-related problems than counterparts do. Population level data suggest Latinos are less frequent users of most illicit substances than non-Latino whites — although there are some exceptions noted, e.g., the 2005 data from the National Survey on Drug Use and Health (NSDUH). Among Latino nation of origin subgroups, Mexican Americans and Puerto Ricans generally reported the highest rates of substance abuse; all Latinos men (versus women) and more acculturated women (versus less acculturated women) also show the highest rates.

Lipsky and Caetano also conduct data analysis using NSDUH data on the risk factors for alcohol and illicit drug outcomes. Some of their notable findings indicate that Latino self-identification is a protective factor for illicit substance use, and that being male, unmarried, under/unemployed, and of younger age are risk factors for heavy drinking among Latinos. They also affirm the ambiguity in the literature on the relations of acculturation and alcohol and substance abuse in Latinos (particularly in men) and note this research is limited because the acculturation measures employed in most major national surveys are relatively crude, while the complexity of the acculturation process for different Latino persons and groups is high.

Use of Cultural Interventions among American Indians

The use of cultural interventions for American Indian/Alaska Native clients with substance abuse problems is not without controversy. One issue that arises at facilities that provide treatment programs to AI/AN clients is to what extent the treatment plans developed for these clients should include traditional AI/AN practices and ceremonies. Not all AI/AN clients feel that they benefit from such ceremonies. Many AI/AN come from non-traditional backgrounds and may or may not be interested in their traditions; others are affiliated with various Christian denominations, a number of which frown on participation by their members in traditional ceremonies. Some clients may be interested in participating but whether they would benefit from such participation is unknown.

This question of participation in a culturally based treatment intervention is the subject of the third paper included in this Proceedings. The article, Cultural Practices and Spiritual Development for Females in a Native American Alcohol and Drug Treatment Program by Chong, Fortier, and Morris-Carlston, discusses a research project to develop an instrument to assess whether AI/AN female clients would benefit from participating in traditional spiritual practices as a part of their treatment program at Native American Connections, an urban rehabilitation facility in Phoenix, Arizona. The AI/AN clients at this facility come from both urban and reservation environments. Spiritual practice components include opportunities to use talking circles, sweats, and counseling with a traditional healer. The authors conducted focus groups and a survey using their instrument in an effort to develop a profile of the client that would most benefit from participating in traditional ceremonies and other cultural interventions as part of their treatment plan.

Tribal communities are understandably sensitive about adverse publicity over alcohol and illicit drug consumption and are very cognizant of abuses committed by researchers in native communities in the past (see Foulks, 1989). As a result of these abuses, particularly in the area of substance abuse research, many tribal communities are reluctant to allow investigators to conduct research about substance abuse within their communities. In the fourth paper included in this proceedings, The Community Pulling Together: A Tribal Community-University Partnership Project to Reduce Substance Abuse and Promote Good Health in a Reservation Tribal Community, Thomas, Donovan, Sigo, Austin, and Marlatt, describe the use of a tribal participatory research model to develop and implement a substance abuse prevention program. This program, called “Healing of the Canoe”, is focused on youth from a Northwest tribe that use their tribal traditions and culture as the basis of the prevention program. In this participator model, the tribe serves as a co-investigator involved in all phases of the project. The authors describe some of the problems associated with this research process while underscoring the critical importance of including tribal community people in all stages of project development, implementation, evaluation, and dissemination.

Use of Cultural Interventions among Latinos

In terms of integrating indigenous paradigms of healing in substance abuse treatment and recovery, the progression of cultural interventions among Latinos in practice has lagged behind approaches used by American Indians. Nevertheless there have been other types of culturally relevant programs, and there are important discussions of new paradigms that might be applied to improve substance abuse treatment for Latinos.

The contribution of Vasquez titled Latino Culture and Substance Abuse in this proceedings covers a number of important areas, including epidemiology, etiology, and clinical guidelines for treatment of Latinos with substance abuse problems. Included in this paper are additional epidemiological data on alcohol abuse and use of illicit drugs by Latinos, with data on usage among youth that complements that provided by Lipsky and Caetano. Vasquez notes the disturbing and consistent trend that substance abuse and alcohol use in Latinos occurs at younger ages than found among non-Latino Whites and African Americans. Vasquez also notes that cirrhosis death rates are higher for Latinos than most other groups—highlighting the public health importance of bringing more effective alcohol treatment to Latino populations.

One important area for research and practice identified by Vasquez is whether substance abuse by more acculturated Latinos reflects a consequence of stresses associated with navigating multiple cultures, or whether the exposure to US dominant culture is chiefly responsible for higher substance abuse. Also noted is the increase in substance abuse within Mexico, perhaps in part a function of the flooding of illicit drugs in Mexican markets as a consequence of increased border militarization and increased activity along drug trafficking corridors. This could also change the dynamic between acculturation and illicit substance use observed in previous studies.

Concerning treatment of substance abuse issues in Latinos, Vasquez also reviews the most relevant clinical guidelines from the American Psychological Association’s Multicultural Guidelines. She identifies two general themes to guide multicultural practice. One is that providers (e.g., psychologists, counselors, therapists) should understand that they might have a bias against ethnically and racially different persons, which they should strive to be aware of. Second, providers should value multicultural sensitivity/responsiveness with regard to ethnically and racially different clients. All persons have their cultural experiences and backgrounds—and thus providers should make efforts to be aware of their own worldviews and how these worldviews differ from the views of their clients. Vasquez also discusses specific influences that may be relevant for Mexican American/Chicano clients--for instance, the influence of multiple cultures, languages, acculturation, and the history of oppression--but she also recognizes the heterogeneity of clients’ personal experiences and perceptions and the importance of avoiding an “ethnic gloss.”

In Shifting Perspectives: Culturally Responsive Interventions with Latino Substance Abusers, Gallardo and Curry focus on ways the therapeutic context for treatment should be culturally responsive to Latino clients. They also note with some alarm the high rates of early termination by therapy of Latinos and that the traditional Western model of addiction treatment often is not adequately culturally responsive.

Much of the basis for their paper includes and integrates extant models of multicultural counseling, most notably from Santiago-Rivero & Arredondo (2002) and Parham (2002). They make an important distinction between cultural sensitivity and cultural specificity. Sensitivity refers to awareness that all persons have culturally-based schema that guide how they interact with the world, and specificity is where the provider is as informed as possible about the particular culture(s) of their clients. Both are instrumental in effective substance abuse treatment. They also describe common influences among many Latinos, including high rates of poverty, low educational attainment, acculturation stressors, minority status stressors, and discrimination. This paper also provides an extensive review of cultural constructs that might be informative for the practitioner (developing cultural specificity), including orgullo, confianza, personalismo, familismo, simpatia, respecto, espiritismo, and the commonly misunderstood concept of machismo. The authors also offer many practical suggestions for ways to change the cultural context of substance abuse recovery consistent with those cultural values that will lead to greater retention and more effective treatment.

Another challenge they identify is that intervention paradigms that view substance abuse as a biological disease inadequately link social, family, and cultural contexts that may lead Latinos to alcohol and substance abuse problems. The model of Szapocznik and colleagues (1997) is presented as an important alternative to conceptualizing substance abuse within culturally consistent family and systems perspectives. Additionally, they note providers might consider the use of traditional healers (e.g., curanderas for Mexican Americans; those practicing Santeria for Carribean descent groups) for some substance abusing clients who identify with or employ those approaches to healing and wellness.

The contribution by Estrada, Historical Trauma and Mexican Americans, focuses on the potential of the concept of historical trauma to inform substance and alcohol abuse research and treatment within Mexican Americans. Historical Trauma is a paradigm that asserts the role of intergenerational stressors and their health effects. This paradigm has most prominently been applied with regard to holocaust survivors, American Indians, African Americans, and Native Hawaiians. Estrada outlines several prominent models and concepts described by such scholars as Brave Heart (2004), Sotero (2006) and Walters and Simoni (2002). With regard to Mexican Americans, Estrada reviews several broad historical themes as well as specific historical events--such as the European Colonization and subjugation of indigenous peoples in North America, US military expansion and manifest destiny in the Western US, Spanish colonization in Mexico and its associated ethnic/racial caste and prejudices, the US-Mexico War and post-war discrimination, and the relatively more recent events of worker exploitation and militarization of the border--that could certainly form the basis for historical trauma interpretations underlying health disparities in Mexican Americans.

Estrada also notes some significant challenges to more broadly using an historical trauma framework for Mexican Americans. For instance distinguishing what is historical trauma from more proximal sources of health disparities (e.g., current discrimination, economic subjugation, depersonalization of migrants) may prove difficult. Another challenge is the vastness and heterogeneity of Mexican Americans, including regional variation in cultural, social, educational, and economic influences as well as exposure to violence. Despite these challenges, using historical trauma as a descriptive model for Mexican Americans may have utility for understanding and treating substance abuse. Contemporary issues such as discrimination, subjugation, depersonalization—consistent with historical trauma events—no doubt have a role for many Mexican American substance abusers, and a responsive, culturally appropriate approach to treatment might consider addressing them in a constructive, culturally resilient perspective.

Gender Issues in the treatment of substance abuse with minority clients

The eighth and final paper in this Proceedings provides a review of the importance of cultural sensitivity and gender awareness in providing treatment to minority women in recovery from substance abuse problems. As reflected in data discussed in the papers in this Proceedings by Lipsky and Caetano and by Young and Joe, Hispanic and AI/AN women in general drink and use illicit substances at lesser rates than do men. In this paper, Women and Substance Abuse: Gender, Age, and Cultural Considerations, Stevens, Andrade, and Ruiz discuss gender specific issues associated with substance abuse among minority women. The authors examine the history of substance abuse among these women, analyze cultural issues and gender specific factors that impact women’s use of illicit substances and accessing treatment, briefly discuss treatment approaches specific to minority women, and review the differences in the impact of alcohol and drugs on women physiologically compared to the effects on men. The authors note that prior to the mid-twentieth century, substance abuse among women was not acknowledged by mainstream society. Research in the last two decades indicates that substance abuse rates among minority women are increasing, particularly among younger women, underscoring the need for studies of the factors contributing to this increase. The authors also provide recommendations for cultural and gender appropriate approaches to conducting research and providing treatment to this population.

Some final observations

This conference represented an initial effort to bring together therapists, counselors, policy makers, and researchers that work with two different racial/ethnic groups to discuss common issues and the important role that culture plays in the treatment process for clients in recovery from substance abuse Despite some differences, presenters agreed on the importance of recognizing when cultural interventions are appropriate for their clients, reviewed the kinds and variations of cultural interventions that are available as part of the treatment process, and discussed the need for culturally responsive counselors and therapists. Participants also called for further research on the efficacy of using cultural interventions, particularly as part of an effort to determine which clients would benefit from these interventions. To date there has been substantially more development in describing, conceptualizing and theorizing about culturally-responsive alcohol and drug treatment programs for Native Americans and Latinos than there have been evaluations of extant programs guided by such principles. We hope that the present conference represents the beginning of a trend to take a more serious look at systematically investigating the role of culture in the substance abuse treatment process and in the therapist-client relationship.