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Culturally Adapted Approaches in Substance Use Disorder Treatment: Serving Under-Resourced Populations
Cultural diversity issues impact access to healthcare and the experience of substance use disorder treatment for under-resourced populations. These populations are those having particular characteristics based on ethnicity, race, religion, or other cultural factors representing diversity in the treatment community (SAMHSA, 2022). Treatment professionals must be aware of the cultural impacts and use appropriate culturally adapted approaches to best meet the needs of the patients in their care.
How Culture Impacts Access to Treatment
People who experience discrimination are more likely to misuse alcohol than those who do not experience discrimination in their daily lives (SAMHSA, 2022). Black, Native American, and Alaska Native youth are most likely to receive cannabis-related legal charges, even in states which have legalized medical or recreational marijuana use (Haines-Saah, & Fischer, 2021). Increased opioid-involved overdose deaths among middle-aged Black and Hispanic persons reveal the disproportionate impact of fentanyl on these populations (Lippold et al., 2019). Although younger, White males are more likely than other groups to intentionally seek out fentanyl (Foglia et al., 2021), the proliferation of fentanyl in under-resourced communities has resulted in higher fentanyl overdose deaths among Black 45- to 54-year-olds when compared to other groups (Lippold et al., 2019). Fentanyl’s strong presence in under-resourced communities seems to have disproportionately increased their exposure and risk for overdose.
Between April 2020 and April 2021 more than 100,000 people died by drug overdose in the United States (CDC, 2021). While more than 40 million Americans aged 12 or older met the DSM-5 diagnostic criteria for substance use disorder (SUD), only 2.6 million engaged in treatment (SAMHSA, 2021). Why do so many people shy away from treatment, and what impact does culture have on the experience of those needing care?
A 2021 report from the Substance Abuse and Mental Health Services Administration (SAMHSA) reported that people are often reluctant to participate in treatment for their SUD (SAMHSA, 2021). Reasons for this include the following (SAMHSA, 2021):
- Inability to afford the cost of treatment (19.1%)
- Inability to find a desirable treatment program (14.4%)
- Concern that other people would have a negative opinion if they got treatment (11.9%)
- Not wanting anyone to find out about their substance use disorder (6.5%)
Of those who do engage, many drop out before their treatment is complete (Brorson et al, 2013). Under-resourced populations are less likely to seek or receive treatment and face particular barriers when accessing the care they need (SAMHSA, 2022). Biased policies, organizational practices, and cultural representations perpetuate racial and cultural inequities in healthcare (SAMHSA, 2022).
How Stigma Affects Treatment
Of all health conditions, SUD is the most stigmatized (Cano et al., 2020). People receiving publicly funded substance use disorder treatment attributed their most frequent experiences with discrimination to their SUD, even more so than their race or co-occurring mental health conditions. (Matsumoto et al., 2021). Compared to White patients, under-resourced populations experience less compassion even from the treatment professionals providing their care (Roberts et al., 2021).
Ethnic and racial minorities report lower quality of care than their non-Hispanic White counterparts, are less likely to experience benefits from counseling, and are more likely to drop out of treatment (Steinfeldt et al., 2020). Treatment providers who fail to acknowledge the particular needs of under-resourced populations perpetuate these barriers and limit the effectiveness of the services they provide. (Steinfeldt et al., 2020). Optimal treatment outcomes can only be achieved with a culturally responsive approach, including culturally adapted therapies specific to the people needing care (Hays, 2016; SAMHSA, 2022).
How Cultural Experience Impacts Treatment
Most SUD treatment includes members from diverse backgrounds, and only 10% of treatment facilities in the United States offer single-race treatment groups (Wendt & Gone, 2018). Each treatment professional and participant brings his or her own unique identity, opinions, experiences, and attitudes into the treatment setting. Therefore, unconscious bias can impact the treatment process and make it more difficult for under-resourced people to participate (SAMHSA, 2022). Racial, religious, and sexual minorities may experience a lack of connection or sense of belonging in these settings, contributing to low self-disclosure and limited outcomes (Wendt & Gone, 2018).
Under-resourced populations are often not considered in research that tests the efficacy of SUD treatment practices. Evidence-based treatment approaches may have limited effectiveness with under-resourced populations unless they are adapted to the values and cultural norms of the people receiving care. Appropriate cultural adaptations are those that maintain the core elements of an evidence-based approach while also considering language, culture, and context to be consistent with participants’ cultural patterns and values (SAMHSA, 2022).
Treatment professionals have cultural integrity when they respect cultural traditions and demonstrate knowledge of the particular culture or population that they serve. Appropriate cultural adaptations can better engage under-resourced populations and increase the effectiveness of SUD treatment (SAMHSA, 2022). When treating members of under-resourced populations, tailored delivery of evidence-based approaches best meets the needs of diverse participants. For example, online services increase access for patients, and incorporating content that reflects participants’ values and experiences during therapy helps to ensure cultural relevance (SAMHSA, 2022).
Substance use disorder treatment programs must use appropriate, culturally adapted, evidence-based approaches to best meet the needs of a diverse treatment community. Culturally responsive treatment programs consider the unique experiences of the populations served and incorporate culturally adapted evidence-based approaches where appropriate. In this way, substance use disorder treatment becomes more accessible to people seeking help and produces more positive outcomes (SAMHSA, 2022).
Wendy Insalaco, LGADC, LGPC, is director of quality and model of care at Ashley Addiction Treatment
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Addiction Professional, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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