Drug and alcohol abuse

The following nine steps are important to incorporate in drug and alcohol assessment and treatment planning processes to ensure culturally competent clinical and programmatic decisions and skills.

Step 1: Engage clients.

• Use culturally appropriate greetings and start with small talk—to begin building the therapeutic relationship.
• Involve one’s whole being in a greeting—thought, body, attitude, and spirit.
• Aim to ensure that the client leaves the initial meeting feeling hopeful and understood.
• Try to establish rapport before launching into a series of questions.
• Draw attention to the presenting problem without probing too deeply.
• Ensure that the client feels engaged with any interpreter used in the intake process.
• Use culturally responsive interview behaviours.

Step 2: Familiarise clients and their families with assessment and treatment processes.

• Remember that clients are typically new to treatment language or jargon, programme expectations and schedules, and the intake and treatment process.
• Educate clients and their families about treatment expectations.
• Walk clients through the treatment process, starting with the goals of the initial intake and interview.

Step 3: Endorse collaboration in interviews, assessments, and treatment planning.

• Take time to familiarise clients with the intake, interview, assessment, and treatment planning processes and how they can participate in these processes.
• Use a collaborative approach in the initial interview and assessment to discuss the expectations of both therapist and client.
• Establish ways for the client to seek clarification of his or her assessment results.
• Encourage collaboration by emphasising the importance of client input and interpretation.
• Use client feedback to help interpret results and identify cultural issues that may affect intake and assessment.
• Extend collaboration to client preferences regarding inclusion of family and community members in assessment and treatment planning.

Step 4: Integrate culturally relevant information and themes

• Explore culturally relevant themes to more fully understand clients and identify their cultural strengths and challenges. Themes include:
• Immigration history.
• Cultural identity and acculturation.
• Membership in a subculture.
• Beliefs about health, healing, help-seeking, and substance use.
• Trauma and loss.

Step 5: Gather culturally relevant information

• Obtain supplemental information, with the client’s permission, from sources other than the client (eg, family members, medical and court records, probation and parole officers, community members).
• Obtain culturally relevant information from the family (eg, religious beliefs, cultural practices that shape the client’s cultural identity and understanding of the world).
• Engage families early in the treatment process and be especially sensitive to the cultural background of family members providing cultural information.

Step 6: Select culturally appropriate screening and assessment tools

• Explore the availability of mental health and alcohol and drug use screening and assessment tools that have been translated into or adapted for other languages and have been validated for that particular population group.
• Consider instruments’ cultural applicability to the client being served (eg, a screening instrument that asks the respondent about his or her guilt about drinking could be ineffective for members of cultural, ethnic, or religious groups that prohibit consumption of alcohol).
• Keep in mind the fact that research is limited on the cross-cultural applicability of specific test items or questions, diagnostic criteria, and psychologically oriented concepts in evaluative and diagnostic processes.

Step 7: Determine readiness and motivation for change

• Clients enter treatment programmes at different levels of readiness for change; these different levels require different approaches.
• Motivational interviewing can help therapists prepare culturally diverse clients to change their behaviour and keep them engaged in treatment (Miller & Rollnick, 2013).

Stages of change

• To understand motivational interviewing, it is first necessary to examine the process of change that is involved in recovery. The transtheoretical model of change—which is applicable to culturally diverse populations—divides the change process into several stages (Prochaska & DiClemente, 1984):
• Precontemplation. The individual does not see a need to change. For example, a person at this stage who misuses substances does not see any need to alter use, denies that there is a problem, or blames the problem on other people or circumstances.
• Contemplation. The person becomes aware of a problem but is ambivalent about the course of action. For instance, a person struggling with depression recognises that the depression has affected his or her life and thinks about getting help but remains ambivalent about how to do this.
• Preparation. The individual has determined that the consequences of his or her behaviour are too great and that change is necessary. Preparation includes small steps toward making specific changes. For example, the client may have begun experimenting with possible change approaches such as going to an Alcoholics Anonymous (AA) meeting or stopping substance use for a few days.
• Action. The individual has a specific plan for change and begins to pursue it. In relation to substance misuse, the individual may make an appointment for a drug and alcohol assessment prior to becoming abstinent.
• Maintenance. The person continues to engage in behaviours that support his or her decision. For example, an individual with bipolar I disorder follows a daily relapse prevention plan that helps him or her assess warning signs of a manic episode and reminds him or her of the importance of engaging in help-seeking behaviours to minimise the severity of an episode.

Progress through the stages is:

• Nonlinear, with movement back and forth among the stages at different rates.
• Not a one-time process, but rather a series of trials and errors that eventually translates to successful change.

Motivational Interviewing (Miller & Rollnick, 2013).

• Motivational interventions assess a person’s stage of change and employ techniques likely to move the person forward in the sequence. Motivational interviewing is characterized by the strategic therapeutic activities of:
  • Expressing empathy.
  • Developing discrepancy.
  • Avoiding argument.
  • Rolling with resistance.
  • Supporting self-efficacy.
• The therapist’s major tools are engaging in reflective listening and soliciting change talk. This non-confrontational, client-centred approach to treatment differs significantly from traditional treatments in several ways, creating a more welcoming relationship.
• Be mindful of each client’s linguistic requirements and the availability of interpreters.
• Be flexible in designing treatment plans to meet client needs.
• Draw, when appropriate, upon the institutions and resources of clients’ cultural communities.
• Culturally responsive treatment planning is achieved through:
  • Active listening.
  • Making interpreters available when required.
  • Consideration of client values, beliefs, and expectations.
  • Incorporation of client health beliefs and treatment preferences in addressing specific presenting problems.
  • Referrals to appropriate traditional treatment resources to supplement clinical treatment activities (eg referral for acupuncture for Chinese clients).

Step 8: Provide culturally responsive case management

Case management:

• Provides a single professional contact through which clients gain access to a range of services.
• Helps identify the need for (and then helps coordinate) social, health, and other essential services for each client.
• Can be helpful during treatment and recovery for a person with limited English literacy and knowledge of the treatment system.
• Focuses on the needs of individual clients and their families and anticipates how those needs will be affected as treatment proceeds.

The case manager:

• Advocates for the client.
• Eases the way to effective treatment by assisting the client with critical aspects of life (eg, food, child care, employment, housing, legal problems).

The case manager who cannot provide culturally or linguistically competent services himself or herself should:

• Provide an interpreter who communicates well in the client’s language and dialect and who is familiar with the vocabulary required to communicate effectively about sensitive subject matter.
• Build and maintain rich referral resources to meet the clients’ multiple needs.

Step 9: Incorporate cultural factors into treatment planning

Typically, programmes that provide culturally responsive services:

• Approach treatment goals holistically and include objectives to improve physical health and spiritual strength.
• Stress implementation of strength-based strategies that fortify cultural heritage, identity, and resiliency.
• Operate on the premise that treatment planning is a dynamic process that evolves along with an understanding of client history and treatment needs.