List and discuss two major concerns in working with each of the following populations:adolescent substance abusing clientswomen substance abusing clientslesbian or gay, bisexual, and transgender subst

DAAC 1319: Intro to AOD

Module Three Notes

Understanding Special Populations & Diversity

Module Three:

Understanding Special Populations & Diversity

Adolescents

In terms of public health, adolescent substance use disorders have far-reaching social and economic ramifications. The numerous adverse consequences associated with teenage drug abuse include:

• fatal and nonfatal injuries from alcohol and drug related motor vehicle accidents (the number one killer of young people today);

• homicides (the number 2 killer of young people);

• suicides (while suicide is the number 3 killer of young people, some form of drug use is involved in the majority of suicides both committed and attempted by this age group);

• violence;

• delinquency;

• psychiatric disorders;

• and risky sexual practices (it is important to note that HIV/AIDS is the number 6 killer of young people).

Substance use by young people is on the rise, and initiation of use is occurring at ever‑younger ages. Patterns of substance use over the past 20 years have been documented by two surveys‑‑the National Household Survey on Drug Abuse conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Monitoring the Future Study conducted by the National Institute on Drug Abuse (NIDA). Data released in 1996 indicated that in the early to mid‑1990s, the percentage of 8th graders who reported using illicit drugs (i.e., drugs illegal for Americans of all ages) in the past year almost doubled, from 11.3 percent in 1991 to 21.4 percent in 1995. Drug use by high school students also has risen steadily since 1992. The survey also indicates that 33 percent of 10th graders and 39 percent of 12th graders reported the use of an illicit drug within the preceding 12 months. These estimates are probably low because the statistics are gathered in schools and do not include the high‑risk group of dropouts.

An estimated 15 percent of 8th graders, 24 percent of 10th graders, and 30 percent of 12th graders reported having had five or more drinks within the preceding 2 weeks. Slightly more than half of high school students (grades 9 through 12) reported having had at least one drink of alcohol during the past 30 days. It is further estimated that 9 percent of adolescent girls and up to 20 percent of adolescent boys meet adult diagnostic criteria for an alcohol use disorder. Furthermore, the proportion of daily smokers among American high school seniors remains disturbingly high at about 20 percent.

The surveys have found that the perceived risk of harm from drug involvement has been declining while the availability of drugs has been rising. Particularly in the case of marijuana, sharp declines in harm perception have been observed among 8th, 10th, and 12th graders. This shift has occurred at the same time that marijuana use has spread. Since 1991, the percentage of students who thought that regular marijuana use carries a "great risk" of harm has dropped from 79 percent to 61 percent among 12th graders, from 82 percent to 68 percent among 10th graders, and from 84 percent to 73 percent among 8th graders. During the same period, reported use of marijuana within the preceding year rose for all these grades by an average of 11 percent.

Household products are abused as well as illegal drugs: The percentage of youths 12 to 17 years old who tried inhalants rose from 1.1 percent in 1991 to 2.2 in 1994. "Heroin chic" as exemplified by rock stars and fashion models has boosted the popularity of that drug among young people. Surveys reported that in some areas, the adolescent use of heroin mixed with water and then inhaled has increased. Clearly, drug use trends among young people are a major national concern. Within the context of national surveys of frequency of use, the prevalence of those meeting criteria for a diagnosis is becoming clearer.

The Consequences

In terms of public health, adolescent substance use disorders have far‑reaching social and economic ramifications. The numerous adverse consequences associated with teenage drinking and substance use disorders include fatal and nonfatal injuries from alcohol‑ and drug‑related motor vehicle accidents, suicides, homicides, violence, delinquency, psychiatric disorders, and risky sexual practices. Longitudinal studies have established associations between adolescent substance use disorders and (1) impulsivity, alienation, and psychological distress, (2) delinquency and criminal behavior, (3) irresponsible sexual activity that increases susceptibility to HIV infection, and (4) psychiatric or neurological impairments associated with drug use, especially inhalants, and other medical complications.

Substance use disorders that begin at an early age, especially when there is no remission of the disorder, exact substantial economic costs to society. The trend toward early onset of substance use disorders has increasingly resulted in adolescents who enter treatment with greater developmental deficits and perhaps much greater neurological deficits than have been previously observed. Moreover, the risks of traumatic injury, unintended pregnancy, and sexually transmitted diseases (STDs) are high in adolescents in general. Drug involvement that is superimposed on these already high risks has numerous potentially adverse consequences that have not yet been the subject of in depth study beyond basic population studies.

Mortality

Alcohol‑related motor vehicle accidents exact a heavy toll on society in terms of economic costs and lost productivity. Nearly half (45.1 percent) of all traffic fatalities are alcohol‑related, and it is estimated that 18 percent of drivers 16 to 20 years old‑‑a total of 2.5 million adolescents‑‑drive under the influence of alcohol. According to the Youth Risk Behavior Surveillance System conducted by the CDC, which monitors health risk behaviors among youths and young adults, unintentional injuries, including motor vehicle accidents, are by far the leading cause of death in adolescents, causing 29 percent of all deaths. An estimated 50 percent of these deaths are related to the consumption of alcohol.

Sexually Risky Practices

Adolescents are at higher risk than adults for acquiring STDs for a number of reasons. They are more likely to have multiple (sequential or concurrent) sexual partners and to engage in unprotected sexual intercourse. They are also more likely to select partners who are at higher risk for STDs. Among females, those 15 to 19 years old have the highest rates of gonorrhea, while 20‑ to 24‑year‑olds have the highest rate of primary and secondary syphilis.

Adolescents who use alcohol and illicit drugs are more likely than others to engage in sexual intercourse and other sexually risky behaviors. A positive correlation has been demonstrated between alcohol use and frequency of sexual activity. In a Massachusetts survey of adolescents 16 to 19 years old, two‑thirds reported having had sexual intercourse, 64 percent reported having sex after using alcohol, and 15 percent reported having sex after using drugs.

Providers of adolescent treatment for substance use disorders must sometimes grapple with these two questions:

• Can the provider admit an adolescent into the treatment program without obtaining the consent of a parent, guardian, or other legally responsible person?

• How can substance use disorder treatment programs communicate with others concerned about an adolescent's welfare without violating the stringent Federal regulations protecting confidentiality of information about clients?

The answers to these questions are especially complex for those who treat adolescents for substance use disorders because a mix of Federal and State laws govern these areas; "adolescence" spans a range of ages and competencies; and the answer to each question may require consideration of a matrix of clinical as well as legal issues.

Consent to Treatment

Americans attach great importance to being left alone. They pride themselves on having perfected a social and political system that limits how far government and others can control what they do. The principle of autonomy is enshrined in the Constitution, and U.S. courts have repeatedly confirmed Americans' right to make decisions for themselves. This tradition is particularly strong in the area of medical decision making: An adult with "decisional capacity" has the unquestioned right to decide which treatment he will accept or to refuse treatment altogether, even if that refusal may result in death.

The situation is somewhat different for adolescents because they do not have the legal status of full‑fledged adults. There are certain decisions that society will not allow them to make: Below a certain age (which varies by State and by issue), adolescents must attend school, may not marry without parental consent, may not drive, and cannot sign binding contracts. Adolescents' right to consent to medical treatment or to refuse treatment also differs from adults'. Whether a substance use disorder treatment program may admit an adolescent without parental consent depends on State statutes governing consent and parental notification in the context of substance use disorder treatment and a number of fact‑based variables, including the adolescent's age and stage of cognitive, emotional, and social development. Although it may make clinical sense to obtain consent for treatment from an underage adolescent, it is relevant to consider the wide range of factors that contribute to a program's decision to admit an adolescent for treatment without parental consent.

State Laws

More than half the States, by law, permit adolescents less than 18 years of age to consent to substance use disorder treatment without parental consent. In these States, providers may admit adolescents on their own signature. (The important question of whether the provider can or should inform the parents is discussed below.)

In States that do require parental consent or notification, a provider may admit an adolescent when there is parental consent or (in those States requiring notification) when the adolescent is willing to have the program communicate with a parent. Presumably, a parent whose child seeks treatment will consent. (A parent or guardian who refuses to consent to treatment that a health care professional believes necessary for the adolescent's well‑being may face charges of child neglect.)

The difficulty arises when the adolescent applying for admission refuses to permit communication with a parent or guardian. As is explained more fully below, with one very limited exception, the Federal confidentiality regulations prohibit a program from communicating with anyone in this situation, including a parent, unless the adolescent consents. The sole exception allows a program director to communicate "facts relevant to reducing a threat to the life or physical well‑being of the applicant or any other individual to the minor's parent, guardian, or other person authorized under State law to act in the minor's behalf," when the program director believes that the adolescent, because of extreme youth or mental or physical condition, lacks the capacity to decide rationally whether to consent to the notification of her parent or guardian. The program director believes the disclosure to a parent or guardian is necessary to cope with a substantial threat to the life or physical well‑being of the adolescent applicant or someone else.

Impact of Chemical Dependency on Adolescent Development

Cognitive Development

· Continuation of personal fable thinking.

• Distorted cognition as a result of the adolescent delusional system.

• Interferes with maturation of abstract thinking.

• Limited life experiences prevent opportunity to develop or refine reasoning and thinking skills.

• Drug induced states perpetuates adolescents illusion of accomplishment.

Language Skills

• Language skills may be impeded by problems with recall, retrieval, and short term memory.

• Remain stuck in early adolescent phase in which they are more likely to use acting out behavior or avoidance as opposed to language to deal with conflict.

• Language skills may be impacted because of decline of academic performance.

• Lack of adequate language skills present barriers in academic and interpersonal functioning and may present limitation for adolescent, in engaging in and benefiting from treatment.

Physical Development

• Adolescent avoids uncomfortable feelings about sexual development as opposed to mastering them

• Heavy use of marijuana at an early age interferes with the development of secondary sex characteristics.

• Adolescents frequently engage in sexual activity for which they are emotionally unprepared.

• Adolescents do not obtain accurate sexual information.

• Adolescents do not develop appropriate outlets for sexual energy or control over sexual impulses.

• Adolescents are confused by sex roles and often experience guilt and shame regarding sexual activity.

Role of The Family

• Adolescents avoid true separation task. They pretend to be declaring independence from family by drug use, but continue to display behavior which will ensure parental over involvement in their lives.

• Adolescent ensures that no one will expect competency or independence from them.

• Adolescent avoids tasks of moving into young adulthood; thereby, ensuring continued and prolonged dependency on their family.

• Adolescent is incompetent to meet their own needs.

• Emotional rifts caused by substance abuse may prevent peace making at the appropriate times.

Social Development

• Adolescent relies on drugs as primary relationship; drugs provide the experience that people should.

• Adolescent depends on chemicals to ease discomfort in social situations thereby not developing basic social skills such as starting a conversation, dancing at parties, feeling that others like and accept you.

• Adolescent may become involved in a peer group that remains narcissistic, lacks empathy for others, and is based on drug using values.

• Adolescent remains stuck in developmental phase in which the most pathological peer has the most power.

• Adolescent is not developing a self-image, but rather works hard to develop a “druggie” facade.

• Adolescent avoids social realities such as rules, mores and values.

• Adolescent does not take the social risks necessary to grow and mature.

• Adolescent perceptions of others are distorted.

• Socialization is seriously impeded due to drug using peer group which sets standards and dictates roles to the adolescent.

• Adolescent does not develop past egocentric state of early adolescence.

• Drug use provides a false sense of achievement.

Emotional Development

• Adolescent medicates emotions and does not learn emotional impulse control.

• Adolescent does not learn that they can manage emotions instead they continue to be afraid of their feelings.

• Adolescent protects self from fear, feelings of isolation, anxiety, vulnerability, shame and quilt by projecting blame and grandiose attitudes.

• Adolescent remains emotionally immature.

Academic Development

• Academic underachievement.

• Low energy level in regards to school or job performance.

• Ability to function impaired by use.

• Maintain false sense of accomplishment at school.

• Never matures past the "life has limitless possibilities" phase into the realization that the future depends on one making responsible choices; or maintains an external locus of control that attributes blame to the system for failing to meet their needs.

• Maintains immature attitude that they should not have to do this because it is boring.

• Remains suck in the critical thinking phase.

• Is exposed to easier ways to make money than working (i.e., selling drugs).

• Does not appreciate need to set goals and choose a vocation/career.

• May realize that they are not academically or vocationally equipped to move into adulthood, which in turn contributes to low self-esteem.

It is useful to characterize adolescent substance use behavior on a continuum of severity ranging from:

• abstinence;

• use: minimal or experimental use with minimal consequences;

• abuse: regular use or abuse with several and more severe consequences;

• abuse/dependence: regular use over an extended period with continued severe consequences;

• recovery: return to abstinence, with a relapse phase in which some adolescents cycle through the stages again; and

• secondary abstinence.

Any response to an adolescent who is using substances should be consistent with the severity of drug involvement. Youth treatment providers should be sensitive to the developmental differences among adolescents and make necessary adjustments to accommodate such differences. The treatment needs and techniques in working with a 13 year old should be different than those used in working with a 17 year old.

One of the factors that contribute to adolescents not being screened and diagnosed for substance use disorders is that many health service providers, juvenile justice workers, educators and others who work with at-risk youth have little or no training in these techniques and instruments. The juvenile justice systems should screen all adolescents at the time of arrest or detention, to include status offenders. In addition all adolescents receiving mental health assessments should be screened. Adolescents entering the child welfare system; school dropouts in vocational, or alternative school programs; and runaway youth in emergency shelters should be screened. Adolescents who present with substantial behavioral changes or needing emergency medical services for trauma, or who suddenly begin to experience medical problems such as accidents, injury, or gastrointestinal disturbances should be screened. In addition, schools should screen youth who show increased oppositional behavior, significant changes in grade point average, and a great number of unexcused school absences (TIP 31). Early identification and intervention is critical to prevent the long term ramifications of a full blown substance use problem.

Women’s Issues

“Today we know that when a woman abuses alcohol or other drugs, the risk to her health is much greater than it is for a man. Yet there is not enough prevention, intervention, and treatment targeting women. It is still much harder for women to get help. That needs to change.”

Former First Lady Betty Ford, April 1995

Alcohol, tobacco, and other drug abuse can have devastating consequences on women’s health. Lung cancer rates among females, for example, have increased six fold in the past 40 years. Lung cancer now has passed breast cancer as the leading fatal cancer for women. Women who abuse alcohol and/or drugs are at particular risk for: sexual assault; unprotected sex; unwanted pregnancies; sexually transmitted diseases, including HIV/AIDS. The incidence of AIDS is increasing more rapidly among women than men, with heterosexual contact rather than intravenous drug use fast becoming the primary method of transmission to women. Some women use alcohol and drugs as a way of coping with past abuse. For example, childhood sexual abuse is a strong predictor of later problem drinking. Alcohol is associated with domestic violence. Over half of the defendants accused of murdering their spouses and almost half of the victims of spousal murders were drinking alcohol at the time of the offense. Women become more intoxicated than men when drinking identical amounts of alcohol. With lower water and higher fat contents in their bodies, the alcohol is less diluted and therefore has a greater impact. Enzymes that help metabolize alcohol in the body are less efficient in women than in men. Cirrhosis of the liver, a result of chronic alcohol consumption, occurs in women after a shorter period of consumption than in men.

Adolescent girls are at particular risk for alcohol, tobacco, and other drug abuse:

• Adult males drink more than adult females, but young males and females consume similar amounts of alcohol. Some surveys show more alcohol consumption among females 12-17 years old than among males in the same age group.

• Among 12 to 17 year olds, females surpass males in the use of cigarettes, cocaine, crack, and prescription drugs for non-medical reasons.

• Alcohol use by preteen girls can delay the onset of puberty, interfering with adolescent maturation.

• Alcohol, cocaine, and/or opiates in high doses disrupt the menstrual cycle in women of child bearing age, inhibiting ovulation and adversely affecting fertility and sometimes leading to early menopause.

Women are more likely than men to combine alcohol with prescription drugs. Dangerous alcohol-drug or drug-drug interaction occurs more frequently in older than younger women for a number of reasons, including declining health leading to more prescribed medications and inadequate communication among various prescribing doctors.

Pregnancy provides a strong motivation for alcohol, tobacco, and drug using women to seek help. However, fear of reprisals, legal interventions, and loss of child custody prevents many women from getting help. The often punitive actions taken against women who seek treatment has served to deter many women of color and poverty from treatment.

Short and Long Term Effects of Prenatal AOD Exposure:

The chart below shows possible consequences from the use of commonly abused substances by the mother during pregnancy (CWLA, 1993).

Barriers to Treatment For Women

There are a number of barriers that prevent women access to treatment services. These include but are not limited to: stigma associated with addiction within certain cultural groups; shame associated with sexual abuse issues; child care issues; financial resources; lack of programs designed to address the unique issues faced by women; appropriate aftercare services; links by treatment providers to resources serving women; and lack of effective case management services. In addition to these barriers, women who often need these services are unaware that they exist. Non-profit organizations historically have had difficulty in creating appropriate marketing strategies to reach the populations they serve.

Two critical issues often faced by women seeking treatment include domestic violence, and sexual abuse. Treatment Improvement Protocol (TIP) Series 25, Substance Abuse Treatment and Domestic Violence looks at the impact of domestic violence on women and its implication for substance abuse treatment providers. This TIP is an excellent source of information. Specific recommendations can be found on screening, referral and treatment of survivors of domestic violence.

Domestic violence

In the United States, a woman is beaten every 15 seconds. At least 30 percent of female trauma patients (excluding traffic accident victims) have been victims of domestic violence, and medical costs associated with injuries done to women by their partners total more than $44 million annually. Much like patterns of substance abuse, violence between intimate partners tends to escalate in frequency and severity over time. "Severe physical assaults of women occur in 8 percent to 13 percent of all marriages; in two‑thirds of these relationships, the assaults reoccur". In 1992, an estimated 1,414 females were killed by "intimates," a finding that underscores the importance of identifying and intervening in domestic violence situations as early as possible.

An estimated three million children witness acts of violence against their mothers every year, and many come to believe that violent behavior is an acceptable way to express anger, frustration, or a will to control. Some researchers believe, in fact, that "violence in the family of origin [is] consistently correlated with abuse or victimization as an adult". Other researchers, however, dispute this claim. The rate at which violence is transmitted across generations in the general population has been estimated at 30 percent and at 40 percent. Although these figures represent probabilities, not absolutes, and are open to considerable interpretation, they suggest to some that 3 or 4 of every 10 children who observe or experience violence in their families are at increased risk for becoming involved in a violent relationship in adulthood.

Identifying the Connections

Researchers have found that one fourth to one half of men who commit acts of domestic violence also have substance abuse problems. A recent survey of public child welfare agencies conducted by the National Committee to Prevent Child Abuse found that as many as 80 percent of child abuse cases are associated with the use of alcohol and other drugs, and the link between child abuse and other forms of domestic violence is well established. Research also indicates that women who abuse alcohol and other drugs are more likely to become victims of domestic violence and that victims of domestic violence are more likely to receive prescriptions for and become dependent on tranquilizers, sedatives, stimulants, and painkillers and are more likely to abuse alcohol. Other evidence of the connection between substance abuse and family violence includes the following data:

• About 40 percent of children from violent homes believe that their fathers had a drinking problem and that they were more abusive when drinking.

• Childhood physical abuse is associated with later substance abuse by youth.

• Fifty percent of batterers are believed to have had "addiction" problems.

• Substance abuse by one parent increases the likelihood that the substance‑abusing parent will be unable to protect children if the other parent is violent.

• A study conducted by the Department of Justice of murder in families found that more than half of defendants accused of murdering their spouses as well as almost half of the victims had been drinking alcohol at the time of the incident.

• Teachers have reported a need for protective services three times more often for children who are being raised by someone with an addiction than for other children.

• Alcoholic women are more likely to report a history of childhood physical and emotional abuse than are nonalcoholic women.

• Women in recovery are likely to have a history of violent trauma and are at high risk of being diagnosed with posttraumatic stress disorder.

No less troubling is the impact of sexual abuse on female clients. It is not unusual for 40 % or more of the women clients in a treatment program to have unresolved incest issues. Statistics show that one in every three women in the general population will be assaulted sexually before the age of 18. Assessment procedures must include questions to evaluate if either domestic violence or sexual abuse are issues for each woman. If uncovered, the program must be prepared to make appropriate referrals to other community providers who specialize in these areas. LCDC’s are not qualified to address sexual abuse issues, in fact any counselor who has not had significant specialized training in this area can cause more harm than good.

Lesbian, Gay & Bisexual Youth/Adults (LGBT)

Research has found that gay, lesbian, and bisexual Americans are at increased risk for alcohol and other drug problems. This population remains misunderstood and undeserved. Few prevention or treatment programs address risk factors for this group. These factors include:

• history of family alcohol and other drug problems

• physical, sexual or psychological abuse and victimization

• school drop-out

• attempted suicide

• low self-esteem/self-efficacy

• inadequate social services

• homelessness

• pro-use norms within their group

• lack of role models

It is not enough to assume that gay, lesbian, and bisexual youth and adults are included in other high-risk category prevention and treatment programs. Their vulnerability to alcohol and other drug use is unique and exacerbated by feelings of rejection by their environment and self. They often feel rejected because of their sexual orientation, over which they have no control.

The Connection Between Substance Use Among LGBT Populations

A tremendous controversy exists over the exact rates of substance use within lesbian, gay, bisexual, and transgender populations (LGBT). It is frequently reported that people who are LGBT experience increased risk for substance use and abuse. Many sources report that one out of every three gay men and lesbians, or over 8 million LGBT men and women, struggle with alcohol and drug‑related problems. But, this data is not universally accepted. Other research studies have found that moderate alcohol use rates in the LGBT communities are similar to those of the mainstream populations, but that the LGBT population is over‑represented on both ends of the spectrum (those who abstain and those who are heavy drinkers). More research is needed in order for prevention and treatment efforts to target these communities effectively!

Three main factors have made it difficult to determine the extent of the substance use and abuse in LGBT populations.

• No one can say with certainty the number of individuals who are LGBT.

• Alcoholism, drug abuse, and addiction have only recently been highlighted as significant social problems.

• Denial and secrecy commonly characterize alcoholism and drug abuse in all populations.

Why is it Important to Develop and Implement Specific LGBT Programs? According to health professionals, it is crucial for outreach and prevention programs to reach people where they are. Counselors and service providers need to be sensitive to the issues faced by the LGBT population, and treatment facilities need to accept them without discrimination, without denying their sexuality, and without attempts to "cure" their sexual preference. LGBT‑specific programs also lend assistance in establishing new social and emotional networks to maintain recovery and provide support from members of their community in maintaining a sober, drug‑free life.

In addition to issues of social and family rejection, reality is that many counselors are unprepared to serve these clients. Homophobia is not limited to the general population. It is critical that you examine your values and biases on this subject. The reality that you will work with clients whose sexual orientation may be different than your own can not be avoided. Only through self-awareness will you be able to prepare yourself to serve these clients fairly and effectively. Having a general understanding of heterosexism and homophobia is important in working with LGBT individuals. Heterosexism and homophobia describe the forms of bigotry against LGBT people. Heterosexism resembles racism or sexism and denies, ignores, denigrates, or stigmatizes non-heterosexual forms of emotional and affectional expression, sexual behavior, or community. Homophobia is defined as the irrational fear of, aversion to or discrimination against LGBT behavior or persons. Internalized homophobia describes the self-loathing or resistance to accepting an LGBT sexual orientation and is an important concept in understanding LGBT clients.

Legal Issues

Although Federal and a number of State statutes protect recovering substance abusers from many forms of discrimination, LGBT individuals are not afforded the same protections in many areas of the country. Disclosure of one’s sexual orientation can lead to employment problems or the denial of housing and social services. LGBT individuals may lose custody of their children if their sexual orientation becomes known during a custody dispute. Even in those States that have enacted statutes prohibiting discrimination on the basis of sexual orientation, LGBT individuals have sometimes been denied protection. LGBT individuals regard protecting information about their sexual orientation and substance abuse histories as critically important. Programs that treat this population must be particularly sensitive about maintaining clients’ confidentiality, because the consequences of an inappropriate disclosure can be devastating.

Treatment Issues

The term “coming out” refers to the experiences of some, but not all, gay men and lesbian women as they explore their sexual identity. There is no correct process or single way to come out, and some LGBT individuals do not come out. This process is unique for each individual, and it is the choice of the individual. A counselor may do harm if he or she forces openness by questioning a client’s sexuality before the client is ready.

Providing support for LGBT clients and their families is a significant element of substance abuse treatment. Like other clients, LGBT individuals in treatment are involved in multidimensional situations and come from diverse family backgrounds. A family history and a review of the dynamics of the family of origin are part of a thorough biopsychosocial assessment. Counselors need an understanding of the dynamics of LGBT interpersonal relationships. This understanding includes awareness of the internal and external problems of same-sex couples and the diversity and variety of relationships in the LGBT community. Although many individuals have a life partner, others are single or in non-traditional arrangements. Counselors need to be aware of their own biases when working with individuals who find themselves outside the cultural norm of a heterosexual, monogamous, and legally sanctioned marriage.

LGBT individuals may be victims of anti-gay violence and hate crimes such as verbal and physical attacks. Some victims may turn to alcohol or drugs as a coping method. It is important that substance abuse counselors obtain training and education about interpersonal violence and stigmatized client populations.

Lesbians resemble other women in that their patterns of substance use vary. However, fewer lesbians than heterosexual woman abstain from alcohol; rates of reported alcohol problems are higher from lesbians than for heterosexual women; and drinking, heavy drinking and problem drinking show less decline with age among lesbians than among heterosexual women. Risk factors for abusing alcohol include relying on women’s bars for socializing and peer support; the negative effects of sexism and heterosexism; additional stressors related to coming out or “passing” as heterosexual; and the effects of trauma from violence or abuse. The trauma experienced by some lesbians may affect their behavior and emotional state. One study reported that 21 % of lesbians were sexually abused as children and 15 % were abused as adults.

In spite of growing acceptance of gay people, social outlets for gay men still tend to be limited. The “gay ghetto,” the section of town where gay people feel comfortable, usually is identified by the presence of gay bars. The number of gay coffee shops, bookstores, and activities that involve alcohol and drug use is increasing, but gay bars and parties that focus on alcohol and drug use are still very visible elements of gay social life.

HIV/AIDS continues to be a major factor in gay male fie. The percentage of HIV-infected people in the United States who are gay has steadily dropped, but many gay men in treatment may be HIV sero-positive, have AIDS, or have a sense of loss from losing friends. For some gay men, sex and intimacy may be disconnected. Substance use allows them to act on suppressed or denied feelings but makes it harder to integrate intimacy and sex.

Bisexual identity is not necessarily defined by sexual behavior. An assessment of a self-identified bisexual client includes sexual behavior and identity issues and the range of psychosocial issues that may complicate substance abuse treatment. The current conceptualization of bisexuality is that it is a sexual orientation. Counselors may have biases about bisexuals, believing that they are psychologically or emotionally damaged, are developmentally immature, or have a borderline personality disorder, with changing poor impulse control or acting-out behavior. Bisexuals may feel alienated not just form the heterosexual majority but also from the lesbian and gay community. Internalized Biphobia may result in a struggle toward self-acceptance.

The psychiatric model views trans-sexualism as psychopathological and classifies it as a gender identity disorder. Many in the transgender community disagree with this classification. Issues in substance abuse treatment for transgender clients include societal and internalized trans-phobia, violence, discrimination, family problems, isolation, lack of educational and job opportunities, lack of access to health care, and clients’ low self-esteem. Many transgender people have had negative experience sight providers of health care, and they may be distrustful of providers.

Hormone therapy is often overlooked as a clinical issue. Hormone treatment is a standard medical practice for transsexuals, and clients may need assistance in maintaining regular legally prescribed hormone therapy while in treatment for substance abuse. It is important that both the counselor and the client understand that hormone therapies can affect mood, especially when taken improperly. Transgender clients may face and additional risk from using “street” or “black market” hormones. Because testosterone must be injected, obtaining or using needles may be relapse triggers for clients in early recovery. Logistics such as rest room use and sleeping arrangements need to be sensitive to both transgender clients and other clients. Evidence suggests that transgender individuals have a higher rate of exposure to violence and discrimination than lesbians and gay men, and such experiences can influence a transgender client’s ability to complete and maintain successful recovery form substance abuse. Some transgender clients have been prostitutes or sex workers, resulting in clinical issues that can also block recovery if they are not adequately addressed.

It is important that the counselor respect the client and his or her frame of reference; recognize the importance of cooperation and collaboration with the client; maintain professional objectivity; recognize the need for flexibility and be willing to adjust strategies in accordance with client characteristics; appreciate the role and power of a counselor as a group facilitator; appreciate the appropriate use of content and process therapeutic interventions; and be non-judgmental and respectfully accepting of the client’s cultural, behavioral, and value differences.

Elderly

Alcohol and other drug abuse by the elderly is a largely hidden problem. While the rate of misuse and abuse of prescription and other drugs is much higher for this age group than for younger adults, these problems are less likely to be detected or treated. Relatively few chemically dependent elderly are treated in substance abuse treatment programs.

Researchers are only beginning to realize the pervasiveness of substance abuse among people age 60 and older; until relatively recently, alcohol and prescription drug misuse, which affects as many as 17 percent of older adults, was not discussed in either the substance abuse or the gerontological literature.

The reasons for this silence are varied: health care providers tend to overlook substance abuse and misuse among older people, mistaking the symptoms for those of dementia, depression, or other problems common to older adults. In addition, older adults are more likely to hide their substance abuse and less likely to seek professional help. Many relatives of older individuals with substance use disorders, particularly their adult children, are ashamed of the problem and choose not to address it. The result is thousands of older adults who need treatment and do not receive it.

Alcohol Abuse

Alcohol problems among the elderly are typically categorized into early and late onset alcoholism. Early onset alcoholism is used to describe individuals who experienced chemical dependency problems in early and middle adulthood that carried over into late adulthood. Late onset alcoholism refers to those who developed chemical dependency problems later in life, in reaction to the stresses of aging.

Physiological changes, as well as changes in the kinds of responsibilities and activities pursued by older adults, make established criteria for classifying alcohol problems often inadequate for this population. One widely used model for understanding alcohol problems is the medical diagnostic model as defined in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‑IV). The DSM‑IV criteria for substance dependence include some that do not apply to many older adults and may lead to under identification of drinking problems.

Some experts use the model of at‑risk, heavy, and problem drinking in place of the DSM‑IV model of alcohol abuse and dependence because it allows for more flexibility in characterizing drinking patterns. In this classification scheme, an at‑risk drinker is one whose patterns of alcohol use, although not yet causing problems, may bring about adverse consequences, either to the drinker or to others. As their names imply, the terms heavy and problem drinking signify more hazardous levels of consumption. Although the distinction between the terms heavy and problem is meaningful to alcohol treatment specialists interested in differentiating severity of problems among younger alcohol abusers, it is less relevant to older adults. To differentiate older drinkers it is recommended that the terms at‑risk and problem drinkers be used.

Abuse of Prescription Drugs

Prescription medication misuse is the most common form of drug abuse among the elderly. Prescription drugs are used by older people at much greater rates than other age groups. The elderly make up 11 % or the U.S. population, yet they account for 25 to 33 % of the prescription drugs used each year.

Estimates of chemical dependency problems among U.S. elderly rage from 2 to 10 %, or between 500,000 and 2.5 million people over the age of 55. Many life changing events place the elderly at risk for substance abuse problems. They retire and begin to outlive spouses, friends and family members. Not only do they lose these significant others, but the life roles that these relationships represent. Limited financial resources and physical ailments take their toll as well.

People 65 and older consume more prescribed and over‑the‑counter medications than any other age group in the United States. Prescription drug misuse and abuse is prevalent among older adults not only because more drugs are prescribed to them but also because, as with alcohol, aging makes the body more vulnerable to drugs' effects.

Any use of drugs in combination with alcohol carries risk; abuse of these substances raises that risk, and multiple drug abuse raises it even further. For example, chronic alcoholics who use even therapeutic doses of acetaminophen may experience severe heap-toxicity. Alcohol can increase lithium toxicity and enhance central nervous system depression in persons taking tricyclic antidepressants. High doses of benzodiazepines used in conjunction with alcohol or barbiturates can be lethal.

Benzodiazepines

Benzodiazepine use for longer than 4 months is not recommended for geriatric patients. Furthermore, among the different benzodiazepines, longer acting drugs such as flurazepam (Dalmane) have very long half‑lives and are more likely to accumulate than the shorter acting ones. They are also more likely to produce residual sedation and such other adverse effects as decreased attention, memory, cognitive function, and motor coordination, and increased falls or motor vehicle crashes. By contrast, some shorter acting benzodiazepines such as oxazepam (Serax) and lorazepam (Ativan) have very simple metabolic pathways and are not as likely to produce toxic or dependence‑inducing effects with chronic dosing.

Sedative/Hypnotics

Aging changes sleep architecture, decreasing the amount of time spent in the deeper levels of sleep (stages three and four) and increasing the number and duration of awakenings during the night. However, these new sleep patterns do not appear to bother most medically healthy older adults who recognize and accept that their sleep will not be as sound or as regular as when they were young. Although benzodiazepines and other sedative/hypnotics can be useful for short‑term amelioration of temporary sleep problems, no studies demonstrate their long‑term effectiveness beyond 30 continuous nights, and tolerance and dependence develop rapidly. It is recommended that symptomatic treatment of insomnia with medications be limited to 7 to 10 days with frequent monitoring and reevaluation if the prescribed drug will be used for more than 2 to 3 weeks. Intermittent dosing at the smallest possible dose is preferred, and no more than a 30‑day supply of hypnotics should be prescribed.

Identification of elderly in need of treatment is difficult because they are often retired, live away from their families, do little or no driving, and participate in few social activities. This lack of coercive forces can make it difficult to determine if a cd problem exists. Physicians and counselors also find it hard to differentiate between cd problems and what would be normal physical and mental ailments for this age group. The elderly are often viewed as poor treatment risks because society sees them as physically, mentally and economically unstable. However, successful treatment and recovery are highly possible for this population if intervention and treatment are designed to meet their needs.

Substance Abuse Among Older Adults, TIP 26 provides information on identification, screening, assessment and treatment strategies for working with this population.

People with Disabilities

The burdens that alcohol, tobacco, and other drug problems pose are compounded when the individual is one of the estimated 43 million Americans who have one or more physical or mental disabilities. For these individuals, the process of recovery is made more difficult by barriers that do not exist for others.

In 1990, Congress passed the Americans with Disability Act (ADA), which describes people with disabilities as “a discrete and insular minority who have been subjected to a history of purposeful, unequal treatment and relegated to an inferior status in our society.” Congress noted that people with disabilities face discrimination in employment, housing, public accommodations, education, transportation, communication, recreation, institutionalization, health services, voting, and access to public service.

Congress passed the ADA to eliminate major forms of discrimination against people with disabilities including

• overprotective rules and policies;

• segregation or relegation to lesser services or programs;

• outright intentional exclusion;

• exclusionary standards, and

• architectural, transportation, and communication barriers.

Alcohol and drug problems are significantly more prevalent among people with disabilities. One possible reason for increased problems is that regular use of prescription medication, both non-psychoactive and psychoactive, may serve to potentiate the effects of drugs such as alcohol. Another reason may be that alcohol, tobacco, and other drug problems that existed prior to the disability tend to continue and worsen.

In 1990, it was estimated that 36.1 million people in America (14.5 percent of the population) had a disability that limited their functioning in some manner. A great number of people with disabilities have struggled for years with barriers to employment, inaccurate and hurtful stereotypes, and inaccessible community services. In order to redress these barriers that affect millions of Americans, President Bush in 1990 signed into law the Americans With Disabilities Act (ADA), the most significant civil rights legislation in two decades. The legislation prohibits discrimination on the basis of disability, including substance use disorders, and guarantees full participation in American society, including access to community services and facilities, for all people with disabilities. It makes provision for many accommodations that may be necessary in substance use disorder treatment, such as the use of large print materials, reading services, attended care, adaptive equipment such as listening devices, and flexible schedules to accommodate different physical needs. Because of this legislation, many people today are more aware of the problems faced by people with physical and cognitive disabilities.

Though the ADA is correcting the situation, many people with disabilities remain stigmatized and shut out. They are also at much higher risk than the rest of the population for substance abuse or dependence. A study of adult males receiving treatment for alcoholism, for instance, revealed that 40 percent had a history indicative of learning disabilities. Another study indicated that at least one half of persons with a substance use disorder and a coexisting disability are not being identified as such by the systems providing them services.

New York State maintains within their Office of Alcoholism and Substance Abuse Services (OASAS) some of the most comprehensive records in the country on substance use disorder services for persons with disabilities. The OASAS client services statistics for 1997 showed that of 248,679 clients served by licensed facilities in New York, a total of 55,719 (or 22.4 percent of the total clientele) were recorded as having a coexisting physical or mental disability. Of these clients, 58.9 percent had a disability not related to mental illness (e.g., mobility impaired, visually impaired, and deaf). These records were generated by treatment staff personnel who were not necessarily trained in disability assessment or by client self‑reports, which suggests that some disabilities (e.g., traumatic brain injury [TBI], learning disability, attention deficit/hyperactivity disorder [AD/HD]) may be greatly under‑reported. Given that these "hidden" conditions affect more than half of all special education students, coexisting disabilities may actually affect up to 40 percent of all clients served by substance use disorder treatment programs.

Yet despite the prevalence of substance use disorders among people with disabilities, these individuals are less likely to enter or complete treatment. This is because physical, attitudinal, or communication barriers often limit their treatment options or else render their treatment experiences unsatisfactory.

Fortunately today, substance use disorder treatment providers are better able to face the challenges of accommodating people with coexisting disabilities because they have already had the experience of making treatment modifications for other constituencies. Over the past decades, the substance use disorder treatment field has matured through the challenges of treating populations with specific needs, such as women, adolescents, people from various racial and ethnic minority groups, and gay men and lesbians. The effectiveness of treatment has improved as a result‑‑it has become more developmentally and culturally specific, flexible, and holistic. Rather than placing a person in an established treatment "slot," treatment providers are learning the importance of modifying and adapting services to meet an individual client's needs. Thus, the knowledge and skills necessary to adapt a treatment program to meet the needs of people with coexisting disabilities are a logical extension of existing principles.

Disabilities: Diseases, disorders, and injuries, whether congenital or acquired, can have various effects on organs and body systems. Conditions (and diseases) such as multiple sclerosis, TBI, spinal cord injury, diabetes, and cerebral palsy can lead to impairments, such as impaired cognitive ability, paralysis, blindness, or muscular dysfunction. These impairments in turn cause disabilities, which limit an individual's ability to function in various areas of life, such as learning, reading, and mobility. While diseases, impairments, and disabilities are distinct categories, they are often used interchangeably; to ensure clarity.

The field of disability services has developed its own terminology to discuss physical and cognitive disabilities, and many substance use disorder treatment providers will not be familiar with these terms.

The World Health Organization (WHO) has devised a method for the classification of impairments and disabilities. This complex system has been simplified here into four main categories:

• Physical impairments are caused by congenital or acquired diseases and disorders or by injury or trauma. For example, spinal cord injury is a disorder that can cause paralysis, and impairment.

• Sensory impairments include blindness and deafness, which may be caused by congenital disorders, diseases such as encephalopathy or meningitis, or trauma to the sensory organs or the brain.

• Cognitive impairments are disruptions of thinking skills, such as inattention, memory problems, perceptual problems, disruptions in communication, spatial disorientation, problems with sequencing (the ability to follow a set of steps in order to accomplish a task), misperception of time, and perseveration (constant repetition of meaningless or inappropriate words or phrases).

• Affective impairments are disruptions in the way emotions are processed and expressed. For the purposes of this discussion, affective impairments are considered to include problems caused by both affective and mood disorders, such as major depression and mania. These impairments include the symptoms of mental disorders, such as disorganized speech and behavior, markedly depressed mood, and anhedonia (joylessness).

What Is the ADA?

The Americans With Disabilities Act of 1990 is the first federal law initiated and championed by persons with disabilities. Unlike prior laws and regulations, the ADA puts the onus of accommodation on society rather than the individual with a disability. The ADA guarantees equal opportunity for individuals with disabilities in public and private sector services and in employment. It is a comprehensive anti‑discrimination law which extends to virtually all sectors of society and every aspect of daily living. The ADA is a federal civil rights act which provides the same basic civil rights protections to persons with disabilities as afforded all other Americans.

The ADA is organized into five titles.

• Title I: Employment‑‑Employers with 15 or more employees must ensure that their employment practices do not discriminate against qualified people with disabilities. (In California, this applies to employers who have 5 or more employees.) Title I provides protection for job applicants and employees during all phases of employment, including the application process, interviewing, hiring, employment itself, and discharge from employment. Employers must also reasonably accommodate the disabilities of qualified applicants and employees, unless an undue hardship would result.

• Title II: State and local government services‑‑Requires that public programs and services are made accessible to persons with disabilities. Mandates nondiscrimination on the basis of disability in policy, practice and procedure. Prescribes a self‑evaluation process, and requires that architectural and communications barriers be removed to the extent required to provide full access to program services.

• Title III: Public accommodations‑‑Title III requires places of public accommodation to be accessible to, and usable by, people with disabilities. Places of public accommodation are all private businesses and privately owned and operated programs that offer goods and services to the general public. Title III entities must not discriminate by excluding people with disabilities, treating them separately, or requiring them to participate in separate programs. Reasonable modifications must be made to policies, practices, and procedures so that people with disabilities may participate. Auxiliary aids and services that ensure effective communication with people with disabilities must also be provided so long as they do not create an undue burden or fundamentally alter the services that the program offers. New construction must be barrier free. In existing buildings, architectural barriers to disability access must be removed when it is readily achievable. "Readily achievable" means "easily accomplishable and able to be carried out without much difficulty or expense." Programs must review possible readily achievable barrier removal on an ongoing basis, typically annually or with each new program budget.

• Title IV: Telecommunications‑‑Title IV has mandated the establishment of a national network of telecommunication relay services that is accessible to people who have hearing and speech disabilities. It also requires captioning of all federally funded television public service announcements.

• Title V: Non-retaliation and other provisions‑‑Title V explicitly prohibit retaliation against people exercising their rights under the ADA. It sets forth specific responsibilities for the adoption of enforcement regulations by federal agencies. It also includes a number of miscellaneous provisions.

The ADA includes a set of architectural standards called the Americans With Disabilities Act Accessibility Guidelines (ADAAG). All Title II and Title III entities must comply with ADAAG requirements for new construction and alteration building projects. In California, public and private building projects must also comply with state accessibility regulations (Title 24). Title 24 has recently been revised to incorporate specifications found in the ADAAG. The Equal Employment

Opportunity Commission and the U.S. Department of Justice have been designated as the lead ADA enforcement agencies. The Architectural and Transportation Barriers Compliance Board develops accessibility guidelines (architectural standards) for enforcement of the Act.

Clients in the Criminal Justice System

Another category of special needs clients are those who are involved in the criminal justice system. On any given day, some 1.7 million men and women are incarcerated in Federal and State prisons and local jails in the United States. Recent studies suggest that more than 80 % of them are involved in substance use. Substance use disorders disproportionately affect incarcerated Americans. Although prison substance use disorder programs annually treat more than 51,000 inmates, this figure represents less than 13 % of the offender population identified as needing treatment. Studies also indicate that with the exception of detoxification most offenders have never received treatment in the community. Offenders with substance use disorders not only crowd the nation’s prisons, they are also responsible for a disproportionate amount of crime and for relatively violent crime. Compared to offenders who do not use drugs, drug-using “violent predators” commit many more robberies, burglaries, and other thefts (TIP 30) @ www.health.org/survey/30.htm.

On any given day, some 1.7 million men and women are incarcerated in Federal and State prisons and local jails in the United States, and a recent study suggests that more than 80 percent of them are involved in substance use. In 1996 alone, taxpayers spent over $30 billion to incarcerate these individuals ‑‑ who are the parents of 2.4 million children. Put another way, one of every 144 American adults is behind bars for a crime in which substances are involved.

By a variety of measures, it is clear that substance use disorders disproportionately affect incarcerated Americans. Yet this population is significantly under treated: Although prison substance use disorder programs annually treat more than 51,000 inmates, this figure represents less than 13 percent of the offender population identified as needing treatment. Studies also indicate that (with the exception of detoxification) most offenders have never received treatment in the community. Clearly, the majority of individuals in the criminal justice system in need of substance use disorder treatment are not receiving services either while they are incarcerated or after release to the community.

Providing substance use disorder treatment to offenders is good public policy. Recent research shows that punishment is unlikely to change criminal behavior, but substance use disorder treatment that also addresses criminal behavior can reduce recidivism. Inmates with substance use disorders are the most likely to be re‑incarcerated again and again and the length of their sentences continually increases. The more prior convictions an individual has, the more likely he has a substance use disorder. In State prisons, 41 percent of first offenders have used drugs, compared to 63 percent of inmates with two prior convictions and 81 percent of inmates with five or more prior convictions. Half of State parole and probation violators were under the influence of drugs, alcohol, or both when they committed their new offense. State prison inmates with five or more prior convictions are three times more likely than first‑time offenders to be regular crack cocaine users. Offenders with substance use disorders not only crowd the nation's prisons, they are also responsible for a disproportionate amount of crime and for relatively violent crime. Compared to offenders who do not use drugs, drug‑using "violent predators" commit many more robberies, burglaries, and other thefts.

However, offenders who have completed substance use disorder treatment during incarceration are still at great risk for relapse and recidivism when released. They need a variety of services to maintain sobriety during their transition from the institution to the community. This chapter provides an overview of the benefits of those transitional services. It also discusses obstacles to implementing such services and provides strategies for overcoming these obstacles. Finally, models for transitional

services are described.

Some incarcerated offenders enter treatment for the same reasons as those "on the outside": They want to stop using substances and need help. Others, however, may have different motivations: boredom, the desire to improve their chances for parole, a wish to escape the violent culture of general population, or some combination of the above. Others may be mandated to treatment by the courts. Surprisingly, research shows that once an offender begins treatment, outcomes are not affected by the reasons for entering treatment. A certain proportion of those who undergo treatment within the institution will succeed if supervised closely. Other key findings on the effectiveness of substance use disorder treatment within correctional institutions include the following:

• Pre-release therapeutic communities have shown high rates of success among inmates studied.

• Involvement in substance use disorder treatment is associated with decreased criminal recidivism. Improvements have been seen in rates of re-arrest, conviction, re-incarceration, and time to recidivate.

• Involvement in substance use disorder treatment is associated with decreased substance use and relapse and other health‑related outcomes.

• Duration of correctional substance use disorder treatment is associated with positive treatment outcomes. Research has shown that, up to a point, longer lengths of treatment are more effective than shorter lengths of treatment for substance‑using offenders.

• Involvement in substance use disorder treatment, such as prison‑based therapeutic communities, is associated with successful parole outcomes (including reductions in parole revocations).

• Inmates involved in substance use disorder treatment had reduced rates of re‑arrest and relapse when compared with inmates who did not participate.

Treatment During Transition To the Community

Service systems should provide offenders with appropriate treatment, since no treatment is likely to lead to continued drug use and crime. Treatment that stops when the offender is released, however, may not be enough. Release presents offenders with a difficult transition from the structured environment of the prison or jail: Despite the hardships endured "inside," they at least knew what to expect. Many offenders are released with no place to live, no job, and without family or social supports. They often lack the knowledge and skills to access available resources for adjustment to life on the outside, all factors that significantly increase the risk of relapse and recidivism. The positive effects of substance use disorder treatment within correctional institutions may diminish once the offender moves out of the institutional environment unless follow-up care is provided in the community.

The benefits of treatment during the transition from incarceration to the community are substantiated in several recent studies. In a study of drug offenders in Delaware, offenders who participated in 12 to 15 months of treatment in prison and another 6 months of treatment in the community were more than twice as likely to be drug‑free 18 months after release as those who had only the prison treatment. Those offenders were also arrested much less in the year and a half following release. A similar study in California had comparable results. Continuity of care from the institution to the community is associated with positive outcomes for prevention of relapse and criminal recidivism in other research as well.

It is well documented that the most effective substance use disorder treatment is multifaceted and addresses many aspects of the substance user's life. This is particularly true for criminal justice populations, yet treatment providers generally do not match offenders with substance use disorders to services tailored to their needs. Effective care for those with mental and physical health problems, for example, must incorporate the care of these illnesses into the plan for treatment of substance use disorders and criminality. Assessment and treatment efforts must also acknowledge and incorporate the offenders' differences in culture, gender, age, and type of criminal offense.

People with mental and physical health problems constitute a major category of special needs populations. Society's failure to provide appropriate options for them contributes to disproportionately high numbers of these individuals who eventually find themselves under criminal justice supervision and many of these offenders, particularly the mentally ill, cycle through the criminal justice and social services systems repeatedly because their problems are not fully addressed in any system. For example, once individuals with mental illness are incarcerated, short‑term goals of controlling undesirable behavior and a reliance on medication often take precedence over more comprehensive approaches to treatment.

Upon release, offenders with multiple problems suffer from an additional stigma and may be denied services because community providers lack training to deal with their problems. For example, providers who do not understand the issues for those with mental illness or mental retardation may believe that these individuals cannot benefit from treatment and are dangerous. Part of the case manager's job is to add to the transition team those specialists who can correct such misinformation.

However a population is defined (e.g., by a health problem or cultural background), it is important to know the substances of choice, types of crime, and other life patterns. Elderly people, for example, abuse prescription drugs and alcohol, but rarely use illicit drugs. People with mental retardation are often arrested for nuisance offenses and may be manipulated into criminal activities. Women's substance use is often woven into their intimate relationships; many are incarcerated for possession of a drug that their significant others are selling. These substance use patterns have significant implications for treatment.

Cultural sensitivity and cultural competency, important in all treatment, are particularly essential with offender populations, because minorities are notoriously over represented in incarcerated settings. For example, 40.5 percent of the prison population is African‑American, even though African Americans make up only 12.7 percent of the general U.S. population according to September 1998 census data. For some offenders, such as those of African‑American and Latino heritage, the family and extended family should be specifically included in the transition plan because of the importance those cultures place on family relationships. Self‑help models of treatment may need adaptation for different cultures and for women.

Ideally, staffing patterns at all levels of the treatment system should reflect the population served, from clerical staff through executive management. Specific efforts should be made to recruit and maintain such staff members. Licensing, certification, and credentialing should support the use of culturally competent staff, and support continuing education in the knowledge and skills relevant to the population. Staff members should be able to communicate in local languages and dialects, and published materials and consent forms should be available in these languages as well. If this is not possible, staff members should find creative means to compensate for this deficit, although family members, especially children, should never be used as interpreters. Incentives that encourage culturally sensitive client interactions should be woven into the employee performance evaluation system.

Whether the differences are cultural, medical, age‑, or gender‑related, it is important to remember that offenders are not a homogenous population. This chapter will help community treatment providers and correctional workers deliver effective transitional services to groups with special needs.

Women

In 1997, slightly less than 8 percent of those incarcerated were women 6.4 percent of the prison population and 10.6 percent of the jail population, but that percentage is rising. Women are substantially more likely than men to serve time for a drug offense rather than a violent crime. Compared to men, women are more heavily drug‑involved, and are often polydrug and intravenous drug users, though they use less alcohol than men. Women in prisons in 1996 were most likely to be black (46 percent), ages 25‑34 (50 percent), unemployed at the time of arrest (53 percent), and never married (45 percent). In State prisons in 1991 more than 75 percent of the women had children; two‑thirds had children under the age of 18.

Incarcerated women and women with substance use disorders are more likely to have suffered physical and sexual abuse. Incarcerated women's physical health profiles include a high incidence of HIV/AIDS and other STDs, pregnancy, and certain types of coexisting mental disorders. The most common mental health disorder among female offenders is depression. At the Turning Point Alcohol and Drug Program for women in Oregon, approximately 50 percent were diagnosed with depression. Another commonly found disorder is post-traumatic stress disorder, not uncommon in victims of physical and sexual abuse. The importance of addressing women's health care in correctional settings is spelled out by the National Commission on Correctional Health Care's (NCCHC) position statement on Women's Health Care in Correctional Settings. In it, NCCHC recommends, among other things, intake procedures that include gynecologic history and nutritional intake, pregnancy tests, tests for STDs, counseling for depression, substance use disorders, and other disorders common to incarcerated women.

Until recent years, substance use disorder treatment programs for women have been slow to emerge in correctional institutions and in the community, and many institutions still have no women‑specific treatment services. Those services that are available often evolved from models developed for men.

Incarceration disrupts relationships with children, as well as with a spouse or partner. If a woman is a single parent involved in drugs and criminal behavior, a child protective service agency generally steps in after the arrest to take control and custody of dependent children. A high percentage of mothers have their children permanently removed from their custody as a result of

their incarceration. Parental rights for mothers (perceived as chief caretakers) are scrutinized closely by social services and foster care workers. In some jurisdictions, women have been increasingly criminalized for using drugs when pregnant.

To work effectively with this special population, counselors need to have training on criminal thinking errors and how they are used to keep the criminal from taking responsibility for their own actions. To date the most successful treatment programs for working with criminals are Therapeutic Communities (TCs). Techniques utilized by these programs will be discussed in other modules.

As you can see from both the information presented in the text and in this module, effective counseling does not just happen. Counselors must take responsibility for learning about special population categories and needs. They must take a long hard look at themselves to identify prejudices and biases which may affect their ability to work with certain client populations. Without this self-knowledge, counselors end up doing harm, intentionally or unintentionally to their clients. The process of becoming a culturally competent counselor is a life long journey.

Overview of Dual Disorders

The information provided below on dual disorders/diagnoses; has been taken from Treatment Improvement Protocol 9: Assessment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse, by the Center for Substance Abuse Treatment unless otherwise noted.

The Relationships Between AOD Use and Psychiatric Symptoms and Disorders

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Establishing an accurate diagnosis for patients in addiction and mental health settings is an important and multifaceted aspect of the treatment process. Clinicians must discriminate between acute primary psychiatric disorders and psychiatric symptoms caused by alcohol and other drugs (AODs). To do so, clinicians must obtain a thorough history of AOD use and psychiatric symptoms and disorders.

There are several possible relationships between AOD use and psychiatric symptoms and disorders. AODs may induce, worsen, or diminish psychiatric symptoms, complicating the diagnostic process. All of these possible relationships must be considered during the screening and assessment process.

Mood Disorders

The term mood describes a pervasive and sustained emotional state that may affect all aspects of an individual's life and perceptions. Mood disorders are pathologically elevated or depressed disturbances of mood, and include full or partial episodes of depression or mania. A mood episode (for example, major depression) is a cluster of symptoms that occur together for a discrete period of time.

A major depressive episode involves a depression in mood with an accompanying loss of pleasure or indifference to most activities, most of the time for at least 2 weeks. These deviations from normal mood may include significant changes in energy, sleep patterns, concentration, and weight. Symptoms may include psychomotor agitation or retardation, persistent feelings of worthlessness or inappropriate guilt, or recurrent thoughts of death or suicide. The diagnosis of major depression requires evidence of one or more major depressive episodes occurring without clearly being related to another psychiatric, AOD use, or medical disorder. Major depression is sub-classified as major depressive disorder, single episode and recurrent. There are nine symptoms of a major depressive episode listed in the DSM‑IV draft, and diagnosis of this disorder requires at least five of them to be present for 2 weeks.

Dysthymia is a chronic mood disturbance characterized by a loss of interest or pleasure in most activities of daily life but not meeting the full criteria for a major depressive episode. The diagnosis of dysthymia requires mild to moderate mood depression most of the time for a duration of at least 2 years.

A manic episode is a discrete period (at least 1 week) of persistently elevated, euphoric, irritable, or expansive mood. Symptoms may include hyperactivity, grandiosity, flight of ideas, talkativeness, a decreased need for sleep, and distractibility. Manic episodes, often having a rapid onset and symptom progression over a few days, generally impair occupational or social functioning, and may require hospitalization to prevent harm to self or others. In an extreme form, people with mania frequently have psychotic hallucinations or delusions. This form of mania may be difficult to differentiate from schizophrenia or stimulant intoxication.

A hypomanic episode is a period (weeks or months) of pathologically elevated mood that resembles but is less severe than a manic episode. Hypomanic episodes are not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization.

A bipolar disorder is diagnosed upon evidence of one or more manic episodes, often in an individual with a history of one or more major depressive episodes. Bipolar disorder is sub-classified as manic, depressed, or mixed, depending upon the clinical features of the current or most recent episodes. Major depressive or manic episodes may be followed by a brief episode of the other.

Cyclothymia can be described as a mild form of bipolar disorder, but with more frequent and chronic mood variability. Cyclothymia includes multiple hypomanic episodes and periods of depressed mood insufficient to meet the criteria for either a manic or a major depressive episode. The revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‑IV) states that for a diagnosis of cyclothymia to be made, there must be a 2‑year period during which the patient is never without hypomanic or dysthymic symptoms for more than 2 months.

Substance‑induced mood disorder is described in the DSM‑IV according to the following criteria:

A A prominent and persistent disturbance in mood characterized by either (or both) of the following:

1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities,

2) elevated, expansive, or irritable mood.

B. There is evidence from the history, physical examination, or laboratory findings of substance intoxication or withdrawal, and the symptoms in criterion A developed during, or within a month of, significant substance intoxication or withdrawal.

C. The disturbance is not better accounted for by a mood disorder that is not substance induced. Evidence that the symptoms are better accounted for by a mood disorder that is not substance induced might include: the symptoms precede the onset of the substance abuse or dependence; they persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication; they are substantially in excess of what would be expected given the character, duration, or amount of the substance used; or there is other evidence suggesting the existence of an independent non‑substance‑induced mood disorder (e.g., a history of recurrent non‑substance‑related major depressive episodes) .

D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance does not occur exclusively during the course of delirium.

Substance‑induced mood disorder can be specified as having 1) manic features, 2) depressive features, or 3) mixed features. Also, it can be described as having an onset during intoxication or withdrawal. For most of the major mental illnesses, the DSM‑IV includes the alternative of a substance‑induced disorder within that diagnosis. </SEC><SEC>

Prevalence

The most common psychiatric diagnoses among patients with an AOD disorder are anxiety and mood disorders. Among those with a mood disorder, a significant proportion has major depression. Mood disorders may be more prevalent among patients using methadone and heroin than among other drug users. In an addiction treatment setting, the proportion of patients diagnosed with major depression is lower than in a mental health setting.

During the first months of sobriety, many AOD abusers may exhibit symptoms of depression that fade over time and that are related to acute withdrawal. Thus, depressive symptoms during withdrawal and early recovery may result from AOD disorders, not an underlying depression. A period of time should elapse before depression is diagnosed.

Anxiety Disorders

The anxiety disorders are the most common group of psychiatric disorders. The term anxiety refers to the sensations of nervousness, tension, apprehension, and fear that emanate from the anticipation of danger, which may be internal or external. Anxiety disorders describe different clusters of signs and symptoms of anxiety, panic, and phobias.

A panic attack is a distinct period of intense fear or discomfort that develops abruptly, usually reaching a crescendo within a few minutes or less. Physical symptoms may include hyperventilation, palpitations, trembling, sweating, dizziness, hot flashes or chills, numbness or tingling, and the sensation or fear of nausea or choking. Psychologic symptoms may include depersonalization and derealization and fear of fainting, dying, doing something uncontrolled, or losing one's mind. A panic disorder consists of episodes of panic attacks followed by a period of persistent fear of the recurrence of more panic attacks.

When the focus of anxiety is an activity, person, or situation that is dreaded, feared, and probably avoided, the anxiety disorder is called a phobia. Phobia‑inspired avoidance behavior as well as travel and activity restrictions may become intense and incapacitating. The phobias include agoraphobia, social phobia, and simple or specific phobia; panic attacks and panic disorders are often but not necessarily involved.

Specific phobia, also called single or simple phobia, describes the onset of intense, excessive, or unreasonable fear, stimulated by the presence or anticipation of a specific object or situation. The causes may be naturally occurring (for example, animals, insects, thunder, water), situational (such as heights or riding in elevators), or related to receiving injections or giving blood. Social phobia describes the persistent and recognizably irrational fear of embarrassment and humiliation in social situations. The social phobia may be quite specific (for example, public speaking) or may become generalized to all social situations. Agoraphobia is the fear of being caught in a situation from which a graceful and speedy escape would be impossible, difficult, or embarrassing. Examples of feared situations include attendance in an auditorium, being stuck in traffic, and being outside the house.

In generalized anxiety disorder, there is no specific focus to the anxiety; symptoms are free‑floating. Generalized anxiety disorder involves excessive anxiety, worry, and apprehensive expectations focused on many life circumstances, more days than not, for a period of at least 6 months. The intensity, duration, and frequency of symptoms are out of proportion to the probability or consequences of the feared event. Somatic symptom clusters often involve:

1) motor tension (such as trembling, restlessness, and fatigue),

2) autonomic hyperactivity (for example, shortness of breath, palpitations, sweating, dry mouth, dizziness, and abdominal distress), and

3) hyperarousal (such as exaggerated startle response, irritability, insomnia, and poor concentration).

Obsessive‑compulsive disorder (OCD) is an anxiety disorder involving obsessions or compulsive rituals or both. Obsessions are repetitive and intrusive thoughts, impulses, or images that cause marked anxiety. They often involve transgressing social norms, harming others, and becoming contaminated, but they are more intense than excessive worries about real problems. Compulsions are repetitive rituals and acts that people are driven to perform and which they perform reluctantly to prevent or reduce distress. The frequency and duration of their repetition make them inconvenient and often incapacitating. Examples include ritualistic behaviors (such as hand‑washing and rechecking) and mental acts (for example, counting and repeating words silently); they are time‑consuming and interfere significantly with daily functioning.

Post‑traumatic stress disorder (PTSD) involves an individual's experiencing a psychologically traumatic stressor such as witnessing death, being threatened with death or injury, or being sexually abused. At the time of the stressor event, the individual experiences intense fear, helplessness, or horror. PTSD entails a persistent re-experiencing of the trauma in the form of recurrent and intrusive images and thoughts, or recurrent dreams, or experiencing episodes during which the trauma is relived (perhaps with hallucinations). People with PTSD experience persistent symptoms of increased arousal such as insomnia, irritability, hypervigilance, and exaggerated startle response. They persistently avoid stimuli related to the trauma such as activities, feelings, and thoughts associated with the traumatic event.

Interest in the role of sexual abuse and incest in PTSD and other psychiatric and AOD disorders has increased. Clinicians note that long‑term responses to childhood and adult sexual abuse often include symptoms associated with PTSD and other psychiatric problems, including an increased risk for AOD disorders. Many such problems are addressed in treatment efforts popular in adult children of alcoholic (ACOA) programs, some of which are controversial and unsubstantiated by research or long‑term observation. Such treatment approaches may exacerbate AOD use and psychiatric disorders and should be cautiously undertaken. Amnesic periods have to be carefully evaluated both as blackout phenomena and as possible dissociated states. Such differentiation can be extremely complicated. While a clinician's immediate response may be to identify these patients as being intoxicated, they may be experiencing independent psychiatric phenomena.</SEC><SEC>

Personality Disorders

Several alcohol and other drug (AOD)‑induced states can mimic personality disorders. If a personality disorder coexists with AOD use, only the personality disorder will remain during abstinence. AOD use may trigger or worsen personality disorders. The course and severity of personality disorders can be worsened by the presence of other psychiatric problems such as mood, anxiety, and psychotic disorders.

Antisocial personality disorder involves a history of chronic antisocial behavior that begins before the age of 15 and continues into adulthood. The disorder is manifested by a pattern of irresponsible and antisocial behavior as indicated by academic failure, poor job performance, illegal activities, recklessness, and impulsive behavior. Symptoms may include dysphoria, an inability to tolerate boredom, feeling victimized, and a diminished capacity for intimacy.

Borderline personality disorder is characterized by unstable mood and self‑image, and unstable, intense, interpersonal relationships. These people often display extremes of over-idealization and devaluation, marked shifts from baseline to an extreme mood or anxiety state, and impulsiveness.

Narcissistic personality disorder describes a pervasive pattern of grandiosity, lack of empathy, and hypersensitivity to evaluation by others.

Passive‑aggressive personality disorder involves covertly hostile but dependent relationships. People with this disorder commonly lack adaptive or assertive social skills, especially with regard to authority figures. They often display a passive resistance to demands for adequate social and occupational performance. They generally fail to connect their passive‑resistant behavior with their feelings of resentfulness and hostility toward others.

Avoidant personality disorder includes social discomfort, hypersensitivity to both criticism and rejection, and timidity, with accompanying depression, anxiety, and anger for failing to develop social relations.

Obsessive‑compulsive personality disorder describes a disorder of perfectionism and inflexibility. Symptoms may include distress associated with indecisiveness and difficulty in expressing tender feelings, feelings of depression, and anger about being controlled by others. Hypersensitive to criticism, these people may be excessively conscientious, moralistic, scrupulous, and judgmental.

Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Behavior may include constant seeking of approval or attention, striking self‑centeredness, or sexual seductiveness in inappropriate situations.

Paranoid personality disorder is characterized by a pervasive and unjustified proclivity to interpret the actions of others as intentionally threatening, demeaning, and untrustworthy.

Dependent personality disorder is characterized by a pervasive pattern of dependent and submissive behavior and an intense preoccupation with possible abandonment. Persons with this disorder often feel anxious and depressed, and may experience intense discomfort when alone for more than a brief time.

Schizoid personality disorder involves a pervasive pattern of indifference to social relationships and a restricted range of emotional experience and expression.

Schizotypal personality disorder entails deficits in interpersonal relatedness and peculiarities of ideation, appearance, and behavior and dysphoric states such as anxiety and depression.

Self‑defeating personality disorder is characterized by a pattern of self‑defeating behavior in work and personal relationships, often with complaints of exploitation by others; these persons are often unaware of their contributions to the outcomes of their behavior.

Personality disorders not otherwise specified (NOS) include disorders of personality functioning that are not classifiable as specific personality disorders. Instead, individuals do not meet the full criteria for any one personality disorder; yet their symptoms cause significant impairment in social or occupational functioning, or cause subjective distress. Personality disorders NOS include impulsive, immature, and sadistic personality disorders.

Diagnoses should be clinically based, and not influenced by professional, personal, cultural, or ethnic biases. For example, in the past some African Americans were stereotyped as having paranoid personality disorders; women have been diagnosed too frequently as being histrionic, but they are seldom diagnosed as antisocial or psychopathic; Native Americans with spiritual visions have been misdiagnosed as delusional or having borderline or schizotypal personality disorders.</SS1><SS1>

People with borderline personality disorder often use AODs in chaotic and unpredictable patterns and in polydrug patterns involving alcohol and other sedative‑hypnotics taken for self‑medication. People with personality disorders often develop problems with benzodiazepines that have been prescribed for complaints such as anxiety, which may lead to relapse to the primary drug of choice.

Many people with antisocial personality disorder use AODs in a polydrug pattern involving alcohol, marijuana, heroin, cocaine, and methamphetamine. The illegal drug culture corresponds with their view of the world as fast‑paced and dramatic, which supports their need for a heightened self‑image. Consequently, they may be involved in crime and other sensation‑seeking, high‑risk behavior. Some may have extreme antisocial symptoms. They tend to prefer stimulants such as cocaine and the amphetamines. Rapists with severe antisocial personality disorder may use alcohol to justify conquests. People with less severe antisocial personality disorder may use heroin and alcohol to diminish feelings of depression and rage.

Psychotic Disorders

All too often, AOD use disorders are undetected in patients with psychotic disorders, and traditional treatment approaches are often inadequate. For example, attempts have been made to treat psychotic and AOD use disorders in a sequential manner, treating one disorder first and then the other. While a single‑focus approach is helpful for differential diagnosis, and is effective in treating some patients, it is frequently unsuccessful for patients with AOD problems who have severe and recurrent psychotic episodes. This information provides an overview of a dual‑focus approach to the assessment and treatment of patients with these dual disorders. A single‑focus approach emphasizes the importance of developing a diagnosis and subsequent treatment plan ‑‑ such as is done when treating patients who have a single disorder. In a dual‑focus approach, the emphasis is not on making a diagnosis, but rather on 1) the severity of presenting symptoms, 2) crisis intervention and crisis management, 3) stabilization, and 4) diagnostic efforts within the context of multiple‑contact, longitudinal treatment. By concentrating on symptoms, crisis management, and stabilization, clinicians can simultaneously focus on patients' treatment needs that are caused by both the psychotic disorder and the substance use disorder. It is important to focus on the following:

• Initial focus on severity of presenting symptoms, not on diagnosis of one disorder or another

• Acute crisis intervention and crisis management

• Acute, sub-acute, and long‑term stabilization of patient

• Ongoing diagnostic efforts

• Multiple‑contact longitudinal treatment.

The term psychosis describes a disintegration of the thinking process, involving the inability to distinguish external reality from internal fantasy. The characteristic deficit in psychosis is the inability to differentiate between information that originates from the external world and information that originates from the inner world of the mind (such as distortions of normal thinking processes) or the brain (such as abnormal sensations and hallucinations).

Psychosis is a common feature of schizophrenia. Psychotic symptoms are often a feature of organic mental disorders, mood disorders, schizophreniform disorder, schizoaffective disorder, delusional (paranoid) disorder, brief reactive psychosis, induced psychotic disorder, and atypical psychosis.

Schizophrenia is best understood as a group of disorders with similar clinical profiles, invariably including thought disturbances in a clear sensorium and often with characteristic symptoms such as hallucinations, delusions, bizarre behavior, and deterioration in the general level of functioning.

Severe disturbances occur with relation to language and communication, content of thought, perceptions, affect, sense of self, volition, relationship to the external world, and motor behavior. Symptoms may include bizarre delusions, prominent hallucinations, incoherence, flat affect, avolition, and anhedonia. Functioning is impaired in interpersonal, academic, or occupational relations and self‑care.

Schizophrenia can be divided into subtypes:

1) in the paranoid type, delusions or hallucinations predominate;

2) in the disorganized type, speech and behavior problems predominate;

3) in the catatonic type, catalepsy or stupor, extreme agitation, extreme negativism or autism, peculiarities of voluntary movement or stereotyped movements predominate;

4) in the undifferentiated type, no single clinical presentation predominates; and

5) in the residual type, prominent psychotic symptoms no longer predominate. The diagnosis of schizophrenia requires a minimum of 6 months' duration of symptoms, with active psychotic symptoms for 1 week (unless successfully treated).

Clinicians generally divide the symptoms of schizophrenia into two types: positive and negative symptoms. Acute course schizophrenia is characterized by positive symptoms, such as hallucinations, delusions, excitement, and disorganized speech; motor manifestations such as agitated behavior or catatonia; relatively minor thought disturbances; and a positive response to neuroleptic medication.

Chronic course schizophrenia is characterized by negative symptoms, such as anhedonia, apathy, flat affect, social isolation, and socially deviant behavior; conspicuous thought disturbances; evidence of cerebral atrophy; and generally poor response to neuroleptics. In general, acute substance‑induced psychotic symptoms tend to be positive symptoms.

Schizophreniform disorder is a condition exhibiting the same symptoms of schizophrenia but marked by a sudden onset with resolution in 2 weeks to 6 months. Some patients exhibit a single psychotic episode only; others may have repeated episodes separated by varying durations of time.

Schizoaffective disorder is a condition that includes persistent delusions, auditory hallucinations, or formal thought disorder consistent with the acute phase of schizophrenia, but the condition is also frequently accompanied by prominent manic or depressive symptoms. Schizoaffective disorder is further divided into bipolar (history of mania) and unipolar (depression only) types.

Delusional disorders are characterized by prominent well‑organized delusions and by the relative absence of hallucinations; disorganized thought and behavior; and abnormal affect. The delusional disorders are divided into six types: persecutory, grandiose, erotomanic, jealous, somatic, and unspecified.

Brief reactive psychosis describes a condition in which an individual develops psychotic symptoms after being confronted by overwhelming stress. The onset of symptoms is abrupt, without the gradual symptom development often seen in schizophrenia or schizophreniform disorder, and the duration is brief (no longer than 1 month).

Induced psychotic disorder describes a disorder characterized by the uncritical acceptance by one person of the delusional beliefs of another. In other words, a dominant partner has a delusional psychosis that is believed and accepted by a passive partner.<SS1>

AOD‑induced psychotic disorders are conditions characterized by prominent delusions or hallucinations that develop during or following psychoactive drug use and cause significant distress or impairment in social or occupational functioning. This disorder does not include hallucinations caused by hallucinogens in the context of intact reality testing.

Although there can be great variability in individual susceptibility to AOD‑induced psychotic symptoms, it is important for the clinician to determine if the presenting symptoms could plausibly be induced by the type and amount of drug apparently consumed. For example, vivid auditory, visual, and tactile hallucinations are plausible side effects of a 5‑day, high‑dose cocaine binge. However, should these symptoms emerge during a brief episode of mild alcohol intoxication, it is likely that the symptoms represent an underlying psychotic process that has been exacerbated by the use of alcohol.

Pharmacologic Management

Addiction is not a fixed and rigid event. Like psychiatric disorders, addiction is a dynamic process, with fluctuations in severity, rate of progression, and symptom manifestation and with differences in the speed of onset. Both disorders are greatly influenced by several factors, including genetic susceptibility, environment, and pharmacologic influences. Certain people have a high risk for these disorders (genetic risk); some situations can evoke or help to sustain these disorders (environmental risk); and some drugs are more likely than others to cause psychiatric or AOD use disorder problems (pharmacologic risk).

Pharmacologic effects can be therapeutic or detrimental. Medication often produces both effects. Therapeutic pharmacologic effects include the indicated purposes and desired outcomes of taking prescribed medications, such as a decrease in the frequency and severity of episodes of depression produced by antidepressants.

Detrimental pharmacologic effects include unwanted side effects, such as dry mouth or constipation resulting from antidepressant use. Side effects perceived as noxious by patients may decrease their compliance with taking the medications as directed.

Some detrimental pharmacologic effects relate to abuse and addiction potential. For example, some medications may be stimulating, sedating, or euphorigenic and may promote physical dependence and tolerance. These effects can promote the use of medication for longer periods and at higher doses than prescribed.

Prescribing medication involves striking a balance between therapeutic and detrimental pharmacologic effects. For instance, therapeutic anti-anxiety effects of the benzodiazepines are balanced against detrimental pharmacologic effects of sedation and physical dependency. Similarly, the desired therapeutic effect of abstinence from alcohol is balanced by the possibility of damage to the liver from prescribed disulfiram (Antabuse).

Side effects of prescription medications vary greatly and include detrimental pharmacologic effects that may promote abuse or addiction. With regard to patients with dual disorders, special attention should be given to detrimental effects, in terms of 1) medication compliance, 2) abuse and addiction potential, 3) AOD use disorder relapse, and 4) psychiatric disorder relapse.

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Not all psychiatric medications are psychoactive. The term psychoactive describes the ability of certain medications, drugs, and other substances to cause acute psychomotor effects and a relatively rapid change in mood or thought. Changes in mood include stimulation, sedation, and euphoria. Thought changes can include a disordering of thought such as delusions, hallucinations, and illusions. Behavioral changes can include an acceleration or retardation of motor activity. All drugs of abuse are by definition psychoactive.

In contrast, certain non-psychoactive medications such as lithium can, over time, normalize the abnormal mood and behavior of patients with bipolar disorder. Because these effects take several days or weeks to occur, and do not involve acute mood alteration, it is not accurate to describe these drugs as psychoactive, euphorigenic, or mood altering. Rather, they might be described as mood regulators. Similarly, some drugs, such as anti-psychotic medications, cause normalization of thinking processes but do not cause acute mood alteration or euphoria.

However, some antidepressant and anti-psychotic medications have pharmacologic side effects such as mild sedation or mild stimulation. Indeed, the side effects of these medications can be used clinically. Physicians can use a mildly sedating antidepressant medication for patients with depression and insomnia, or a mildly stimulating anti-psychotic medication for patients with psychosis and hypersomnia or lethargy. While the side effects of these drugs include a mild effect on mood, they are not euphorigenic. Nevertheless, case reports of misuse of non-psychoactive medications have been noted, and use should be monitored carefully in patients with dual disorders.

While psychoactive drugs are generally considered to have high risk for abuse and addiction, mood‑ regulating drugs are not. A few other medications exert a mild psychoactive effect without having addiction potential. For example, the older antihistamines such as doxylamine (Unisom) exert mild sedative effects, but not euphoric effects.</SS1><SS1>

Some drugs promote reinforcement, or the increased likelihood of repeated use. Reinforcement can occur by either the removal of negative symptoms or conditions or the amplification of positive symptoms or states. For example, self‑medication that delays or prevents an unpleasant event (such as withdrawal) from occurring becomes reinforcing. Thus, using a benzodiazepine to avoid alcohol withdrawal can increase the likelihood of continued use. Positive reinforcement involves strengthening the possibility that a certain behavior will be repeated through reward and satisfaction, as with drug‑induced euphoria or drug‑induced feelings of well‑being. A classic example is the pleasure derived from moderate to high doses of opiates or stimulants. Drugs that are immediately reinforcing are more likely to lead to psychiatric or AOD use problems. </SS1><SS1>

Eating Disorders

Anorexia nervosa

Anorexia nervosa is a life‑threatening eating disorder defined by a refusal to maintain body weight within 15 percent of an individual's minimal normal weight. Other essential features of this disorder include an intense fear of gaining weight, a distorted body image, and amenorrhea (absence of at least three consecutive menstrual cycles when otherwise expected to occur) in women. Sometimes people starve and binge‑purge, depending on the extent of weight loss. This can be physically very dangerous. People who present an on‑going preoccupation with food and weight even at lesser weight reductions would benefit from exploring their cognitive and relationship skills.

The term anorexia literally means loss of appetite, but this isn't a true symptom of the disorder. In fact, people with anorexia are usually hungry, but they control their eating. This is frequently sublimated through cooking for others or hiding food in their personal space which they will not eat.

Who develops anorexia?

Like all eating disorders, it tends to occur in pre or post puberty, but can develop at any life change. Anorexia nervosa predominately affects adolescent girls, although it can also occur in men and older women. One reason younger women are particularly vulnerable to eating disorders is their tendency to go on strict diets to achieve an "ideal" figure. This obsessive dieting behavior reflects a great deal of today's societal pressure to be thin, which is seen in advertising and the media. Others especially at risk for eating disorders include athletes, actors, and models for which thinness has become a professional requirement.

How many people suffer from anorexia?

Conservative estimates suggest that one‑half to one percent of females in the U.S. develop anorexia. Because more than 90 percent of all those who are affected are adolescent and young women, the disorder can be characterized as primarily a women's illness. It should be noted, however, that children as young as 7 have been diagnosed and women 50, 60, 70, and even 80 fit the diagnosis.

How is the weight lost?

People with anorexia usually lose weight by reducing their total food intake and exercising excessively. Many persons with anorexia nervosa restrict their intake to 1,000 calories a day or less. Most avoid fattening, high‑calorie foods and eliminate red meat or meat altogether. The diet of persons with anorexia may consist almost completely of low‑calorie vegetables like lettuce and carrots or popcorn.

Common signs of anorexia

The hallmark of anorexia nervosa is denial and preoccupation with food and weight. In fact, all eating disorders share this trait including binge eating disorder and compulsive eating. One of the most frightening aspects of the disorder is that people with anorexia continue to think they look fat, even when they are bone‑thin. Their nails and hair become brittle, and their skin may become dry and yellow. Depression is common in patients suffering from this disorder. People with anorexia often complain of feeling cold (hypothermia) because their body temperature drops. They may develop long, fine hair on their body as a way of trying to conserve heat.

Persons with anorexia develop strange eating habits such as cutting their food into tiny pieces, refusing to eat in front of others, or fixing elaborate meals for others that they themselves don't eat. Food and weight become obsessions as people with this illness constantly think about their next encounter with food. Generally, if a person fears she may have anorexia, she should see a doctor to rule out other physical disorders.

What are the causes of anorexia?

Knowledge about the causes of anorexia is inconclusive, and the causes may be varied. In an attempt to understand and uncover the origins of eating disorders, scientists have studied the personalities, genetics, environments, and biochemistry of people with these illnesses. Certain personality traits common in persons with anorexia are low self‑esteem, social isolation, and a perfectionist attitude. These people tend to be good students and excellent athletes.

Eating disorders also tend to run in families, with female relatives most often affected. A girl has a 10‑ to 20‑times higher risk of developing anorexia, for instance, if she has a sibling with the disease. This finding suggests that genetic factors may predispose some people to eating disorders or acceptance of the social ideal of thinness by selves and parents. Behavioral and environmental influences may also play a role. Eating disorders are seen primarily in Western and industrialized countries, where slimness is a model of attractiveness. Stressful events are likely to increase the risk of eating disorders as well, but this is the case for psychiatric disorders in general.

In studies of the biochemical functions of people with eating disorders, scientists have found that the neurotransmitters serotonin and norepinephrine are decreased in those with anorexia, which links them with patients suffering from depression. This link is supported by studies showing that certain antidepressants can be used to successfully treat some people with eating disorders. People with anorexia also tend to have higher than normal levels of cortisol (a brain hormone released in response to stress) and vasopressin (a brain chemical found to be abnormal in patients with obsessive‑compulsive disorder). Other psychiatric disorders can occur together with anorexia, such as OCD, self-mutilation, or bipolar disorder. In general, people with anorexia nervosa have responded minimally to antidepressants. The most effective strategy for treating a patient has been weight restoration within 10% of normal and individual and family therapy.

Are there medical complications?

The starvation experienced by persons with anorexia nervosa can cause damage to vital organs such as the heart and brain. Breathing, pulse, and blood pressure rates drop, and those suffering from this illness may experience irregular heart rhythms or heart failure. Nutritional deprivation causes calcium loss from bones, which become brittle and prone to breakage. In the worst‑case scenario, people with anorexia can starve themselves to death. Eating disorders have among the highest mortality rates of all mental disorders, killing up to 6 percent of their victims.

Bulimia nervosa

Bulimia nervosa is a serious eating disorder marked by a destructive pattern of binge‑eating and recurrent inappropriate behavior to control one's weight. It can occur together with other psychiatric disorders such as bipolar disorder, self-mutilation, obsessive‑compulsive disorder, or dissociative identity disorder. Binge‑eating is defined as the consumption of large amounts of food within a short period of time. The food is often sweet, high in calories, and has a texture that makes it easy to eat fast. "Inappropriate compensatory behavior" to control one's weight may include purging behaviors (such as self‑induced vomiting, abuse of laxatives, diuretics, or enemas) or non‑purging behaviors (such as fasting or excessive exercise). For those who binge eat, sometimes any amount of food, even a salad or half an apple, is perceived as a binge and is vomited.

People with bulimia nervosa often feel a lack of control during their eating binges. Their food is usually eaten secretly and gobbled down rapidly with little chewing. A binge is usually ended by abdominal discomfort. When the binge is over, the person with bulimia feels guilty and purges to rid his or her body of the excess calories. To be diagnosed with bulimia, a person must have had, on average, a minimum of two binge‑eating episodes a week for at least three months. The first problem with any eating disorder is constant concern with food and weight to the exclusion of almost all other personal concerns.

Who develops bulimia?

Bulimia nervosa typically begins in adolescence or early adulthood. Like anorexia nervosa, bulimia mainly affects females. Only ten percent to 15 percent of its victims are male. An estimated two percent to three percent of young women develop bulimia, compared with the one‑half to one percent that is estimated to suffer from anorexia. Studies indicate that about 50 percent of those who begin an eating disorder with anorexia nervosa later become bulimic.

It is believed that more than seven million women and one million men experience an eating disorder in this country alone. This indicates a need for concern and preventive measures on college campuses across the country, especially for female students.

How do people with bulimia control their weight?

People with bulimia are overly concerned with body shape and weight. They make repeated attempts

to control their weight by fasting and dieting, vomiting, using drugs to stimulate bowel movements and urination, and exercising excessively. Weight fluctuations are common because of alternating binges and fasts. Unlike people with anorexia, people with bulimia are usually within a normal weight range. However, many heavy people who lose weight begin vomiting to maintain the weight loss.

What are the common signs of bulimia?

Constant concern about food and weight is a primary sign of bulimia. Common indicators that suggest the self‑induced vomiting that persons with bulimia experience are the erosion of dental enamel (due to the acid in the vomit) and scarring on the backs of the hands (due to repeatedly pushing fingers down the throat to induce vomiting).

A small percentage of people with bulimia show swelling of the glands near the cheeks called parotid glands. People with bulimia may also experience irregular menstrual periods and a decrease in sexual interest. A depressed mood is also commonly observed as are frequent complaints of sore throats and abdominal pain.

Despite these telltale signs, bulimia nervosa is difficult to catch early. Binge eating and purging are often done in secret and can be easily concealed by a normal‑weight person who is ashamed of his or her behavior, but compelled to continue it because he or she believes it controls weight. This preoccupation and these behaviors allow the person to shift their focus from painful feelings and reduce tension and anxiety perpetuating the need for these behaviors.

Are there any serious medical complications?

Persons with bulimia‑‑even those of normal weight‑‑can severely damage their bodies by frequent binging and purging. Electrolyte imbalance and dehydration can occur and may cause cardiac complications and, occasionally, sudden death. In rare instances, binging can cause the stomach to rupture, and purging can result in heart failure due to the loss of vital minerals like potassium.

Do we know what causes bulimia?

The current obsession with thinness in our culture certainly has a large influence. There is some evidence that obesity in adolescence or obese parents predisposes an individual to the development of the disorder. Parents' anxiety over a chubby child can perhaps also be a contributor. Some bulimics report feeling a "kind of high" when they vomit. People with bulimia are often compulsive and may also abuse alcohol and drugs. Eating disorders like anorexia and bulimia tend to run in families, and girls are most susceptible. Recently, scientists have found certain neurotransmitters (serotonin and norepinephrine) to be decreased in some persons with bulimia. Most likely, it is a combination of environmental and biological factors that leads to the development of this disorder. During the early 1970s almost all persons with an eating disorder believed they had invented the behaviors and that no one else had such a problem. As in anorexia nervosa, the behaviors associated with bulimia provide temporary relief from tension and allow ill persons to focus less on problems perceived as irresolvable and to instead focus on body weight and food.

Compulsive/Pathological Gambling

According to the Webster’s New Collegiate Dictionary; gamble is defined as: to play a game of chance for stakes (i.e. money or property); to bet on an uncertain outcome. Gambling takes on many forms in this country. The most common is pari-mutuals such as horse and dog racing, off-track-betting parlors, lotteries, casinos (slot machines, table games), bookmaking (sports books and horse books), card rooms, bingo, on line gambling now brings gambling into the office or home. Some even speculate that the stock market is a form of gambling. Based on the definition it would seem to be. Pathological gambling is a progressive disease that devastates not only the gambler but everyone around them. Much of the information in this section is complements of the Texas Council on Problem and Compulsive Gambling.

Women Gamblers

Generally, women begin gambling later in life as a coping strategy to mask underlying emotional pain. They rely on the excitement of gambling to make themselves feel good. They gamble for the sense of "empowerment" or for the freedom that they lack in other areas of their lives. Women usually play bingo, lottery or casino machines (slots and video poker) to "escape". Women are also "closet" gamblers and seldom brag about their wins.

While nearly all problem gamblers suffer from guilt and shame over the problems gambling creates, women seem to do so much more deeply. When entering treatment they are more likely to be subdued, withdrawn and frightened, and are more hesitant to talk about their gambling experience. As one recovering gambler said, "Men wear both their gambling and recovery as a badge of honor. Women are ashamed and don't want to talk about it".

Senior Gamblers

Seniors are very often socially isolated due to physical restrictions or lack of social outlets. They become involved in gambling via mail or sweepstakes companies. Some have limited financial resources or are looking for that big payoff to compensate an ever-shrinking limited retirement income. Casinos push bus trips to casinos.

Senior problem gambling can start with loss of interest and participation in normal activities with friends and family, or when confronted with lots of time on their hands. They may also have feeling of oppression from family and others, that they need to find relief from. Loneliness and boredom are the two conditions that drive seniors to gamble.

Teen Gamblers

Problem gambling is an obsession that can overtake and destroy a young person's life Gambling attracts kids from all types of families, economic background, ethnic groups and religious faiths. Most teens with serious gambling problems were introduced to gambling by a parent or other adult close to them. While society increasingly frowns on youthful smoking, sex, alcohol and other drug use kids have been given the message that gambling is "legitimate, fun and safe".

Teens with problem gambling will gamble to escape other problems and /or reality. They may be lonely, depressed or bored. Teens may feel pressure from their peers and want to impress others. They may want to be the center of attention and they think they can win friends if they buy things for them. They think it's a quick way to get rich. Winning provides an instant, temporary boost of self-confidence.

GA 20 Questions

One of the first indicators that gambling is becoming a problem in an individual's life is when the gambling "just isn't fun anymore." If you are wondering about your own gambling behavior or that of a loved one, consider the following questions:

· Did you ever lose time from work or school due to gambling?

Has gambling ever made your home life unhappy?

• Did gambling affect your reputation?

• Have you ever felt remorse after gambling?

• Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties?

• Did gambling cause a decrease in your ambition or efficiency?

• After losing did you feel you must return as soon as possible and win back your losses?

• After a win did you have a strong urge to return and win more?

• Did you often gamble until your last dollar was gone?

• Did you ever borrow to finance your gambling?

• Have you ever sold anything to finance gambling?

• Were you reluctant to use "gambling money" for normal expenditures?

• Did gambling make you careless of the welfare of yourself or your family?

• Did you ever gamble longer than you had planned?

• Have you ever gambled to escape worry or trouble?

• Have you ever committed, or considered committing, an illegal act to finance gambling?

• Did gambling cause you to have difficulty in sleeping?

• Do arguments, disappointments or frustrations create within you an urge to gamble?

• Did you ever have an urge to celebrate any good fortune by a few hours of gambling?

• Have you ever considered self-destruction or suicide as a result of your gambling?

Most compulsive gamblers will answer yes to at least seven of these questions.

According to Dr. Henry Lesieur, M.D., there are two types of gamblers, those who are action seeking and those who gamble to escape some aspect of life:

Dr. Robert Custer, M.D., identified three distinctive phases in the progression of gambling addiction:

Winning Phase: during this phase the gambler experiences a big win or a series of wins that leaves them with unreasonable optimism that their winning will continue. This leads them to become very excited when gambling and they begin to increase the amounts of their bets, or how much time they spend gambling.

Losing Phase: during the losing phase, the gambler often begins to brag about wins they have had in the past, they start gambling alone, think more about gambling and borrow money to gamble. Borrowing may be done legally or illegally. They being lying to family and friends and become more irritable, restless and withdrawn. They begin to “chase” their losses, believing they must gamble again as soon as possible to win back what they have lost.

Desperation Phase: during this phase there is a marked increase in the time spent gambling. This is accompanied by remorse, blaming others and alienating family and friends. Eventually, the gambler may engage in illegal acts to finance their gambling. They may experience hopelessness, suicidal thoughts and attempts, arrests, divorce, alcohol and/or other drug abuse, or a complete emotional break down.

Types of Gamblers

Dr. Custer identified six types of gamblers:

In 1996, Congress authorized The National Gambling Impact Study Commission by passing Public Law 104-169. The Commission is responsible for conducing comprehensive legal and factual studies of the social and economic impacts of gambling on (1) federal, state, local, and Native American tribal governments; and (2) communities and social institutions including: individuals, families and businesses. The Commission must report its finding and conclusions together with its recommendations to the President of the United States, the United States Congress, the State Governors, and Native American tribal governments. The Commission filed its report on June 18, 1999. You may visit the National Gambling Impact Study Commission at www.ngisc.gov/.

In this section of the module we will review six different special population categories and the impact of addiction on each. The categories include: cultural and ethnic diversity, adolescents, gender and sexual preference issues, the elderly, the disabled, and individuals in the criminal justice system. Each category presents with differences that effect how counselors should work with clients and their families. Dual disordered clients, another category of significance, will be discussed in Module Seven.

Culturally and Ethnically Diverse Groups

The text book does an outstanding job of reviewing four major cultural groups: Native Americans and Alaska Natives, Asian Americans, African Americans, and Latino/Hispanic Americans.

Native American & Alaska Native Groups

We have known for some time that substantial differences in patterns of substance abuse exist among ethnic groups. Overall rates of alcohol and other drug use are high among members of Native American and Alaska Native groups, although the rates vary by age and gender across and within tribes. Native Americans and Alaska Natives are currently the smallest minority group in the United States, constituting 0.7 % (about 2 million) of the population in 1997. It is important to recognize that Native American tribes cannot be placed into a large “melting pot”, because tribally-specific differences must be acknowledged. Each tribe, whether from the Plains, Plateau, or Costal Regions, have separate and often vastly different beliefs, ceremonies, governments, practices and traditions. Differences may occur within a tribe, since the bands and clans within it often possess practical and theoretical differences. In 1995, the large majority of admissions (77%) to substance abuse treatment among Native Americans was due to alcohol. American Native youth have very high rates of drug use compared to their non-Native American counterparts. They also tend to begin using alcohol, illicit substances, cigarettes, and inhalants at a younger age, at higher rates and in combination with one another. They also have the highest level of need of illicit drug abuse treatment compared to any other group.

Asian American and Pacific Islanders

The Asian American and Pacific Islander populations pose intellectual and pragmatic challenges to providers of substance abuse treatment. First, they are the fastest growing minority group in the United States. Census figures from 1997 estimate that about 9.6 million Asian Americans and Pacific Islanders reside in the United States. This represents 4 % of the total population. Based on projected growth rates, this group will number in excess of 41 million by 2040. Chinese are the largest Asian subgroup residing in the United States (23 %), followed by Filipinos (19 %), Korean Americans and Asian Indians at 11 % each. Vietnamese represent 8 % of all Asians and Pacific Islanders in the United States, followed by Cambodians and Laotians with 2 % each and Hmong and Thai with 1 % each. As you can see this population is characterized by huge ethnic, cultural and socio-demographic heterogeneity. Until recently, this population’s substance abuse problems have not received close attention. Asian Americans and Pacific Islanders have been under represented in most surveys because they do not reside in the areas sampled. Although it is largely agreed that they tend to have fewer substance abuse-related problems than the other groups, these problems are on the rise, particularly among specific subgroups.

African Americans

According to the 1997 U.S. Census Bureau figures, non-Hispanic African Americans make up about 12.1 % of the total U.S. population and number approximately 32.5 million. While a large number of African Americans abstain from alcohol and other substances, a significant number use and abuse alcohol and other substances. To make an already complex picture more complicated, substances abuse patterns vary by age group. African Americans tend not to use and abuse substance at an early age, but there is a high prevalence of alcohol and other substance use among those age 21 and older. African Americans 18 and older are second only to Native Americans in their need for substance abuse treatment. There are no universally accepted theoretical perspectives that explain the causes for the high incidence of substance abuse among African Americans. There is agreement that poverty, overcrowding, illiteracy, unemployment, the breakdown of two-parent families, and environmental stressors associated with both structural and interpersonal racism are contributing factors.

Latino/Hispanic Populations

Latino/Hispanic Americans constituted the second largest ethnic minority group in the United States. In 1997, they comprised 11.1 % of the total population, numbering approximately 30 million). This figure does not include the approximately 3.8 million people residing in Puerto Rico. At the current rate of growth, projections indicate that Latino/Hispanic Americans will become the largest ethnic minority group in the United States by the year 2010. This group is diverse in terms of their country of origin and in their geographic location in the United States. Sixty-four % of all Latino/Hispanics residing in the United States are Mexicans living in the Southwest and West. Puerto Ricans living in the U.S. constitute 10.4 % of the Latino/Hispanic population, most of whom reside in the Northeast, although a significant number have recently moved to the Southeast. Cubans account for 4.2 %, and are located primarily in the Southeast. The remaining 21 % are comprised of a large number of immigrants from Central and South American and the Dominican Republic. Dominicans are the fasting growing subgroup within the Latino/Hispanic population.

Barriers to Treatment

Individuals with substance abuse problems from racial/ethnic groups tend to underutilize health care, prenatal care, mental health care, and substance abuse treatment, or they seek them as a last resort. Treatment may be sought only when the resources of the traditional family/social support network have been exhausted; at this point, problems may be so chronic and severe that treatment outcomes may be poor. This pattern of utilization is the result of complex factors.

Those needing treatment may live in areas where access to health care providers is limited because of distance or transportation problems. Those with access often find that services are inadequate or inconveniently scheduled. Others may not realize that they are eligible, or may not know what services a local program offers. Many treatment providers are not able to address treatment needs of individuals from cultural backgrounds different than their own even when they speak the client’s language of origin. This is further compounded when trying to develop written materials for linguistic and culturally diverse populations. Issues such as literacy levels and regional language differences need to be taken into account when developing written treatment program materials.

Health and illness beliefs and attitudes may act as obstacles keeping racial and ethnic populations from seeking treatment for a substance abuse problem. More is known about the impact of health beliefs and attitudes on physical health than on drug treatment behavior. Reliance on folk remedies may cause some underutilization of treatment services. Cultural stigma attached to psychiatric care may involve fear of losing status and of being judged a failure by the family and the community. Cultures differ in their explanations, views, and acceptance of abnormal behaviors; what is defined as abnormal behavior in one culture may be sanctioned or encouraged in another. Abnormal behaviors may be attributed to physical or psychological causes or they may be viewed as the direct result of supernatural or spiritual forces.

Regardless of the treatment model in use, racism on an institutional or individual level can be a barrier to treatment effectiveness. Institutional racism within a treatment system is evident when the program or treatment design is oblivious to the racial, cultural, or ethnic backgrounds, values, and mores of its client population. Latent prejudice on the part of treatment staff as well as language and cultural differences undermine efforts to help clients succeed. The use of indigenous treatment professionals (individuals who come from the same community as those being served) is strongly encouraged to assist programs in accessing community networks and to help ensure that program design accounts for the belief systems, cultural values, attitudes and behaviors of the clients to be served.

The significant majority of minorities live in the Border States of Texas, California, New Mexico and Arizona. They include: 59.5 % of Latino/Hispanics; 44.5 % of Asian Americans/Pacific Islanders; 33 % of Native Americans/Alaska Natives; 14.6 % of African Americans; while only 16.3 % of Caucasian Americans reside in these states. These specific minority groups make up 24.8 % of the total U.S. population, but constitute 41.5 % of the population in these four states according the U.S. Bureau of Census. This has significant implications for treatment providers in these states. The need to develop strategies for addressing minority populations must include designing programs that:

• acknowledge and utilize cultural strengths and values in the treatment setting;

• recruit and retain bilingual/multi-ethnic and multicultural indigenous staff;

• provide ongoing training to address issues of cultural diversity and competence;

• and utilize research and program outcome measures that are culturally sensitive.

Examining Cultural Beliefs Related to Chemical Dependency:

Myth: “Most people in the U.S. who use alcohol and other drugs are people of color.”

Fact: Unfortunately, most of our impressions about who uses or abuses drugs are shaped by the media and the entertainment industry. We are bombarded by stereotyped images that depict people of color as being “the problem”. These stereotypes conflict with the fact about actual alcohol or drug use. Use and abuse of AOD cuts across all racial, cultural, gender, age, and socioeconomic lines. The lifetime prevalence rates clearly reveal that Caucasians in the U.S. consume more alcohol and drugs than all other populations combined (CWLA, 1993).

Myth: “Families of color are more likely to refer chemically dependent family members to treatment programs and to be more involved and supportive of the treatment process than chemically dependent Caucasian families.”

Fact: Research on treatment suggest that families of color are not as likely as Caucasian families to refer chemically dependent family members to treatment, or to be as involved and supportive of the treatment process. This difference is most apparent in low-income, urban families of color. There are several plausible explanations for the apparent lack of support. Consider the following:

• Treatment programs, designed for and run by predominantly Caucasian staff members, have not reached out to other racial/cultural populations in the community to encourage entry into treatment.

• Treatment programs are often based on “12-Step Models”, which encourage open disclosure to a group by family members and the chemically dependent individual. Airing personal information to strangers or individuals outside their ethnic group may be difficult or unacceptable for members of some racial/cultural groups.

• Chemically dependent individuals of color are more likely than their Caucasian peers to access treatment through the court system at the latter stages of dependency when the individual is more likely to have serious social/legal problems related to their drinking or drug use. At this point it is also likely that family members, regardless of racial, ethnic, or cultural group, are going to be less willing to participate actively in treatment.

• Few treatment programs build upon cultural values and the importance of the family in the recovery process. The few that do exist are even less likely to try to engage or structure the program around the needs of the “working poor” who cannot afford to take days off from work to participate in traditional “family week programs” (CWLA. 1993).

Myth: “All racial and cultural populations share similar attitudes about the nature of chemical dependency.”

Fact: There are many different views and beliefs about the nature of chemical dependency. Throughout history, families from all cultural backgrounds have often shrouded chemical dependency in secrecy. A chemically dependent family member was often a source of embarrassment or ridicule. Since many AOD programs were initially designed for Caucasian, middle-class Americans, it is not surprising that members of this population have been most willing to view chemical dependency as a treatable condition. Because of this de-stigmatization of the condition, chemically dependent Caucasian individuals and families may be more open to entering treatment programs that are based on medical models, firmly grounded in the values and attitudes of their culture.

In contract, other racial, ethnic, and/or cultural populations in our society might not view chemical dependency as a primary problem requiring professional intervention. Instead, they may see the problems as one of willful misconduct, a moral failing, or an unfortunate condition caused by other outside forces such as poverty or racism. AOD abuse may be seen as a consequence of the stress and pain of living in a society that is racist and restrictive, and that often destroys an individual’s spirit and self-esteem. If this is a commonly held attitude of an individual’s cultural group, it is less likely that they will feel comfortable seeking help outside of their own cultural community (CWLA. 1993).

Myth: “Afford ability is the only barrier to the use of alcohol and drug treatment programs by people with various cultural identifications who are chemically dependent.”

Fact: Economic barriers do exist, but many other factors deter people from entering the treatment system. Until recently, little attention was given to tailoring the program or services to the needs of minority cultures. Barriers have included:

• Even if treatment were affordable, the demand for multifaceted, comprehensive, culturally responsive, coordinated prevention, treatment, and aftercare services far exceeds the supply. This is particularly true for programs tailored to the unique needs of women. Finding appropriate, accessible and affordable services may be quite difficult.

• Cultural values or attitudes may discourage an individual or family from accessing appropriate services. While cultural and racial groups vary, there are some commonly held attitudes or beliefs that may affect alcohol or drug use or recovery. Families form some cultures may not approach chemical dependency as an illness, and therefore, may not appreciate efforts to engage the chemically involved person in treatment (CWLA. 1993).

Myth: “The negative consequences of alcohol or drug use/dependency affect all racial and cultural groups equally.”

Fact: Although over 60% of AOD users are Caucasian, Native Americans/Alaska Natives, African Americans and Latino/Hispanic Americans are more likely to experience more negative consequences as a result of alcohol or drug use or dependency. There is no evidence to suggest that people of color abuse alcohol and drugs more than Caucasians but rather, that they are more often identified and reported in the latter stages of dependency when problems are more acute.

Additional Resources

Reference materials used in this module have been taken from the following sources:

• Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; 1994. American Psychiatric Association, Washington D.C.

• CSAT. TIP 9: Treatment Improvement Protocol: Assessment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse

Other Resources of Interest:

• American Psychiatric Association @ www.psych.org/

Fact Sheets @ www.psych.org/public_info/dpa_fact.html

• Fact Sheets on Mental Disorders @ the National Mental Health Association

www.nmha.org/infoctr/factsheets/index.cfm

• Addiction & the Addictive Disorders @ the American Academy of Health Care Providers

www.americanacademy.org/resources/info.html

• Interfaces Between Criminal Behavior, AOD and Psychiatric Disorders

@ www.treatment.org/Communique/Comm93/peper.html

• National Alliance for the Mentally Ill @ www.nami.org/

• APA Links on Psychiatric Medications

@ www.psych.org/psych/htdocs/public_info/psy_med_links.html

• Dual Diagnosis and the Schizotypal Personality Disorder

@ www.monumental.com/arcturus/dd/schtypal.htm

• Dual Diagnosis and the Schizoid Personality Disorder

@ www.monumental.com/arcturus/dd/schizoid.htm

• Dual Diagnosis and the Paranoid Personality Disorder

@ www.monumental.com/arcturus/dd/paranoid.htm

• Dual Diagnosis and the Borderline Personality Disorder

@ www.monumental.com/arcturus/dd/borderln.htm

• Dual Diagnosis and the Histrionic Personality Disorder

@ www.monumental.com/arcturus/dd/histrion.htm

• Dual Diagnosis: Personality Disorders and Addiction

@ www.monumental.com/arcturus/dd/pdsa.htm#1

• Dual Diagnosis and the Passive-Aggressive Personality Disorder

@ www.monumental.com/arcturus/dd/papd.htm

• Dual Diagnosis and the Obsessive-Compulsive Personality Disorder

@ www.monumental.com/arcturus/dd/ocpd.htm

• Dual Diagnosis and the Dependent Personality Disorder

@ www.monumental.com/arcturus/dd/depend.htm

• Dual Diagnosis and the Narcissistic Personality Disorder

@ www.monumental.com/arcturus/dd/narc.htm

• Dual Diagnosis and the Avoidant Personality Disorder

@ www.monumental.com/arcturus/dd/avoid.htm

• Dual Diagnosis and the Antisocial Personality Disorder

@ www.monumental.com/arcturus/dd/antisoc.htm

Information on Gambling

• National Gambling Impact Study Commission @ www.ngisc.gov/

• Gamblers Anonymous International Service Office @ www.gamblersanonymous.org/

• Heartskober Manor @ www.heartskobermanor.com/

• America a Bettor Nation

@ www.abcnews.go.com/sections/living/DailyNews/gambling990319.html

• Gambling Treatment @ www.robertperkins.com/gambling-treatment.htm

• Illinois Institute for Addiction Recovery @ http://addictionrecov.org/addicgam.htm

• Youth Gambling Growing In Prevalence Article from the American Psychological Association @ www.apa.org/releases/gamble.html

• Researchers Identify Cognitive Process That Contributes to Gambling Behavior Article from the American Psychological Association @ www.apa.org/releases/gambling.html

• National Council on Problem Gambling, Inc. @ www.ncpgambling.org/

• Problem Gambling Association @ www.problemgambling.com/

• Gambling in Texas: 1995 Survey: Executive Summary from TCADA

@ www.tcada.state.tx.us/research/gambling/1995/

References

Reference materials used in this module have been taken from the following sources:

• U.S. DHHS, CSAP, 1999. Cultural Issues in Substance Abuse Treatment.

• U.S. DHHS, Bureau of the Census, 1997.

• U.S. DHHS, Bureau of the Census, 1998.

• Beauvais, F. 1996. Trends in Drug Use Among American Indian Students and Drop-outs, 1975-1994. American Journal of Public Health 86(1): 1594-1598.

• U.S. DHHS, CDC, HIV/AIDS Surveillance Report, 1997.

• Gray, M. 1997. Cultural competence in Substance Abuse Prevention. Washington D.C., National Association of Social Workers Press.

• Jones-Webb, Snowden, L., Herd, D. Short, B. and Hannen, P. 1997. Alcohol-related Problems among Black, Hispanic and White Men: The Contributions of Neighborhood Poverty. Journal of Studies on Alcohol 58(5): 539-545.

• Child Welfare League of America CWLA. 1993. Act 1 Alcohol and Other Drugs: A Competency-Based Training.

• TIP 31: Screening & Assessing Adolescents for Substance Use Disorders

@ www.health.org/survey/31.htm

• TIP 32: Treatment of Adolescents with Substance Use Disorders

@ www.health.org/survey/32.htm

• U.S. DHHS, CSAT, 1994. Practical Approaches in the Treatment of Women Who Abuse Alcohol and Other Drugs.

• U.S. DHHS, CDC, Office on Smoking and Health, 1989. Smoking Tobacco & Health: A Fact Book.

• U.S. DHHS, CDC, Morbidity and Mortality Weekly Report, Vol 44, No. 5, Feb 10,1995.

• U.S. DHHS, NIDA, 1993. Eighth Special Report to U.S. Congress on Alcohol and Health.

• TIP 25: Substance Abuse Treatment and Domestic Violence @ www.health.org/survey/25.htm

• U.S. DHHS, CSAP, 1992. Cultural Competence for Evaluators.

• TIP 26: Substance Abuse Among Older Adults @ www.health.org/survey/26.htm

• National Alliance for the Mentally Ill, The ADA-Americans with Disabilities Act

@ www.nami.org/helpline/ada.htm

• TIP 30: Continuity of Offender Treatment for Substance Use Disorders From Institutions to Community @ www.health.org/survey/30.htm

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