SAMHSA logo Report to Congress - Nov 2002








Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Chapter 4 - Evidence-Based practices for Co-Occurring Disorders - High-Risk Populations


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High-Risk Populations

Individuals with co-occurring substance abuse disorders and mental disorders are at particular risk for negative outcomes, including HIV/AIDS, homelessness, and contact with the criminal or juvenile justice systems. Likewise, childhood trauma, and past or ongoing violence put vulnerable individuals at risk for developing substance abuse and mental disorders. SAMHSA constituents identified the need to support treatment for co-occurring disorders in programs that serve populations at particular jeopardy for co-occurring disorders (SAMHSA, 2002f). This section examines challenges and opportunities in serving people with these and other multiple vulnerabilities.

People with Co-Occurring Disorders and HIV/AIDS

HIV infection is a major and growing problem among people who have co-occurring substance abuse disorders and mental disorders; the onset of HIV often adds its own behavioral health complications (Mahler, 1995; Kalichman et al., 1994; Osher, 1996, 2001; Drake, Essock et al., 2001). Up to 15 percent of people with serious mental illnesses may have HIV, and up to 13 percent of those being treated for substance abuse are likely infected (Mahler, 1995).

Individuals with co-occurring substance abuse disorders and mental disorders who also have HIV/AIDS face many of the same barriers to treatment noted throughout this report, but they must deal, not just with two systems of care, but three. The combined stigma of the three illnesses, separate and inadequate funding streams, and professional norms that differ among programs serving those with HIV/AIDS, substance abuse, and mental disorders, make it difficult for individuals with all three illnesses to obtain a full range of needed and appropriate help.

Effective Interventions

If mental disorders, substance abuse and HIV/AIDS each alone pose challenges to the health care system as a whole, the problem is multiplied many-fold for individuals experiencing all three simultaneously. Individuals with these three conditions can be difficult to engage and retain in treatment and to support in the community (SAMHSA, 2002a). They can be helped, generally, with attention to culturally competent outreach and engagement strategies, stress reduction, substance abuse treatment, mental health services, and medical management of the HIV (Mahler, 1995). Some State HIV, mental health, and substance abuse agencies have integrated services. For example, an HIV/AIDS clinic may also offer mental health and substance abuse services. These and other similar ways of coordinating care can help reach people with co-occurring substance abuse disorders and mental disorders and HIV/AIDS.

People with Co-Occurring Disorders Who Have Other Concurrent Medical Conditions

In addition to HIV/AIDS, many individuals with co-occurring disorders experience other medical conditions such as hypertension, chronic liver disease, and hepatitis C. Individuals with substance abuse and mental disorders are about two to three times more likely to be nicotine dependent than the general population (Breslau, 1991; Huges, 1986); they experience medical morbidity and mortality at an increased rate. While smokers with mental illnesses and addictions experience the same smoking-related physical health consequences as the general population, they do so in greater numbers and are more likely to die of smoking caused illnesses (Lasser, 2000; Brown, 2000; Dixon, 1999; Hurt, 1996).

Effective Interventions

Research has found that individuals with substance-related medical conditions benefit from integrated treatment for both disorders. Moreover, those receiving integrated services show a higher rate of abstinence than those in non-integrated services (Weisner et al., 2001). While such an approach appears cost-effective as well, a number of impediments to its adoption by treatment programs exist. Start-up costs are high, and integrated care can increase utilization as previously undetected or neglected problems are diagnosed and treated (Managed Behavioral Health News, 1999).

At a minimum, screening for physical ailments and brief interventions can be provided to individuals in substance abuse treatment, yielding good outcomes (Fleming et al., 1997). Providing a mental health call service that provides consultation by or referral to a mental health provider within 24 hours of a physician's call can reduce the use of high-cost interventions such as hospitalization (Managed Behavioral Health News, 1999).

People with Co-Occurring Disorders Who Are Homeless

An estimated 637,000 adults in the United States are homeless on any given night, 2.1 million people over the course of a year (Burt et al., 1999). Approximately 39 percent of people who are homeless also have a mental disorder; an estimated 50 percent of adults with serious mental disorders who are homeless experience a substance abuse disorder as well (U.S. DHHS, 1999b; Lehman and Cordray, 1993; Fisher and Breakey, 1991). One-third of veterans experiencing homelessness who were treated in specialized Veterans Affairs programs in 2001 were found to have had co-occurring substance abuse disorders and mental disorders (Kasprow et al., 2002).

People with serious mental illnesses and co-occurring substance abuse disorders who also are homeless experience other medical conditions. Life on the streets makes it difficult for individuals to avoid malnutrition and to receive appropriate care for such chronic conditions as diabetes, HIV/AIDS, tuberculosis, and pulmonary and heart disease. At the same time, homelessness itself is a contributing factor in acute illnesses among people with co-occurring disorders (Federal Task Force, 1992).

People with both of these disorders are at greater risk for homelessness as they tend to have more severe symptoms of their mental illnesses, deny both their mental illnesses and their substance abuse problems, refuse treatment (including medications), and abuse multiple substances. They may be antisocial, aggressive, and, when not receiving treatment, sometimes may be violent. They also have higher than average rates of suicidal behavior and ideation (Burt et al., 1999; Federal Task Force, 1992; Fisher and Breakey, 1991). Individuals with co-occurring disorders who are homeless often have more severe health problems, poorer community adjustment, and poorer one-year outcomes compared to other homeless individuals with serious mental illnesses alone (Gonzalez and Rosenheck, 2002).

Once homeless, people with co-occurring disorders require extensive assistance to reach and receive services they need and are more likely to remain homeless than other groups (Winarski, 1998). They are more likely to be older, male and unemployed; to be homeless longer and living in harsher conditions; and to suffer greater distress, demoralization, and alienation from their families. They tend to be isolated, mistrustful, and resistant to help (Dixon and Osher, 1995).

Currently, the Secretary of Health and Human Services is sponsoring a workgroup to reduce chronic homelessness. The workgroup is identifying the service needs of persons experiencing chronic homelessness - among them individuals with substance abuse and mental disorders, including those with co-occurring disorders. HHS also is collaborating with the VA and HUD to identify and address the specific needs of homeless veterans as part of its overall effort to reduce chronic homelessness.

Effective Interventions

People with co-occurring disorders who are homeless need to interact with multiple service systems, and often fall through the cracks of fragmented care. As noted previously, integrated treatment for co-occurring substance abuse disorders and mental disorders for people who are homeless yielded fewer days of hospitalization, more days in stable housing, and greater recovery from substance abuse, especially alcoholism, than did non-integrated services (Drake et al., 1997). Successful interventions for this particular population include motivational interviewing; engagement which includes prolonged outreach and provision of basic necessities; assessment that is continuous from the point of engagement; persuasion; active treatment; relapse prevention through on-going services and careful follow-up; evening and weekend hours; and attention to other needs, such as childcare and employment (Winarski, 1998; Dixon and Osher, 1995). Intensive case management and housing vouchers also are effective (Rosenheck et al., 2002).

A "housing-first" approach also may help. Experience and research indicate it can be particularly effective with people who at least initially, are resistant to treatment. The New York City homeless program, Pathways to Housing, for example, provides support services through a team that uses a modified assertive community treatment model. Over 5 years, 88 percent of the program's tenants remained housed, and most clients eventually reduced or stopped their substance abuse and showed other improvements (Tsemberis and Eisenberg, 2000). Programs that add work and housing to day treatment or that use a modified therapeutic community approach also show promise for individuals with co-occurring disorders who are homeless (CSAT, in press).

Women with Co-Occurring Disorders

Approaches to treatment for women with co-occurring disorders cannot be undertaken in the same way as they are for men. Women differ in how their mental disorders may present, the mixture of problems, their response to medication and non-somatic treatments, and even the illnesses they are likely to develop. According to national surveys, women with co-occurring disorders are more likely than men to have affective disorders, while men are more likely to have antisocial disorders. Women are also more likely to suffer from three or more disorders simultaneously (Zweben, 1996). Compared to men, women with co-occurring disorders are more likely to seek help in mental health and out-patient settings; have stressful life situations (e.g., single parenthood, children and other dependents, unsupportive families); have poorer job skills and fewer social networks; and suffer from serious health problems.

Barriers to Treatment

Just as in many other areas of healthcare, when it comes to women's health, research about co-occurring substance abuse disorders and mental disorders in women is severely limited. As a result, little is known about what approaches to outreach and treatment work best. What is known, however, is that women with co-occurring disorders often have numerous medical and social problems such as homelessness, poverty, hospitalization, and separation from children. Their families often are overwhelmed; their children are more prone to various problems (Jessup, 1996).

When women do seek treatment, it often is geared to men and conducted with little attention to women's special needs. For instance, women often dislike the confrontational approach common in substance abuse treatment. In addition, many programs do not offer day care or parenting education. For these and other reasons, mothers are underrepresented among women in treatment, leading many to postpone getting help until a real crisis occurs (Ringwald, 2002; Zweben, 1996).

Women involved with the child welfare system may resist mental health or substance abuse treatment for fear that they will risk losing custody of their children. This is especially true for women who are being abused and who fear their batterer will use a diagnosis of mental or substance abuse disorders against them (Warshaw, 2001).

Pregnancy can complicate care of women with co-occurring disorders who may find themselves seeking help from three or more clinics or providers, one for each of their conditions. Pregnancy makes women more vulnerable to their other problems, such as domestic violence or caretaking chores, while also making their treatment all the more critical. Research on this topic is sparse (Kessel, 1994).

Effective Interventions

Treatment for women with co-occurring disorders needs to address the issues most critical in their lives. Among the most salient is the history of physical or sexual abuse that has been experienced by (or may still be a fact of life for) many women with co-occurring substance abuse disorders and mental disorders. Trauma and abuse must be addressed both in treatment and in aftercare.

To avoid returning to a dangerous household, women may need specialized residential assistance. The period immediately following treatment often is the most difficult. Clinicians should coach women in the use of 12-step groups, often a critical adjunct to treatment, since these groups or some of their members may appear intimidating or unsympathetic to the needs of members with co-occurring disorders (Zweben, 1996).

While the treatment needs of women with co-occurring disorders may challenge providers, the benefits of treatment often extend beyond the women themselves. Many are mothers, caretakers, or spouses whose well-being and recovery affect many others. Prenatal care for pregnant women with co-occurring disorders offers a window of opportunity to identify other needs for which they may be ready to seek care (Kessel et al., 1994).

Innovative collaborations among mental health, substance abuse, and other services have yielded good results with women (Jessup, 1996). More research is needed on specific interventions for women with co-occurring disorders and how to integrate them into a comprehensive system of care.

Co-Occurring Disorders and Trauma

Present or past trauma - whether sexual, physical, psychological or emotional - is common in the lives of people with co-occurring substance abuse disorders and mental disorders. In studies that ask about lifetime abuse, between 51 and 97 percent of women with serious mental illnesses report some form of physical or sexual abuse (Goodman et al., 1997). Women with co-occurring disorders are even more likely to have experienced abuse than those who have a mental disorder but are not drug dependent (Alexander, 1996).

Forty-one to 71 percent of women in treatment for drug or alcohol disorders report having been sexually abused as children or adults; and 38 percent have been victims of violent crimes (Alexander, 1996). Women who had experienced any form of sexual abuse as children are three times more likely than other women to report drug dependence as adults (Zickler, 2002). Overall, sexual or physical abuse has been associated with post traumatic stress disorder, anxiety, depression, psychotic symptoms, personality disorders, and correlated with suicidal tendencies, risky sex and drug practices, and substance abuse (Goodman et al., 1997).

Though the causal relationship between trauma and either substance abuse and mental disorders is not always clear, a growing body of evidence suggests that PTSD precedes substance abuse or dependence (Jacobsen et al., 2001). People with PTSD are more likely to abuse substances than those without (Jacobsen et al., 2001) and to abuse the more severe illicit drugs such as cocaine and opiates (CSAT, in press). The combination of trauma and co-occurring disorders makes an individual all the more vulnerable to victimization. In a study of veterans in a PTSD assessment unit, 42 percent were found to be using drugs of abuse (excluding alcohol); the diagnosis of substance abuse was significantly associated with greater marijuana and depressant use as compared with stimulant (cocaine and amphetamines) use (Calhoun et al., 2000).

The toll of terrorism is a relatively new concern, though the traumatic past of many political refugees who come to the United States has concerned mental health professionals for years. Terrorism in the homeland is a growing factor. Researchers found that six months after the Oklahoma City bombing, almost half of the 182 survivors had a post-disaster mental disorder, and one-third had full-blown PTSD (North et al., 1999). A recent survey done by NIDA identified that there was an increase in use of cigarettes, alcohol, and other substances among individuals in New York City who experienced PTSD and depression after the September 11, 2001 terrorism attacks. Symptoms of panic attack were associated with this increase in use of all substances (NIDA, 2002).

A more recent survey by the New York Academy of Medicine reveals that Manhattan residents drank more alcohol and smoked more cigarettes and marijuana after the terrorist attacks of September 11. PTSD and depression were more common among those who said their smoking and drinking increased (Galea et al., 2002). The effects of the terrorist attacks and the subsequent war on terrorism are expected to be widespread in terms of mental health and substance abuse repercussions and treatment needs.

Dr. Jacobsen and colleagues have published an excellent literature review of substance use disorders in patients with post traumatic stress disorder. The authors concluded that vigorous control of withdrawal and PTSD-arousal symptoms should be sought during detoxification of individuals with co-occurring PTSD and substance use disorders. NIDA is currently supporting research on the development of effective behavioral treatments for this severely symptomatic population (Jacobsen et al., 2001).

Barriers to Treatment

Since abuse so often is perpetrated by partners or relatives, survivors often are cut off from helping social and support networks already frayed by co-occurring disorders (Harris, 1994). Further, the emotional pain of trauma and abuse alone can deter people from seeking help. Among people with PTSD, a significant portion said emotional pain, shame, and lack of trust deterred them from seeking treatment (DATA, 1999). For these same reasons, many people in treatment avoid talking about their experiences (Goodman et al., 1997). Many providers are uncomfortable or unprepared to raise these issues, as well.

When services are sought and received, recurring trauma may hinder continued engagement in that treatment program (Goodman et al., 1997). Equally, the nature of the services themselves may not meet the special needs of women. For example, since substance abuse treatment was designed predominantly for men, the special needs of women - who suffer higher rates of trauma - may be ignored (Ringwald, 2002).

Effective Interventions

Providers must be prepared to assess and treat the sequalae of trauma in individuals who have co-occurring disorders. To do so, they must be trained to work with trauma survivors. Providers must learn that a graduated approach to addressing trauma and its effects can help (CSAT, in press) as can modification of traditional approaches to care. For example, confrontational methods, so common in substance abuse treatment, must be amended to avoid retraumatizing clients (Harris, 1994).

Women often appreciate gender-specific groups and therapies since the presence of men may remind them of their abusers or create self-consciousness (Alexander, 1996). Likewise, men often benefit from single-sex therapy groups. Further, patients may need to express powerful emotions such as pain, blame, anger, or sadness. Clinicians should see this as part of the healing process and not automatically judge such expressions as psychiatric symptoms in need of medication (Harris, 1994).

Moreover, treatment for the trauma should occur concurrent with the treatment for the mental and substance abuse disorders. In fact, while integrated treatment has gained support with researchers, it also appears to be the preference of patients. For instance, those with PTSD and substance abuse see the two conditions as related and in need of simultaneous treatment (DATA, 1999). As part of that integrated service approach, both treatment and aftercare must include plans to prevent further victimization. Clients can benefit from education about physical and sexual abuse, sexuality, relapse prevention, stress management, personal safety, social and vocational skills, leisure activities, parenting, healthy relationships, and safe housing, (Alexander, 1996; Harris 1994).

People with Co-Occurring Disorders in the Criminal Justice System

Estimates of the rates of severe mental and substance abuse disorders in jail and prison populations range from 3 percent to 16 percent (Peters and Hills, 1993; Teplin, 1990; Steadman et al., 1987). Offenders report a high incidence of substance abuse, and 6 in 10 were under the influence at the time of their crime (CSAT, in press). One-quarter of veterans with co-occurring disorders discharged from inpatient services were incarcerated during the first year after discharge (Rosenheck et al., 2000).

According to the U.S. Department of Justice, in 1998, nearly 284,000 prisoners -16 percent of State prisoners and local jail inmates and 7 percent of Federal inmates-had a mental illness (Ditton, 1999). Among detainees with mental disorders, 72 percent also have a co-occurring substance abuse disorder.

Compared to others in the justice system, individuals with mental illnesses are more likely to be using drugs or alcohol when they commit a crime, to have been homeless in the prior 12 months, and to have been in jail or prison or on probation prior to their current sentence (Ditton, 1999). Studies indicate that people with mental illnesses have a 64 percent greater chance of being arrested for committing the same offense as a person who does not have a mental illness (Teplin, 1984). People with serious mental illnesses, especially those who are homeless, frequently are arrested for minor felonies or misdemeanors such as trespassing, petty theft, shoplifting, and prostitution. In fact, both homelessness and substance abuse among people with mental illnesses are associated with higher arrest and incarceration rates. Among these individuals, men, young adults, and urban residents have higher arrest rates than women or individuals in rural areas (Clark et al., 1999). Further, many people with serious mental illnesses living on the streets or in shelters are themselves the victims of criminal activity.

Barriers to Treatment

Some jurisdictions may find it easier to incarcerate, rather than treat, a person with co-occurring disorders. This can result in delayed evaluations, leaving a person to languish in jail longer than if they had been formally charged with a crime (Champlain and Herr, 1995). Just as in communities, individuals in the criminal justice system who have co-occurring disorders have poorer chances at treatment; more difficulties with social and family relations, jobs, and housing; and greater chance of relapse.

In some respects, justice systems have become default providers of care, for many people with co-occurring disorders. Police, courts, and corrections departments often lack the resources to assess and treat these problems (National GAINS Center, 1999). Not surprisingly, most jails and prisons, as elsewhere, lack coordinated services for treating both disorders simultaneously if treatment is available at all (National GAINS Center, 1999).

Effective Interventions

Communities are developing innovative ways to connect mental health, substance abuse, and criminal justice systems in an effort to intervene, divert, and treat people with co-occurring disorders. The prevailing theme is one of systems integration, which follows from a shared commitment in all three service sectors (National GAINS Center, 1999). The Bureau of Unified Services in King County (Seattle), Washington, for example, operates under a philosophy that there is "no wrong door" into treatment for those in need - a philosophy shared by SAMHSA.

Effective interventions for defendants/offenders with co-occurring disorders include all of the program elements highlighted elsewhere in this chapter, such as individualized, flexible treatment provided by well-trained staff; a long-term focus; and integrated services (CSAT, in press). Treatments, such as therapeutic communities or cognitive behavioral methods used for other inmate groups, can be adapted.

During probation and parole, people with co-occurring disorders require additional monitoring of abstinence and symptoms. Smaller caseloads will help supervision officers, who should belong to multi-disciplinary teams operating in a flexible and supportive, rather than confrontational, manner (Peters and Hills, 1997).

Certainly the most effective way to address the problem of people with co-occurring disorders in the justice system is to keep them from entering the system in the first place. A three-year study found that effective treatment of substance abuse among people with mental disorders reduced arrests and incarcerations, but not non-arrest encounters with the police. Housing may further reduce these encounters (Clark et al., 1999).

Successful jail, court diversion, and treatment programs must be part of a comprehensive array of other jail services. These include screening, evaluation, short-term treatment, and discharge planning that are integrated with community-based mental health, substance abuse, housing, and social services (CMHS, 1995).

Youth with Co-Occurring Disorders in the Justice System

There is limited data on youth with co-occurring disorders in the criminal justice system in terms of prevalence as well as proper treatment and outcomes. Each year, more than 2 million youth under the age of 18 are arrested. Of these, one-half or 1 million youth will have formal contact (i.e., charges and/or a court appearance) with the justice system, and more than 100,000 will be placed in juvenile detention and correctional facilities (National GAINS Center, 1999).

Preliminary data suggest that two-thirds of the 1 million youth who have formal contact with the justice system, or more than 670,000 youth, have one or more alcohol, drug, and mental disorders (OJJDP, 2001). Youth with serious mental disorders constitute 20 to 30 percent of those in the justice system, and their numbers appear to be increasing (Underwood and Berenson, 2001). These youth may have other problems, as well, such as learning disabilities, histories of abuse, personality disorders, aggression and suicidal tendencies. As many as 50 to 75 percent of youth in the juvenile justice system have serious substance abuse problems (National GAINS Center, 1999).

As with adults, juveniles in the justice system need integrated and coordinated care that addresses all of their needs. They should, whenever possible, be diverted from the justice system into community-based care that has a multidisciplinary approach. One model is the Persons in Need of Supervision (PINS) Diversion Program in New York State (Cocozza and Skowyra, 2000). Further, Community Assessment Centers help divert and treat youth who are at risk of becoming serious, violent, and chronic offenders by bringing together services in a collaborative, timely, cost-efficient, and comprehensive manner. Key elements include single point of entry, immediate assessment, integrated case management, and comprehensive management information systems (OJJDP, 1999).

Individuals with Co-Occurring Disorders in Rural Areas

According to the 1990 Census (2001), 61.6 million people live in rural area. People with co-occurring disorders who live in rural areas, and those who would treat them, face many of the challenges common to general health care in America's non-urban areas. Rural and frontier areas have disproportionately fewer health and mental health resources despite sizable population (Sawyer, 2002).

Rural Americans have high rates of substance abuse, often higher than in cities and suburbs where rates have dropped off, and comparable or higher rates of co-occurring disorders (Sawyer, 2002). The "individualistic ethic" that still prevails in many rural and frontier communities may serve as an impediment to seeking treatment for co-occurring mental and addictive disorders.

Geographic isolation is a factor in rural health care. Driving 100 miles or more to attend an Alcoholics Anonymous meeting or to visit the doctor is not unusual. There is virtually no access to a specialized program that treats co-occurring disorders unless the individual is willing to travel hundreds of miles from home (Sawyer, 2002).

Treatment for people with co-occurring disorders in rural areas also is complicated by the fact that rural programs often have insufficient professional staff, especially psychiatrists and certified alcohol and drug abuse counselors. In part, for this reason, care often takes place in primary care settings or from church-sponsored programs. Many individuals seek help from family or friends. Clergy, tribal authorities, and other community figures are important to the care of people who have co-occurring disorders in rural areas (NARMH, 1998). In addition, SAMHSA has contributed to staff training in rural or remote areas by means of teletraining courses offered by Addiction Technology Transfer Centers, including offerings in the specialized field of co-occurring disorders.

State Offices of Rural Health are in an excellent position to work closely with State mental health and substance abuse authorities to address the challenges of treating individuals with co-occurring disorders in rural areas. Existing Federal programs, such as HRSA's Rural Health Outreach Grant Program and Rural Telemedicine Grant Program, help improve services for people with co-occurring substance abuse disorders and mental disorders in rural and frontier communities.

Co-Occurring Disorders in Racial and Ethnic Minorities

Race, culture, ethnicity, gender, sexuality, and identity are associated with variations in prevalence, diagnoses, and treatment of substance abuse and mental disorders, and must be considered in treating co-occurring disorders. As the Surgeon General's report, Mental Health, Culture, Race, and Ethnicity (U.S. DHHS, 2001b) notes, "racial and ethnic minorities bear a greater burden from unmet mental health needs and thus suffer a greater loss to their overall health and productivity."

Culture determines how individuals describe symptoms and assign meaning to them, how they cope with personal difficulties, whether they are willing or reluctant to seek treatment, and how they confront the stigma associated with both substance abuse and mental disorders (U.S. DHHS, 2001b). For example, a traditionally raised Asian American client may tend to express his or her complaints as physical symptoms and expect the clinician to offer relief. The same client may be offended by too many probing, personal questions early in treatment and never return (CSAT, in press). Likewise, the provider's cultural beliefs will shape his or her interaction with a client, for better or for worse.

Little research has been conducted on how the treatment of co-occurring substance abuse disorders and mental disorders may vary based on cultural differences. However, one study found that, compared to white clients, African American, Asian American, and Hispanic clients tend to self-report a lower level of functioning and to be "viewed by clinical staff as suffering from more severe and persistent symptomatology and as having lower psychosocial functioning" (Jerrell and Wilson, 1997). Nonwhite clients tended to have fewer community resources available to them than white clients, and clinicians had greater difficulty connecting them with needed services.

American Indian and Alaskan Native communities have been found to have disproportionate rates of suicide, alcoholism, illicit drug use, and placements out of the home in behavioral and judicial institutions, according to SAMHSA's National Household Survey on Drug Abuse, the Indian Health Service, and the Federal Bureau of Prisons. Related to these high rates of co-occurring substance abuse disorders and mental disorders are similarly disproportionately high rates of cirrhosis of the liver, accidents, violence, and intentional/unintentional overdoses. Tribal communities also face difficulties recruiting and retaining licensed and certified service providers.

Increasingly, recent immigrants and refugees are being served in mental health and substance abuse treatment programs. Many have entered the country following traumatic circumstances that could lead to PTSD, depression, and self-medication with drugs or alcohol (CSAT, in press). The loss of family structure and community experienced by many refugees also is a common factor in substance abuse.

Sex roles as defined by cultures also may figure in the expression of substance abuse or mental disorders. For example, Hispanic women often model themselves after passive female caretakers, while men may be influenced by machismo and its emphasis on aggression, sexual experience, and protection of women. At the same time, Hispanic emphasis on family and religion may serve as protective factors (Martinez, 1999). Such differences between cultures, age groups, or the sexes serve as both risk and protective factors in regard to mental disorders and substance abuse (Westermeyer, 1995), but more research is needed in this area.

Effective Interventions

Cultural competence - the knowledge, skills, and attitudes to enable administrators and practitioners to provide effective care for diverse populations within each individual's values and reality conditions - ensures that minority clients with co-occurring disorders receive services that are meaningful to them (CMHS, 2000).

Culturally competent services should be consumer-driven, community-based, and accessible. Individuals and their families should be empowered to participate in treatment planning, and those plans should make full use of natural community supports. In addition, service providers need to be sensitive to how inter-generational issues among family members may affect responses to treatment.

Because many minority groups have higher than expected frequencies of physical, mental and substance abuse problems, health care should be integrated to offer comprehensive services (CMHS, 2000). The availability of resources, such as transportation, also can affect an individual's ability to access care. This is especially critical in rural areas and among older adults.

SAMHSA's Substance Abuse Treatment for Persons with Co-Occurring Disorders (CSAT, in press) includes some specific suggestions for working with clients of different ethnic and cultural backgrounds with co-occurring disorders.

Whenever possible, familiar healing practices meaningful to individuals should be integrated in treatment, such as the use of acupuncture to calm a Chinese client or help control cravings, or the use of traditional herbal tobacco with some American Indians to establish rapport and aid emotional balance.

Because levels of acculturation may vary, clinicians should avoid making generalizations about clients of different cultures. For the same reason, diagnoses should be as free as possible of cultural, ethnic, sexuality and gender biases. In the past, for example, some African Americans were stereotyped as having paranoid personality disorders, while women have been diagnosed too frequently as being histrionic. American Indians with spiritual visions have been misdiagnosed as delusional or having borderline personality disorders.


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