especially the hispanic population, because the male issue of machismo brings a lot of issues with a woman in terms of not being felt respected and being wanted, and especially with addictions. and i suspect that if programs were looking for not only what you have mentioned in terms of adapting programs to latino communities, but also to really- we haven't really talked about checking, and i don't want to create a stereotype while talking about diversity- but really checking, having talked about the machismo, checking for other factors such as the domestic scene, and making sure- dealing with issues of co-occurring issues of domestic violence. is that appropriate? absolutely. in our center, we have a co-occurring mental health and substance abuse and domestic violence and substance abuse. not everybody has suffered those conditions,

but you have to be cognizant in terms of being aware of that, especially in the hispanic population. and william? i was going to say with the native american population, unfortunately, domestic violence is very, very high, so gender-specific programs are fundamental to the healing process. it's just amazing to see how on my particular reservation that 99 percent of the domestic violence situations are alcohol related. wow, that is very high. that is very high. what other factors within the native community should other programs be aware of? as far as cultural sensitivity? that is correct. it's been my experience on the reservation, i went to the reservation in 2000. i was raised in the city, i am what you would call an urban indian.

so my upbringing was completely different than reservation life. so when i returned to the reservation in 2000, i was an outsider. even though i was a cherokee indian and an enrolled member, i was an outsider because nobody knew who i was. what seemed to work was when i started learning about them. not saying oh, i'm one of you, learning about them, sharing their experiences, talking to them about their families, that's when they embraced me. and it's been my experience as well with counselors or clinicians that come from the outside, well intentioned, big hearts, but don't take the time to get to know their client. they move right into the disorder and working on the mental health issues, but don't take the time to know the person. and in indian country, when you take the time to know the person, you build that therapeutic relationship,

and that's where you get your success from. and then you get your trust. exactly. let's get into lgbt again, because i find that fascinating. one of the things with lgbt, john, that i want you to address is if in fact they are lucky enough to get into a specific program such as stepping stone, it's wonderful. but if in fact there are other general programs for the general population, how would one go about to doing some outreach, how would one make it easier for them to come into a program? well, we do- regularly we do trainings of other alcohol and drug treatment programs that are not lgbt specific in order to transfer the expertise that we have. and it is very specific. getting back to treatment adaptations, we learned a number of years ago that a number of our clients were relapsing because of the sex, the high risk sex/drug link when they would come out of treatment.

so we designed a program during our treatment episode where we addressed very directly high risk sexual behavior and the relationship with drug use. and as a result of that, the evaluations of that particular aspect of our program have been very powerful. and in fact, that is something that we are also trying to disseminate to other treatment programs. because i think there is a strong link between alcohol and drug use, whether it's gay, lesbian, transgender, bisexual, or the general population, there's a strong link between sexual behavior and the shame associated with it and drug use. so we try and address that directly and we think others should kind of follow our lead. and when we come back, you know, one of the things that i also want us to share is co-occurring issues within special populations and also issues of other health concerns, such as hiv aids and hep-c. so we'll be right back. [music]

[music] it's important to be familiar with the proper terminology surrounding addiction and recovery. one of the terms you want to be familiar with is continuity of care. continuity of care describes the continuum of care, including pretreatment, treatment, continuing care, and ongoing support to sustain long-term recovery. continuity of care provides individuals access to a full range of stage- appropriate services at any point in the recovery process. for more information on this and other recovery jargon, visit the recovery month web site.

where's mom? did she forget me? i wonder what happened to her. what if i get left here? drugs and alcohol may make you forget your problems, for a moment. but that's not all you forget. my mother worked hard to be in recovery, and i love her for that. for drug and alcohol treatment for you or someone you love, call 1-800-662-help. brought to you by the u.s. department of health and human services. [music] [music] what we're going to do now is we're

going to talk about some of those training issues that make our jobs as trainers a little bit more difficult. and what we thought we would do is get from you, first of all, some idea about what you are concerned about. who are or how are- the purpose of this training is really to help providers develop skill and expertise in responding to the particular needs of lgbt clients so that when they come in, they feel understood, they feel valued and they feel like this is a safe place where they can honestly receive help. this traraining really started with a publication from samhsa that provided kind of a guidebook and overview for treating lgbt people. but what we know is that a book is never enough; it tends to end up on someone's shelf never to be used. and so a small group of people started doing training in this area. we recruit particpants from around the country, experienced trainers, we bring them in. they spend about 2 and a half days going through the training.

they're lead through the various modules of the curriculum, and then during the second and third day, the participants themselves actually do teachbacks on the curriculum. i was very pleased to be able to come and take this training. i participated in the original book the training is based on, but this is a way of translating that information into something that people can really use, that's much more live, much more interactive and i think much more effective that way. and i needed to have some help with those skills in how to do that. by participating in this training, addiction counselors will be able to continue to do all of the good work that they do in providing addiction treatment. they generally really have the foundations of that, but what they need is a way to address those same issues in a culturally sensitive and culturally appropriate way. this training is really designed to help them do that. well, i hope to take back a sense of urgency that we should work on lgbt issues,

that issues of discrimination really impact lgbt individuals. i think coming to the training, i bring a lot of passion for the subject, but it's easy for the passion to sometimes turn off other people who may not share my views on the subject. so it's helping to create more effective advocates. well, when you are dealing with the lesbian, gay, bisexual, transgender population, you have to be aware of the unique culture that people come from and also the discrimination and stigma they have suffered, all which can contribute to substance abuse, as well as to relapses in treatment. and those pile on other stigmas and discrimination that people face and you have to understand the whole gamut of identities that people bring. and this is a very good place that training helps you do that and then helps to translate that into a treatment approach. i also find that depending on the nature of the room, when you can walk around the room, it's a great way to make that connection with someone. yes, i hear and get right up to them and at the same time- i think there is some obvious positive results such as a unified curriculum that is being offered, improving clinical skills for many clinicians,

making the training available to other parts of the country where this type of training has never been offered. but i think ultimately the long-term and the real goal is that we're actually saving lives. being able to have federal support, both financially and ideologically, to get this into a national network like the attc network is crucial for this to be adopted in main street treatment centers. my hope for this training is that every client can receive the treatment that they deserve and feel like they are respected and valued in that context. people come into addiction treatment in general with stigma and shame, feeling bad about the behaviors that they've been involved in. when you add the stigma and shame that are often felt by the lgbt people living in this culture, it becomes even more complicated. i want them to know that they are valuable, i want them to know that they deserve the same respect.

dr. clark, we were talking about, john was talking about complicating factors in terms of health challenges that may present at the time of intake for some special population individuals. can you address, continue to address that? well, one of the things that we at samhsa are stressing is that every person who has a mental health issue or substance use issue needs to also get a good physical health assessment. one of the things we know about the misuse of alcohol or drugs is that it does have an effect on the organic integrity of the body. so you may get liver disease, you may get gastritis, you may get heart disease, you're at greater risks for various infections like hepatitis c or hiv. and we want to make sure that anybody who is on the course of recovery has as much information as possible. there was one quote i read recently and a guy says,

"i spent all this time using alcohol and drugs and shooting up, etc., etc., so i finally get into treatment only to discover that i have hepatitis c." so we want to have that as an integral part because that becomes part of the cultural dynamic. and especially from a religious point of view, because you start feeling that you've been visited by god in a negative way because after all, you finally get your life on a proper course, and boom, you've got to deal with either hiv or you've got to deal with the hepatitides. and when you are dealing with that, that becomes an important part. and the other factors in that sort of i've been doomed by god is also age. as you get older, your body responds differently and what we're finding epidemiologically is that we've got a whole cohort of baby boomers who are flirting with marijuana, prescription drugs and other substances, misuse of alcohol,

because they still think they are 25. and they have disposable incomes. and they have the disposable incomes associated with that. so we're finding then this uptick in use of marijuana and other substances. so we need to have treatment programs and providers and people who are recovery facilitators understanding that you are dealing with an older population, as well as, you've got to deal not only with young people, adolescents and young adults, but you're now dealing with baby boomers who are entering a seniority. that is an important part. and then when you look at it from a cultural point of view, particularly in cultures where age commands respect, the person who has the alcohol or drug problem is in a conundrum. because they are an elder, if you're dealing with a tribal context, they are someone who is experienced or who is seen by younger people as a person of great respect,

and yet they are struggling with their own alcohol and drug problem. when we're talking about at-risk behavior, we know that it exists among the- and is prevalent among the general population. but when it comes to special populations, it's almost something that people really don't stop to address as much. you know because it's- there's a certain amount- and particularly you mentioned the seniors, there's a certain amount of more freedom now to start dating again, and so i suspect that there's a lot of hiv worries. because hiv, even though we think that it's been taken care of, i think it's showing its ugly head again. you know, our treatment approach we took, we take the public health approach which the only person, not only been looking into addiction, but what is still the conditions it might bring, especially with the hispanic population.

the socioeconomic part plays a major role because people who have been in addiction haven't seen the doctor for years. so you know, primary care health is a big issue with us. when they are doing recovery and they find out- oh, my gosh, i haven't seen my doctor, now i'm scared to see what else is the condition i have. so it's important to address, it's important to address not only, you know, from the addiction perspective, but also the primary health and health education, all areas of life. because recovery means that you are changing behaviors in all areas of your personal life. and i'm glad you mentioned recovery. faces and voices for recovery provides an individual an opportunity to join others and to figure out ways to support each other and to sustain recovery. and we haven't gotten to the fact that once we do get a person to go into recovery, that there

is also a need for either a mutual support group or some other type of activities. within the context of ethnic and racial and other special populations, what is important to keep in mind in terms of a person that is in recovery in order for them to sustain their recovery? well, in order to sustain recovery, as we all know, a mutual support network is vital. and from a tribal standpoint, it's community support. because unfortunately, with faces and voices, what we are striving to do is continue to battle the stigma of discrimination that people with an addiction continue to face. well, in indian country, it's almost twofold. you have still the struggling addict that is criminalized and when they get into recovery, if they have a mutual support network and the community embraces

them and continues to nurture them on their recovering journey, they are successful. but it's important. i mean, you can go to- i'll use a personal example of myself. when i sat there and having been raised off the reservation, i had tried traditional 12-step meetings, counseling, inpatient, outpatient, something just wasn't working. because even though i would go into these 12-step meetings, i just did not feel a part. for whatever reason at that particular time, i did not feel a part. well, when i went to the reservation and got into a culturally specific recovery plan that taught me culture and tradition, something happened. but what basically saved my life was, like most tribes, historically, when one member is down, the whole tribe comes together. well, for my particular case when i was down,

my immediate family that was in recovery came around me, as well as the community, and that is what saved me. we've kind of taken the community aspect to another level as well because so many of our clients are marginalized- they are hiv positive, they are in recovery, they are lesbian or gay. we decided to introduce into treatment the whole concept of advocacy, both self-advocacy, but also societal change advocacy. and it came to the fore last year when the state was cutting hiv services, some of our clients in treatment said you know, we'd like to start a letter-writing campaign to the governors and see if we can reverse this, because this is important to us. so we facilitated that. so we do advocacy, as well as treatment in stepping stone. well, one of the greatest things, and i think from the federal government perspective, has taken an approach not only that the treatment is one of the ingredients for recovery, so many doors for recovery.

and creating an ecosystem in our communities, making responsible communities that, you know, recovery is important and that the person who is in recovery to feel part of the ecosystem, the community. and that is a great thing. i think now the emphasis is not only treatment is important, but what happens after treatment. and that is the federal government, one of the blessings that they have done. but i think we need to disseminate to state government, it's still not happening. they are paying for treatment, but what happens after treatment? they are not paying for the recovery. they are not paying for recovery. they don't see the outcomes. and i don't think they- paying, but i think we have to create this ecosystem in our community, make them part of, the community is responsible for the individual to support and to access all of the areas they need. well, marco, i know you are very good because i have been to chicago to some of the recovery month events

and they are very well attended. you know, you get almost 200 people in a room to recognize those that have graduated and those that have been in recovery for many, many years. and it's growing. actually, the last time, we were probably 3 years ago now, we have about 500 people who celebrate in terms of acknowledging their recovery and the years. and we do the walk also recovery, a whole bunch of organizations, we get together and things like that. but dr. clark, i think it has to go beyond the recovery month. i mean, recovery month is fantastic and we certainly support it, but really what do ethnic, racial, and special populations need to be cognizant of that maybe they are not yet? well i think, as with any population, what we're trying to foster is this understanding that we're dealing with powerfully reinforcing psychoactive substances when we talk about the misuse of alcohol, when we talk about the use of methamphetamine,

cocaine, heroin, or prescription drugs. and that the person who is at risk is anybody in the community. so from a prevention point of view, you understand that and from a recovery oriented point of view, it's not just the individual who is the beneficiary, that individual's family is very important. especially when you're dealing with racial and ethnic groups, family becomes very important. so the family benefits and then the community as a whole, as william was pointing out, the community not only contributes to the recovery of the individual who has the alcohol and drug problem, but the community benefits from that because with regard to the substance use, that person who is now in recovery can give back. it can function as a role model for young people, young adults, adolescents who are struggling with alcohol and drugs and the pressure to use alcohol or drugs. and that person is able to give back and then rallies around.

so the cultural dynamic is very, very important. so recovery as a cultural motif is- i like the whole notion of the recovery ecosystem, the recovery-oriented environment which allows everyone to participate. not just the person who has the alcohol and drug problem, but that person's family and that person's community because the beneficiaries go well beyond the individual. and when we come back, we're going to continue to chat about this. i'm going to come back to you, william. and we're also going to get into- you mentioned something very interesting that i think we need to cover, it's the whole issue of prevention. we'll be right back. for more information on national alcohol and drug addiction recovery month, events in your town and how you can get involved, visit the recovery month web site at recoverymonth.gov. people trapped by drug or alcohol addiction often feel like there's no hope, no way out. but for every lock, there's a key.

and if you have a problem, it's good to know there are real solutions to help you get free. for drug or alcohol treatment referral for you or someone you know, call 1-800-662-help brought to you by the u.s. department of health and human services. [music] our program is multifaceted. it incorporates both group treatment and individual treatment for asian and pacific islanders who are struggling with chemical dependency. we use incentives to keep people motivated in treatment and we use both sort of informal and formal interventions.

i like the diversity of the clientele that we get here at team 360. regardless of ethnicity, each of their stories is so different from the next. but for some reason, when they come into group, they support each other and they know how to- there's just this warmth and this support, even though they are so different. it's just a very comfortable place to be at and i think there's a lot of open-minded individuals. so like if i come in, they are not going to be like look at that drug addict. just like the opposite, they are like out here willing to help you out. the challenge and the rewards of what i do in recovery is that i get to see individuals really improve their lives, not only in their recovery, but focus on their everyday stressors, and they are able to cope with it in a much better improved way.

our program is based on the matrix model intervention, which uses cognitive behavioral tools. so we talk a lot about how thinking affects feeling and behavior and we challenge negative, cognitive distortions that lead to emotional symptoms that lead often to use. i look at it like this: using drugs is going the wrong way on a wrong way street, a one-way street. the further you go, when you make that u turn, it's going to be further to come back. so the sooner you realize, it's less you have to come back. we are very strong in our advocacy for our clients to avoid the people and places that lead to dangerous situations that can lead to use. and that's one of the things we celebrate as well. if someone recognized what their trigger was and they didn't use when in the past they might have used in that situation, we publicly recognize that in our group setting. with the asian pacific islander, there is stigma

that has to do with substance use and mental health issues and just getting people in the door to come to group is a big step for a lot of them. and that's why i feel really proud that our staff is very sensitive to this and there's no shaming in group and we have a very positive supportive environment. because, you know, we're a community that, it's all about saving face. so if you have a problem, you know, whether it's substance abuse or maybe getting mental health treatment, you're supposed to just deal with it by yourself, you're not supposed to go outside of your family, you're not supposed to talk about your problems. being able to educate our clients on how confidentiality works and how they will be protected through it has been a very important piece of this, of what we do. i think that the glue of team 360 is the feeling

of trust and support that is generated within the groups. our staff is very caring and we are committed to this issue and we don't shame our clients at any time, we support them in their positive life change and we celebrate their life changes. william, you know, so far we've been talking about very specialized programs that deal with special populations. any examples that you can bring forward of mainstream service providers that have dealt with issues related to native country addiction issues? well, mainstream providers, the one that really comes to mind is the white bison organization and the wellbriety movement. they started out as an original rcsp program and they developed into basically the number one culturally sensitive program that is showing

great promise in indian country. it's beginning to take hold on my reservation. it seems to be taking even quicker hold out west. because as each tribe is different, culture out west is completely different than the tribal nations that are on the east coast. so the white bison organization seems to be the one that is working the best. and dr. clark, i know that in csat, for example, a lot of special population clients go to mainstream programs, to nonspecialized programs. what kind of success are we seeing with that? well, the issue of cultural competence is really the important discussion point here. we do find that programs that are run by american indians, alaska natives, for american indians, alaska natives or programs that target hispanics, run by hispanics, tend to produce better outcomes

than programs that are not sensitive to those issues. so we use sort of a bias force paradigm. there are programs that are not run by the specific population group, but have modules that are targeted to the unique needs of that group. so they do not as well as the programs that are run by the specific population group, but they do better than programs that are general. so when we look at the outcomes of, say, a woman in a male program or a general program that doesn't have any gender specific programming, she doesn't do as well as the program that is targeted to, for women, run for women or a program that has gender-specific issues. the same thing for american indian, alaska natives, hispanics, african americans, and the same thing would be applicable to