[music] hello, i'm ivette torres and welcome to another edition of "the road to recovery." today we will be talking about diversity issues within the addiction and recovery field. joining us in our panel today are dr. h. westley clark, director, center for substance abuse treatment, substance abuse and mental health services administration, u.s. department of health and human services, rockville, maryland.

marco e. jacome, chief executive officer, healthcare alternative systems incorporated, chicago, illinois. john de miranda, president and ceo, stepping stone, san diego, california. william lossiah-bratt, board of directors, southeastern regional representative, faces and voices of recovery, cherokee, north carolina. dr. clark, why should we be concerned about ethnic and racial differences within the addiction and recovery field, as well as other differences? well, one of the things that we want to make sure is that people who have substance use problems are able to recover and that materials that we use can assist them in that process. and so, you know, there are differences associated with cultural values and beliefs, starting from how

one physiologically responds to a particular substance misuse to how certain substances are used in a cultural context. so if we're going to facilitate recovery, we need to understand the language, the beliefs, the social context associated with those substances. and that will help us facilitate that person's recovery by showing that we understand the life experiences that they have associated with their use of substances. and i gather that includes prevalence as well. well, yes, but from a clinical point of view, i mean people look at the epidemiologic data and there are differences in prevalence. but the key issue for the individual who has the problem, whether you have a low prevalence phenomenon- for instance, asians tend to have a lower prevalence of alcohol misuse than other ethnic groups- imagine you are that person who has the alcohol problem. now from a cultural point of view, it may mean that you may have a harder time getting support from

your community, but the fact is you need to be able to put together a recovery plan and need to be able to operate with that recovery plan in mind. and i think then people who are helping to facilitate your recovery need to be aware that you may have fewer assets in your community because the problem tends to be rare, but you still have the problem. and, marco, that includes also socioeconomic differences, right? i am sure that in your practice, you see a difference between one sector and another. absolutely. you know, even within cultures, we have subcultures and socioeconomic status, education, plays a major role in terms of recovery. we target mostly in our center blue collar workers and the approach is totally different than middle class and upper class hispanic. william, within the native, american indian community,

i am sure there are going to be so many differences, differences among the tribes and even within the tribe. can you address some of those? most definitely. the interesting thing with native american tribes is previously people would automatically assume that one tribe was the same as the next. my particular tribe, the cherokee, are completely different than our cousins out in oklahoma, the cherokee nation of oklahoma. within our reservation in north carolina, we have seven individual communities and each of those communities is completely different. we're a collective people, but we're all individualized in our communities. and how do they differ in terms of service delivery, for example, when you have to address their addiction issues? it comes down to developing that level of trust. some of our communities, it seems to be the communities that are closest to the center of

the reservation are more apt to seek services as opposed to some of our more isolated communities, especially up in the mountain regions. very good. john, in your line of work you deal mostly with lgbt communities and i know you have experience with the disability sector as well. can you talk to us about particular idiosyncrasies within these that need to be addressed as opposed to the rest of the population? yes, certainly. the lesbian, gay, bisexual, transgender community has a variety of idiosyncrasies, but i'd like to o go back to your first point, too, and say that one reason to have culturally specific treatment is because sometimes people cannot access treatment. stepping stone came into existence 35 years ago because gay men and lesbian women in san diego could not get into those recovery resources that were available then. or if they could, their experience was negative.

so a number of people came together and said, well, let's start something for our community, and that was really the beginning of stepping stone, and i think that is true for a lot of these kind of culturally specific treatment programs. idiosyncrasies, sure. life in an alcohol and drug treatment program for the lgbt community is very different in many ways because the issues are very different. for example, when we built the facility 10 years ago, we had this very nice staircase that was going up to the second level. and our then ceo said to the architect, "i want that staircase to look like a woman's high heel shoe." it does, and that's one thing that is what makes stepping stone different from other treatment programs. so they adapted to their aesthetic. exactly, exactly. and the jokes are different and the interactions are often very different. and i suspect that that makes a difference. i mean, when somebody walks in and, you know- it's an icebreaker, almost. yes. the dynamics are very different. we have also transgender clients in our treatment

program which again change the dynamics again kind of like what william was saying. that the transgender community is very different from the gay community and the lesbian community, so we have to make accommodations for that, too. marco? it has been proven that when you have treatment, culture specific enhances the ability to recover the individual. i will give you an example in terms of the hispanic population. we have a residential program where meals are prepared by home, you know. it's not a cafeteria meals that we prepare, but we have cooks who are sensitive to the culture. and that really brings home to a particular person who is in recovery and engagements. so, so important for recovery to be culture sensitive and ingredients that enhance recovery and the support in our environment of treatment. and i'm glad you mentioned the whole issue of culture sensitive.

i want to go back to dr. clark. what does culture sensitive mean? if someone is listening to this show, what does it mean to be culture sensitive? we've heard from our speakers addressing the cultural differences and the culture sensitivity means that the clinician particular or the recovery dynamic recognizes that a person's life experiences have to be taken into consideration, so the idioms, the beliefs, the perceptions, the mores, all of those things. so you may make an assumption based on your own culture that has nothing to do with this other person's life experiences. as was pointed out - food, for instance, is often a cultural dynamic and you can assume that here's a dish that everyone relates to and it actually may be so alien to the person that you're trying to help that they don't understand what you're trying to accomplish.

so cultural competence is what we're trying to foster, recognizing the diversity of cultural experiences. and in the substance abuse arena, what we are trying to facilitate is that recovery and in the mental health arena, we're trying to facilitate that recovery. so we need to take into consideration all of those things - mores, beliefs, icons, that affect that person's perception. and the clinician or the facilitator, if you're talking about recovery, needs to recognize that. we do have an advantage, though, when we talk about cultural competence. we know we're trying to facilitate the recovery from alcohol and drugs. that's the common motif that we can relate to. so whether it's an aesthetic in terms of a woman's shoe, in a treatment program, you're still trying to facilitate the recovery, whether it's a gay, lesbian, bisexual individual, an american indian, alaska native, someone from the hispanic community, a white from appalachia.

you're still trying to facilitate recovery. so that is the one thing that we have in terms of cultural competence and we have to radiate out from that by bringing in all the other idioms and icons and beliefs associated with substance use, but we're trying to achieve that. so that gives us a good position to start from. very good. when we come back, i want to get more into really the specifics among groups of what the, basically, the approach should be for each one of these groups within the context of providing services. we'll be right back. well, i think treatment programs that recognize that language and cultural icons and support and cultural imagery play a critical role

in how a person relates both psychologically and socially could position themselves to do a better job at reaching the person who is affected. so one size does not fit all, but the strategy is one of welcoming and incentivizing through environmental and social and psychological support. so whether you're in a hispanic social organization or an african american social organization or a gay, lesbian, bisexual, transgender social organization, that is not the issue. the issue is, are you having a problem with alcohol and drugs and if so, does your social context acknowledge that there are those problems and does it embrace recovery as a construct. because that's the other thing we want to push is social support for being in recovery. treat me- treat me with understanding.

treat me- treat me with courtesy. drug and alcohol addiction is an equal opportunity disease. individuals in recovery come from all walks of life and deserve to be treated with respect and admiration for winning one of the hardest battles there is. treat me without judgment. treat me- with humanity. alcohol and drug addiction deserves proper treatment. for drug and alcohol information and treatment referral, call 1-800-662-help. i had no idea it was going to be so hard. i didn't know what to expect. you hear the stories, but i never took any of it seriously until i found myself here. and then i realized i was going to have to work hard for my recovery. if you or someone you know has a drug or alcohol problem, you are not alone. call 1-800-662-help recovery was the hardest job i ever had. and the most important. brought to you by the u.s. department of health and human services.

i am a person in long-term recovery and in my case that means i've been without alcohol or drugs for 35 years. during that time, i have noticed that there is a new recovery movement starting in this country and probably about 10 years ago and i have gotten very involved in an organization called faces and voices of recovery, which is a leadership group within that movement. it's been very exciting to see that more and more people are coming out of the closet, that reducing stigma, reducing discrimination and kind of normalizing recovery is what is happening in this country. it's very exciting to see that having a longer term perspective that goes back 35 years when everybody seemed to be in the closet back then. dr. clark, i know that we've talked a little bit about certain aspects of diversity and one of them is gender.

i know that samhsa has a program that is targeted to women and children and pregnant postpartum. do you want to talk a little bit about that? you are correct when you mention that gender is an important part of cultural dynamics and cultural competence. one of the things that we recognized a long time ago was that we needed to make sure we had some gender-specific programming. and that also included programming that allows women to bring their children into the treatment environment and to allow women who are pregnant to deliver in the treatment environment. it works to their benefit and it also reassures the larger community that that woman who has an alcohol or drug problem will deliver a child who is free of alcohol and drugs. so that reassures the community and also gives

that woman a greater sense of personal dignity and responsibility as a parent. because we're dealing with powerfully reinforcing psychoactive substances, that many times when people have the responsibility for children, but who have addiction problems, they are unable to maintain the necessary balance. by having support, they can achieve that balance. so we fund a number of programs that offer a continuum of support, the acute support during the time the woman is pregnant to when she delivers. also allowing, in some programs, up to five kids to be brought into the therapeutic environment so that the mom can continue with her treatment. and one of the other things that we're doing is also bringing in fathers into the calculus. sometimes the father or the other parent has a

substance use problem, sometimes they don't. but we're able to make sure that the mom and her child are safe and then the co-parent who is interested in being in the life of the mother and child is able to do so, so that we give the child the best support possible and at the same time helping the mom in her recovery. so these become very important strategies to help facilitate, because gender is important, parenting is important. and the social expectations, many of these women feel that they are less than because they have an alcohol or drug problem and sometimes they are judged harshly by the communities because they are- well, why didn't you- if you're pregnant, you just don't stop using? well, these are powerfully reinforcing psychoactive drugs and psychoactive substances, so you need some- an environment where you can facilitate stopping use of these substances. you can't just automatically stop for many women.

so these programs offer that. one dynamic of that program is that i thought was extremely helpful was that you teach the mothers to be better mothers. you teach them parenting skills while they are, as you mentioned, working with the children to adapt better to a family situation. even though they may be single mothers, but it helps them to adapt. and marco, in terms of your program with the latino community, i suspect that you have similar approaches. absolutely. gender specific is so crucial because- let's just talk about a woman's different issues than the male population. in our center, you know, women come for an outpatient and the issues that they are bringing to the table is totally different than the male population. so i encourage programs that even though limitation of resources might not be there to have gender specifics because women's issues of being a mother, being a wife,

being a good parent has a different connotation than a male population. so also the issue of, again, feeling as a second citizen, they have never been given the respect at home to be a good mother, to address issues that they might have, feelings. 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