Demographics

Of the approximately 40 million Hispanic/Latino people living in the United States and its Territories, Mexican Americans are the largest group (64 percent), followed by Puerto Ricans (10 percent), Central and South Americans (13 percent), Cubans (4 percent), and other Hispanics or Latinos (9 percent) (U.S. Census Bureau 2007). Half the U.S. Hispanic/Latino population is concentrated in California and Texas. An additional 23 percent reside in Florida, Illinois, New Jersey, Arizona, and New York (U.S. Census Bureau 2007). Women of Hispanic origin in the United States numbered 17 million or slightly less than half the total U.S. Hispanic population (U.S. Census Bureau 2001d).

The Hispanic/Latino population is a young, rapidly growing ethnic and cultural group in the United States. At 14 percent of the population, Hispanics/Latinos currently are the largest ethnic subpopulation (U.S. Census Bureau 2007). The recent population growth of Hispanics/Latinos is mainly due to the relative youth and high birth rates of this population (Bachu and O'Connell 2001) and, in part, to immigration. Yet, most Hispanics/Latinos are born in the U.S. and are not immigrants (U.S. Census Bureau 2007). By 2050, Hispanics/Latinos are expected to nearly triple in number (U.S. Census Bureau 2000b).

The socioeconomic status of the U.S. Hispanic/Latino population may reflect the circumstances of immigration; that is, those who immigrated for economic reasons (the vast majority) tend to be poorer, less well educated, and younger than the overall population. More than a quarter of all Hispanics/Latinos lack health insurance coverage for more than 1 year (Cohen et al. 2004). Approximately 40 percent of Hispanic/Latino families headed by women live in poverty (U.S. Census Bureau 2007), and many of these women are likely to face the combined stresses of poverty, lack of health insurance, and lack of health care (U.S. Census Bureau 2002).

Substance use among Hispanics/Latinas

Sociodemographic factors associated with substance use and substance use disorders

Socioeconomic status, age, and length of time in the United States are associated with substance use and substance use disorders among Hispanic/Latina women. Among this population, those with the most notable risks for substance use disorders are women who immigrated to the U.S. at an earlier age (before 7 years of age) or who were born in the U.S. (Canino et al. 2008; Vega et al. 2003). Of particular concern, the 2007 Youth Risk Behavior Survey found a growing prevalence of alcohol and other drug use among adolescent Hispanic/Latina females (Eaton et al. 2008). Studies have also isolated employment, marital status, and educational level as predictors of alcohol consumption and substance use disorders among Hispanics/Latinas. In a study evaluating racial/ethnic differences among women with co-occurring mental and substance use disorders, Hispanic/Latina women possessed significant social vulnerability characterized by lower socioeconomic and educational status, exposure to violent crimes, and higher rates of criminal justice involvement (Amaro et al. 2005).

Gender socialization

In the Hispanic/Latina culture, women often are afforded special status and respect as matriarchs of extended family networks (Mora 2002). Some Hispanics/Latinas, especially those who are more acculturated, may deemphasize or reject these cultural expectations, but early childhood messages (e.g., the “proper role of a señorita”) may remain embedded in the cultural and personal identities of many in this group (Mora 1998). The stresses of negotiating and integrating traditional cultural expectations with new cultural values may result in or exacerbate the prevalence of mental and substance use disorders for many Hispanics/Latinas; more research is needed on this subject (Gloria and Peregoy 1996; Mora 1998).

Box

Advice to Clinicians and Administrators Substance Abuse Treatment and Hispanic/Latina Women.

Acculturation

It has been suggested that acculturation, the process of adapting and adjusting to new surroundings while maintaining a cultural identity, more than any other factor, affects Hispanics/Latinas' substance abuse (Caetano 1989, 1994; Gilbert 1991; Keefe and Padilla 1987; Markides et al. 1988). The onset of alcohol and drug abuse among some Hispanics/Latinas may be explained by acculturative and environmental stresses (e.g., new roles, expectations, opportunities) that result in greater exposure to these substances (Gilbert 1991; Mora 1998). HHANES data study revealed that, for women of all ages in three major subgroups (Mexican American, Puerto Rican, and Cuban American), level of acculturation was correlated consistently with both increased frequency of consumption and increased probability of being a drinker at all (Black and Markides 1993).

Studies consistently have shown that acculturation is positively correlated with consumption of greater quantities of alcohol, greater frequency of alcohol use, and higher rates of drug abuse among Hispanics/Latinas (Amaro et al. 1990; Mora 1998). These findings have significant implications in providing substance abuse treatment, in that the role of acculturation and gender socialization should be a central theme in treatment planning. Specifically, Mora (1998) suggests that clinicians explore with Hispanic/Latina clients several key questions: How have their traditional roles changed since immigration or in comparison to their own mothers? How have these changes in roles influenced their substance use behavior? In what ways have educational and employment opportunities influenced or altered their substance use?

Clinical treatment issues

At first glance, the heterogeneity of Hispanics/Latinas in terms of language, values, and backgrounds may seem to challenge the creation of effective, culturally responsive treatment programs for Hispanic/Latina women. Programs committed to serving Hispanics/Latinas, however, can develop effective services by endorsing culturally competent practices, such as culturally specific assessment tools, counseling that endorses the clients' worldviews, staff training to increase cultural awareness and knowledge, and programs that reflect and respect cultural values. For example, substance abuse treatment programs can create a treatment environment that honors cultural heritage and incorporates values such as familismo (reliance on and regard for family and family cohesiveness), when appropriate.

Some treatment issues reflect beliefs or traditions more specific to Hispanics/Latinas. A strong cultural prohibition exists against discussing family matters such as substance use or abuse during childhood, thus the use of psychoeducational groups to provide information on these topics may be more effective initially than therapy groups, where experiences are discussed openly. However, substance abuse counseling based on a family model often is well suited and is more culturally congruent for many Hispanics/Latinas. When engaging in family therapy, therapists need to enter the family relationship as a “learner,” since Hispanic/Latino families are so diverse. Counselors need to take the time to understand each client's family history within a cultural context (Rotter and Casado 1998), including the initial identification of the country of origin and family members' acculturation history and levels. Counselors also need to embrace a more expansive definition of family that may include extended family members and others. Early on in treatment, counselors need to assess how the current substance-related problems affect the family's culture and how the culture affects the current presenting issues. Because the exalted role of motherhood in Hispanic/Latino culture often makes loss of child custody especially stigmatizing, treatment programs need to provide support for appropriate family reunification. On a more fundamental level, Hispanics/Latinas may benefit from assistance in gaining English language skills, in job training that leads to employment, in finding stable housing, and in negotiating the requirements for treatment entry (Amaro et al. 1999; Kail and Elberth 2002).

Another treatment concern expressed among some Hispanics/Latinas in treatment—particularly those who are highly acculturated or isolated from a larger Hispanic/Latino community—is alienation from their cultural heritage. It may be difficult to address cultural alienation in treatment because a client may be far removed from her cultural background. A therapeutic decision must be made whether a cultural framework for recovery and empowerment should be utilized for all clients or only for those who request or show interest in this approach. Cultural knowledge can be empowering for many women of color, but not for all; care should be taken to adopt this approach only for those who are comfortable with it.

Hispanics/Latinas represent 14 percent of all new HIV/AIDS cases among women (CDC 2007). Among Hispanic women, 65 percent acquired HIV/AIDS through high-risk heterosexual transmission and 33 percent were infected through injection drug use. Since Hispanic women represent the second largest ethnically diverse group of women living with HIV/AIDS at the end of 2005, education and other prevention services should be essential components of substance abuse treatment.

Similar to other population groups of women, Hispanics/Latinas with substance use disorders experience a high rate of co-occurring mental disorders (Amaro et al. 2005). These disorders also need to be identified and treated if substance abuse treatment is to lead to recovery. A study of 66 Hispanics/Latinas enrolled in a residential substance abuse treatment program found that most (80 percent) reported a childhood history of abuse, as well as mental health problems (76 percent) and physical health problems (68 percent) (Amaro et al. 1999). Compared with women who had not experienced childhood abuse, those with such a history experienced more severe health problems and were more likely both to lose custody of their children and to drop out of treatment. To treat these problems adequately, the relationship between a woman's abuse history and substance use or co-occurring mental disorders must be determined. See TIP 36 Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (CSAT 2000b) for more information.

Demographics

There are major differences in cultural identification, income, education, marital status, occupation, and lifestyle between African-American women born in the United States and foreign-born women of African descent (Gray and Littlefield 2002; NIH, ORWH 1999). While this section focuses primarily on African-American women born in the United States, further research is needed to identify intragroup variations in substance abuse etiology and effective treatments.

More than 32 million African Americans live in the United States, including sizable numbers of both African and African-Caribbean immigrants. It is a relatively young population: 32 percent of all African Americans are under age 18. More than half live in a central city within a metropolitan area. African Americans represent 12.3 percent of the U.S. population (U.S. Census Bureau 2001f). Nineteen million, or more than half, of all African Americans are females (U.S. Census Bureau 2001d). Among African-American women, poverty is more prevalent than in the general population (Gray and Littlefield 2002). Among African-American single mothers, approximately 35 percent live in poverty compared to 19 percent of non-Hispanic single white mothers.

Although genetics account for differential rates of some diseases among African Americans (e.g., sickle cell anemia), biology alone explains very little about the disparities in health status between African Americans and Caucasians. Overall, African Americans have disproportionately higher rates of disease and illness, a wider variety of undetected diseases, more chronic health conditions, and shorter life expectancies than Caucasians. African-American women experience higher morbidity and mortality rates than do Caucasian women for many health conditions (Minino et al. 2002).

Substance use among African Americans

Even though the total substance abuse admissions among African Americans has been steadily declining since the 1990s, TEDS reports that 21 percent of admissions to substance abuse treatment facilities were African American in 2006 in comparison to 12 percent of non-Hispanic population (HHS 2008a). The primary source of referral to treatment among African-American women was through self-referral or by family and friends (SAMHSA 2004).

Clinical treatment issues

Beginning in the 1990s, research on African-American women with substance use disorders focused on low-income, urban women who were dependent on cocaine (Roberts et al. 2000). Now, literature on substance abuse and treatment among African-American women has expanded and environmental stressors have been examined, including psychosocial, sociodemographic, and economic disparities. While research remains limited in the area of treatment approaches and strategies, literature is beginning to reflect promising practices for African-American women.

From the outset, it is vital that African-American women have access to services that provide social support during their pursuit of recovery. Research suggests that African-American women are at risk for substance abuse due to the level of exposure to biopsychosocial and economic stressors and the subsequent difficulty in coping with these life circumstances (Gray and Littlefield 2002). They often experience greater emotional distress and more relationship problems (Liepman et al. 1993; Henderson 1994). Similar to all groups of women, African Americans have very high rates of trauma and abuse, so treatment needs to utilize trauma-informed services.

Coupled with direct and indirect effects of historical trauma (including a history of slavery, lynchings, and racism) (Barnes-Josiah 2004), African-American women disproportionately experience negative health and social consequences of alcohol and drug use (Boyd et al. 2006). For example, African-American women are more likely to have their children legally removed from their custody, in part, as a result of societal bias and discrimination (Wallace 1990). Additionally African-American women are 10 times more likely than Caucasian women to have positive drug screens. Yet, this difference may be directly related to a disproportionate percentage of testing among African-American women (Neuspiel 1996). Subsequently, this threat of loss of child custody or legal sanctions for drug use during pregnancy may prevent African-American women from obtaining prenatal care or seeking substance abuse treatment. Nonetheless, once treatment is initiated, issues surrounding pregnancy, child care, parenting, and custody need be addressed in a nonthreatening but constructive manner—showing support and guidance in promoting and nourishing a healthy parent–child relationship. Other health consequences include a higher risk for developing alcohol-related disorders, including liver cirrhosis, and a greater propensity to experience toxic effects of cocaine that may lead to earlier onset or greater risk for health problems, particularly cardiovascular disease (D'Avanzo et al. 2001). According to the HIV/AIDS Surveillance Report (CDC 2007), African-American women are 23 times as likely to be diagnosed with HIV/AIDS in comparison to white women, and 4 times more likely than Hispanic women. Among African-American women with HIV/AIDS, 74 percent acquired HIV/AIDS through high-risk heterosexual transmission and 24 percent were infected with HIV through injection drug use. To effectively address pertinent health and clinical issues, treatment programs also need to incorporate HIV/AIDS prevention, intervention, and treatment services.

Coupled with these risk factors, there is a common myth that African-American women “can withstand any amount of pain and keep on working” (McGee et al. 1985; p. 7). This myth may have significant consequences for African-American women who have substance use disorders—delaying treatment, sacrificing self to care for others, and negating the need for preventive health care and substance abuse treatment. (For further review of roles and expectations of African-American women, see Reid 2000.)

Once in treatment, African-American women need a gender-responsive, strengths-based model to develop or enhance a sense of empowerment by recognizing their assets and history of fortitude (Roberts et al. 2000; p. 905). This model provides a framework whereby treatment shifts the focus away from individual internal deficits. For African-American women with substance use disorders, treatment approaches need to extend beyond the general parameters of gender-responsive treatment to include interventions that focus on social contexts across multisystems including social networks or groups, family involvement and therapy, and community involvement and interventions (Boyd-Franklin 1989; Bell 2002). Likewise, spiritual components and Afrocentric perspectives need to be incorporated into treatment to ensure a holistic approach and to assist African-American women in recovery (Brome et al. 2000; Rhodes and Johnson 1997; Roberts et al. 2000).

Role of spirituality and faith-based recovery

Although there is no “one size fits all” definition of spirituality, spiritual activities nevertheless offer women in recovery an outlet to express problems, seek guidance from others or from a higher power, and move from disharmony to harmony with self and others without fear of repercussion, shame, or punitive actions (Brome et al. 2000). America has an extensive history of religious movements and spiritually led programs that address substance abuse (White and Whiters 2005). Today, there is more focus on the importance of integrating these faith-based approaches into addiction treatment, and more recognition that African-American churches can be a vital recovery tool.

Spirituality has been an important source of support for many African-American women (Lewis 2004). Historically, spirituality and religion have provided a central organizing framework for self-definition, problemsolving, and connection to self and others, especially among African-American women. Black churches have led the promotion of health care, disease prevention, and psychological well-being (Leong 2006). Overall, women in recovery from substance use disorders who express high levels of spirituality demonstrate a more positive self-concept, better attitude toward parenting and perception of family climate, more active coping style, and greater satisfaction with their social support than women who are in recovery but expressed lower levels of spirituality (Brome et al. 2000). Notably, treatment providers need to understand how African-American women relate to traditional religion and spirituality and how that relates to positive mental health outcomes. For an overview of spirituality and religion and its implications for psychotherapy with African-American families, refer to Boyd-Franklin and Lockwood 2009.

Role of an Afrocentric perspective

Though it is important not to make the assumption that all African-American women want to identify with a particular African tradition, acknowledgment of the richness of the African-American heritage or adoption of an Afrocentric perspective is another crucial component of a culturally and gender-responsive treatment program for many African-American women. As an example, The Iwo San Program, located in Cleveland, Ohio, incorporated an Afrocentric component in treatment, along with cognitive–behavioral therapy and an Afrocentric approach to the 12-Step program, with a primary goal of increasing the women's understanding of what it means to be African American and of promoting self-pride through embracing African ancestry, history, and culture (CSAT 2003b). Women learned and used the “Seven Principles” from the Swahili tradition and community as a guide for daily living. (For review, see text box below.)

The concepts of empowerment, the positive role of African-American women in the family and larger community, and the ability to build on their inherent strengths in the face of adversity are important to culturally responsive treatment (Rhodes and Johnson 1997). By incorporating an Afrocentric worldview in substance abuse treatment, African-American women will likely benefit from this critical protective factor in enhancing self-image, self-esteem, and centeredness in recovery (Roberts et al. 2000).

Role of group, cognitive–behavioral, and family therapy

Group therapy and adapted cognitive–behavioral therapy (CBT) show promise when grounded in the African-American worldview (Brown et al. 1995; Holcomb-McCoy 2004; Washington and Moxley 2003). By placing emphasis on the importance of community, group therapy can be a powerful and culturally appropriate approach that provides a supportive recovery environment and acts as a buffer to stressors associated with recovery. In essence, it is an opportunity to reinforce or rebuild a community connection that supports health. (Refer to Figure 6-1 for a review of promising practices and strategies.)

Figure 6-1

Group Therapy: Promising Practices and Strategies for African-American Women.

CBT may be a noteworthy substance abuse treatment approach if adapted to fit the African-American worldview. Yet, minimal research has been carried out on the effectiveness of CBT and substance use disorders. Between 1950 and 2006, only 12 studies have examined CBT among ethnically diverse populations, with only one study focused on substance abuse and CBT (Horrell 2008). While this one study suggests effectiveness with CBT (as measured by reduction in frequency and amount of drug use among African-American clients), the results need to be cautiously interpreted due to a high participant dropout rate. To date, more research is needed to examine the effectiveness of CBT with ethnically diverse adult populations with substance use disorders. While research is limited, there is emerging evidence that CBT can be a helpful approach among African-American clients. Kelly (2006) states that CBT may offer African-American women an opportunity of empowerment, supported by a nonjudgmental and collaborative therapeutic relationship, and centered on skill and support system development. It can be easily adapted to match a strength-based approach rather than a deficit model. To help decrease the Eurocentric bias in CBT, clinicians should avoid projecting or overemphasizing the value of cognition without incorporating the relevance of emotional expression and spirituality. As important, CBT should recognize and emphasize the importance of family and community support as an integral part of recovery.

Box

Nguzo Saba: The Seven Principles.

Regardless of approach, treatment should evolve around the premise that family and community are essential elements to healing and recovery. Treatment programs and counselors can endorse these values within the program by using mentors from the community for women in early stages of recovery (Stahler et al. 2005). Overall, more attention is needed to involve and incorporate a multisystems framework including a family systems approach in treatment. Family therapy is characteristically a more pertinent mode of therapy for African-American women (Boyd-Franklin 1989).

Resiliency factors

Consistent with earlier work (Hill 1972), Gary and Littlefield (1998, p. 99) identified the following resiliency factors in their study of African-American families:

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A high degree of religious or spiritual orientation (as evidenced by church membership, church attendance, a sense of right and wrong, teaching moral values, and a shared religious core)

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A sense of racial pride (telling their children about Black history, discussing racism in one's family, telling children what it is like to be African American, preference for being identified as an African American)

Box

Advice to Clinicians and Administrators: Substance Abuse Treatment and African-American Women.

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A strong achievement orientation (high expectations for achievement and attainment, goal directedness, etc.)

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Resourcefulness (possessing personal talents and skills, self-reliance, self-sufficiency, independence, and the ability to cope with crises)

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Family unity (possessing a sense of cohesiveness, family pride, family togetherness, and commitment; i.e., the family comes first)

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Display of love and acceptance (the ability to affirm one another and to respect, appreciate, and trust one another)

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An adaptability of family roles (having role flexibility, sharing responsibility, and communicating with one another)

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A strong kinship bond (e.g., a high degree of commitment to the family, a feeling of mutual obligation, kin interaction, and support)

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Community involvement (service to others and membership and active involvement in community organizations)

Demographics

Asian origins can be traced to many countries, including Cambodia, China, India, Japan, Korea, Laos, the Philippines, Vietnam, and others. By some counts, the number of national and ethnic groups is nearly 50, representing more than 60 primary languages (Barnes and Bennett 2002; Grieco 2001; New York State Education Department 1997). The three largest groups of Pacific Islanders are Hawaiians, Guamanians or Chamorros, and Samoans (from the Mariana Islands, of which Guam is the largest). In all, 24 different groups are considered Pacific Islander, and individuals from many of these groups have migrated to the United States. More than half of U.S. residents who are Pacific Islanders live in California and Hawaii (Grieco 2001). Yet, over the past few decades, the Asian-American and Pacific-Island populations have become increasingly dispersed across the United States (U.S. Census Bureau 2001f).

Asian and Pacific Americans are a rapidly growing group, increasing by more than 7 million over the last 20 years (U.S. Census Bureau 2001c). According to the 2002 Census, Asian and Pacific Americans constitute about 4.4 percent of the total U.S. population (12.5 million individuals), of whom slightly more than half (51.6 percent) are women (U.S. Census Bureau 2001d). Asian- and Pacific-American women represent 13 percent of all women of color (U.S. Census Bureau 2001d). They are a relatively young group with 25 percent under age 18. Asian and Pacific Americans are both more likely to occupy one or the other end of the continuum in educational and income levels—either obtaining the highest educational and income levels or experiencing considerable poverty and a lack of education in comparison to non-Hispanic whites (Reeves and Bennett 2003).

Substance abuse among Asian and Pacific Americans

Although Asian and Pacific Americans constitute about 4 percent of the population, they represent less than 1 percent of admissions to substance abuse treatment facilities in 1999. However, this represents an increase in treatment admissions of 37 percent from 1994 to 1999 among this population (SAMHSA 2004).

Illicit drug use

The rates of illicit drug use are relatively low among Asian- and Pacific-American women compared with other racial and ethnic groups. Currently, methamphetamine (33 percent) bypasses alcohol as the primary drug of abuse upon treatment admission. After methamphetamine, the most frequent cause of admission for illicit drug use among Asian-American women is marijuana (16 percent), followed by opioids (11 percent), and cocaine/crack (11 percent) (HHS 2008a). Yet, variations exist across subpopulations in drug and alcohol patterns.

Box

Advice to Clinicians and Administrators: Substance Abuse Treatment and Asian- and Pacific-American Women.

Clinical treatment issues

Foremost, treatment providers need to understand, acknowledge, and incorporate cultural values within the treatment process. The family is the center of most Asian and Pacific Island cultures and is an important consideration for effective treatment for women. The definition of family is expansive and includes not only immediate and extended family members determined by blood and marriage, but also other members of the community. Among women, family ties, loyalties, cultural expectations, and beliefs can serve as a protective factor against substance abuse (Joe 1996). Moreover, the concept and value of interrelatedness among family, community, environment, and the spiritual world is essential in many Asian and Pacific Island cultures, and these tenets should be woven throughout the treatment program and clinical services (for an overview of treating Asian- and Pacific-American clients and their families, refer to Chang 2000).

“Acculturation… refers to the manner in which individuals negotiate two or more cultures where one culture is considered dominant while the other culture is perceived to have less cultural value” (Leong et al. 2007, p. 424).

More than 65 percent of the Asian-American population is foreign-born (U.S. Census Bureau 2004). Thus, stress specific to immigration and acculturation is more likely. This has significant implications for treatment planning and services in a variety of ways, particularly in accessing and addressing acculturation stress and its relationship to substance use and other psychological symptoms, specifically depression (Chen et al. 2003).

A complex set of barriers to care can discourage Asian- and Pacific-American women from availing themselves of substance abuse treatment and other health care. Asian-American women who do not speak English or whose cultural traditions include a sense of shame for ill health often do not seek medical care (Leigh 2006). The problem is compounded by the unsurprising denial of substance abuse in a climate that favors family ties, a reverence for authority, and the dearth of culturally responsive substance abuse treatment services (Kitano and Louie 2002, p. 352). In addition, women typically assume the role of primary caretaker, holding the essential responsibility of nurturing and supporting the family, even at the expense of individual health concerns.

The development of empirically supported methods is evolving, yet research relevant to specific treatment needs among Asian- and Pacific-American women is sparse. Borrowing from the field of cross-cultural psychotherapy (Chang 2000; Leong and Lee 2006), treatment requires thorough assessment that includes such factors as circumstances of immigration, degree of assimilation, ethnic background, and health beliefs. The Asian American Multidimensional Acculturation Scale shows considerable promise in assessing women's multidimensional levels of acculturation (Chung et al. 2004). It provides a more comprehensive assessment of acculturation and its effect on psychological functioning. Although outcome research specific to Asian- and Pacific-American women in substance abuse treatment is lacking, preliminary research with Asian Americans in community-based substance abuse treatment found no overall group differences in treatment retention and outcomes (Niv et al. 2007).

Resiliency factors

As mentioned above, Asian and Pacific Americans share an ethic of hard work and family orientation, as well as a cultural concept of interrelatedness among family, community, environment, and spiritual world. In addition, the following observations have been noted in the literature:

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If incorporated thoughtfully into the treatment process, the family can have a significant influence on treatment outcome. At the very least, consideration should be given to the family's role in substance abuse as well as to members' participation in treatment and influence on recovery (Chang 2000).

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Some clients might find incorporation of indigenous treatment modalities—such as healing ceremonies, acupuncture, meditation, massage, tai-chi, and herbal medicines—helpful (Kitano and Louie 2002).

Demographics

In the 2000 census, those who reported Alaska Native or American Indian as their only race/ethnic group totaled nearly 2.5 million, while the number reporting Alaska Native or American Indian in combination with another race/ethnic group numbered 4.1 million (U.S. Census Bureau 2001e), or 1.5 percent of the U.S. population. Alaska Native/American Indian is the smallest of the four major racial/ethnic groups currently recognized in the United States. Their small numbers, however, mask significant diversity.

The largest concentrations of Native people reside in three States: Arizona, California, and Oklahoma (U.S. Census Bureau 2001f). However, American Indians and Alaska Natives may live anywhere in North America on and off reservations or other forms of tribal land, in rural or urban areas, and within villages (Coyhis 2000). Today, American-Indian and Alaska-Native nations (e.g., Navajo, Iroquois) encompass more than 560 federally recognized Tribes, including more than 220 Alaskan villages, in addition to numerous Tribes that are not yet federally recognized. Historically, this diversity, as well as the separation of this group into many small segments scattered throughout the United States, has complicated efforts to identify commonalities through classification (NIH; ORWH 1999). Nevertheless, some experiences shared by many Tribes have been noted (NIH; ORWH 1999):

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Rapid change from a cooperative, self-sufficient, clan-based society to a family-based community dependent on trade

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Prior government criminalization of the use of native language and spiritual practices

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Deaths of members of the older generations to infectious diseases and war

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Loss of the ancestral lands

The rates of unemployment, poverty, and education; poor health status; and alcohol and drug use vary by Tribe and by region. The current poverty level is 27 percent among Native Americans (U.S. Census Bureau 2006). Unemployment hovers at about 13 percent for females older than age 16 (Indian Health Service [IHS] 2002). The proportion of family households maintained by women with no spouse is approximately 21 percent (U.S. Census Bureau 2000).

Substance use among American Indians and Alaska Natives

Although representing only 1.5 percent of the U.S. population, American Indians/Alaska Natives represented 2.1 percent of all admissions to publicly funded substance abuse treatment facilities. Of these, 36 percent were female (SAMHSA 2004). Based on the NSDUH, including alcohol and illicit drugs, Native American women were more likely than any other ethnic group to have met criteria for past year need for substance abuse treatment (OAS 2006a). For more comprehensive information on substance abuse treatment, see the planned TIP Substance Abuse Treatment with American Indians and Alaska Natives (CSAT in development e).

Clinical treatment issues

Substance use patterns and treatment issues among many groups of American Indians and Alaska Natives have not been studied adequately; as a result, many issues specific to these groups are not well known. Overall, wide variations in alcohol and drug use patterns—along with access to treatment and other needed health services—exist across American-Indian and Alaska-Native communities (Berkowitz et al. 1998; Vernon 2007). While similar barriers exist for Native-American women in comparison to other women with substance use disorders, Native-American women often encounter more barriers that impede access to treatment; i.e., economic hardships, treatment accessibility, lack of screening and assessment, and gender-responsive programming (Berkowitz et al. 1998; Parks et al. 2003).

Comprehensive attention to health care and health status is crucial for treatment of American-Indian and Alaska-Native women. Stevens (2001) suggests that medical and substance abuse treatment providers need to work hand-in-hand to meet the needs of Native-American women, and that primary care providers should routinely screen for alcohol and drug abuse and discuss the negative health consequences of substance use in a culturally responsive manner during regular examinations.

Unfortunately, few American-Indian and Alaska-Native women who abuse alcohol and illicit drugs are referred or enrolled in treatment programs of any type. For Native-American women living in rural areas, available treatment programs usually are neither woman-centered nor culturally specific. Moreover, many Native-American women are reluctant to attend treatment programs with non-Native Americans (Hussong et al. 1994). Some prefer participating in reservation-based programs, while others may be reluctant to participate in small community programs or urban health centers due to concerns surrounding confidentiality (Jumper Thurman and Plested 1998). Others may seek treatment elsewhere but express concerns surrounding available support upon reentering the reservation after treatment (Berkowitz et al. 1998). Subsequently, Native-American women are more likely to need help deciding on the location of their treatment program.

Trauma-informed services

American-Indian women are disproportionately affected by violent crimes, childhood sexual abuse, and physical abuse. Nearly three-fourths (73.3 percent) of Alaska-Native women in one program reported sexual abuse histories (Brems 1996). Beyond specific traumas among Native Americans, treatment programs need to incorporate a culturally responsive framework that understands and addresses the legacy of historical and cumulative trauma (Robin et al. 1997), including forced acculturation and deculturalization (e.g., loss of cultural, community, individual identity) of American-Indian and Alaska-Native communities. These losses have sometimes been expressed in higher suicide and homicide rates among Native-American community members. As part of recovery, women will likely need to address the loss of family members or friends. Likewise, screening for traumatic events, posttraumatic stress disorder (PTSD), grief, and depressive symptoms should be routine. Treatment programs for Native-American women need to incorporate culturally congruent trauma-informed and integrated trauma services to build a stronger bridge to recovery (Saylors and Daliparthy 2006).

Box

Advice to Clinicians and Administrators: Substance Abuse Treatment and Native-American Women.

HIV/AIDS prevention and intervention comprehensive services

In 2005, Native Americans ranked third in HIV/AIDS rates, with Native-American women accounting for 29 percent of the diagnoses. While rates vary from community to community (Vernon and Jumper Thurman 2005), the rise in HIV/AIDS cases among Native-American communities reflects the need for attention in program development and treatment services for substance use disorders among women. Simoni and colleagues (2004) coined the term “Triangle of Risk” in reference to the HIV risk factors: history of sexual trauma, injection drug use, and HIV sexual risk behaviors. Each risk factor is highly interrelated to the other factors and strongly associated with substance use disorders. While risk factors are not limited only to the “triangle of risk” (Vernon 2007), the prevalence of these risk factors clearly represents the necessity of comprehensive HIV/AIDS prevention and intervention services among Native-American women seeking treatment for substance abuse.

“The work we do today will provide for the freedom of our future generations (Mohawk).”

Source: The Freedom Way: The Native American Program at the Margaret A. Stutzman Addiction Treatment Center, NY

Fetal alcohol prevention services

Fetal Alcohol Spectrum disorders (FASD) are very serious problems in some Native communities. A four-State study showed that fetal alcohol syndrome (FAS) among American Indians and Alaska Natives occurred at the rate of 3.2 per 1,000 population over a 2-year period, compared with 0.4 per 1,000 in the total population of the same four States (Hymbaugh et al. 2002). As a means of prevention, gender-responsive treatment services have an opportunity to educate Native-American women on the impact of alcohol and drugs on fetal development. By adding prevention approaches for FASD in treatment, women can make better and more informed decisions regarding alcohol use during pregnancy.

Culturally congruent substance abuse services

Treatment professionals must approach health and well-being through the complementary lenses of culture, history, and the beliefs of Native-American people (LaFromboise et al. 1998; Stevens 2001). For many Native-American women, the journey to reclaim their identities and culture is central to recovery (Brems 1996). The most critical feature for treatment of American-Indian and Alaska-Native women is that programs be culturally responsive, gender-responsive, and community-based, and that they “reaffirm cultural values and consider the individual in the context of the community” (LaFromboise et al. 1998, p. 150). A series of IHS-funded focus groups for women in treatment found that an emphasis on cultural activities was important to the women (Berkowitz et al. 1998), including sweat lodges, powwows, talking circles, tribal music and crafts, traditional foods, and meetings with medicine people and tribal elders. For many women, participating in tribal activities gave them a sense of belonging—some for the first time (Berkowitz et al. 1998). This is important because the reasons that some Native-American women have given for alcohol and drug use include low self-esteem and “not fitting in with the white world” (Hussong et al. 1994). While it should not be assumed that every Native-American woman is traditional; traditional healing should be made available as a treatment option or as an adjunct to treatment.

Family and community involvement

Strong ties to family and community make community-based approaches appropriate because substance abuse is considered a family and community problem (Berkowitz et al. 1998). In some Native-American communities, alcohol consumption is the norm; abstainers may be ostracized. When drinking together is a major family activity, the woman who abstains may, in effect, lose her family. With such high rates of alcohol and drug use, a woman's family and friends are unlikely to offer strong support for recovery. By acknowledging the role and the importance of family and community in either perpetuating the substance use or in providing a nurturing recovery environment, treatment providers must involve family and community members from the outset. As highlighted in the IHS-funded research on substance abuse treatment for Native Americans, comprehensive treatment must embrace and encourage community involvement and commitment to support long-term recovery (Berkowitz et al. 1998). Literature suggests that the key factor in maintaining abstinence among Native-American women is the presence of tangible support (Oetzel et al. 2007).

Resiliency factors

In recent years, American-Indian communities have organized to promote their economies and cultures. In the mid-1990s, an Executive Order mandated the establishment of tribal colleges on or near reservations, and at least 50 percent of the registered student population of these colleges must, by definition, be American Indians or Alaska Natives. Currently, American Indians are developing economic enterprises in the casino, recreation, and computer industries. Along with these advances, American-Indian and Alaska-Native peoples are revitalizing their native languages and cultures. Recent trends include movement back to the reservation. In addition, many American-Indian communities are very proactive about substance abuse issues.

On reservations, many women have gone back to talking circles and are promoting the need to do things within cultural, family, and community contexts, including the creation of communities that are alcohol free (Berkowitz et al. 1998). The Williams Lake Band in Canada, for example, has become entirely alcohol and drug free. Another success story involves the Alkali Lake Band in British Columbia, which achieved a communitywide sobriety rate of 95 percent over a 15-year period (Berkowitz et al. 1998).

Alcohol

Later research (Cochran et al. 2000; Hughes et al. 2000) supports the idea that earlier estimates of the relationship between sexual orientation and alcoholism are inflated. Nonetheless, these and other studies (Case et al. 2004; Cochran et al. 2000, 2001; Cochran and Mays 2000; Gilman et al. 2001; Parks and Hughes 2005; Sandfort et al. 2001) suggest that lesbian women—in comparison to heterosexual women—are more likely to use and abuse alcohol, less likely to decrease their use of alcohol with age, and more likely to report alcohol-related problems. Literature suggests that this greater prevalence of substance use and abuse may be related to more opportunities to drink, fewer traditional sex role expectations, and different social conventions about drinking (Hughes and Wilsnack 1997).

Illicit drugs

While little is known about drug patterns among lesbian and bisexual women, research suggests that they are at a heightened risk for drug use, with specific subpopulations showing more prevalence, such as young adult lesbian women (Hughes and Eliason 2002). In two studies (Cochran et al. 2004; Corliss et al. 2006), researchers report that women with female sexual partners had at least one symptom of dysfunctional drug use and were more likely to display impairment and meet criteria for any drug dependence in comparison to heterosexual women. Lesbians report greater problems associated with marijuana, cocaine, and hallucinogens. In a study conducted in urban primary care sites, bisexual women were about twice as likely as heterosexual women to report having used illicit drugs in the past month (Koh 2000).

Substance use among women in later life

Alcohol

In comparing trends from 1992 to 2002 in alcohol abuse and dependence among women as they age, the National Epidemiologic Survey on Alcohol and Related Conditions showed a significant inverse relationship between rates of dependence and successive age groups—that as women age, prevalence of alcohol dependence decreases (Grant et al. 2006). While there is earlier empirical evidence to support that late-middle-age to older women have fewer drinking problems (known as “maturing-out”; Brennan et al. 1993), this trend has to be approached with a conservative lens since older women tend to hide their use and not seek alcohol treatment. In addition, the prevalence and risk of alcohol abuse and dependence among women appears to vary among subgroups. For example, widowed women were found to be three times more likely than married women to drink heavily (The National Center on Addiction and Substance Abuse at Columbia University [CASA] 1996). The most consistent predictors of alcohol-related problems among women were friends' approval of alcohol use, financial stressors, and avoidance coping (Moos et al. 2004).

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Signs of Alcohol-Dependence and/or Drug Abuse in an Older Woman.

Prescription Drugs

Prescribed medications are the most common drugs of abuse, outside of alcohol, among older adults (National Institute on Drug Abuse [NIDA] 2001). Approximately 30 percent of all prescriptions and 40 percent of all benzodiazepine prescriptions are prescribed to elderly individuals. An older woman is more likely than an older man to visit a physician and to be prescribed a psychoactive drug. Problems can result if prescriptions are written by several physicians who do not know the full range of prescribed and over-the-counter medications being taken. Older women often are prescribed medications highly susceptible to abuse (NIDA 2001). Medications frequently prescribed for and used by older women include anxiolytics and sedative-hypnotics. Alcohol–drug interactions are more likely to occur among older adults simply because they take more medications than younger adults and may continue to drink at levels consistent with earlier patterns. These interactions can cause problems in older adults because of slowed metabolism in later life and greater reliance on medications for chronic medical conditions (CSAT 1998d). With age-related changes, prescription medications are more potent, less predictable in effects, and more likely to increase negative outcomes (Allen et al. 2006).

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Advice to Clinicians and Administrators: Substance Abuse Treatment and Older Women.

Alcohol

Beliefs and expectations about alcohol strongly predict potential alcohol abuse. Women in some rural communities hold more positive beliefs about alcohol than those in other communities or in comparison to urban women. The beliefs involve the notion that alcohol enhances sexual, physical, and social pleasure; reduces tension; and increases arousal, power, and control over life circumstances (Boyd 1998; Marlatt et al. 1988).