Cultural Considerations in Addiction Treatment

Cultural Considerations in

Addiction Treatment

The Application of Cultural Humility

By Connie T. Jones, PhD, LCMHCA, LCAS, NCC, ACS and Susan F. Branco, PhD, LPC, LCPC,

NCC, ACS, BC-TMH

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Addiction transcends all social identities, including race, ethnicity, gender, sexual orientation, social class, and re-ligion. As such, it is vital that addiction professionals learn behaviors, strategies, and techniques that are culturally responsive and create an inclusive treatment environment.

The goal of this article is to provide practical implications aimed to im-prove addiction professionals’ treatment and client outcomes.

Culturally Responsive ServicesEvery individual has a sociocultural makeup that consists of varying identities. The intersectional nature of these identities is referred to as intersectionality (Crenshaw, 1989). Intersectionality is not just about in-tersecting identities, but is primarily concerned with the power, privilege, and oppression associated with the identities (Crenshaw, 1989). Every person has a sociocultural makeup that consists of both marginalized and privileged identities (Ratts, 2017). For those with a substance use disorder or process addiction, this is an additional identity that comes with its own stigma, bias, stereotypes, and marginalization (Stein, 2020). Understanding someone’s life experiences and identities, and their daily impact, is essential to working from a culturally responsive perspective. Culturally responsive treatment leads to positive health behaviors and outcomes and it is also a professional duty (Tucker et al., 2011; Davis et al., 2005; Knox et al., 2003; Fuertes et al., 2002; NAADAC/NCC AP Code of Ethics, 2021).

To provide culturally responsive services, one must work from a cul-turally humble stance. Cultural humility describes the provider’s willing-ness and openness to demonstrate respect and a lack of superiority when interacting with those whose cultural identities, values, and worldviews differ from their own (Hook et al., 2013). This includes considering so-ciocultural factors during assessment, individualizing treatment based on unique needs, factoring in client strengths, and maintaining overall re-spect for the person with whom you are working (i.e., cultural humility).

Broaching is a skill or strategy that demonstrates and enhances cultural humility (Day-Vines et al., 2007; Jones & Welfare, 2017). Broaching can be thought of as cultural humility in action (Jones & Branco, 2020). The strategy of broaching describes the process of intercultural dialogues about sociocultural factors between the provider and the client; it is an invita-tion to the client to share how their sociocultural factors impact their life, worldview, presenting problem, and potential treatment (see example in case study) (Jones & Welfare, 2017). Broaching can increase therapist credibility, enhance client satisfaction, deepen client disclosure, reduce premature termination rates, and increase clients’ willingness to return for sessions (Sue & Sundberg, 1996). Broaching is a helpful place to begin as you work to establish rapport and build trust within the provider-client relationship. Broaching should occur in every provider-client treatment relationship regardless of sociocultural identity similarities or differences between the dyad. Jones and Welfare (2017) found that broaching can be beneficial when working with those impacted by substance use disorders.

Application of Cultural Humility The application of cultural humility and the strategy of broaching can be incorporated by a provider working with an individual with addic-tion. Start by applying the main features of cultural humility: openness;

willingness and ability to accurately assess one’s own personal character-istics and achievements; the ability to recognize one’s own imperfections, mistakes, and limitations; and other-orientation (see Figure 1) (Watkins et al., 2019; Worthington et al., 2017). The attitude applied during the case illustration should be the provider’s stance when working from a culturally humble stance and is one of openness, empathy, self-aware-ness, respect, authenticity, humility (i.e., lack of superiority), and non-judgment (Hook et al., 2013). The case study highlights a client profile with multiple and intersecting identities as a biracial person of color and a transracially adopted person.

THE CASE OF CHARLESCharles is a 28-year-old transracially adopted person. He identifies as a Black and Latinx cisgender heterosexual male and his adoptive family identifies as White. Charles has struggled with alcohol use since he was a teenager. He was recently referred for court mandated substance use treatment after a second arrest for driving while intoxi-cated. In this example, the intake worker identifies as a White, cis-gender, lesbian woman, age 39 who is not adopted. The substance use treatment provider may demonstrate tenets of cultural humility by enacting the following:• The treatment agency ensures intake documentation includes ra-

cial and ethnic identities as well as adoption status to allow clients to self-identify. When the counselor notes Charles’ adoptive status they utilize the broaching strategy (Baden et al, 2017; Day-Vines et al., 2007; Jones & Welfare, 2017) to discuss the identity with him by using an open-ended question, such as “I noticed you indicated you are an adoptee. Please feel free to share how being adopted impacts your life,” or “Would you like to share with me as your treatment provider about being an adopted person or about any other identities?,” What would be helpful for me to know as we begin working together?,” “Would you like to discuss with me or ask me anything about my identities and how they may impact our work together?” The provider then follows up with, “If at any time during our work together you feel as though I am not understand-ing your perspective or who you are, please let me know and I am open to engaging in dialogue with you, as it is not my intention to overlook your experiences.”

• By initiating treatment with a broaching statement, the counselor demonstrated awareness of Charles’ adoptive status and other iden-tities as well as an openness to learn more about his life experiences. It is through the initial broaching that Charles shares his adoptive family is White while he identifies as Black/Latinx.

• Upon learning about Charles’ transracial adoptee identity, the provider conducts an honest self-critique and acknowledges that she has limited preparedness to fully address the unique treatment needs of Charles. Therefore, the provider seeks consultation to consider her capacity to provide quality, equitable, and culturally responsive treatment to Charles. The provider’s awareness of her own personal characteristics and achievements also fits within the cultural humility tenets.

• After this self-evaluation, the provider sought additional consul-tation and training to learn to address the unique substance use

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counseling needs of persons who identify as transracially adopted (Branco et al., 2020). For example, the provider reviewed coun-seling competencies specifically developed for members of the Transracial Adoption Kinship Network (Kenney et al., 2015) and reviewed counseling guidelines, such as Roszia and Maxon’s (2019) Seven Core Issues in Adoption and Permanency. The addi-tional preparation allowed the provider to move forward in a more informed way with Charles in treatment.

• Next, the provider follows another cultural humility tenet, to recog-nize one’s own imperfections, mistakes, and limitations, and assessed her possible biases related to transracial adoption and adoption in general as well as fully consider her limitations in assessing and providing treatment for Charles. This awareness was generated after the counselor fully examined her preconceived ideas related to adoption as well as stereotypes related to transracial adoption. In this instance, the provider considered what she had learned or heard about adoption being a mostly positive outcome for a child in need. She acknowledged that she had not necessarily consid-ered the other aspects, such as loss of connection to birth family members and culture inherent in transracial adoption and how this may impact clients.

• To continue with the previous tenet, the provider also addressed a microaggressive (Baden, 2016) comment she made when she suggested Charles must feel “grateful” to his adoptive family for his adoption. While the provider did not intend to microinvalidate Charles’ varied feelings surrounding his adoption status, she was able to recognize her comment related to stereotypical beliefs and myths surrounding adoption after she reviewed adoption compe-tency literature. This could be a possible alliance rupture. An al-liance rupture refers to missteps that occur in session that have a

corrosive effect (Davis et al., 2016). In this case, the microaggres-sion was a cultural misstep that could possibly negatively impact the therapeutic relationship. Cultural humility aids in repairing the working alliance by providing a corrective cultural experience. The provider initiated a repair with Charles at their next session where she admitted (i.e., cultural humility) her comment was a result of a lack of awareness and apologized for the dismissal of other pos-sible feelings Charles may have about his experience. The repair initiative demonstrated the provider’s willingness to learn about Charles’ experience.

• To continue the reparative process, the provider asked Charles to complete the Cultural Humility Scale (Hook et al., 2013) to signal her genuine interest in learning more about how Charles perceived her cultural humility in an effort to strengthen their counseling relationship. For this reason, the provider emphasized her recep-tiveness to Charles’ honest feedback. Charles completed the brief 12-question scale while in the waiting room before their session and the provider reviewed the results together. The review process held some uncomfortable moments for the provider, particularly when discussing questions, such as “thinks he/she/they under-stands more than he/she/they actually does” (Hook et al., 2013, p. 365). Ultimately, the assessment aided both parties. The provider and Charles developed strategies by which the provider could en-gage in more open-ended inquiry into his experience and Charles was encouraged to offer clarifications and explanations whenever possible to ensure he was fully heard and seen. Subsequently, the provider worked with Charles on adoption-related loss and grief and the myriad ethnic and racial identity challenges he faced as a Black Latinx person raised in a White family and mostly White community. These concerns were related to Charles’ substance use.

Openness

Ability to recognize one’s own imperfections, mistakes, and limitations

Willingness and ability to accurately assess one’s own personal

characteristics and achievements

Other-orientation

Figure 1: Cultural Humility Main Features

Attitude needed: openness, respect, humility, empathy, self-awareness,

authenticity, and non-judgment

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• As the provider aimed to maintain an other-orientation to Charles’ experiences, she was able to question, rather than assume, about Charles’ ability to access this information. She learned that Charles did not have readily available access to his birth family’s information and was not sure how to start the process. It was discovered that this was causing Charles great concern and contributed to some of the feelings underlying his substance use. Through a culturally humble approach, the provider was able to discover information about Charles that would have otherwise gone unnoticed. The provider was able to effectively advocate for and assist Charles to obtain his birth family medical history to better assess for heredi-tary factors relevant to his substance use.

• Ultimately, the provider maintained the culturally humility tenet of an other-orientation by continuously assessing her willingness (i.e., openness) and ability to bracket her own worldviews in order to fully absorb and situate herself in Charles’ worldview and to provide culturally sensitive and ethical substance use treatment and care. In other words, the provider committed to and enacted the philosophy that no one culture, belief system, or lived experi-ence is superior to another.

In the above example, the provider works to continuously and honestly evaluate her cultural humility by aligning with the core tenets of cultural humility. In practice, this is not a simple endeavor and requires transpar-ency, self-awareness, self-reflection, and consultation and supervision with other like-minded culturally humble practitioners. The following are guidelines for providers as they begin or enhance their work from a culturally humble stance with those impacted by substance use disorders. • Review the main features of cultural humility and identify those areas

that may be more easily enacted and those that may require more ef-fort. Reflect on growth areas and discern factors contributing to those tenets that may be easier to exemplify than others.

• Conduct an honest, critical analysis on oneself to identify biases, ste-reotypes, and reactions towards the different sociocultural identities. Be honest and acknowledge feelings towards the varying social identi-ties and sociopolitical issues that may impact a client. When working with clients diagnosed with a SUD or process addiction, it is important to reflect on thoughts and feelings concerning specific sociocultural

identities in relation to addiction. For example, women who are strug-gling with addiction are often stereotyped as selfish, promiscuous, and powerless (Anderson, 2008). Examine thoughts in relation to certain groups struggling with addiction.

• Increase self-awareness regarding one’s own sociocultural makeup and identities and the impact of those identities on one’s worldview and way of operating in society. Conduct a value inventory and plan out how to work through value conflicts. Reflect on one’s own iden-tities that are dominant versus those that are more recessive. Explore why some personal identities are more salient than others and how those identities situate oneself in society. Explore the privileges and disadvantages that result from personal aspects of identity. To under-stand the cultural world of others, one must recognize the impact of culture on oneself.

• Use the Cultural Humility Scale (Hook et al., 2013) to measure the level of cultural humility in the provider-client relationship and/or within each session. This instrument is a 12-item scale to be completed by the client. The Cultural Humility Scale can provide important feed-back to the provider as to what they may be doing well and in what ways improvements may need to be made. The results from the scale also allow dialogue to take place between the provider and the client.

• Do not make assumptions about clients based on their sociocultural group. Use that information to recognize that there may be cultural similarities and differences in the working relationship but treat each client as a unique individual with their own experiences within their sociocultural groups and their own experiences with substance use and/or process addiction. Remember it is not just about how they identify; it is about what that identity means to them, how it has im-pacted their life, and how they view the world. Use broaching to en-gage in intercultural dialogue concerning sociocultural identities of the client, the similarities and difference between the provider and client, the sociopolitical nature associated with the identities, and what the identities mean to and have impacted the client.

• Recognize that one does not have to be a diversity and/or social justice expert to work from a culturally humble stance. To practice cultural humility, one must only be open to and aware of the importance of culture and the concepts of power, privilege, marginalization, and oppression in society. Use respectful inquisitiveness, be self-aware, practice empathy and non-judgment, and approach clients from an authentic and respectful place (see Figure 1).

• Push through discomfort. Discomfort is a common and “normal” feeling for many as they apply cultural humility to their work. Dis-comfort is often a sign of growth and means that one is learning and pushing oneself outside their comfort zone. Stay in discomfort and seek supports to help navigate any challenging emotions.

The provider committed to and enacted the philosophy that no one culture, belief system, or

lived experience is superior to another.

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• Mistakes are inevitable! If a mistake is made, apologize to the client, acknowledge that what may have broken or strained the trust (i.e., rupture) in the provider-client relationship, work to rebuild trust (i.e., repair), seek feedback from the client and others, and work to grow and develop from the mistake. Owning a mistake demonstrates cul-tural humility. Research suggests that repairing a clinical rupture with a client can enhance the relationship (Davis et al., 2016).

• When working from a culturally humble stance becomes a challenge, remember that assessing for and including culture in addiction work leads to more effective treatment outcomes for clients, which is the ultimate treatment goal. Working with a cultural humble perspective allows providers to learn about the clients’ view of the world, addic-tion, treatment, and what, if any, recovery expectations they may have.

Addiction professionals are treatment providers to members of a di-verse and marginalized population; therefore, it is essential to employ cultural humility in this work. Ignoring the diverse needs of clients is ne-glectful and does not support effective treatment outcomes. A culturally humble approach requires providers to maintain the core tenets of open-ness, self-assessment, recognition of one’s own mistakes and limitations, and an other-orientation. Providers who strive to incorporate cultural humility in their work allow opportunities for treatment relationships to strengthen and withstand any ruptures that may arise along the course of treatment. In turn, clients receive culturally sensitive care and quality overall treatment services.

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Connie T. Jones, PhD, LCMHCA, LCAS, NCC, ACS, is an Assistant Professor in the Department of Counseling and Educational Development at The University of North Carolina at Greensboro (UNCG) in Greensboro, NC. Her areas of clinical research and teaching interests include addictions, broaching, and social justice. Jones is a past-president of the International Association of Addictions and Offender Counselors. She has a particular interest in the concept of cultural considerations in addiction treatment. Jones holds a Doctorate degree in Counselor Education and Supervision from Virginia Tech, a Master of Social Work from Virginia Commonwealth University, and a

Bachelor of Arts degree in Anthropology from the University of Virginia. 

Susan F. Branco, PhD, LPC, LCPC, NCC, ACS, BC-TMH, is a Clinical Assistant Professor with the Clinical Mental Health Counseling program at the Family Institute at Northwestern University. She maintained an independent practice for 14 years serving adoptive families and individuals and has authored multiple peer reviewed publications on transracial adoption. Branco received a Bachelor of Arts degree in Human Services, a Master of Education in Rehabilitation Counseling from the George Washington University, and a Doctor of Philosophy in Counselor Education and Supervision from Virginia Polytechnic Institute and State University. 

Ignoring the diverse needs of clients is neglectful and does not support effective

treatment outcomes.

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