Course Description:

The purpose of this course is to fulfill the new continuing education requirements in the Texas Administrative Code, RULE 681.140 (a) (1) regarding competency when providing services to distinct populations. This course examines some of the common attributes, traits, and defining characteristics of three population groups that most, if not all, Texas LPCs will serve.

Objectives:

After taking this course, pariticipants will be able to:

1. Identify at least three of their own personal biases, stereotypes, and assumptions related to African Americans, Asian Americans, and Hispanic Americans.

2. Explain at least three specific cultural nuances for each of the three distinct populations (African American, Asian American, and Hispanic American), covering topics such as communication styles, family structures, or help-seeking behaviors.

3. Describe how they would modify a standard therapeutic approach (e.g., CBT, motivational interviewing) to make it culturally appropriate and relevant for a client from one of the three distinct populations, providing at least two specific examples.

4. Identify at least four key steps from the course recommendations (e.g., engaging clients, obtaining distinct population-relevant information, selecting appropriate screening tools) and describe how they would implement them in a hypothetical client scenario.

5. Summarize at least three significant mental health or substance use disparities (e.g., misdiagnosis rates, access to care, overdose death trends) for one of the three distinct populations and explain two potential contributing factors based on the course materials.

Introduction:

The new Texas Administrative Code Rule 681.140 (a) (1) became effective for Texas LPCs on July 20, 2025. The new Rule changed the continuing education requirement of, “3 hours in cultural diversity or competency” to the following:

“3 hours designed to ensure competency when providing services to a distinct population, defined as a group of people who share a common attribute, trait, or defining characteristic of the licensee's choice.” TAC Rule 681.140 (a) (1)

According to the Texas Register, Preamble, the rationale for this change provided by BHEC on behalf of the LPC Board is as follows:

“…the rule change is designed to allow greater flexibility for a licensee to target the continuing education they believe will most enhance their competency based on the clients they choose to serve.”

The term, “Culture” is a broad concept that encompasses these more specific elements, using them as its building blocks. In essence, culture is the complete, interconnected system, while common attributes, traits, and defining characteristics are the specific features and components that make up that system. This course focuses on many of the common attributes, traits, and defining characteristics that comprise the African American, Asian American, and Hispanic American cultures.  

The populations that might share a common attribute, trait, or defining characteristic are incredibly diverse and can be defined in many different ways. Specific populations might be characterized by:

·         Demographic Characteristics: Age, gender, socioeconomic status, family status

·         Geographic Characteristics: location, climate/environment

·         Health and Medical Characteristics: Health conditions, Mental Health Disorders, Behavioral Patterns

·         Social and Cultural Characteristics: Race or ethnicity, language, religion, lifestyle/subculture.

·         Occupational Characteristics: Profession, employment status

·         Educational Characteristics: Level of education, enrollment status

Here are some key ways Texas LPCs can demonstrate competency with distinct populations:

1. Self-Awareness and Reflection

A competent counselor first recognizes their own cultural biases, values, and worldview. This is the foundation of cultural competence.

• Examine personal biases: Actively explore and acknowledge one's own prejudices, stereotypes, and assumptions about people from different backgrounds.

• Understand personal privilege: Recognize how their own race, gender, socioeconomic status, and other identities may have provided advantages or shaped their worldview.

• Acknowledge limitations: Be honest about the limits of their own knowledge and experience and be willing to seek consultation or make a referral when necessary.

2. Knowledge and Education

Competency requires a continuous effort to learn about the cultural contexts of clients.

• Learn about diverse groups: Study the historical, social, and political experiences of various minority groups, including the impact of oppression, discrimination, and systemic racism.

• Understand cultural nuances: Gain knowledge about the cultural values, communication styles, family structures, and help-seeking behaviors of the populations they serve. This includes understanding how mental health symptoms may be expressed differently across cultures.

• Stay current: Keep up with the latest research on the mental health challenges and strengths of specific minority groups.

3. Practical Skills and Application

Knowledge without action is not enough. Competent counselors translate their awareness and knowledge into effective practice.

• Tailor therapeutic approaches: Adapt counseling techniques and interventions to be culturally appropriate and relevant to the client's worldview. A one-size-fits-all approach is not effective.

• Promote a safe environment: Create a therapeutic space where clients feel safe, respected, and understood. This includes using inclusive language and demonstrating empathy for their unique experiences.

• Address issues of oppression: Be prepared to discuss and validate a client's experiences with racism, microaggressions, and other forms of discrimination as a part of their therapeutic work. Help clients develop a "critical consciousness" about these experiences.

• Advocacy: Go beyond the counseling room to advocate for social justice within their communities and institutions. This can mean challenging discriminatory policies, consulting with community leaders, or working to reduce barriers to mental healthcare for minority populations.

4. Continuous Learning and Humility

Competence is not a destination but a journey.

• Engage in ongoing training: Actively seek out professional development, workshops, and continuing education courses on multicultural counseling.

• Practice cultural humility: Maintain an attitude of curiosity and respect. Rather than claiming to be an "expert" on a client's culture, a competent counselor approaches each individual with a genuine desire to learn from them and understand their unique experience.

• Seek supervision and consultation: Consult with peers and supervisors who are also trained in multicultural competence to discuss cases and challenge their own assumptions.

By consistently applying these principles, a counselor can demonstrate the competency necessary to build trust, establish a strong therapeutic alliance, and provide truly effective and ethical services to clients from various backgrounds.

Recommendations for all Texas LPCs serving distinct populations served:

Step 1: Engage clients.

Because the intake meeting is often the first encounter clients have with the behavioral health system, it is vital that they leave the meeting feeling understood and hopeful. Counselors should try to establish rapport with clients before launching into a series of questions.

Step 2: Familiarize clients and family members with the evaluation and treatment process.

Often, clients and family members are not familiar with treatment jargon, the treatment program, the facility, or the expectations of treatment; furthermore, not all clients will have had an opportunity to express their own expectations or apprehension. Clinical and other treatment staff must not assume that clients already understand the treatment process. Instead, they need to take sufficient time to talk with clients (and their families, as appropriate) about how treatment works and what to expect from treatment providers.

Step 3: Endorse a collaborative approach in facilitating interviews, conducting assessments, and planning treatment.

Counselors should educate clients about their role in interview, assessment, and treatment planning processes. From first contact, they should encourage clients and their families to participate actively by asking questions, voicing specific treatment needs, and being involved in treatment planning. Counselors should allow clients and family members to give feedback on the distinct population relevance of the treatment plan.

Step 4: Obtain and integrate distinct population relevant information and themes.

By exploring distinct population relevant themes, counselors will better understand each client and will be better equipped to develop a culturally informed evaluation and treatment plan. Areas to explore include immigration and migration history, cultural identity, acculturation status, health beliefs, healing practices, and other information culturally relevant to the client.

Step 5: Gather distinct-population relevant collateral information.

Such information is a powerful tool in assessing clients’ presenting problems, understanding the influence of cultural factors on clients, and gathering resources to support treatment endeavors. By involving others in the early phases of treatment, providers will likely obtain more external support for each client’s engagement in treatment services. Counselors can obtain supplemental information (with client permission) from family members, medical and court records, probation and parole officers, community members, and so on.

Step 6: Select distinct-population appropriate screening and assessment tools.

In selecting evaluation tools, counselors should note the availability of normative data for the populations to which their clients belong, the incidence of test item bias, the role of acculturation in understanding test items, and the adaptation of testing materials to each client’s culture and language.

Step 7: Determine readiness and motivation for change.

Although few studies focus on the use of motivational interviewing with specific cultural groups, its theories and strategies may be more appropriate for most clients than other approaches. Through reflective listening, motivational interviewing focuses on helping clients explore ambivalence toward change, decisions, and subsequent treatment.It is a nonconfrontational, clientcentered approach that reinforces clients as the experts on what will work and supports the key idea that change is a process.

Step 8: Provide distinct-population responsive case management.

Many core competencies for counselors are also relevant to case managers. Like counselors, case managers should possess cultural self-knowledge and a basic knowledge of other cultures. They should possess traits conducive to working well with diverse groups and the ability to apply cultural competence in practical ways. Case management includes the use, as necessary, of interpreters who can communicate well in the specific dialects spoken by each client and who are familiar with behavioral health vocabulary relevant to the specific behavioral health setting in which service provision will occur. Case managers should acquire cultural and community knowledge to assist with the coordination of social, health, and other essential services and to secure distinct population relevant services in and outside the treatment facility. Case managers should also keep a list of distinct population appropriate referral resources to help meet client needs.

Step 9: Integrate cultural factors into treatment planning.

Counselors should be flexible in designing a treatment plan to meet the cultural needs of clients and should integrate traditional healing practices into treatment plans when appropriate, using resources available in the clients’ cultural communities. Treatment goals and objectives need to be distinct population relevant, and the treatment environment must be conducive to client participation in treatment planning and to the gathering of client feedback on the cultural relevance of the treatment being provided.

African Americans

Surveys and questionnaires, such as the Pew Research Center and Gallup, offer valuable insights into the lifestyles, attitudes, and challenges of African Americans. These studies often focus on cultural identity, social issues, and personal well-being, providing a more nuanced picture than what is typically available through demographic data alone.

Social and Cultural Life

• Racial Identity and Community: Research consistently shows that race is a central part of identity for many Black Americans. A Pew Research Center survey found that most Black adults believe that U.S. institutions were designed to hold Black people back, reflecting a deep-seated awareness of systemic inequality.

• Spirituality and Religion: The Black church remains a powerful force in African American communities, serving as a hub for social, political, and spiritual life. Surveys indicate that religious and spiritual practices are significant sources of joy and fulfillment for a majority of Black adults.

• Views on Discrimination: The majority of Black adults (around 79%) report having personally experienced discrimination due to their race or ethnicity. This experience is often cited as a major barrier to progress and a significant source of stress.

Economic and Personal Well-being

• Happiness and Finances: A 2023 Pew Research Center survey found that while most Black adults are at least "somewhat happy," there's a strong correlation between income and happiness. Black adults in upper-income families are about twice as likely as those in lower-income families to report being "extremely or very happy."

• Sources of Joy: The same survey revealed that Black adults find a great deal of joy in spending time with family and friends, their spiritual or religious practices, and traveling. However, joy from activities that cost money, like traveling or the arts, is more common among those with higher incomes.

• Defining Success: For many Black Americans, personal success is defined by more than just financial achievements. In addition to being debt-free and having enough money, a majority also cite personal happiness, having a job they enjoy, and using their talents to help others as essential to their definition of success.

Health and Healthcare

• Health Disparities: Research from organizations like KFF (Kaiser Family Foundation) highlights persistent health disparities. Black people have a shorter life expectancy than White people and are more likely to die from heart disease and cancer.

• Trust in Healthcare: A significant number of Black adults report feeling they need to be "very careful" about their appearance to be treated fairly during healthcare visits. This finding points to a broader issue of mistrust and the impact of perceived bias within the healthcare system.

• Mental Health: The National Survey of American Life (NSAL) is a major non-census research effort that provides a detailed look at the mental health of African Americans. While the overall picture is complex, some studies show that rates of serious mental disorders are comparable to, or even lower than, those of White Americans, but the level of unmet need for mental health care is substantially higher.

As of August, 2025, the U.S. Census Bureau defines "Black or African Americans" as a person whose origins are "in any of the Black racial groups of Africa." The term is used to describe a diverse population, including those descended from enslaved Africans in the U.S. as well as more recent immigrants from Africa, the Caribbean, and Central and South America.

The 2020 Census made changes to how it collects and processes race and ethnicity data, which led to a more nuanced view of the population. For the first time, the census included a write-in area for respondents who selected "Black or African American" to provide more detail about their specific origins, such as "African American," "Nigerian," "Haitian," or "Somali."

Key statistics from the 2020 Census related to the Black or African American population include:

·         Total Population: In 2020, 46.9 million people identified as Black or African American, either alone or in combination with one or more other races. This represents about 14.2% of the total U.S. population.

·         Detailed Groups: The most common detailed response was "African American," with over half of all Black respondents providing this as their detailed identity.

·         Sub-Saharan and Caribbean Groups: The combined Sub-Saharan African and Caribbean regional groups made up more than 10% of the Black population. The largest groups within these categories were Nigerian, Ethiopian, Jamaican, and Haitian.

·         Geographic Concentration: Over half of the nation's Black population lives in the South. The states with the largest African American populations are Texas, Georgia, and Florida. Caribbean groups are highly concentrated in states like Florida and New York.

Mental and Co-Occurring Disorders

A number of studies have found biases that result in African Americans being overdiagnosed for some disorders and underdiagnosed for others. For instance, Black adults are less likely than White adults to receive treatment for anxiety and mood disorders, but they are more likely to receive treatment for drug use disorders.

A key issue is the misdiagnosis of mental health conditions. Black individuals are more likely to be diagnosed with schizophrenia and less likely to be diagnosed with affective disorders like depression, even though the rates of these disorders are comparable across these populations. Studies indicate that clinician bias in symptom evaluation is a likely factor. For example, some research has found that Black patients are more likely to be misdiagnosed with schizophrenia when their symptoms are indicative of a mood disorder.

Black adults are twice as likely as White adults to report serious psychological distress and, in some cases, have higher rates of certain conditions. Data from the Centers for Disease Control and Prevention (CDC) shows that the rate of mental health-related emergency department visits is highest among non-Hispanic Black adults at 96.8 visits per 1,000 adults, compared to 53.4 for non-Hispanic White adults. This highlights a reliance on emergency care, rather than routine mental health services.

Trauma exposure and its link to mental health are also a significant concern. The prevalence of posttraumatic stress disorder (PTSD) is higher in some Black communities. Research suggests that racial trauma is a contributing factor, with Black people in some communities having a higher rate of PTSD (8.7%) compared to White people (7.4%). Black youth are also at a higher risk, with nearly 65% of African American youth reporting traumatic experiences, compared to 30% of their peers from other ethnic groups. Trauma history can also have a greater effect on relapse for African American clients with substance use disorders.

Access to mental health treatment remains a major disparity. Only about 25% of African Americans seek mental health treatment, compared to 40% of White Americans. In 2020, 10.4% of Black adults in the U.S. had no health insurance, compared to 5.2% of non-Hispanic White adults, creating a significant barrier to care. Even when Black individuals do receive mental health care, it is more likely to be of poorer quality. One study found that physicians were 33% less likely to engage in patient-centered communication with Black patients than with White patients. A lack of diversity in the mental health workforce is also a factor, as only 4% of psychologists in the U.S. are Black.

Limited research also indicates differences in mental health needs and diagnoses among various groups of Black people. For example, Black immigrants may be less likely to be diagnosed with mental disorders than Black people born in the United States, but research suggests that cultural responses and rates of disorders can still vary and may not be solely a reflection of acculturation.

Treatment Patterns

Mental Health Services

While the prevalence of mental illness is similar across many racial and ethnic groups, there are notable disparities in the use of mental health services.

• Service Utilization Rates: Data from 2019-2021 shows a significant gap in mental health treatment. Among adults aged 18-44, non-Hispanic White adults were the most likely to have received any mental health treatment, with a rate of 30.4% in 2021. In comparison, the rate for non-Hispanic Black adults was 14.8% in the same year.

• Barriers to Care: Cost and lack of insurance remain significant barriers. As of 2023, among adults with fair or poor mental health, 39% of Black adults and 36% of Hispanic adults reported receiving mental health services in the past three years, compared to 50% of White adults. A 2023 survey found that Black and Hispanic adults were more likely than their White counterparts to report difficulties in finding a provider who could understand their background and experiences.

• Types of Services: African Americans are less likely to receive care from mental health specialists and are more likely to seek services from general practitioners. Additionally, inpatient mental health service utilization is higher among Black adults (1.5%) compared to Hispanic (1.0%), White (0.8%), and Asian (0.6%) adults.

• Misdiagnosis: Research indicates that Black and Latino children with symptoms of anger, sadness, and thoughts of death are more likely to be diagnosed with conduct disorder or oppositional defiance disorder, while White children with similar symptoms are more likely to be diagnosed with depression.

Beliefs About and Traditions Involving Substance Use

In many African American communities, beliefs about and traditions involving substance use are complex and multifaceted, reflecting a history of both strong cultural norms and oppression.

Significant alcohol or drug use is often socially unacceptable or viewed as a sign of personal weakness. This perspective is rooted in cultural and religious traditions that promote self-control, community responsibility, and abstinence (Borker, Hembrey, & Herd, 1980; Klein, Elifson, & Sterk, 2006). This social disapproval can act as a protective factor, contributing to lower rates of alcohol use and binge drinking compared to other populations (Caetano, 1997).

However, current research adds a crucial layer to this understanding by highlighting the role of systemic factors. Many African Americans may have difficulty accepting the "disease model" of addiction due to a historical mistrust of medical institutions and a preference for viewing substance use as a matter of personal responsibility and will (Okamoto et al., 2014). This perspective is often tied to the disproportionate criminalization of drug use in Black communities, which has historically framed addiction as a moral failing rather than a public health issue (American Society of Addiction Medicine, 2021).

Furthermore, socioeconomic factors and the chronic stress of racism and discrimination are increasingly recognized as primary drivers of substance use disorders. Research shows that individuals may turn to substances as a coping mechanism to manage feelings of marginalization, economic hardship, and hopelessness (Fernander & Schumacher, 2008; Purnell et al., 2019). While the prevalence of substance use may be similar or even lower than in some other groups, African Americans often experience a disproportionately higher burden of negative health, social, and legal consequences ("less drinking, yet more problems"). Access to culturally competent and affordable treatment remains a significant barrier, and a history of racial bias in the healthcare system continues to influence treatment engagement and recovery outcomes (American Society of Addiction Medicine, 2021; Williams et al., 2012).

1. Social Unacceptability and Personal Responsibility:

• Recent research largely supports the premise that substance use is often socially disapproved of in many African American communities.

• Studies point to strong cultural and religious norms that promote abstinence or moderate use and frown upon intoxication. These norms can act as protective factors against heavy drinking and drug use.

• The concept of personal responsibility remains a significant factor in how substance use is perceived. This is often intertwined with cultural norms that emphasize self-control and community responsibility. However, this is a complex issue, as new research highlights how structural factors like racism and socioeconomic stress significantly influence substance use patterns.

2. The "Disease Model" and Treatment Acceptance:

• The original text (SAMHSA TIP 59 from 2014) suggests a difficulty in accepting the "disease model" of addiction. Newer research provides a more nuanced view.

• While mistrust of a "disease" narrative can persist, it is often tied to a broader, historical mistrust of medical and governmental institutions. This mistrust is a response to systemic issues, such as the disproportionate criminalization of drug use in Black communities and a history of substandard medical care.

• Newer studies show that African Americans are more likely to seek and enter specialty treatment for substance use problems than the general population, suggesting that the "disease" model is not uniformly rejected. The challenge is not necessarily in accepting the disease model itself, but in overcoming historical and systemic barriers to accessing effective, culturally competent care.

3. The Role of Socioeconomic Factors and Racism:

• This is a major area of expansion and clarification since the original text's publication. The original text only briefly mentions "limited resources." Current research explicitly identifies racism, discrimination, and socioeconomic status (SES) as primary drivers of substance use and its related health disparities.

• Studies show that chronic stress from racial discrimination and financial difficulties can be a direct predictor of alcohol and drug use, as individuals may use substances to cope with feelings of marginalization, frustration, and hopelessness.

• The "minorities' diminished returns" theory suggests that educational attainment and other markers of SES may have a smaller protective effect against substance use for African Americans compared to their white counterparts, due to racism.

• The high rates of incarceration for drug offenses and a lack of access to quality, culturally sensitive treatment are identified as significant barriers to recovery.

4. Substance Use Patterns:

• Current data shows that while African Americans have lower rates of alcohol use and binge drinking compared to white Americans, they often experience a disproportionately higher rate of negative health consequences (e.g., liver disease, HIV/AIDS) and legal problems at similar or even lower levels of use. This phenomenon is referred to as "less drinking, yet more problems."

• There are also distinct patterns in drug use. For example, some studies find higher rates of illicit drug use overall, particularly marijuana, while lifetime cocaine use may be lower than in white populations. There is also a more rapid progression from initial use to addiction for certain substances ("telescoping effect") for some African Americans, which is linked to socioeconomic factors.

Substance Use and Substance Use Disorders

The landscape of substance use and substance use disorders (SUDs) in the United States continues to evolve, with recent data highlighting significant differences across various groups, including by race and ethnicity, age, and gender. While the original article provided a valuable overview based on older data, updated references from sources such as the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Disease Control and Prevention (CDC) offer a more current and detailed picture.

Research continues to show that patterns of substance use and the prevalence of SUDs vary significantly among racial and ethnic groups. For instance, the 2022 National Survey on Drug Use and Health (NSDUH), a key source of data on this topic, reveals that:

·         Illicit Drugs: In 2022, 21.3% of non-Hispanic Black people aged 12 or older reported using illicit drugs in the past year, compared to 20.3% of non-Hispanic White people. The highest rates were seen in people identifying as American Indian/Alaska Native (30.1%) and those of two or more races (27.2%).

·         Marijuana: Past-year marijuana use was reported by 17.6% of non-Hispanic Black people aged 12 or older, compared to 16.6% of non-Hispanic White people.

·         Opioid Misuse: In 2022, non-Hispanic Black people and those of two or more races had the highest rates of opioid misuse in the past year, at 4.1% and 4.5% respectively, compared to 3.0% for non-Hispanic White people.

·         Substance Use Disorders: People identifying as two or more races (17.3%) and American Indian/Alaska Native people (16.4%) had the highest rates of past-year SUDs in 2022. Rates were 14.3% for non-Hispanic Black people and 13.5% for non-Hispanic White people.

The "crossover effect" previously described—whereby Black youth are less likely to use substances than their White counterparts, but rates become comparable in adulthood—has been a focus of ongoing research. Recent data suggests that this pattern may still be present for certain substances and age groups, but the overall picture is more complex and influenced by a variety of socioeconomic factors. As noted in the original article, systemic issues like lower income and education levels are still considered major contributors to substance use patterns among Black adults.

In terms of alcohol use, the 2022 NSDUH reported that non-Hispanic White people had the highest rates of past-month alcohol use (52.2%) and binge drinking (26.3%) among people aged 12 or older, while non-Hispanic Black people had rates of 45.4% and 21.0% respectively. Heavy alcohol use was also highest among non-Hispanic White people at 6.6%, compared to 4.2% for non-Hispanic Black people.

One of the most dramatic and concerning updates is in the area of overdose deaths. While the article noted a decline in heroin-related treatment admissions for Black individuals, recent data indicates a troubling and sharp increase in overdose deaths in this group. According to a Pew Research Center analysis, drug overdose death rates among Black men have more than tripled between 2015 and 2020, rising by 213%. This increase has positioned Black men and American Indian/Alaska Native men as the demographic groups most likely to die from overdoses, surpassing White men. This surge is largely attributed to synthetic opioids, such as fentanyl, which have been a primary driver of the overall overdose crisis.

Disparities in health outcomes also persist. The original article mentioned that Black individuals, despite appearing less likely to develop alcohol use disorders, experience higher rates of certain alcohol-related health problems. This remains a critical issue, often tied to disparities in access to and quality of healthcare, which can affect the progression and treatment of various health conditions, including SUDs. The continued need for culturally and linguistically effective care models is a key area of focus for researchers and public health officials.

Substance Abuse Services

Disparities in substance abuse treatment also persist, affecting access, completion rates, and types of services received.

• Treatment Rates: While some studies have found similar rates of substance use disorder (SUD) treatment seeking between African Americans and White Americans, there are also reports of disparities. One analysis found that among individuals who needed treatment for illicit substance use disorders, White individuals received treatment 23.5% of the time, compared to 18.6% of Black individuals and 17.6% of Hispanic individuals.

• Treatment Completion: Research has shown that African American and Hispanic patients are less likely to complete publicly funded alcohol treatment programs compared to White patients. For example, roughly half of Black and Hispanic patients complete treatment, compared to 62% of White patients. This disparity is often linked to socioeconomic factors such as unemployment and housing instability.

• Criminal Justice System Involvement: African Americans are overrepresented in the criminal justice system. A 2022 study found the imprisonment rate for Black adults was nearly 6 times the rate for White adults. Within the correctional system, African Americans with substance dependence disorders are less likely to participate in substance abuse treatment while incarcerated.

Intersection of Mental Health and Substance Abuse

• Co-Occurring Disorders: Among adults with a co-occurring substance use disorder and any mental illness, a study found that past-year mental health service use without specialty substance use treatment was higher among White adults (43.2%) than among Black (28.6%) and Hispanic (26.9%) adults. This suggests that White adults with co-occurring disorders are more likely to receive mental health-specific care.

Beliefs and Attitudes About Treatment

According to the 2022 NSDUH, 54.2 million people aged 12 or older were classified as needing substance use treatment in the past year, but only a fraction of those received it.

African Americans, like other racial and ethnic minorities, are less likely to receive mental health and substance use treatment compared to white individuals. The 2021 NSDUH found that among Black and African Americans who reported a mental health concern, only 39% received services, compared to 52% of non-Hispanic white individuals.

A lack of perceived need for treatment is a factor across all groups, but logistical and systemic barriers also play a significant role.

Barriers to Treatment

Data indicates that cost and lack of insurance coverage are the most frequently cited reasons for not using mental health services across all racial and ethnic groups. However, other significant barriers exist and can disproportionately affect certain communities.

For example, African Americans and other minority groups often face challenges rooted in historical and ongoing mistrust of the healthcare system.

• Discrimination and Mistrust: A 2024 report from the Commonwealth Fund found that 47% of healthcare workers have witnessed discrimination against patients, and 52% believe that racism against patients is a crisis or major problem. This historical context of bias, from past events like the Tuskegee syphilis experiment to contemporary experiences of racial trauma, contributes to a well-documented apprehension about seeking care.

• Cultural Stigma: Stigma surrounding mental health and substance use treatment is a widespread issue, but it can be compounded in minority communities by cultural factors and a persistent belief that treatment services are not culturally congruent.

• Access to Culturally Competent Care: A lack of representation among providers can be a barrier. For instance, in 2024, only 4% of psychologists in the U.S. were Black. This can make it difficult for individuals to find a provider who understands their cultural context and experiences. Studies have shown that when clinicians have more experience with diverse cultural groups, client outcomes improve.

Treatment and Outcomes

While there are disparities in who seeks and receives treatment, there is evidence that when African American clients do engage in treatment, they are as likely to continue participation as members of other groups. This highlights the importance of initial engagement and culturally responsive care.

Strategies such as motivational enhancement therapy, when adapted to be culturally relevant, can be effective in addressing ambivalence about treatment and improving engagement and retention among African American clients. These approaches focus on building motivation for change and fostering a collaborative, non-judgmental relationship between the client and the provider.

Treatment Issues and Considerations

Building a strong therapeutic relationship with African American clients often involves an approach that is both egalitarian and authentic. This approach is rooted in the understanding that historical and ongoing experiences of racism and discrimination can lead to a fundamental distrust of systems and individuals, including those in the healthcare and mental health fields.

Establishing a Collaborative and Trusting Relationship

• Pacing and Gradual Information Gathering: Counselors should develop a collaborative relationship, requesting personal information gradually. This is in contrast to a more interrogative, rapid-fire approach to data-gathering, which can be perceived as an interrogation and may erode trust.

• Credibility and Cultural Competence: Counselors must establish credibility by demonstrating an understanding of the unique challenges faced by African Americans. This includes being aware of their own biases and having knowledge of the historical and current sociocultural experiences of various racial groups. Studies have shown that when working with clients of color, a therapist’s multicultural counseling competence is a critical factor.

Addressing Race and Racism

• Validating Experiences: It is crucial for counselors to be willing to address the issue of race and validate the client's experiences of racism and its reality in their lives. This includes acknowledging that the client's experiences may differ from their own and avoiding a "colorblind" approach, which can be seen as dismissive. In a study of African American clients' perceptions of their White counselors, expressions of more subtle racist attitudes were predictive of a weaker therapeutic alliance.

• Psychological Effects: Racism and discrimination can lead to feelings of anger, anxiety, and depression. These feelings are often pervasive, rather than specific to a single event. Counselors should explore the psychological effects of racism with clients. Research has linked experiences of racial discrimination with negative mental health outcomes, including higher rates of depression, anxiety, and hopelessness.

• Racial Trauma: The experience of racism can be a form of racial trauma, with symptoms comparable to PTSD. For example, some researchers believe that racial trauma contributes to the fact that African Americans have higher rates of PTSD (8.7%) compared to White people (7.4%). Additionally, nearly 65% of African American youth report traumatic experiences, compared to 30% of their peers from other ethnic groups.

Empowerment and Strengths-Based Approaches

• Focus on Strengths: Interventions that promote empowerment by emphasizing strengths rather than deficits are often more effective. Counselors should explore the personal, community, or family strengths that have helped clients through difficult times.

• Peer-Supported Interventions: Peer-supported interventions and the use of community-based resources can also be highly effective. The reliance on family, community, and spiritual support is a common and important element in many African American communities. This is partly due to a higher level of mistrust of the healthcare system, with statistics showing that only about 25% of African Americans seek mental health treatment, compared to 40% of White Americans. Unequal access to health care is a major contributor to this disparity, as nearly 10% of Black people in the U.S. do not have health insurance, compared to 5.2% of non-Hispanic White people.

• Family and Community Strengths: Strengths of African American family life can include strong bonds and kinship, adaptability of family roles, a strong family hierarchy, a strong work orientation, a high achievement orientation, and a strong religious orientation. Tapping into these resources can be a powerful way to support a client's recovery efforts.

Theoretical Approaches and Treatment Interventions

Culturally congruent interventions have been shown to be effective in treating substance use disorders among African Americans. These interventions often incorporate core African American values, such as communalism, to address how an individual's substance use affects their community. Some approaches also use African American music, artwork, and food to create a welcoming and familiar atmosphere in clinical settings.

Here is an updated summary of theoretical approaches and treatment interventions, with a focus on specific findings for African American clients:

·         Motivational Interviewing (MI): While research on MI's effectiveness among African American clients has yielded some conflicting results, some studies have shown promise. One study found that MI may be less effective for smoking cessation induction in African American smokers compared to their White counterparts, but this difference could be accounted for by factors like baseline relationship status and preference for a more directive counseling approach. Another study suggested that Motivational Enhancement Therapy (a form of MI) may be more effective for African American clients with higher readiness to change.

·         Node-Link Mapping: This intervention, which uses visual diagrams to improve client-counselor communication, has been found to be particularly effective for African American and Latino clients. One study found that this approach was associated with lower rates of substance use, better treatment attendance, and better counselor ratings of motivation and confidence among African Americans compared to White Americans.

·         Cognitive-Behavioral Therapy (CBT): CBT is generally effective for a wide range of mental health and substance use disorders and has distinct advantages for African American clients, as it fosters a collaborative relationship. In a study of mostly African American (80%) homeless men, CBT was found to achieve significantly better abstinence outcomes than 12-Step facilitation, except for those who were very religious, who had better outcomes with the 12-Step program.

·         Contingency Management (CM): A number of studies have evaluated CM with predominantly African American client populations. CM has been effective at reducing cocaine and opioid use and improving employment outcomes for clients in methadone maintenance. However, one study found that CM was not as effective in reducing drug use among African American patients who initiated treatment with a positive cocaine sample compared to White patients in a similar situation.

·         Supportive-Expressive Psychotherapy: This form of therapy has been evaluated with African American clients and was found to be effective in reducing substance use and improving psychological functioning, particularly for those in methadone maintenance treatment.

·         Medication-Assisted Treatment:

o    Methadone: Studies have shown that African Americans are more likely than Latinos or White Americans to report that they found methadone helpful. Additionally, African American participants in a methadone program had significantly fewer adverse medical events (e.g., infections, gastrointestinal complaints) than White American participants. While African Americans are more likely to receive methadone for opioid use disorder compared to White patients, they are less likely to receive buprenorphine.

o    Disulfiram: In a study of cocaine-dependent individuals, African Americans who received disulfiram remained in treatment significantly longer than other African Americans in the study.

·         Gender-Specific Treatment: Research suggests that there are biological, social, and cultural differences in substance use patterns and treatment needs between men and women. For instance, women tend to enter treatment sooner after becoming substance dependent compared to men, but they often present with more co-occurring mental health disorders. Gender-specific programs are designed to address these unique needs, such as creating a safe space for women to discuss trauma and providing men with treatment methods that address specific thought patterns and behaviors.

Family Therapy

African American clients often maintain strong family connections, which can be a valuable resource in addiction treatment. Research, such as a study by Bourgois et al. (2006), has indicated that African Americans who inject heroin may be more likely to stay in touch with their extended families compared to their White American counterparts. Furthermore, some studies suggest a higher prevalence of substance abuse histories among family members of African American clients with substance use disorders (Brower and Carey 2003), underscoring the critical need to address substance abuse within a family context.

Given the importance of strong family bonds in African American culture, counselors should adopt a flexible and expanded definition of "family." This includes biologically related individuals as well as those considered "like family." Counselors should ask clients to identify whom they consider family, who lives with them, and who they rely on for support (Hines and Boyd-Franklin 2005). Building a recovery support network for African American clients involves asking them to identify individuals—regardless of biological relation—who are willing and able to help, and then seeking permission to involve these individuals in the treatment process.

Family therapy is a highly effective approach for African American clients (Boyd-Franklin 2003; Hines and Boyd-Franklin 2005). However, because extended family networks can be extensive and deeply embedded in the community, therapists may need to take on additional roles, such as case management, and incorporate community-wide interventions into their work (Sue 2001). The multisystem family therapy approach, which considers social services and other community agencies as part of the family system, is a model that is particularly well-suited for African American families (Boyd-Franklin 2003). Network therapy, which involves a client's extended social network, has also been shown to improve substance use outcomes for African American clients when used in conjunction with standard treatment (Keller and Galanter 1999). Similarly, the family team conference model is another useful strategy, as it mobilizes extensive support from both formal and informal relationships within and around the family (State of New Jersey Department of Human Services 2004).

For African American youth, specific family therapy models have been studied. Brief structural family therapy and strategic family therapy have been found to reduce substance use in this population (Santisteban et al. 1997; Santisteban et al. 2003; Szapocznik and Williams 2000). Multidimensional family therapy has also been shown to increase abstinence from substance use among African American adolescents, with more lasting effects than cognitive-behavioral therapy (Liddle et al. 2008). While the majority of research has focused on youth, there are promising interventions for adults as well. A family therapy intervention for African American families in public housing that included psychoeducation and a strength-based approach showed promising preliminary results, with a high treatment completion rate and positive recovery outcomes for a majority of participants (Larkin 2003).

Another family-oriented program, "Engaging Moms," was developed specifically for African American mothers who use cocaine. This intervention focuses on mobilizing family members to motivate mothers to enroll in and remain in treatment (Dakof et al. 2003). While long-term impact has not been shown, the program significantly increased treatment entry and initial retention, with 88% of women in the program entering treatment compared to 46% of the control group.

Group Therapy

For many African Americans, the collective, cooperative values often prevalent in their communities can make group therapy a particularly effective component of the treatment process. This is often supported by a strong oral tradition, which makes speaking in a group setting more comfortable and acceptable. However, it's important to recognize that not all Black communities share the same values regarding therapy and self-disclosure. For example, some research suggests that Black Caribbean Americans may be less comfortable with the requirement to self-disclose personal problems to relative strangers in a group setting (Bibb & Casimer, 2000).

When it comes to group composition, studies have shown that African Americans may be less likely to self-disclose about their past in group settings that include non-Hispanic White individuals (Richardson & Williams, 1990; Johnson et al., 2011). As a result, groups composed solely of African Americans can be more beneficial. These homogeneous groups can also provide a safe space to address systemic issues such as racism and a lack of economic opportunities, which are significant stressors in the African American community (Jones et al., 2000).

According to a 2023 survey by KFF, among adults who report fair or poor mental health, 39% of Black adults and 36% of Hispanic adults had received mental health services in the past three years, compared to 50% of White adults. This same survey found that 46% of Black adults and 55% of Asian adults reported difficulty finding a provider who could understand their background and experiences, a challenge reported by 38% of White adults.

Some researchers, such as Sue and Sue (2013), have emphasized the importance of developing cultural competence in mental health professionals to ensure that treatment is effective and does not pathologize or alienate minority clients. This includes being aware of how cultural values and beliefs influence how psychological distress is expressed and how individuals seek help.

Mutual Help Groups

A variety of mutual-help groups are available for African Americans. While the literature has historically focused on 12-Step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), there are now more diverse options, including culturally specific, faith-based, and peer-led groups. Some African Americans may still find that the concept of "powerlessness" in the traditional 12-Step model is difficult to reconcile with their experiences of discrimination and historical disempowerment, and some community-based groups have modified the model to be more empowering.

Concrete Numbers and Statistics

• AA Membership: The most recent available data from the AA 2022 U.S./Canada Membership Survey indicates that 8% of its members identify as Black or African American. This is an increase from the 4% reported in their 2011 survey.

• Substance Use Disorder Treatment: According to the 2021 National Survey on Drug Use and Health (NSDUH), a higher percentage of American Indian or Alaska Native people (27.6%) and multiracial people (25.9%) had a substance use disorder in the past year compared with Black or African American (17.2%), White (17.0%), Hispanic or Latino (15.7%), or Asian people (8.0%).

• Treatment Utilization: The same 2021 NSDUH report shows that among adults with a past-year major depressive episode, Black or African American adults (51.0%) were less likely to have received treatment for depression than White adults (64.0%). Similarly, among adults with any mental illness, Black or African American adults (39.4%) were less likely to have received mental health services than White (52.4%) or multiracial (52.2%) adults.

• Treatment Completion: A study using national data found that Black and Hispanic individuals were 3.5% to 8.1% less likely than White individuals to complete treatment for alcohol and drugs.

Participation and Engagement in 12-Step Programs

Some research suggests that African Americans who attend 12-Step programs have higher levels of affiliation than White Americans in the same programs. However, they may be less likely to have a sponsor or to read program materials. Other studies have found that African Americans are more likely to express comfort with sharing in meetings and to report a spiritual awakening as a result of their participation.

For African Americans who consider themselves religious, mutual-help groups, particularly those with a spiritual component, can be particularly effective. Research has found that highly religious individuals with alcohol-related problems did significantly better with 12-Step facilitation compared to cognitive behavioral therapy (CBT).

Other Mutual-Help Groups

Beyond 12-Step programs, other mutual-help options for African Americans include faith-based programs and groups that address the unique challenges faced by those transitioning from correctional institutions. The Nation of Islam, for example, has been involved in successful recovery efforts, particularly for incarcerated individuals. Additionally, a growing number of community-based and online groups specifically serve Black, Indigenous, and people of color (BIPOC) communities to address mental health and substance use in a culturally affirming way.

Traditional healing and complementary methods

While there are studies that have shown African Americans are less likely to use popular alternative or complementary healing methods than White Americans or Latinos, other research has found that African Americans have a high prevalence of complementary and alternative medicine (CAM) use, with some studies showing a higher rate than White patients. For example, one study found that patients of African descent had a higher rate of CAM use (72.73%) compared to White patients (63.53%).

African American culture has a long history of healing traditions, including herbal remedies and root medicines. Psychological and substance abuse issues may be viewed as having spiritual causes that can be addressed by traditional healers or religious practices.

A strong connection to religion and spirituality is a significant factor in health and wellness for African Americans. A 2024 Pew Research Center report found that while there has been a general decline in Christian identification across racial groups, 73% of Black Americans identified as Christian. In 2024, Black Americans represented 13% of all American Christians. Most Black Americans who are Christian are affiliated with historically Black churches, with Baptists and African Methodist Episcopal churches having the largest percentages. A growing number of African Americans are converts to Islam, and many recent immigrants from Africa are also Muslim.

Research has also highlighted the role of religion and spirituality in coping with health problems. A 2016 survey of individuals with mental health conditions and their family members found that 88% of African Americans agreed or strongly agreed that faith is an essential component of their or their family member's wellness. A 2019 study also reported that 90.4% of African Americans use religious coping to deal with mental health issues. Furthermore, a 2022 study on cardiovascular health in African Americans found that more frequent participation in religious activities and a deeper sense of spiritual beliefs were linked to a higher likelihood of meeting key health metrics.

Relapse prevention and recovery

Research on relapse prevention and recovery for African Americans has highlighted several key findings, emphasizing the importance of culturally specific interventions and the impact of systemic factors.

Disparities in Treatment and Outcomes

·         Treatment Completion: African Americans often face disparities in substance use disorder (SUD) treatment completion. Studies have shown that Black adults and older adults are less likely to complete treatment programs compared to their White counterparts. For example, a study using the Treatment Episode Data Set found a 40% completion rate for Black participants, significantly lower than the 50% rate for White participants.

·         Access to Care: Despite similar or even lower rates of substance use compared to White individuals, African Americans are more likely to have a need for treatment that goes unmet. When they do seek care, they may be less likely to receive certain evidence-based treatments, such as medication for opioid use disorder (OUD). Studies have shown that Black patients are significantly less likely to receive buprenorphine prescriptions compared to White individuals.

·         Delayed Treatment Entry: Research suggests that African Americans tend to enter treatment later in their addiction process compared to White individuals. This delay may be influenced by socioeconomic factors and a greater mistrust of the medical system, which can be rooted in historical and ongoing experiences with discrimination.

The Role of Continuing Care

·         Effectiveness: Research consistently shows that continuing care interventions—less intensive treatment following an initial, more intensive phase—are beneficial for sustained recovery. This is particularly relevant for African Americans, who have been found to be responsive to and more likely to participate in continuing care programs.

·         Promising Models: Recovery-oriented systems of care (ROSC) and community-based organizations (RCOs) are seen as vital in supporting African Americans in recovery. When led by Black individuals in recovery, these organizations can provide culturally inclusive spaces and positive role models, which are crucial for engagement and long-term success.

Cultural and Environmental Factors

·         Socioeconomic and Structural Barriers: Social determinants of health, such as poverty, limited job opportunities, and residential segregation, are significant factors contributing to SUDs in African American communities. Research indicates that these environmental factors are closely linked to higher rates of substance use and can impede treatment initiation and completion.

·         Mistrust and Stigma: Many African Americans have a deep-seated mistrust of the healthcare and criminal justice systems, which can act as a major barrier to seeking and engaging in treatment. In some communities, there's also a cultural norm that discourages "airing dirty laundry," which can make it difficult for individuals to be open and honest about their struggles in a treatment setting.

·         Spirituality and Community: Spirituality and the Black church have been identified as powerful sources of strength and resilience for many African Americans. Culturally sensitive treatment models that incorporate these elements can lead to better outcomes and lower relapse rates. This includes leveraging the role of the Black church as a community hub for support, values, and positive role models.

Culturally Specific Interventions

·         Cultural Adaptation: Standard "one-size-fits-all" treatment models often fail to meet the unique needs of African Americans. Research has shown that culturally adapted interventions, which incorporate specific cultural values and experiences, are more effective. This can involve making the treatment environment more welcoming, ensuring staff are culturally competent, and using materials and language that are relatable and respectful.

·         Addressing Systemic Issues: Effective interventions must go beyond individual-level factors and address the systemic barriers that African Americans face. This includes providing comprehensive care that not only targets substance use but also addresses housing, employment, and medical needs. By offering "wraparound" services, treatment programs can better equip clients to navigate the challenges they face after leaving a structured environment.

Fatherless Homes

Studies from different organizations provide varying statistics on the percentage of African American children living in fatherless homes, but they consistently show a higher rate compared to other racial groups.

Here's a summary of recent data:

·         A 2023 report from the Office of Juvenile Justice and Delinquency Prevention (OJJDP) states that 44.6% of Black children lived in two-parent homes, meaning a slight majority lived with a single parent (Office of Juvenile Justice and Deliquency Prevention).

·         Another 2023 report from the National Fatherhood Initiative found that 47.5% of Black children lived without a resident father (National Fatherhood Initiative).

These figures show a significant portion of African American children growing up without a father present in the home. However, the percentage of African American children growing up in fatherless homes had decreased by 15% in 2023 compared to 1995 (National Fatherhood Initiative).

The consequences associated with growing up in a fatherless home are extensive and affect various aspects of a child's life. It's important to note that these are correlations and not every child from a single-parent household will experience these negative outcomes. However, research highlights that children without an involved father are at a higher risk for:

·         Poverty: Children in fatherless families are more likely to experience poverty. A 2021 study by the Institute for Family Studies found that Black children in single-parent homes were about 3.5 times more likely to be living in poverty compared to those in two-parent homes (America First Policy Institute).

·         Behavioral and Mental Health Issues: Research suggests a correlation between fatherlessness and a higher risk of behavioral disorders, substance abuse, and other mental health challenges. Children from single-parent homes are twice as likely to suffer from mental health and behavioral problems.

·         Educational Attainment: Studies have shown that children with actively engaged fathers perform better in school. Conversely, father absence has been linked to lower school attendance and a higher risk of dropping out.

·         Juvenile Delinquency and Crime: The absence of a father is often cited as a significant contributor to juvenile delinquency. Some studies indicate that a large percentage of youth in state-operated institutions and those involved in substance abuse cases come from fatherless homes.

·         Teen Pregnancy: Girls raised in fatherless homes are at a higher risk of becoming pregnant as teenagers (America First Policy Institute)

While these statistics and consequences are significant, it's also crucial to consider the nuances of family structure. Some scholars and organizations argue against placing the blame solely on "fatherlessness" and instead highlight the role of structural racism, economic policies, and other systemic factors that have contributed to the breakdown of the family unit. They also point out that many Black families have strong extended family networks, with grandmothers, aunts, uncles, and other male figures stepping in to provide guidance and support.

Asian Americans

Family and Community

Asian American cultural habits are often characterized by a strong emphasis on family solidarity and a collectivistic mindset. This is in contrast to the individualistic values of mainstream American culture. This collectivist perspective means that choices and decisions are often seen as impacting the larger family unit, not just the individual.

• Intergenerational Relationships: There can be significant differences in cultural values between generations. Younger, U.S.-born Asian Americans may find themselves navigating a "bicultural" identity, balancing their heritage with American norms. This can lead to conflicts with parents, especially regarding expectations for life and career. For example, some younger Asian Americans report feeling pressure to pursue predictable and secure career paths like medicine or engineering, influenced by their parents' values.

• Mental Health: The collectivist culture and emphasis on "saving face" often lead to a stigma around mental illness. Emotional distress is sometimes viewed as a sign of weakness or a lack of discipline, which can bring shame to the family. This has been cited as a reason why Asian Americans, particularly those who are foreign-born or less acculturated, are less likely to seek professional mental health services. Instead, they may rely on their social networks, including friends, family, and religious communities, for support.

Identity and Acculturation

Research on Asian American identity shows that it's a complex and multifaceted concept shaped by a variety of factors, including immigration status, ethnic background, and generational differences.

• Self-Identification: A significant portion of Asian American adults (52%) primarily use ethnic labels that reflect their heritage and family roots, either alone or with "American." A smaller percentage (28%) use pan-ethnic labels like "Asian" or "Asian American."

• Hiding Heritage: A notable number of Asian Americans, especially younger adults, report having hidden some part of their heritage—such as food, cultural practices, or clothing—from non-Asians. This experience is far more common among those aged 18 to 29 (39%) than those over 65 (5%). This may be related to a lack of knowledge or familiarity about Asian cultures among the general public, leading to a feeling of being "othered" or having to constantly explain their background.

• Intermarriage: A large majority of Asian adults (86%) are comfortable with a close family member marrying a non-Asian person, and 87% are comfortable with marriage to someone from a different Asian ethnic group. However, there are some differences by gender and immigrant status; U.S.-born Asian women are the most comfortable with intermarriage, while foreign-born men are the least.

Values and Behaviors

Several studies have explored how cultural values influence the behaviors and attitudes of Asian Americans in various contexts.

• Education and Work Ethic: A high value on education and a strong work ethic are commonly associated with Asian American culture. Research suggests that Asian American students spend more time studying than their non-Asian counterparts, and this habit may even slightly influence the study habits of non-Asian peers in communities with larger Asian populations. This emphasis on hard work is often tied to the belief that it leads to upward mobility and social prestige, a sentiment that may be intensified by immigrant experiences.

• Survey Response Styles: A documented cultural habit among some Asian Americans, particularly those with East Asian backgrounds, is a tendency to avoid extreme responses and select middle options on surveys. Researchers believe this may be rooted in cultural values that emphasize fitting in and avoiding conflict. However, this tendency is less pronounced in U.S.-born Asian Americans, suggesting that acculturation plays a role in shifting this behavior.

• Population: According to the 2020 Census, approximately 19.9 million people identified solely as Asian, making up 6.0% of the total population. An additional 4.1 million people identified as Asian in combination with one or more other races. This brings the total Asian American population to about 24 million, which is 7.2% of the total U.S. population. The Asian American population is the fastest-growing racial group in the U.S.

·         Geographic Distribution: Asian Americans are highly concentrated in urban areas. Three states—California, New York, and Texas—have the largest Asian American populations.

·         Largest Subgroups: In 2020, the largest Asian American populations were Asian Indian (4.4 million), Chinese (excluding Taiwanese) (4.1 million), and Filipino (3.1 million). The Vietnamese and Korean populations were also over 1.5 million each.

Native Hawaiians and Other Pacific Islanders (NHPI)

·         Population: The 2020 Census reported that 690,000 people identified solely as Native Hawaiian or Other Pacific Islander (NHPI), while an additional 900,000 identified as NHPI in combination with another race. The total NHPI population in the U.S. is approximately 1.6 million.

·         Largest Subgroups: The largest NHPI groups in 2020 were Native Hawaiian (680,442, alone or in combination), Samoan (256,997), and Chamorro (143,947).

·         Geographic Distribution: The NHPI population is concentrated in certain states. Hawaii, Alaska, and Utah are the only states where at least 1% of the population identified solely as NHPI. More Native Hawaiians now live on the U.S. mainland than in Hawaii.

Mental and Behavioral Health

·         Access to Treatment: Research indicates that Asian Americans are less likely to seek mental health services compared to non-Hispanic white adults. For example, in 2023, Asian American adults were 50% less likely to have received mental health treatment than non-Hispanic white adults.

·         Mental Health Disparities: While rates of mental illness are believed to be similar to those of the general population, Asian Americans may experience different manifestations of psychological distress. Some studies show that Asian American college students report higher levels of depression and anxiety than their white peers but are less likely to seek help.

·         Suicide Rates: In 2020, the age-adjusted suicide rate for Asian Americans was 6.4 per 100,000 people, which was less than half the rate for non-Hispanic whites (16.9 per 100,000). However, some age-specific data shows different trends. In 2021, the suicide rate for Asian American females aged 15–19 was 5.7 per 100,000, which was higher than the rate for non-Hispanic white females in the same age group (5.0 per 100,000).

Asian Americans and Identity

The original premise remains crucial: "Asian" is a pan-ethnic term covering a vast diversity of cultures, languages, and identities. This diversity is reflected in how people self-identify.

·         Racial and Multiracial Identity: The U.S. Census Bureau reported in 2020 that 19.9 million people identified solely as Asian, while an additional 4.1 million identified as Asian in combination with one or more other races. Multiracial identity is particularly common among some subgroups; for instance, Japanese Americans are among the most likely to identify as multiracial (38% in one analysis).

·         Immigrant vs. U.S.-Born: It is important to distinguish between those who are U.S.-born and those who are immigrants. For example, in 2023, 74% of U.S. Asians aged 5 and older spoke English proficiently. However, this varied significantly by nativity, with 95% of U.S.-born Asians being proficient compared to 59% of Asian immigrants.

Native Hawaiians and Other Pacific Islanders (NHPI) and Identity

Similar to Asian Americans, the NHPI population is diverse. Counselors should be aware that individuals may have strong ties to their specific island culture, while others, particularly those who have moved to the mainland, may have different experiences.

·         Growing Population: The NHPI population is also growing, with a total of about 1.6 million people identifying as NHPI alone or in combination with another race in 2020.

·         Cultural Connection: A 2024 survey of NHPI adults in California found that many use community and family as primary coping strategies for stress. This highlights the importance of understanding and respecting family and cultural values in counseling.

Behavioral Health and Treatment

The literature on behavioral health for these communities has expanded, but significant disparities in treatment access and utilization persist.

·         Substance Use and Mental Disorders: Statistics from the Office of Minority Health show that Native Hawaiian/Pacific Islanders were 70% less likely to receive mental health services or mental health prescription medications in 2019 compared to non-Hispanic whites.

·         Mental Health Service Utilization: A 2023 survey found that Asian American adults were 50% less likely to have received mental health treatment than non-Hispanic white adults.

·         Barriers to Care: Recent research continues to highlight major barriers to care. A 2024 study of adults in California found that among those who needed mental health support, 42% of NHPIs and 31% of Asian Americans had difficulties accessing services, citing reasons such as cost, lack of insurance, and not knowing their options.

·         Suicide Rates: While the overall suicide rate for Asian Americans in 2020 was less than half that of non-Hispanic whites, there are concerning trends in specific age groups. A 2021 study found that the suicide rate for Asian American females aged 15-19 was 5.7 per 100,000, which was higher than the rate for non-Hispanic white females in the same age group (5.0 per 100,000). For NHPI youth, the suicide rate for females aged 15-19 was 14.1 per 100,000 in 2021, which was nearly three times the rate for non-Hispanic white females.

Beliefs About and Traditions Involving Substance Use

It is essential for counselors to understand that beliefs about substance use vary dramatically across the diverse cultures of Asia, Native Hawaii, and the Pacific Islands.

·         Traditional Contexts of Use: The traditional use of substances often differs from Western concepts of recreation or addiction. The idea that alcohol can have curative or ceremonial value, such as its use in some Cambodian postpartum practices or in Traditional Chinese Medicine (TCM) to restore the flow of qi, remains a relevant cultural belief. In TCM, moderate alcohol consumption is seen as having benefits like invigorating blood circulation and promoting qi flow. Similarly, marijuana has been used medicinally in parts of Southeast Asia for centuries to treat pain and other conditions.

·         Evolving Traditions: While some traditional beliefs persist, the context of substance use is changing. For example, in Cambodia, while some traditional postpartum practices involving alcohol still exist, there are also public health campaigns to discourage potentially harmful customs like "roasting" (ang pleung) and heavy alcohol consumption after childbirth due to the health risks to both mother and child.

Stigma and Barriers to Treatment

The stigma surrounding substance use remains a major barrier to seeking help in many Asian American and NHPI communities. The "model minority" myth—the stereotype that all Asian Americans are successful, intelligent, and self-reliant—contributes to this stigma by creating an environment where admitting to a problem like addiction is seen as a sign of personal or family failure.

·         Shame and "Saving Face": The concept of "saving face," or preserving one's dignity and family honor, is a powerful cultural value in many Asian societies. This often leads to substance use disorders being hidden from family members and the community, delaying treatment until problems become severe, such as through legal intervention or hospitalization.

·         Moral Weakness: For some subgroups, such as certain Korean American and Cambodian American communities, substance dependence is viewed as a moral failing, which intensifies the shame and reluctance to seek help. This can lead to families isolating the individual who is struggling.

·         Barriers for NHPI: For Native Hawaiians and Other Pacific Islanders, there is a lack of specific literature on substance use and co-occurring disorders. However, emerging research highlights a high prevalence of certain substance use issues. For instance, methamphetamine dependence is startlingly high in some Pacific Islander populations, and Pacific Islanders tend to have higher rates of alcohol and nicotine use compared to other racial groups.

Implications for Counseling

Counselors should avoid making generalizations and must approach each client with cultural humility. It is essential to:

1.      Conduct a thorough intake: Ask specific, non-judgmental questions about the client's cultural background, family dynamics, and beliefs about health and illness, including substance use.

2.      Recognize the diversity: Be aware that the experiences of a U.S.-born Vietnamese American client may differ greatly from a first-generation Korean immigrant client, or a Native Hawaiian client.

3.      Address the stigma: Acknowledge and validate the client's feelings of shame or guilt without reinforcing the idea of moral weakness. Help the client and their family understand addiction as a treatable health condition.

4.      Consider cultural and family-based interventions: Many Asian American and NHPI individuals may prefer to handle problems within the family unit or seek help from religious or community leaders. Integrating these informal support systems into a treatment plan, where appropriate, can be more effective than a purely individualistic approach.

Substance Use and Substance Use Disorders

While Asian Americans, as a broad group, continue to show lower rates of substance use compared to other racial and ethnic groups, it's crucial to disaggregate the data to understand the diverse experiences within this population. The previously mentioned limitations of surveys, such as being conducted primarily in English and Spanish, continue to be a factor in potentially undercounting substance use.

·         Lower Overall Rates with Growing Concerns: According to recent data from sources like the National Survey on Drug Use and Health (NSDUH), Asian American adults generally have the lowest estimated rates of past-month alcohol use, binge drinking, and heavy alcohol use. However, this overall trend can be misleading.

·         Intra-Group Disparities: The data shows significant variation among specific Asian American subgroups. For example, Korean Americans have notably higher rates of past-month alcohol use and binge drinking compared to other Asian American groups, often attributed to a strong drinking culture. Filipino Americans also have a higher rate of binge drinking, which may be linked to permissive cultural norms around alcohol as a social lubricant.

·         The "Acculturation Effect": The trend that substance use patterns among Asian Americans more closely resemble those of other Americans the longer they reside in the U.S. continues to be a key finding. U.S.-born Asians and second-generation individuals are more likely than foreign-born Asians to engage in high-risk behaviors like binge drinking and to use alcohol to cope with psychological distress. This suggests that acculturation, combined with other factors like racial discrimination, can increase the risk of substance use problems.

Trends in Overdose Deaths

More recent data reveals a concerning rise in drug overdose deaths, particularly from powerful synthetic opioids.

·         Rising Overdose Rates: From 2018 to 2022, drug overdose death rates increased by 75% among Asian Americans and 65% among Native Hawaiians and Pacific Islanders (NHPI).

·         Primary Substances: In 2022, fentanyl was the leading cause of overdose deaths among Asian Americans, while methamphetamine was the leading cause for NHPI individuals. Fentanyl overdoses surged by 223% among Asian Americans and 402% among NHPI individuals in this time frame.

Native Hawaiians and Other Pacific Islanders

Data for NHPI populations is often limited due to their smaller numbers and aggregation with Asian Americans. However, available research points to significant substance use challenges.

·         Higher Rates of Use: NHPI individuals have among the highest prevalence of pre-teen alcohol use and heavy episodic drinking among all racial groups. In adults, one study found that up to 22% of NHPI community-dwelling adults may have had an alcohol use disorder before the COVID-19 pandemic, a rate four times higher than the national average.

·         Other Substances: NHPI individuals also have higher rates of conventional cigarette smoking and e-cigarette use compared to many other racial groups.

·         Vulnerabilities: Life stressors, social pressure to binge drink, and permissive social norms are cited as major risk factors for substance use disorders in this population. At the same time, cultural protective factors like a strong family orientation ("ohana system") and religious faith can help mitigate these risks.

Implications for Counseling

The updated data reinforces the need for culturally competent care. Counselors must be aware of the "model minority" myth's role in hiding substance use problems and be prepared for clients who may be experiencing shame and may not seek help until problems have become severe. It is crucial to address the distinct needs of various subgroups and to recognize that Native Hawaiians and Pacific Islanders face unique challenges and have a higher burden of certain substance use disorders.

Substance Use and Substance Use Disorders

The general trend of Asian Americans having lower rates of substance use compared to other racial and ethnic groups in the U.S. continues. However, recent data highlights critical nuances and rising concerns.

• Overall Rates: According to the 2023 National Survey on Drug Use and Health (NSDUH), 9.2% of Asian people had a substance use disorder (SUD) in the past year, which was the lowest rate among all racial and ethnic groups surveyed. For illicit drug use specifically, the rate was 4.4% for Asian people, also the lowest.

• Subgroup Differences: The aggregated "Asian American" data masks significant disparities. For example, some studies have found that Filipino Americans and Korean Americans have a higher prevalence of substance use compared to other Asian American subgroups. A study using the National Longitudinal Study of Adolescent to Adult Health (Add Health) found that Koreans had the highest likelihood of overall substance use, followed by Japanese and Asian Indians. Filipino Americans were found to have the highest rate of past-year drug use (8.1%) among Chinese, Vietnamese, and other Asian Americans.

• Acculturation and Nativity: The link between acculturation and substance use remains a strong finding. U.S.-born Asian Americans are more likely to use substances than foreign-born Asian Americans. This is particularly true for young adults; one study found that Asian young adults aged 18 to 25 were the most likely to have a past-year SUD, alcohol use disorder, or drug use disorder among Asian adults.

• Substances of Choice: While methamphetamine and marijuana were previously noted as the most common illicit drugs, the landscape is shifting. Recent data indicates a concerning increase in overdose deaths from synthetic opioids. From 2018 to 2022, drug overdose death rates increased by 75% among Asian Americans. In 2022, fentanyl was the leading cause of overdose deaths among Asian Americans, while methamphetamine was the leading cause for Native Hawaiians and Pacific Islanders.

• The Flushing Response: The genetic lack of the enzyme aldehyde dehydrogenase (ALDH2), which causes an unpleasant flushing response to alcohol, continues to be a protective factor against alcohol use disorder for many people of East Asian descent. Approximately 30-50% of Chinese, Japanese, and Koreans have this genetic variant. However, it is not a complete deterrent; studies have found that many individuals with the ALDH2 deficiency still consume alcohol, and some develop alcohol dependence.

Mental and Co-Occurring Disorders

Asian Americans, Native Hawaiians, and Pacific Islanders (NHPI) continue to be underrepresented in mental health care. Their holistic view of health often leads to somatic complaints rather than direct psychological expression of distress, which can complicate diagnosis.

• Lower Rates of Diagnosis, Higher Rates of Need: In 2023, 10.2% of Asian adults reported having any mental illness in the past year, compared to 14.2% of non-Hispanic white adults. However, Asian adults were 50% less likely to have received mental health treatment than non-Hispanic white adults. Only 13.5% of Asian adults received mental health treatment in the past year, compared to 27.0% of non-Hispanic white adults.

• Co-Occurring Disorders (CODs): Due to the lower overall prevalence of SUD, Asian Americans also have the lowest rates of CODs. In 2023, 3.5% of Asian adults had co-occurring SUD and any mental illness.

• Trauma and PTSD: The issue of trauma among certain immigrant and refugee groups remains critical. A study found that 70% of Southeast Asian refugees receiving mental health care were diagnosed with PTSD. Their cultural responses to trauma, which may involve silence or stoicism, can make it difficult for counselors to identify these underlying issues.

• Factors Influencing Risk: The role of external stressors is a growing area of focus. Research suggests that experiences of racism and a weaker sense of ethnic identification are associated with a higher likelihood of alcohol use disorders among Asian Americans. For example, one study found that Asian Americans with alcohol use disorders were more than five times as likely to report unfair treatment due to their race.

Treatment Patterns

Mental and behavioral health treatment-seeking remains low among Asian Americans, Native Hawaiians, and Pacific Islanders (NHPI), although there are signs of change, particularly among younger, U.S.-born generations.

• Low Utilization, but Improving: In 2023, only 13.5% of Asian adults received any mental health treatment in the past year, compared to 27.0% of non-Hispanic white adults. This gap is significant, but it shows an increase from the 2012 statistic of 11.5% of Asian American adults receiving treatment.

• Informal vs. Formal Support: Asian Americans often continue to rely on informal support systems. A 2024 study on NHPI adults found that they primarily used community and family as coping strategies for stress.

• Treatment Trajectory: The trend of Asian Americans entering substance abuse treatment with less severe problems and having more stable living situations at discharge has been consistently observed. They tend to have fewer criminal justice problems and higher treatment completion rates.

• Criminal Justice Involvement: The data regarding criminal justice referrals for substance abuse treatment has shifted. While older data showed a high rate for Asian Americans, more recent data from sources like the Treatment Episode Data Set (TEDS) shows this is no longer the case. For example, in 2021, among all admissions to substance abuse treatment, 30.5% of Asian Americans were referred by the criminal justice system, compared to 34.5% of non-Hispanic white individuals.

• Barriers to Access: A primary barrier to treatment continues to be cost and lack of insurance. According to the 2023 NSDUH, among Asian adults who perceived a need for mental health services but did not receive them, 35.5% cited cost or lack of insurance as a reason. The lack of culturally and linguistically competent providers remains a significant issue.

• Acculturation and Service Use: The finding that U.S.-born and more acculturated Asian Americans have higher rates of service use remains true. The 2022 NSDUH data confirms that U.S.-born Asian American adults have a higher rate of receiving mental health services (17.5%) compared to foreign-born Asian Americans (9.6%).

Beliefs and Attitudes About Treatment

Cultural beliefs and a history of discrimination significantly influence how Asian Americans and NHPI individuals view and interact with the healthcare system.

• Mistrust in Providers: Many Asian Americans continue to have a lower level of trust in their medical providers and feel that their doctors may not understand their cultural backgrounds. This is often related to a lack of culturally competent care and language barriers.

• Medical vs. Mental Health Providers: Asian Americans, particularly immigrants, are still more likely to seek help for mental and substance use disorders from primary care physicians rather than specialized mental health professionals. This is often because physical symptoms (somatic complaints) are a more culturally acceptable way to express distress than psychological ones.

• Generational Status: The strong connection between generational status and treatment-seeking is a consistent finding. The difference in mental health service utilization between first-generation and third-generation Asian Americans remains stark. Data from the 2022 NSDUH showed a similar pattern: Asian adults who were born outside the U.S. had a lower past-year mental health service utilization rate (9.6%) compared to those born in the U.S. (17.5%).

• Impact of Racism and Discrimination: Experiences of racism and discrimination are a well-documented risk factor for mental health issues and a barrier to seeking help. A 2024 survey of Asian American adults found that about one-third of those who experienced discrimination or unfair treatment said it had a negative impact on their mental health.

Beliefs and Attitudes About Treatment

Many Asian Americans and Native Hawaiians/Pacific Islanders (NHPI) continue to hold reservations about substance abuse treatment. These attitudes are rooted in cultural values and a distrust of formal institutions, but recent data also shows a nuanced picture.

• Handling the Problem Alone: The belief that one can handle a substance use problem without professional help remains a significant barrier. A 2023 survey found that among Asian adults who perceived a need for mental health services but did not receive them, 22.1% said they believed they could handle the problem on their own. This was slightly higher than the national average (20.6%). This belief is often tied to cultural values of self-reliance and the stigma associated with seeking external help.

• "Shame" and "Face": The concept of "shame" and "saving face" is still a powerful factor. Seeking help for substance abuse can be seen as a public admission of personal or family failure, which may lead to social isolation and a fear of bringing dishonor to the family. This can result in individuals and families denying the problem until a crisis occurs.

• Lack of Perceived Need: A significant number of Asian Americans who meet the criteria for a substance use disorder do not perceive a need for treatment. This is often linked to the low overall rates of substance use and the "model minority" myth, which can make it difficult for individuals to recognize and admit they have a problem.

Treatment Issues and Considerations

Counseling for Asian Americans and NHPI requires a culturally humble and sensitive approach. While some traditional principles of counseling are still applicable, several key considerations are essential.

• Cultural Explanations for Illness: Counselors must continue to respect and explore clients' culturally-based explanations for their problems. Many Asian cultures view health holistically, where the mind and body are not separate. Therefore, a client may present with physical symptoms (e.g., headaches, stomach pains) that are manifestations of emotional or psychological distress. A counselor should ask about these physical symptoms and their potential connection to the presenting problem.

• Reconceptualizing Problems: Using language that resonates with the client's cultural framework can be effective. For example, discussing a "disruption in qi" or an "imbalance" rather than a clinical diagnosis may be more acceptable and lead to greater buy-in.

• The Counselor's Role: Many Asian American clients, particularly first-generation immigrants, may view the counselor as an expert and authority figure. Displaying professionalism, using formal titles, and clearly explaining the purpose of counseling and therapeutic interventions can help build trust and increase client satisfaction and retention. Passivity on the part of the counselor can be misinterpreted as a lack of confidence or competence.

• Building a Therapeutic Alliance: Building a strong, trusting relationship is crucial. Counselors should be mindful that self-disclosure may be viewed differently in some Asian cultures. While it can be a tool for rapport-building, it should be used judiciously to avoid compromising the counselor's perceived expertise or authority.

• Engaging the Family: Given the collectivist nature of many Asian and NHPI cultures, the family often plays a central role. Involving family members in treatment, with the client's consent, can be a powerful tool for support and can increase the likelihood of success. The counselor should assess the family's attitudes toward the problem and the treatment process.

• Addressing Discrimination and Acculturation Stress: Experiences with racism and acculturation stress are major risk factors for substance use and mental health issues. Counselors should be prepared to discuss these issues and help clients develop coping strategies. These experiences can also erode trust in institutions and make clients hesitant to engage with the healthcare system.

Communication and Therapeutic Alliance

Counselors working with Asian Americans and NHPI must be aware of communication styles that may differ from Western norms. The conflict between a client's cultural deference to authority and a counselor's theoretical approach to collaboration and self-disclosure is still a key issue.

• High-Context Communication: The concept of "high-context communication," where nonverbal cues and the implicit meaning of a message are more important than the explicit words, remains relevant. Counselors should be highly attuned to subtle cues, such as pauses, changes in tone, and body language. For example, a client's silence may not indicate a lack of engagement but rather a sign of respect or a need for time to formulate a thoughtful response.

• Indirect Communication and Confrontation Avoidance: Direct confrontation can still be perceived as disrespectful or rude in many Asian cultures. Instead of direct challenge, a counselor might use more indirect methods, such as storytelling, analogies, or asking questions that allow the client to explore different perspectives without feeling put on the spot.

• Building a Relationship: Given these communication styles, building a strong therapeutic alliance can take more time and requires a foundation of trust and respect. Counselors should prioritize demonstrating their expertise and competence while maintaining a warm and empathetic approach.

Culturally Tailored Programs and Counselor Matching

Research continues to support the effectiveness of culturally tailored programs and the importance of matching clients with counselors who share a similar background.

• Culturally Specific Programs: The finding that Asian Americans are more likely to return to and remain in treatment in programs with other Asian clients holds true. A sense of shared identity and experience within a treatment setting can reduce feelings of isolation and shame, making the environment feel safer and more welcoming. This underscores the need for more culturally and linguistically appropriate services.

• Ethnic/Racial Matching: The evidence for the positive impact of racial or ethnic matching between a client and a counselor is strong. A 2021 study on mental health services for Asian Americans confirmed that ethnic matching was associated with a greater number of therapy sessions and higher satisfaction with treatment. Having a counselor who shares a similar cultural background can reduce communication barriers, increase trust, and lead to a deeper understanding of the client's experiences with racism, discrimination, and acculturation.

Specific Considerations for Asian American Women

Counseling strategies for Asian American women should be tailored to address the unique cultural and social pressures they face.

• Reducing Shame and Stigma: Focusing on a holistic approach to health rather than a narrow focus on "addiction" is a powerful strategy to reduce the shame associated with substance use. Framing treatment as a way to improve overall well-being, family health, and stress management can make it more palatable for both the client and her family.

• Group Therapy Dynamics: The original caution about placing Asian American women in mixed-gender groups is still highly relevant. In cultures with strict gender roles, women may feel pressure to remain silent or defer to men, which can hinder their progress in a group setting. A women-only or culturally specific group may provide a safer space for open communication.

• The Role of Home Visits: While home visits are less common in modern practice, the underlying principle of meeting clients in their own environment to gain trust and respect is still valid. Counselors can explore creative ways to show respect for the client's family and home life, such as asking about their family and involving them in treatment (with the client's consent).

• The "Model Minority" Myth and Gender: The pressure of the "model minority" myth can be particularly acute for Asian American women, who are expected to excel academically and professionally while also adhering to traditional gender roles. This can create significant stress and contribute to mental health issues, which may manifest as substance use.

Theoretical Approaches and Treatment Interventions

The core principles of utilizing cognitive, solution-focused, and family-oriented approaches remain highly relevant and are supported by a growing body of research.

• Cognitive and Behavioral Therapies: The use of Cognitive Behavioral Therapy (CBT) continues to be recommended for Asian American clients. Its structured, problem-focused, and time-limited nature aligns with the desire for concrete, goal-oriented solutions. This approach avoids the direct emotional expression that many Asian Americans are taught to suppress, making it a more culturally acceptable form of therapy. A 2021 review found that CBT, particularly when culturally adapted, is effective in treating depression and anxiety in Asian American populations.

• Culturally-Informed Language: Counselors should continue to use indirect language to discuss emotions. For instance, framing a feeling as a common human experience ("some people might feel frustrated in this situation") rather than a direct personal inquiry ("how do you feel?") can make it easier for clients to open up without feeling ashamed.

• Solution-Focused and Directive Approaches: The preference for a solution-focused and directive approach is a consistent finding. Asian American clients often expect the counselor to be an expert who provides clear guidance and strategies. This contrasts with a non-directive, client-led approach common in some Western therapies. A counselor should be prepared to structure sessions and provide explicit guidance while also empowering the client.

• Traditional and Holistic Explanations: The practice of connecting modern therapeutic concepts to traditional cultural beliefs (e.g., linking a "disruption in qi" to a mental health problem) is a valuable tool. This can increase a client's acceptance of the treatment and build a bridge between their cultural worldview and the counselor's theoretical approach.

Family Therapy and Involvement

Family therapy and family involvement are still considered cornerstones of effective treatment for many Asian Americans and NHPI.

• The Family as the Unit of Care: In many Asian and NHPI cultures, the family is the primary social and emotional unit. Therefore, the problem is often viewed as a family issue rather than an individual one. Successful treatment often involves understanding and working with the family system.

• Barriers to Family Engagement: While family involvement is crucial, the initial desire for individual therapy to protect the family from shame remains a common barrier. Clients may wish to enter treatment secretly. Counselors should validate this need for privacy while also gently reinforcing the benefits of family involvement when appropriate.

• Navigating Generational and Cultural Gaps: Counselors must be aware of how different levels of acculturation, particularly across generations, can create family conflict. For example, a U.S.-born child may have different attitudes toward substance use and emotional expression than their foreign-born parents. The counselor should be sensitive to these dynamics and understand how they influence communication and family roles.

• Protecting Family Dignity: The principle of "avoiding embarrassing the family members in front of each other" remains a critical guideline. The counselor's role is to facilitate communication while protecting the dignity and "face" of each family member. This means framing discussions in a way that avoids blame and focuses on shared solutions. For example, instead of asking a parent, "Why did you not see the problem sooner?" a counselor could ask, "How can we, as a team, work together to support your child now?"

• Involving Family in Individual Therapy: Even when family members are not physically present, the counselor must still work with the client to understand and address the family's influence. This can include exploring family expectations, communication patterns, and how the client's substance use affects their family roles and responsibilities.

Group Therapy

The use of group therapy for Asian Americans continues to require careful consideration due to cultural communication styles and values.

• Preference for Individual Therapy: Many Asian Americans still prefer individual therapy over group settings. This preference is often rooted in the desire for privacy and the fear of bringing shame to oneself or one's family by publicly discussing personal problems.

• Communication and Group Dynamics: The challenges related to communication in a group setting remain highly relevant. Many Asian Americans may be hesitant to speak up or disagree with others, particularly elders or authority figures. They may be more comfortable with a high-context communication style, which can make a fast-paced, direct group discussion feel uncomfortable. The idea of discussing personal issues with "strangers" is still a significant barrier for many.

• Role of the Group Leader: The preference for a directive and authoritative group leader is a consistent finding. Asian American clients often expect the group leader to be an expert who provides structure, guidance, and education. This contrasts with a more peer-led or egalitarian group model.

• Confidentiality: For Asian Americans from close-knit communities, confidentiality is a major concern. The fear that information shared in a group will get back to their community or family can prevent them from participating or opening up. This makes same-community groups particularly challenging unless confidentiality is strictly and repeatedly reinforced.

• Psychoeducational Groups: Psychoeducational groups continue to be a promising modality. The format—which is focused on learning, structured, and goal-oriented—aligns well with the values of many Asian Americans. These groups can serve as an effective gateway to more traditional group therapy by building trust and demonstrating the value of a shared experience.

Mutual-Help Groups

Participation in mutual-help groups, such as 12-Step programs, remains lower among Asian Americans and Native Hawaiians/Pacific Islanders (NHPI) compared to other racial and ethnic groups.

• Low Participation Rates: According to the 2022 National Survey on Drug Use and Health (NSDUH), 1.9% of Asian adults and 2.9% of NHPI adults attended a self-help group for a substance use problem in the past year, compared to 4.7% of non-Hispanic white adults. This indicates that these groups are still not as widely utilized by these communities.

• Barriers to Participation: The challenges of public self-disclosure, the emphasis on emotional expression, and the potential for shame are significant barriers. For many Asian Americans, discussing personal struggles with strangers in a group setting is culturally inappropriate and can be seen as a sign of weakness.

• The Role of Acculturation: The level of acculturation continues to be a factor. Highly acculturated Asian Americans may be more open to mutual-help groups, but they may still face cultural barriers.

• Culturally Specific Alternatives: The importance of culturally specific mutual-help groups, such as Asian American 12-Step groups, is still paramount. These groups provide a space where members share not only their struggles with addiction but also a common cultural background, which can make the process of self-disclosure feel safer.

• Importance of Community Organizations: The role of community-based organizations, mutual aid societies, and faith-based groups (like churches for many Korean Americans) remains a vital resource. These institutions provide a form of social support that is often more culturally resonant and less stigmatizing than traditional mutual-help groups. Counselors should be aware of these resources and, with client permission, explore them as a valuable part of the client's support system.

Traditional Healing and Complementary Methods

The use of traditional and complementary medicine is still prevalent among many Asian Americans, particularly among those who are less acculturated.

• High Utilization of Traditional Methods: According to a 2012 study, approximately 60% of Chinese and Vietnamese Americans who had limited English proficiency had used traditional medicine. However, only 7.6% had discussed this with their Western medical providers. This highlights a significant communication gap that counselors need to be aware of.

• Cultural Explanations for Illness: The belief in a holistic worldview, where physical and emotional health are interconnected and illness is seen as an imbalance of forces like yin and yang, remains central to many traditional Asian medical systems. A counselor who understands this can better frame treatment in a way that resonates with the client.

• Examples of Traditional Practices: Practices like cao gio (coin rubbing) among some Southeast Asians, acupuncture, and traditional herbal medicine continue to be used. For some groups, such as the Hmong, health problems are viewed as spiritual in nature, and traditional healers or shamans are the primary source of help. Counselors should not dismiss these beliefs but rather seek to understand how they can be integrated into the client's recovery plan.

Spirituality and Religion

Spirituality and religion continue to play a significant role in the lives of many Asian Americans and NHPI, influencing their coping mechanisms and treatment-seeking behaviors.

• Religious Affiliation: While the number of Asian Americans identifying as secular, agnostic, or atheist has grown, a substantial number still have religious affiliations. As of 2012, approximately 42% of Asian Americans were Protestant, 19% were Catholic, 14% were Buddhist, and 10% were Hindu. These numbers demonstrate a diverse religious landscape.

• Role of Religious Institutions: For many, religious institutions serve as a primary source of support. For example, many Korean Americans turn to Christian clergy for help with personal and family problems before seeking professional help. Similarly, for some Cambodian immigrants, partnering with Buddhist temples can be a powerful way to facilitate treatment entry.

• Integrating Spirituality: Counselors should be open to discussing and integrating the client's spiritual or religious beliefs into their treatment. Practices like meditation, mindfulness, and prayer can be effective coping strategies for managing stress and anxiety during recovery.

Relapse Prevention and Recovery

Research on relapse prevention specifically for Asian Americans remains limited, but the core principles of addressing cultural factors like shame are critical.

• Shame and Guilt: Shame and guilt are major obstacles in recovery. A client who relapses may feel that they have brought dishonor to their family, which can make them even more reluctant to seek help. Counselors should create a non-judgmental environment where clients feel safe to discuss relapses without shame.

• Family Involvement: Given the family-centric nature of many Asian and NHPI cultures, involving the family in relapse prevention is crucial. Family members can be educated on the nature of addiction as a disease, helping them to move past the idea of moral weakness and support the client's long-term recovery.

• Holistic and Culturally-Specific Strategies: Relapse prevention strategies for these populations should consider a holistic approach that includes physical, mental, and spiritual well-being. This can involve incorporating traditional practices, religious beliefs, and community support systems into the recovery plan.

Summary

The themes of shame, holistic health beliefs, and the importance of family and community remain central to providing culturally competent care for Asian Americans and NHPI. Counselors must approach these topics with a willingness to learn from the client and integrate their unique cultural perspectives into the therapeutic process.

Hispanics

The terms "Hispanic" and "Latino" are widely used to describe a broad and diverse population, but their use and meaning can be complex. In short, Hispanic is generally considered an ethnicity or a pan-ethnic identity, not a race.

Here's a breakdown of the key points:

·         Official Definitions: The U.S. Census Bureau and other government agencies classify "Hispanic or Latino" as an ethnicity. When filling out a census form or other official documents, a person is asked to indicate whether they are of Hispanic, Latino, or Spanish origin, and then separately, to select their race (e.g., White, Black, American Indian, Asian, etc.). The official definition states that a person of Hispanic origin can be of any race.

·         Cultural Connection: The term "Hispanic" is primarily a cultural and linguistic label, referring to people who are from, or whose ancestors are from, a Spanish-speaking country. The term comes from "Hispania," the Roman name for the Iberian Peninsula (which includes Spain). This focus on language and origin makes it an ethnic, rather than racial, category.

·         Latino vs. Hispanic: While often used interchangeably, there's a subtle but important distinction between "Hispanic" and "Latino."

o    Hispanic refers to people with a connection to Spain or Spanish-speaking countries.

o    Latino refers to people from Latin America, which includes countries where Spanish is spoken, but also includes countries like Brazil, where Portuguese is the official language.

·         Self-Identification: While the official classification is "ethnicity," a significant number of people who identify as Hispanic or Latino see it as a key part of their racial identity. Surveys from organizations like the Pew Research Center have found that many Hispanics feel their background is a part of their racial identity, not something separate. This highlights the fact that identity is personal and doesn't always fit neatly into official government boxes.

·         Racial Diversity: The Hispanic and Latino population is incredibly diverse racially. A person of Hispanic origin can have roots in various parts of the world, leading to a wide range of racial backgrounds, including European (Spanish), Indigenous American, African, and Asian. This racial diversity within the Hispanic community is a key reason why it's not considered a single race.

Demographics and Population

• Population Size: According to annual estimates from the U.S. Census Bureau, as of July 1, 2024, the Hispanic and Latino population was estimated at 68,086,153, representing approximately 20% of the total U.S. population. This makes it the second-largest group in the country after the non-Hispanic White population.

• Population Growth: The Hispanic population is the fastest-growing ethnic group in the United States. Between 2022 and 2023, the Hispanic population accounted for nearly 71% of the overall growth in the country, driven primarily by births.

• Subgroups: The Hispanic and Latino population is very diverse and includes more than 30 national and cultural subgroups. According to 2020 Census data, the largest subgroups are:

  • Mexican Americans (61.6%)

  • Puerto Ricans (9.6%)

  • Central Americans (9.3%)

  • South Americans (6.4%)

  • Cubans (3.9%)

• Racial Identity: In the 2020 Census, a large proportion of people who identified as Hispanic or Latino also self-identified with "Some Other Race" alone (42.2%), while 20.3% identified as White and 1.9% as Black. A 2021 survey found that six million people self-identified as Afro-Latino/a or Afro-Caribbean, constituting about 12% of the adult Hispanic population.

Socioeconomic Trends

• Education: Educational attainment has been on the rise for Hispanic Americans. From 1996 to 2022, the share of Hispanic people aged 25-29 who graduated from high school increased from 52% to 88%. College enrollment for Hispanic students has also doubled from 2005 to 2021. However, they still trail non-Hispanic whites in attaining bachelor's degrees or higher.

• Income and Wealth: In 2022, the median household income for Hispanic/Latino households was $65,882, which is lower than the median income for non-Hispanic white households ($80,404). Hispanic households also have a significantly lower median wealth compared to non-Hispanic white households.

• Homeownership: While Hispanic homeownership rates are lower than those of non-Hispanic whites, they have been growing steadily in recent years. In 2022, the Hispanic community added 349,000 homeowner households, which was more than double the growth for non-Hispanic white households.

• Labor Force: Hispanic Americans make up a growing share of the U.S. labor force. They have a higher labor force participation rate and are more likely to be entrepreneurs than the general population.

Cultural Values and Habits

• Family: Family is a central value in Hispanic culture. Surveys have found that a significant number of Hispanic Americans believe "commitment to family" is their community's most important contribution to American society. A large majority also agrees that relatives are more important than friends.

• Religion: A majority of Hispanic Americans identify as Christian, with over half being Catholic. However, younger generations are less likely to identify as Christian than older generations.

• Shopping Behavior: Hispanic consumers are a key demographic for retailers. They tend to have larger households with more children, which influences their spending patterns. They spend more on electronics, sporting goods, and clothing, and are more likely to shop as a family. Foreign-born Hispanics place a higher priority on low prices and Spanish-speaking employees.

• Optimism and Life Priorities: A large majority of Hispanic Americans report being satisfied with their lives and are optimistic about their future, as well as the future of their children. While they place a high value on career success, they also value marriage, children, and religion more than the U.S. population as a whole.

Mental and Behavioral Health

• Prevalence of Conditions: In the past year, 21.4% of Latine/Hispanic adults had a mental health condition. This includes 8.8% who experienced a major depressive episode and 5.3% who experienced a serious mental illness.

• Substance Use: A 2020 study found that 12.7% of Hispanic or Latinx people ages 12 and older had a substance use disorder (SUD). A significant number, 94.8%, of those who needed SUD treatment did not receive it.

• Treatment Disparities: There are significant disparities in access to and use of mental health care. In 2023, Hispanic adults were 60% less likely to have received mental health treatment than non-Hispanic white adults. A major barrier to care is the lack of health insurance; in 2022, 27.6% of Hispanic adults ages 18-64 lacked health insurance.

• Cultural Factors in Counseling:

  • Family and Community: Hispanics often value family and community support, which can be both a resource and a potential barrier to seeking individual counseling.

  • Stigma: Stigma around mental health is a significant issue in many Hispanic and Latino communities.

  • Language and Communication: Language barriers can lead to misunderstandings, poor adherence to treatment plans, and lower quality of care. Many clients find it helpful to work with a therapist who is bilingual and culturally competent.

  • Racial and Ethnic Discrimination: A significant number of Hispanic people, particularly those with darker skin (64%), have reported experiencing discrimination. This can contribute to stress and mental health challenges.

Beliefs About and Traditions Involving Substance Use

Attitudes toward substance use within the Hispanic and Latino population are complex and influenced by a variety of factors, including national origin, gender, generational status, and acculturation. While there is no single monolithic view, some general patterns and recent research findings provide a more current understanding.

General Beliefs and Perceptions:

• Negative Consequences: In general, many Latino cultural groups continue to hold negative views on substance use. Research consistently shows that Hispanics are more likely to expect negative outcomes from substance use compared to White Americans. These negative beliefs often extend to the family, with a strong conviction that an individual's substance abuse causes suffering for their entire family.

• Stigma: A significant barrier to seeking help is the persistent stigma associated with substance use disorders (SUD) and mental illness in many Hispanic communities. Addiction may be viewed as a source of shame, weakness, or a personal failure, which can prevent individuals from reaching out for support.

• Acculturation and Generational Status: A key finding in recent research is the link between acculturation—the process of adapting to a new culture—and increased substance use. Studies consistently show that Hispanics who are more acculturated to U.S. culture, who are U.S.-born, or who have lived in the country for more years are more likely to use and abuse substances than recent immigrants. This is often attributed to the stress of acculturation, including discrimination and a loss of connection to traditional cultural beliefs, which can lead to substance use as a coping mechanism.

Gender-Specific Norms and Trends:

• Gender Roles: Traditional gender roles continue to influence substance use patterns, though these norms are evolving.

  • Men: For many Latino men, social drinking on special occasions and celebrations is a common practice. However, solitary drinking is often seen as a sign of a problem and is discouraged. Traditional gender roles associated with "machismo" can be a risk factor for increased alcohol use.

  • Women: Historically, social norms for Latinas have been much stricter, with expectations of abstinence or limited alcohol use, particularly in public settings. Latinas who struggle with substance abuse are often judged more harshly, facing stigma related to traditional ideals of motherhood and family duty ("marianismo"). However, recent research indicates a concerning trend: younger, U.S.-born, and highly acculturated Latinas are drinking more frequently and in higher quantities, in some cases catching up to their male counterparts. Acculturation stress, along with exposure to a more liberal environment (such as a U.S. college campus), has been identified as a factor in this rise in alcohol use among young Latinas.

Youth and Family Dynamics:

• Parental and Family Influence: Family attitudes and dynamics remain a significant influence on youth substance use. While parents generally disapprove of adolescent alcohol use, recent research highlights the complex intergenerational effects of discrimination. A recent study found that Latinx teens with depression were more likely to use alcohol if they and their mothers experienced bias. This suggests that the stress of discrimination experienced by parents can have a "ripple effect," increasing their children's risk for substance use.

• Generational Divide: A "generational divide" is evident in which second-generation Hispanic teens (born in the U.S.) are significantly more likely to use substances than first-generation teens (born outside the U.S.). This is often linked to the unique stressors of trying to navigate a balance between their parents' traditional cultural values and the pressures of American society.

• Parental Communication: While parents may want to protect their children, some studies show that communication about substance use often relies on "fear tactics," which may not be the most effective approach. This highlights the need for culturally and linguistically appropriate resources to help both parents and youth navigate these issues.

Substance Use and Substance Use Disorders (Updated)

Based on current data from the Substance Abuse and Mental Health Services Administration (SAMHSA) and other recent studies, here is an update on substance use and substance use disorders (SUDs) among the Hispanic and Latino population.

Prevalence of Substance Use:

• Overall Rates: According to the 2022 National Survey on Drug Use and Health (NSDUH), the rates of past-month substance use among Hispanic or Latino individuals are generally lower than those of non-Hispanic Whites.

  • Illicit Drug Use: An estimated 19.3% of Hispanic or Latino individuals aged 12 or older reported past-month illicit drug use, compared to 23.4% of non-Hispanic Whites and 22.8% of non-Hispanic Blacks.

  • Binge Drinking: Among those aged 12 or older, 22.9% of Hispanic or Latino individuals reported past-month binge drinking, compared to 28.5% of non-Hispanic Whites and 20.3% of non-Hispanic Blacks.

  • Heavy Alcohol Use: 5.7% of Hispanic or Latino individuals reported past-month heavy alcohol use, compared to 7.9% of non-Hispanic Whites and 4.2% of non-Hispanic Blacks.

Substance Use Disorders (SUDs):

• Prevalence of SUDs: A significant number of Hispanic and Latino individuals experience substance use disorders.

  • In 2022, 12.5% of Hispanic or Latino individuals aged 12 or older had a substance use disorder in the past year, compared to 16.5% of non-Hispanic Whites and 12.3% of non-Hispanic Blacks.

  • Treatment Gap: There continues to be a significant treatment gap. In 2022, among Hispanic adults with a substance use disorder, only 7.6% received any type of substance use treatment in the past year. This is lower than the rate for non-Hispanic Whites (11.8%) and non-Hispanic Blacks (9.3%).

Specific Substance Use Patterns by Subgroup:

• Heterogeneity of the Population: The Hispanic and Latino population is highly diverse, and substance use patterns vary significantly by national origin, immigration status, and other demographic factors.

• Acculturation and Generational Status: A persistent finding is that acculturation plays a significant role in substance use. Recent data shows that U.S.-born Hispanics have higher rates of binge drinking, illicit drug use, and substance use disorders compared to foreign-born Hispanics.

• Geographic Differences: Rates of specific substance use and treatment admissions also vary by geographic region, which often correlates with the dominant subgroup. For example, Puerto Ricans in the Northeast may have different patterns of substance use than Mexican Americans in the Southwest. Research from the Treatment Episode Data Set (TEDS) continues to show that specific subgroups have higher rates of use for certain substances.

Age and Gender Differences:

• Age: Data shows that Hispanic adolescents and young adults have some of the highest rates of substance use compared to their peers in other racial and ethnic groups.

  • Youth: A 2022 study showed that among high school students, Hispanic youth had higher rates of lifetime use for several substances compared to non-Hispanic White and Black youth, including marijuana, cocaine, and inhalants.

• Gender: Men continue to have higher rates of substance use and SUDs than women. However, as noted in the previous section, recent studies have shown a concerning trend of increasing substance use among young Latinas, with a narrowing gap between genders, especially regarding alcohol use. This is often linked to higher acculturation levels.

Other Factors:

• Socioeconomic Status: Socioeconomic factors, including poverty and lower educational attainment, are correlated with higher rates of substance use and SUDs across all racial and ethnic groups, including the Hispanic population.

• Mental Health Comorbidity: There is a strong link between mental health disorders and substance use disorders. In 2022, among Hispanic adults with a co-occurring mental health and substance use disorder, only 4.8% received treatment for both conditions. This highlights the need for integrated treatment approaches.

Mental and Co-Occurring Disorders (Updated)

Research consistently shows that while the overall prevalence of mental health conditions may appear lower among some Hispanic and Latino subgroups, there is a significant disparity in access to and utilization of mental health and substance use disorder (SUD) services. This is a critical area for addressing health equity.

Prevalence of Mental and Co-Occurring Disorders (CODs):

• Mental Health Conditions: According to the 2022 National Survey on Drug Use and Health (NSDUH), 19.4% of Hispanic or Latino individuals aged 18 or older had any mental illness (AMI) in the past year, compared to 25.1% of non-Hispanic White adults and 20.3% of non-Hispanic Black adults. However, the prevalence of serious mental illness (SMI) was similar: 5.6% for Hispanic or Latino adults, 6.7% for non-Hispanic White adults, and 5.7% for non-Hispanic Black adults.

• Co-Occurring Disorders: Data shows a significant number of individuals with CODs. In 2022, 5.7% of Hispanic or Latino individuals aged 12 or older had a co-occurring mental health disorder and a substance use disorder in the past year. This rate is slightly lower than that of non-Hispanic Whites (7.9%) and similar to that of non-Hispanic Blacks (5.5%).

• Acculturation and Subgroup Differences: As with substance use, mental health conditions and CODs are not uniform across the diverse Hispanic and Latino population. The stressors of acculturation, including discrimination and immigration-related trauma, can increase the risk of developing mental health conditions. Research continues to show that U.S.-born and more acculturated Hispanics may have higher rates of certain mental health disorders than foreign-born Hispanics. For example, a 2021 study found that among adolescents, U.S.-born Hispanic youth had a higher risk for major depressive episodes than foreign-born youth.

Treatment Barriers and Disparities:

• Treatment Gap: There is a significant and persistent treatment gap. In 2022, only 38.6% of Hispanic or Latino adults with AMI received mental health services in the past year, compared to 55.4% of non-Hispanic White adults.

• Top Barriers: The most commonly reported barriers to receiving mental health and/or substance use treatment remain:

  • Cost and Lack of Insurance: In 2022, Hispanic adults were significantly more likely than non-Hispanic White adults to report that they could not afford treatment. Approximately 27% of Hispanic adults lacked health insurance in 2022, a major barrier to accessing care.

  • Stigma: The stigma surrounding mental illness and substance abuse remains a powerful barrier, often rooted in cultural values and beliefs about "keeping problems within the family."

  • Linguistic and Cultural Barriers: The lack of culturally competent and Spanish-speaking providers is a major issue. Many individuals report being unable to find a provider who speaks their language or understands their cultural background, which is essential for effective communication and trust in the therapeutic relationship.

  • Fear of Immigration Consequences: For undocumented individuals and their families, fear of deportation or negative immigration consequences can be a major barrier to seeking any kind of social or healthcare service, including mental health and substance abuse treatment.

  • Logistical Barriers: Logistical issues such as a lack of transportation, time off from work, or childcare remain significant obstacles, with Hispanic individuals often reporting these barriers at higher rates than other groups.

Treatment Seeking Patterns:

• Entering Treatment: Despite the barriers, studies show that when accounting for demographics, Hispanic individuals with SUDs are as likely to enter treatment as non-Hispanic Whites. However, Hispanic individuals are more likely to drop out of treatment early, which is often linked to the aforementioned barriers.

• Youth and Age of Entry: A 2022 study found that among individuals aged 12-17, Hispanic youth had a higher prevalence of substance use and SUDs but were less likely to receive treatment than their non-Hispanic White counterparts. This is a critical period for intervention, and the disparities highlight a need for more accessible and culturally tailored services for youth.

• Subgroup-Specific Patterns: Treatment-seeking patterns continue to vary by subgroup. Research on the types of treatment sought (e.g., methadone maintenance, outpatient services) shows differences across Puerto Rican, Mexican American, and other Central and South American communities, often reflecting regional treatment availability, cultural norms, and historical relationships with the healthcare system.

Beliefs and Attitudes About Treatment (Updated)

Health Care Access and Beliefs:

• Lack of Insurance: While progress has been made, disparities in health insurance coverage persist. According to a 2022 survey by the U.S. Census Bureau, 27.6% of Hispanic adults ages 18-64 lacked health insurance, a rate significantly higher than non-Hispanic White adults (9.6%). Lack of insurance remains a primary barrier to accessing all forms of healthcare, including mental health and substance use disorder (SUD) treatment.

• Perceived Need for Treatment: While some older studies suggested unfavorable attitudes toward treatment, more recent data paints a more nuanced picture. The 2022 National Survey on Drug Use and Health (NSDUH) indicates that Hispanic or Latino individuals are less likely than non-Hispanic Whites to perceive a need for substance use treatment, but among those who do, they are less likely to receive it.

• Cultural and Social Barriers: The barriers identified in previous research continue to be highly relevant:

  • Stigma and Shame: Stigma remains a major obstacle, leading many to avoid seeking help.

  • Immigration Status Concerns: Fear of deportation or other legal consequences due to immigration status is a significant deterrent for many, particularly in the context of accessing healthcare services.

  • Language and Cultural Competence: A lack of Spanish-speaking providers and culturally competent care remains a primary barrier. A 2022 survey by the American Psychological Association found that the majority of Hispanic adults who needed mental health care and did not receive it cited language as a significant obstacle.

  • Knowledge Gaps: Many individuals lack knowledge about available services, how to navigate the healthcare system, and what to expect from treatment.

Treatment Engagement and Outcomes:

• Treatment Satisfaction: A 2023 study found that Hispanic individuals with SUDs reported lower satisfaction with the treatment services they received compared to non-Hispanic White individuals. This dissatisfaction was often linked to a perceived lack of cultural understanding from providers and language barriers.

• Treatment Retention and Dropout: The high rates of treatment dropout among Hispanic clients continue to be a concern. A 2022 meta-analysis found that culturally adapted interventions were more effective at improving treatment retention and outcomes for Hispanic individuals compared to standard treatments.

Culturally Responsive Counseling and Program Strategies:

• Personalismo: The concept of personalismo, or the emphasis on personal warmth and respect for individuals and their families, continues to be a crucial element in building a strong therapeutic alliance with Hispanic and Latino clients.

• Flexible Approaches: The need for flexibility in scheduling and a non-judgmental approach to client behavior remains a key consideration. Counselors should avoid framing non-compliance as resistance and instead explore the cultural and logistical factors that may be at play.

• Integrating Cultural Strengths: Rather than viewing culture as a hindrance, effective counseling should integrate cultural strengths. For example, a focus on family support (familismo) can be a powerful resource in recovery.

• Client–Counselor Matching: While the data on matching by ethnicity is mixed, research consistently supports the value of client–counselor matching based on shared language and cultural understanding. Some studies also suggest that matching clients and counselors by gender may be more impactful for Hispanic clients than for other ethnic groups, particularly in engaging men in treatment.

• Socializing the Client to Treatment: Given the potential for unfamiliarity with the U.S. healthcare system, orienting clients to the treatment process is vital. This includes explaining confidentiality, the therapeutic process, and the purpose of different interventions in a culturally and linguistically appropriate manner.

Theoretical Approaches and Interventions:

• Cultural Adaptations of Evidence-Based Practices: There is a growing body of research on the cultural adaptation of evidence-based practices (EBPs) for Hispanic and Latino populations.

  • Cognitive Behavioral Therapy (CBT): Many providers recommend culturally adapted CBT because its structured, problem-focused, and educational nature aligns with some cultural values. However, it is essential to modify the approach to be more collaborative and to integrate a broader understanding of the client's social context, including family dynamics, immigration status, and experiences with discrimination.

  • Motivational Interviewing (MI): MI is widely recommended for its client-centered approach, which aligns well with the values of respect and warmth. It is particularly effective for engaging clients in the early stages of treatment.

  • Family-Based Interventions: Given the importance of family in many Hispanic cultures, family-based interventions are highly effective for addressing substance use and mental health issues. These interventions often focus on improving family communication, strengthening support systems, and addressing intergenerational conflicts.

Evidence-Based Interventions:

·         Contingency Management (CM) and Motivational Interviewing (MI): These interventions continue to be highly effective. A 2022 meta-analysis found that culturally adapted MI was particularly effective in improving treatment engagement and reducing substance use among Hispanic/Latino clients. CM, which uses incentives to reinforce positive behaviors, has also shown promise, especially for individuals in methadone maintenance programs, as it can be a powerful tool to address motivation and retention challenges.

·         Medication-Assisted Treatment (MAT): Research continues to support the effectiveness of MAT for opioid use disorder. Studies have shown that for Hispanic/Latino individuals, medications such as buprenorphine and naltrexone can be crucial for long-term recovery. However, there remain significant disparities in access to MAT, with Hispanic individuals less likely to be prescribed these medications than non-Hispanic Whites.

Family Therapy:

·         Familismo: The concept of familismo—the strong value placed on family—remains a cornerstone of culturally competent care for this population. Family therapy continues to be one of the most effective interventions for Hispanic/Latino youth with substance use disorders.

o    Effective Models: Evidence-based models like Brief Strategic Family Therapy (BSFT) and Multidimensional Family Therapy (MDFT) have been shown to be effective in reducing substance use and improving family functioning in Hispanic/Latino youth.

·         Evolving Family Dynamics: Counselors should be aware that familismo is not monolithic. The level of family cohesion and support can vary greatly depending on acculturation, socioeconomic status, and national origin. Recent studies suggest that acculturative stress and intergenerational conflict can weaken family bonds, which can be a risk factor for substance use.

·         Addressing "Enabling" vs. "Support": The therapeutic approach should move beyond labeling family behavior as "enabling." Instead, the focus should be on helping families understand the nature of addiction and empowering them to set healthy boundaries while maintaining a supportive role in their loved one's recovery.

Group Therapy:

·         Client Preferences: While older studies showed a preference for group treatment among Latinas, more recent data on this topic is limited. However, the principles of group therapy remain relevant.

·         Culturally Sensitive Groups: Culturally specific or Spanish-speaking groups are often more effective. This is because they provide a safe space for members to discuss issues related to acculturative stress, discrimination, and cultural identity.

·         Trust and Cohesion: Group facilitators should prioritize building trust, loyalty, and a sense of shared community among members. A directive, "content expert" approach can be perceived as oppressive and should be avoided. Instead, a facilitative style that encourages peer support and shared learning is more effective.

Mutual-Help Groups (e.g., 12-Step Programs):

·         Disparities in Participation: Participation rates in 12-Step programs like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) continue to be lower among Hispanic/Latino individuals compared to non-Hispanic Whites. Language barriers are a major factor, although Spanish-language meetings are becoming more common.

·         Cultural Considerations: The traditional 12-Step approach, with its emphasis on "powerlessness" and public sharing, may conflict with cultural values like machismo and the desire to keep family issues private.

·         Culturally Adapted Groups: Research continues to support the value of culturally adapted or all-Hispanic/Latino 12-Step groups. These groups can address cultural nuances and integrate values like spirituality and community in a way that resonates with members.

Traditional Healing and Complementary Methods:

·         Religious and Spiritual Practices: Spirituality and religious beliefs remain a significant source of strength and coping for many Hispanic/Latino individuals, especially recent immigrants. Counselors should be aware of and respect the role of religion (e.g., Catholicism, Protestantism) and folk healing practices (curanderismo, espiritismo) in a client's life.

·         Integration with Standard Treatment: The use of traditional healing practices is not necessarily an alternative to standard care but can be an important complement. A culturally competent counselor can explore these practices with the client to understand their meaning and determine how they can be integrated into a comprehensive recovery plan.

Relapse Prevention and Recovery:

·         Triggers for Relapse: Relapse prevention strategies must be culturally tailored. Hispanic/Latino clients may face unique triggers related to acculturative stress, discrimination, and pressure to conform to rigid gender roles (machismo).

·         Recovery Management: A recovery management approach that focuses on building long-term, community-based support systems is particularly effective. This can involve connecting clients to recovery communities, religious organizations, and social clubs that reinforce recovery-oriented values.

·         Importance of Family Support: Family support systems are a critical factor in long-term recovery. Helping the client rebuild healthy relationships with family members and establishing a supportive home environment can significantly reduce the risk of relapse.