Culturally sensitive treatments

The Need for Culturally Sensitive Treatments (CSTs) for Substance Use Disorders among Racial and Ethnic Minorities

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV-TR (2000), the term substance can refer to a drug of abuse, a medication, or a toxin; and as such can include a wide variety of substances which include, but are not limited to, alcohol, illicit drugs[1] such as cannabis and cocaine, tobacco, caffeine, opioids, and sedatives. However, the majority would agree that most attention is directed substance abuse interventions which revolve around alcohol, illicit drugs, and increasingly tobacco and prescription medication. The DSM-IV-TR also distinguishes between Substance Abuse and Substance Dependence, with the diagnostic criteria for the latter suggesting that it is more severe than the former. However, in lay terms, substance abuse is the more commonly used expression to refer to all the characteristics of the overuse or misuse of any substance. Given that there have been consistent reports over time that substance abuse is an issue, nationwide, it is understandable that there is a proliferation of prevention and intervention approaches for substance abuse (Pichot & Smock, 2009).

The National Survey on Drug Use and Health (Substance Abuse and Mental Health Services Administration, 2009) is an annual report of the national rates of substance usage for the civilian population for the United States of America, aged 12 years and older, which is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). The NSDUH report states that approximately 8.0 percent (20.1 million) of Americans aged 12 or older use illicit drugs[2], 51.6 percent (129.0 million) reported being current drinkers of alcohol, and 28.4 percent (70.9 million) were current users of a tobacco product. Although these figures are estimates of drug usage, it does not suggest the overall nature of abuse or dependence of these drugs. However, in looking at the figures, there is a trend in the data that suggests substance abuse issues are extremely prevalent. In 2008, over 22.2 million (8.9%) Americans were classified with either substance abuse or substance dependence problems, and a total of 23.1 million (9.2%) needed treatment for a substance use problem, with only 0.9 percent of them receiving treatment.

These numbers suggest a national problem, however, in looking at the data on a deeper level, it becomes clear that there are specific subsets of the population that are can be considered to be more at-risk than others. For race or ethnicity, the report (SAMHSA, 2009) shows that those of Mixed Race, African American, American Indians or Alaskan Natives had the highest rates of illicit drug use (14, 7%, 10.1%, and 9.5%, respectively), followed by Caucasians (8.2%), Native Hawaiians or Other Pacific Islanders (7.3%), and Hispanics (6.2%). For rates of alcohol usage, Caucasians reported the highest rates of 56.2%, followed by Mixed Race (47.5%), American Indians or Alaska Natives (43.3%), Hispanics (43.2%), African-Americans (41.9%), and lastly by Asians (37.0%). In looking at gender differences for illicit drug usage, overall males did have significantly higher rates than female, however, the usage rate for these drugs for males have not significantly changed from 2007 to 2008 (10.4% - 9.9%). The rates of usage for females however, have significantly jumped from 2007 to 2008, from 5.8% to 6.3%. The nature of alcohol usage was similar to that for illicit drugs with males reporting higher rates than females, however, for this category, there were no significant differences for both gender from 2007 to 2008.

While the racial/ethnic and gender categories are not the only areas that show significant differences within groups, these two (2) were chosen to show the need for group-specific intervention and prevention strategies. For the purposes of this review, the focus will be on the disparities in racial or ethnic usage rates that support the argument for culturally sensitive treatments. It seems almost obvious that culture is tied into how substance usage, and by default abuse would be characterized, as each culture may have different views on what is considered acceptable and what is not. Therefore, it would then logically progress that prevention and treatment strategies should take this into consideration, and not use a blanket approach to meet the needs of substance abusers. Despite the fact that the effectiveness of traditional treatments has consistently been challenged with ethnic minorities, there has only been a fairly recent push to strongly emphasize the need for culturally sensitive treatments for mental disorders as a whole, including substance use disorders (Resnicow et al., 2000; LaRoche & Christoper, 2009; Pichot & Smock, 2009).

As mentioned earlier, there is a wide assortment of treatments that target substance abuse; however, the most common are cognitive behavior therapy, the 12-step approach, and motivational enhancement therapy (Donovan, Kadden, DiClemente & Carroll, 2002; Pichot & Smock, 2009). In combination to these, pharmacological approaches are sometimes uses, such as using benzodiazepines to alleviate the symptoms of withdrawal, or drugs such as disulfiram which induces the aversion to alcohol such as by producing typical symptoms of a hangover (Durrant & Thakker, 2003). The recommendation is that pharmacological treatments are not used alone, but should be used in conjunction with psychological treatments as well. Overall, the above treatments have been proven to have more than acceptable levels of effectiveness in a wide variety of settings (Botvin, Baker, Filazzola & Botvin, 1990; Ouimette, Finney & Moos, 1997; Morgenstern, Blanchard, Morgan, Labouvie & Hayaki, 2001; Burke, Arkowitz & Menchola, 2003).

Cognitive-Behavior therapy (CBT), which is a brief 12-16 session program, draws on two theoretical perspectives within psychology, the cognitive approach and the behavioral approach. The premise behind behavioral therapy is that any behavior is learned, and as such, anything that is learned can be unlearned. Behaviorists believe that human beings (and animals) can be taught any behavior provided that there are appropriate reinforcements and punishments, both negative and positive, to produce the desired behavior. The foundation of cognitive therapy lies in the conceptualization that behaviors originate and are maintained from thought processes. Problematic behaviors stem from the fact that false self-beliefs lead to a distorted view of the individual's world. Cognitive theorists outlined a variety of these cognitive distortions that lead to negative behaviors such as all-or-nothing thinking, overgeneralization, magnification and minimizing, and personalization.

Ouimette, Finney and Moos (1997) state it best that from the integrative cognitive-behavioral standpoint, substance abuse is a learned, maladaptive behavior "which is initiated and maintained by distorted beliefs about the power of the abused substance and the reinforced use of the substance to cope with stressful situations" (p.231). Treatment from the CBT approach involves three (3) primary components which must be included in the therapeutic process- a functional analysis of substance abuse, coping skills training, and relapse prevention strategies (SAMHSA, 1999; Pichot & Smock, 2009). Functional analysis refers to the analysis of the substance abuse behavior such as their past drug use, the antecedents that precede and possibly trigger or cause the abuse, as well as the consequences of the abuse. This analysis should also include the identification of the client's strengths and adaptive skills which can aid in the therapeutic process. Rotgers (1996) stated that this is possibly the most important step in CBT, as it helps the therapist tailor specific strategies that will best fit the client, and as such without it, the therapy could fail.

The second component involves coping skills training, as there is a belief that one of the contributory factors in substance abuse is a deficit in coping mechanisms, possibly due to the early onset of most substance abuse disorders (SAMHSA, 1999). An important part in this coping skills training is incorporating interpersonal and intrapersonal skills training. The former includes becoming aware of and managing the negative thinking, relaxation training, and problem-solving. Assertiveness training, learning to refuse offers of the addictive substance, enhancing the ability to cope with criticism about the substance abuse problems as well as creating a more stable social support network are all processes to be covered in intrapersonal skills training.

The last component, relapse prevention strategies, does draw from the other two factors, but also includes additional features. It incorporates another major concept, and that is the idea of self-efficacy, which is tied into expectancy effects. Data has shown that individuals who expect positive effects from substance will be more likely to abuse them, and as such, CBT is geared at teaching these individuals to weigh the positive and negative effects of these substances, as those who expect more negative effects from the substance are less likely to use (Brown, 1993). This also explains why males typically have higher rates of substance abuse because they predominantly expect more positive effects than women, who more readily evaluate the positive and negative effects and how they equate to their expectancies (SAMHSA, 1999). Therefore, changing expectancy effects will help substance abusers have more positive self-efficacy, which is their belief that they have the capabilities to overcome their substance abuse problem. As the name suggests, another core skill taught within this step, are the tips and strategies that can be used to help prevent relapses such as avoiding potential triggers, or planning ways to avoid them, stopping relapses before they progress too far, as well as developing a more balanced lifestyle.

The 12-step approach, also known as the Minnesota model, is perhaps the most famous treatment for alcohol abuse, and increasingly more so for a plethora of other substance use disorders. The 12-step approach uses the well-known principles that were originally proposed for Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) (Pichot & Smock, 2009). Using Cook's conceptualization of the nature of substance abuse, the main features of the Minnesota model include accepting the disease concept, which is that this is both a medical and spiritual disease, following the principles of AA or NA, and staying on top of treatment goals, the main one being complete abstinence from the addictive substance (Donovan, Kadden, DiClemente & Carroll, 2002; Pichot & Smock, 2009). It is important to state here that the Minnesota model which is the overarching approach of anonymous fellowships is an empirically supported treatment for substance abuse, and not just the layperson's conceptualization of it being a self-help group with regular meetings.

While the Minnesota model is consistent with the 12 steps or principles used in AA, the primary emphasis is places on steps one (1) through five (5) (Donovan, Kadden, DiClemente & Carroll, 2002). A key goal of the 12-step approach is to foster commitment to attending and participating in regular AA or NA meetings. Pichot and Smock (2009) state that a major guiding principle in the 12-step approach, is helping individuals overcome their denial about their problem as this seems to be a major factor in maintaining their addiction. Morojele and Stephenson (1992) argue that this approach is so effective due to the fact that it combines two theoretical models- attribution theory and the theory of planned behavior. They argue that the 12-step approach emphasizes the possibility of radical change owing to personal control, which underlies the theory of planned behavior which states that the biggest predictor of a behavior is the perceived behavioral control that individuals believe they has over their ability to carry out a specific behavior.

Attribution theory as outlined by Morojele and Stephenson (1992) includes four (4) models, the moral, enlightenment, medical, and compensatory model. In the moral model, the individual is both the cause and solution for a problem, while in the enlightenment model, the individual is not responsible for solving the problem, but is responsible for its cause. The medical model states that the individual is not responsible for neither the cause nor the solution, but in the compensatory model, the individual is responsible for the solution, but not the cause. In looking that 12-principles of the Minnesota model and other such approaches, it is evident that it draws from all four (4) of these models, but more so from the latter, the compensatory model. From a multiple levels-of-analysis approach, propensities for substance abuse can be traced to a variety of influences including genetics (Tate, Drapkin & Brown, 2008), however, the typical belief is that these individuals are the cause of their problems, and as such should be their own solution to the problem. However, the 12-step approach, which characterizes substance abuse disorders as a disease, in essence, exonerates the individual of personal responsibility for the cause of their problem, but, it does suggest that the individual is responsible for bringing about change (Morojele & Stephenson, 1992; Donovan, Kadden, DiClemente & Carroll, 2002).

Given these two approaches, it is clear as to why the 12-step approach is a commonly used and efficacious approach to treating substance abuse. It is interesting to note that this approach shares some similarities with the cognitive-behavioral approach, but this is probably due to the fact that this model draws from some of their techniques. However, given that the CBT approach is a conglomeration of two long-existing theoretical perspectives in psychology, it is of no surprise that other treatment approaches may have comparable strategies since they may be based in either of these two theories. Therapy from the 12-step approach consists of individual interviews, the typical group discussions, as well as psychoeducation about substance abuse which also includes stories of recovery by other addicts who have been through the 12-step approach, in a bid to foster self-efficacy (Borkman, Kaskutas & Owen, 2007).

Motivational Enhancement Therapy (MET) is a brief (usually four sessions) therapy that is used to treat substance use disorders based on Prochaska's stages of change model and Miller's motivational interviewing techniques (Polcin, Galloway, Palmer & Mains, 2003; Galloway, Polcin, Kielstein, Brown & Mendelson, 2007). It is worthy to mention that the original purpose of MET was to increase motivation for problem drinkers for long term therapy; however, it is now widely used as a brief preparatory intervention for substance abuse disorders, as well as other psychological issues. Despite the fact that MET is such a brief therapy, data from the Project MATCH research of 1997-1998 showed that in a comparison of alcohol-dependent subjects, MET showed comparable results beside CBT and 12-step approaches (Cutler & Fishbain, 2005; Galloway, Polcin, Kielstein, Brown & Mendelson, 2007).

The four (4) main steps in MET are developing discrepancies, expressing empathy, rolling with resistance, and supporting self-efficacy. In looking at these steps, there is some similarity between MET and the aforementioned treatments. In the first step of MET, the goal is to help individuals realize that they do indeed have a problem by getting them to see the discrepancy between their real and ideal self, or simply put, by eliciting the client's ambivalence between the positives and negatives of the use and abuse of the substance. The two following steps seem to be geared at aiding the client to achieve the first step, as the goal of expressing empathy and rolling with resistance is simply to help the client achieve the desire change. The therapeutic alliance is considered integral in MET, and these two middle steps are ways in which the therapist can establish and maintain a good therapeutic rapport that will behoove the client. The last step is reminiscent of the other approaches, in that MET is not trying to cure these individuals, but help them to cure themselves, that is, the change is within their own control. Therefore, the therapist should aim to promote self-confidence by providing skills (such as coping or interpersonal) to help them achieve success in using their own abilities.

On a surface analysis of these therapy interventions, they are all fairly analogous as they share common conceptualizations and approaches, and this is possibly why the Project MATCH data provided similar outcome results (Cutler & Fishbain, 2005). With that being said, the question may be raised as to why the effectiveness of these traditional treatments has been consistently challenged in underrepresented populations such as ethnic minorities. To point out one salient fact, what is considered normal or acceptable levels of consumption ranges, not only, from culture to culture, but from time to time, meaning that what is considered the norm in one culture or one society is not, nor is it considered the same from one decade to another. Therefore, it seems almost obvious, that treatment programs should be designed to meet the specific needs of ethnic or cultural groups.

Castro and Alarcn (2002) stated that while the Center for Substance Abuse Prevention (CSAP) of SAMHSA has identified multiple empirically-supported treatment prevention and intervention programs, the majority of these have not been tested for effectiveness among many racial and ethnic groups. It is noteworthy to mention that it was not until the Revitalization Act of 1993 was passed that minority groups were mandated to be included in research funded by the National Institutes of Health, the overarching branch of the government responsible for conducting any medical research; therefore, it is of no surprise that minorities are still underrepresented in empirically supported treatment research (LaRoche & Christopher, 2009). It is a weakness in the field of substance abuse, that there is not a greater impetus for culturally sensitive psychotherapy, which LaRoche and Christopher (2009) defined as the "tailoring of psychotherapy to specific cultural groups, so that persons from one group may benefit more from a specific type of intervention than from interventions designed for another cultural group.

The observations of Resnicow and colleagues (2000) provide the rationale for the dire need of these programs. They pointed out that the differences in substance use rates and patterns of abuse, the differences in the type and prevalence of risk factors, as well as the differences in predictors for substance abuse across different racial or ethnic groups that have been long prevalent in substance use data strongly argue for further study and implementation of culturally sensitive treatments. In addition, the National Institute of Drug Abuse (2003) validated the above observations, as they outlined variations in the nature of alcohol and other drug (AOD) use across youth from different ethnic categories, such as that African Americans tend to report less involvement with drugs than White youth, however, Hispanics have a significantly greater use of drugs than African Americans, but still slightly less than Caucasians. The 2003 treatment trends report, also used by NIDA, reported that 38.2% of patients seeking treatment for a substance abuse issue identified themselves as a minority, with 23.6% claiming the African American racial group (Pichot & Smock, 2009). It seems to be that case that culture is probably the best and most viable, at this point, variable to account for the variation AOD use and abuse prevalence.

While the need for more culturally sensitive programs is pressing, it is not the intent of the reviewer to imply that this is an easy process, as there are many different variables that need to be addressed, before any appropriate culturally sensitive programs can be effectively developed that will meet the target group. Durrant and Thakker (2003) indentify the very basic and most obvious variable, in that from cultural group to cultural group, there will be differing beliefs, norms, values and expectancies regarding the use of a substance that may influence treatment. The United States of America is a perfect example of this, as many have described it as a cultural melting pot, however, it is within that same melting pot, so to speak, that there has become a need for culturally tailored psychotherapy. Perhaps this is why Straussner (2001) and others have reclassified America as not a melting pot, but as an ethnocultural salad, where all the different cultures combine together for a unique mixture, but with each still retaining their own individual flavors.

Another cultural variable that Resnicow and colleagues (2000) pointed out, is that ethnic identity may play a significant role, which they define as essentially the extent to which an individual identifies with their racial or ethnic group, and is inclusive of elements such as "racial/ethnic pride, affinity for in-group culture (e.g. good, media, and language), and attitudes towards majority culture" (p. 273). In looking at Hispanics, Castro and Alarcn (2002) reported that the more minority youth identified with their ethnic culture, the lower their probability of using alcohol. To further complicate matters, in a meta-analytic review, Griner and Smith (2006) found that overall cultural adaptations of treatment approaches do result in clinically significant improvement. However, they also found that multicultural adaptations targeted at groups consisting of mixed-race individuals were less efficacious overall than cultural adaptations which targeted specific ethnic groups, although they were more successful than interventions without cultural adaptations.

Resnicow et al. (2000) further explicated how difficult the process of developing these culturally sensitive treatment programs can be, in that they identified two (2) overall dimensions that need to be targeted as the first step in this process. They explained that the surface and deep structures of culture are two significantly different dimensions that should be addressed in distinct ways to ensure the success of the program. Most often, treatments only target the surface structure, which they explained is the matching of social and behavioral characteristics of a culture to the intervention materials and messages. The second dimension, deep structure takes into consideration how the cultural, environmental, social, historical, and psychological factors influence the perception of the cause, course, and treatment of illnesses, and takes into account religious, familial, societal, and governmental influences. They likened surface structure to the face validity of a construct, that is, does it look to appear to meet the needs of the target group. Simons-Morton, Donohew and Crump (1997) support this dimensional view, as they claim that while surface structure, on a whole, increases the reception and comprehension of these message, program impact is affected by deep structure, which then determines how successful the treatment will or will not be.

Despite the plethora of research demanding the need for culturally sensitive treatments, the reviewer found it virtually impossible finding any manualized cultural adaptations of any of the above discussed treatment therapies regarding substance abuse. A basic Google search on any of the above outlined therapies provided an overabundance of links (scholarly and otherwise) providing an historical overview and treatment process of each. However, what was most prevalent in the literature (using basic Google, as well as Google Scholar, and PsycInfo) were research articles reporting the efficacy of these interventions with differing cultural groups, and making suggestions on how these therapies can be adapted to different racial categories. This is not to say that these recommendations were not meritorious enough to be used successfully in research, such as by some studies reported in Griner and Smith's (2006) meta-analytic review. Nevertheless, it is impossible to expect clinicians to review multiple articles to ascertain the different cultural adaptations for a variety of individuals, and as Persons (2008) states, there is a proliferation of empirically-supported treatments that overlap considerably and pose a significant burden for clinicians to effectively assimilate for therapeutic utility. Therefore, it should be the goal of researchers to include in their manuals of the proposed treatment, a thorough and detailed guide on how to address treatment issues for specific cultural groups.

While this suggestion may seem to be easy enough, there are limitations to this, as it may be impossible to fully capture the spectrum of the varying dimensions of a culture. As Wright (2001) pointed out, there is a tendency to describe all individuals of seeming African heritage as African Americans, but some of these may identify themselves more strongly with their direct heritage, which may be Caribbean, Central American, or even African; and as such, developing treatments that will target all the shades of ethnic category will be challenging, and even more so to do this for all ethnic categories. In that case, it seems almost forgivable that manualized cultural adaptations of these treatments have not been made readily available.

A seemingly successful adaptation of cognitive-behavioral interventions for substance use was utilized in the National Institute on Alcohol Abuse and Alcoholism (NIAAA)-funded Alcohol Treatment Targeting Adolescents in Need Project, which utilized a brief cognitive-behavioral (and motivational) intervention program for Hispanic and African American adolescents (Gil, Wagner & Tubman, 2004). Using the guided self-change treatment approach which is a mixture of cognitive-behavioral and motivation intervention, the researchers developed a youth-specific version which addressed cultural and language preferences in the creation of materials which were provided to the participants. Although they did not state exactly what cultural and language preferences were addressed, they did state that a manual is available for the guided-self change treatment for youth, but did not specify whether it was juveniles overall or Hispanic and African American juveniles. In their findings, the researchers show two important things, that treatment programs can be developed to target various racial groups and that these programs can be implemented in multicultural settings. Additionally, they provide further proof that cultural adaptations of mainstream treatments can be even more effective, as well as show that as the United States becomes increasingly culturally diverse, it will become a necessity.

Longshore and Grills (2000) described their adaptation of a group-administered session of Motivational Enhancement Therapy that was used with a sample of African Americans. They reported success, in that the participants who underwent the culturally-congruent intervention had better 1-year self report of abstinence of AOD use, compared to the control group who only received the generic version. Their result were further boosted by the fact that urine testing supported their findings, and as such, were not based solely on the self-reports of substance abusers. Some of the changes they made were helping the participant to understand that AOD abuse is not only a personal problem, but a community problem, which relates back the distinctions of African American culture from the dominant culture, including their history of oppression. That is to say, that they operationalized AOD abuse as an almost natural response given the African American history of power struggles with the dominant White culture.

Wright (2001) and Durrant and Thakker (2003) state that often times problems from the African American viewpoint is closely related to the historical and sociopolitical forces emanating from oppression dating back to slavery. Therefore, it does seem valid to incorporate this in a treatment program. In addition to this, the program also stressed the understanding of AOD abuse from both the life experience perspective and also from the perspective of being an African American, which includes the unique positives and negatives attributed to this racial group. Interestingly, the authors stated that they presented the intervention after sharing a somewhat traditional African American meal (fried chicken or ribs, mashed potatoes, rice, and beans). This is an important aspect, as this kind of meal sharing is the norm in African American cultures, and as such, it should be recommended that this be used, even at least once in the treatment process. The participants also received psychoeducational materials and messages that featured African-Americans, as well as experiences unique to African Americans. Therefore, on the face of this intervention, it does seem to meet Resnicow et al.'s (2000) dimensional model, as the adaptations seems to reflect the surface and deep structure of culturally-congruency.

In 1993, there were reports of a successful cultural adaptation of the 12-step program designed to be used with African American populations (Smith, Buxton, Bilial & Seymour, 1993). The authors state that the Haight Ashbury Free Clinics (HAFC)/Glide[3] African-American Extended Family Program (AAEFP) provides an example of effective cultural adaptability, . The treatment was the result of a collaboration of the Institute on Black Chemical Abuse with the HAFC, and included "a model synthesis of community activity and involvement, education, intervention, referral, treatment, and community-based support for recovery and reintegration" of substance abusers (p. 99).

Some of the issues that they addressed in the adaptation of the 12-step model included the fact that typically African Americans seek recovery very late in the AOD abuse timeline, and as such, this may necessitate different approaches than an individual just beginning. Added to this, is the fact that many African American AOD abusers are typically forced into treatment by way of their interactions with the criminal justice system, and a part of the treatment process has to include getting over this resentment and resistance to not only the treatment, but the aforementioned notion of oppression. Furthermore, the 12-step Minnesota model requires total abstinence for successful treatment (Pichot & Smock, 2009). However, as Smith and colleagues (1993) elucidate, for African Americans the goal has been on short-term abstinence and recovery, for unstated reasons. The difference between Euro-American culture and African American culture in terms of the family structure, with the latter featuring a matriarchal system, also can play a key role in the understanding of the development and prevalence of AOD abuse. Therefore, it could be argued that an African American child being removed from their mother's care may be more prone to seek an outlet in substance usage, rather than a Euro-American child faced with this same situation, as their family system is more patriarchal.

The researchers included support groups which are typical of the Minnesota model, but in these support groups, they strongly utilized spiritual references such as meeting at churches, and singing spiritual songs that reflect the African American overcoming their struggles, whatever they may be (Smith, Buxton, Bilial & Seymour, 1993). Weekly women's' meeting, African history classes, as well as the typical intervention meetings were integral parts of the AAEFP program. The final aspects of the program essentially invited the participants of this program to become a part of Glide's African American extended family, and in doing so will help to develop strong, positive support systems for these individuals. As they integrate church and religion into the treatment, successful completion of the program involves a graduation that involves the entire church family on specific Sundays. This is done to boost morale and self esteem, as it has been stated that African Americans suffer from low levels of self esteem due to either poor or negative self knowledge of themselves and of their culture.

It is well-established that there is a definite and dire need for culturally sensitive psychotherapy programs that target the spectrum of mental disorders, including substance abuse. As detailed above, there is a lack of these programs within the substance abuse arena, however, the momentum for developing these programs is rapidly gaining as America becomes increasingly diverse. It should be the goal of all therapists and clinicians to determine the most appropriate treatment for their client; but this is not always easy, as there are a wide variety of interventions, and, each client comes with their own unique cultural baggage that may complicate matters even further. With that being said, the goal of researchers should be to culturally adapt the current evidence-based practices, and since Backer (2001) has already provided a 12-step program adaptation guideline, the process should already be underway. Even by following Muoz and Tamar's (2005) recommendations of including the targeted group in the development of the intervention process, addressing the relevant cultural values including such as their religious and spiritual proclivities, the impact of prejudice and discrimination, as well as the varying levels of acculturation (ethnic identification), is a satisfactory first step in the development of a structurally-sound culturally sensitive treatment.

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• Substance Abuse and Mental Health Services Administration. (2009). Results from the 2008 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434). Rockville, MD.
• Tate, S. R., Drapkin, M. L., & Brown, S. A. (2009). Substance abuse: Diagnosis, comorbidity, and psychopathology. In P. H. Blaney, & T. Millon (Eds.), Oxford textbook of psychopathology (pp. 280-297). New York, NY: Oxford University Press.
• Wright, E.M. (2001). Substance abuse in African American communities. In S. L. Strassuner (Ed.), Ethnocultural factors in substance abuse treatment (pp. 31-51). New York, NY: The Guilford Press.

1. Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics used non-medically.
2. The program is called the Glide AAEFP because its first trial was at the Glide Memorial Methodist Church in San Francisco.

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