SITE SEARCH

U.S. society is characterized by a perpetual shifting of ethnic and cultural demographics at local, regional, and national levels of measure (NASW, 1997). The current conceptualization of American society involves a mosaic of various ethnocultural groups, in which separate identities are preserved within the pluralistic whole (Straussner, 2001a). In recognition of this reality, the social work profession and social work educators place a high degree of importance on the development of ethnic-sensitive, culturally competent social work practice (Amodeo & Jones, 1997; Schlesinger & Devore, 1995). This approach to practice is consonant with the values, experiences, histories, heterogeneity, resources, and traditions of members of diverse ethnic and cultural groups. Ethnoculturally competent social work practice is responsive to issues of racism, ethnocentrism, class conflict, and diversity between, as well as within, cultural groups (NASW, 1997). "Cultural competence builds on the professional's valued stance on self-determination and individual dignity and worth, adding inclusion, tolerance, and respect for diversity in all its forms" (NASW, 1997, p. 77; NASW, 2002).

Learning Objectives

By the end of this module, learners should be:
A. Familiar with literature relating alcohol issues to race, ethnicity, and culture;
B. Knowledgeable about diverse patterns of alcohol use among individuals from various racial, ethnic, and cultural groups-differences between and among groups;
C. Knowledgeable about the effects of alcohol on different groups and the factors associated with alcohol use among members of various groups;
D. Prepared to provide effective alcohol intervention and prevention services by exploring strategies appropriate for use with members of varied racial, ethnic, and cultural groups.

Background

Ethnicity is, in part, determined by the cultural attitudes, beliefs, values, customs, and norms of the ethnic group to which an individual belongs. Membership in an ethnic group helps to shape a person's interpretations, responses, options, and behaviors, and should be taken into consideration when developing the clinical picture. However, ethnic experiences are also filtered through that group's history (e.g., colonization, migration, enslavement), religion, physical characteristics, social class and minority status experiences, and experiences of persecution, oppression, discrimination, inequity, hostility, or acceptance. Social work practice, therefore, needs to be informed by knowledge of the ways in which ethnic realities influence individuals (Schlesinger & Devore, 1995). These diverse realities result in individual differences of interpreting and responding to situations, views of the "helping" professions, conceptualizations of self-efficacy, and perceptions about reasonable alternatives and solutions.

In response to these needs, it is critical to appropriately tailor screening, assessment, intervention, and prevention activities to be ethnically sensitive and responsive to the personal, social, economic, and political characteristics associated with individuals who present in social work practice settings. Ethnic and culturally sensitive practice reflects awareness that:

• The individual's personal history, as well as the ethnic/cultural group's history, have an impact on the way that problems arise and are solved;
• Ethnic and cultural factors (many of which a person is unaware) influence behavior;
• Ethnic and cultural groups are characterized by considerable amounts of within-group heterogeneity, as well as between-group heterogeneity;
• Ethnicity and cultural group membership is often a source of strength and resources for an individual.

This module is concerned with the ethnic and cultural aspects of alcohol-related problems. The term "race" only occasionally appears because it reflects a very different and distinct concept. Race basically refers to the classification of people as members of a population defined by genetically transmitted (physical) characteristics (Straussner, 2001a). The relevance of race to social work's understanding of alcohol issues is primarily tied to aspects of individual differences in physical reaction and tolerance to this substance. On the other hand, culture refers to the ways in which individuals structure their behaviors around the worldviews, life patterns, institutions, languages, religious ideals, artistic expressions, and relationships shared by their group's members (Straussner, 2001a). Ethnicity refers to a shared common identity of a group's members, and it helps to determine thoughts, feelings, and behavior in both subtle and obvious ways (McGoldrick, Giordano, & Pearce, 1996). Cultural identification refers to the degree or strength of a person's ethnic or cultural group affiliation (Oetting et al., 1998).

The close interaction and circularity of influence between ethnicity and cultural context leads Straussner (2001a) to recommend that clinicians strive to develop ethnoculturally competent practice in substance abuse services. She suggests that ethnocultural competency is a crucial component in the delivery of effective services, communication between practitioner and client, and client retention. Amodeo and Jones (1997) state that engaging clients in the change process requires that practitioners acknowledge the cultural framework of practice (i.e., client, practitioner, and social system/context factors), and that simply applying mainstream approaches to substance problems of non-mainstream populations is likely to be ineffective or counterproductive. Keys to effective, culturally competent intervention success are: rapport and understanding of a client's cultural identity, social supports, self-esteem, and reticence about treatment due to social stigmas (SAMHSA, 2001).

"Cultural competence," as a term and a social work practice goal, encompasses the processes by which social workers and social systems/institutions demonstrate respect and effective responses to individuals of all cultures, language groups, social classes, races, ethnic backgrounds, religions, or other diversity factors "…in a manner that recognizes, affirms, and values the worth of individuals, families, and communities and protects and preserves the dignity of each" (NASW, 2002). Cultural competence involves behaviors, attitudes, and policies that enable effective work in cross-cultural situations.

Ethnically competent practice is characterized by:

• Self-awareness concerning one's own ethnocultural background and values;
• Basic knowledge about the clients' ethnocultural background;
• A commitment to working with a diverse client population;
• An ability to appropriately adapt social work practices to suit client ethnocultural background and to engage appropriate cultural resources within a given ethnic community (NASW, 2002; Straussner, 2001a).

Culturally competent practice is based on recognition of clients' cultures, and developing a set of skills, knowledge, and policies for delivering effective interventions (Sue & Sue, 2002). These might include skills in attending, listening, affirming, expressing empathy, eliciting an individual's viewpoint, resource identification, and supporting personal choice that are consistent with cultural patterns.

Draguns (2000) summarizes the state of knowledge with respect to the interplay of ethnicity and psychological disorders:

Therefore, this module is structured to first address the current state of knowledge related to the prevalence, incidence, and impacts of alcohol-related problems across and within various ethnic and cultural groups within the United States, and then to examine knowledge related to intervention and modification strategies that might enhance social workers' ethnocultural sensitivity and competence in addressing alcohol problems.

Alcohol Consumption / Drinking Patterns

Alcohol consumption trends and patterns vary markedly across various groups within the U.S. Recognition of diversity in alcohol-related problems is an important aspect of developing tailored and targeted intervention and prevention responses. Most research into this issue is centered on the study of four main groups, often in comparison or contrast to White/Caucasian Americans. The four groups include: African Americans, Hispanics, Asian Americans/ Pacific Islanders, and American Indians/ Alaska Natives. However, "…It is important to note that these categories include hundreds of distinct ethnic or racial populations which differ markedly in cultural characteristics and drinking behavior…" (NIAAA, March, 2002). The problem with aggregate data is that it masks very important differences across subgroups within an ethnic or cultural "category" (Straussner, 2001a).

For example, the group of White/Caucasian Americans includes a membership that is widely diverse in terms of national origin, immigration history, regional distribution, and so forth. Similarly, the Hispanic/Latino group includes individuals from many different regions and language groups, who may be from first, second, third, or earlier generation immigrant families (or families who did not move, but became Americans when national boundaries shifted). Sometimes, specific national origins are important to distinguish (e.g., Mexican American, Puerto Rican, Guatemalan, Cuban, etc.). Asian Americans may or may not include individuals with ties to the Pacific Islands (Indonesia, Micronesia, etc.), Japan, Korea, China, Thailand, Cambodia, Vietnam, and so forth. Again, specific national origins are relevant in terms of understanding historical cohort influences, religious affiliations, social norms, attitudes, experiences of discrimination and oppression, education, and nutrition.

Within group differences relate to factors of:
National origin Immigration/migration histories Region/geographic distribution Generational and cohort influences Group and religious affiliations	Discrimination and oppression experiences Resources, education, language, nutrition, health, etc. Lifecycle phases, age Gender

In addition, the results of ethnic group comparisons may not be consistent across the lifecycle. For example, Muthen and Muthen (2000) observed that gender and ethnicity effects related to alcohol consumption patterns among individuals in their twenties did not follow the same trajectory as for individuals in their thirties. Furthermore, American Indian experiences may vary tremendously depending on where they reside during different periods of their lives-in large urban centers, rural areas, within reservation areas, or as youths living in boarding schools.

Epidemiology of Alcohol Problems

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The SAMHSA National Household Survey on Drug Abuse (1991-1993) indicates that 3.5% of their entire sample could be classified as alcohol dependent. The White non-Hispanic and Black non-Hispanic groups had a similar rate (3.4%) of alcohol dependence, while the rates for Native American (5.6%) and Hispanic-Mexican respondents (5.6%) were somewhat higher. The rates of alcohol dependence were lower among other Hispanic respondents (Caribbean, 1.9%; Central American, 2.8%; Cuban, 0.9%; Puerto Rican, 3.0%; and South American, 2.1%) and Asian/Pacific Islander (1.8%). Makimoto (1998), like the National Household Survey, also found that the group of Asian Americans had higher rates of abstention and lower rates of heavy alcohol consumption compared to Whites, African Americans, and Hispanics. Moncher, Holden and Trimble (1990) observed that an aggregate sample of Native Americans who used alcohol did so at an earlier age and drank more heavily, compared to other ethnic groups in the United States.

Diversity in drinking patterns also exists between subgroups of the same racial or ethnic group. The National Household Survey data concerning Hispanic groups reinforces the importance of disaggregating data on heterogeneous ethnic and cultural populations. Caetano and Raspberry (2000) observed that Mexican Americans born in the U.S. report drinking more often, but consuming less alcohol, and have three times higher rates of alcohol dependence (DSM-IV; 27% vs. 9%) compared to Mexican Americans born in Mexico-at least among individuals in treatment for driving under the influence of alcohol. Furthermore, subgroups are also defined by age (drinking decreases with age), gender (men tend to drink more often than women), and national origin (Delgado, 1995; SAMHSA, 2001). Initiation of use is complexly tied to both gender and degree of linguistic biculturalism/ acculturation (Epstein, Botvin, Griffin, & Diaz, 1999a; Epstein, Botvin, & Diaz, 2000).

Similarly, Makimoto (1998) reported that Japanese Americans describe themselves as drinking more frequently and more heavily than do Chinese Americans, though these two groups are usually combined in research into a single "Asian American" category. Studies of drinking patterns in Hawaii indicate the highest prevalence of alcohol use is among Caucasians (74%), followed by Native Hawaiians (62%), Chinese (58%), Japanese (50%), Filipinos (46%), and others-a pattern that has been similar across surveys conducted in 1960, 1974, and 1979 (Kuramoto, 1995). Furthermore, Hawaiians in Hawaii have the highest rate of binge and chronic drinking, compared to Whites, Filipinos, Japanese, and other Hawaiian groups (Mokuau, 1995). A significant minority of Asians and Pacific Islanders in America are not simply alcohol users but are heavy drinkers-the Japanese Americans may have up to 25% who are heavy drinkers, Filipinos around 20%, Koreans 15%, and Chinese about 10% (Kuramoto, 1995).

Likewise, differences in alcohol consumption are found to vary greatly between Native American tribes (Caetano, Clark, & Tam, 1998). This should not be surprising since there are at least 17 distinct Indian cultures and well over three hundred recognized American Indian and Alaska native tribes (Moran & May, 1995). Some groups, such as the Chippewa (Ojibwe) have rates of alcohol use disorders that are similar to the general population (Draguns, 2000). Prevalence rates vary by tribe and location-urban, rural, and reservation (Draguns, 2000), and problems with alcohol vary between reservations, depending on individual attachments to family and to the Native American community (Milbrodt, 2002).

Impact of Alcohol on Ethnic and Cultural Groups

In addition to differences in drinking patterns, differences in the consequences of alcohol use may exist among various ethnic and cultural groups. The differential consequences may, in part, be a function of different vulnerabilities and resiliencies conferred by biological and genetic factors (NIAAA, 2002). Or, differences in outcomes and impacts may be related to disparities in the timing and types of services experienced by individuals from various ethnic and cultural groups.

Differential consequences of alcohol consumption can be related to:
Differing vulnerability (intrinsic, biological) Differing resiliency (extrinsic, contextual) Service disparities (access to intervention and prevention resources)	Differential rates of alcohol-related medical problems Differential rates of alcohol-related mortality Differential impacts may relate to "drink of choice" Differential impacts may relate to physiology

As the U.S. Surgeon General, Dr. David Satcher issued a statement concerning health disparities and service inequities that exist across our nation. His position is that some communities, defined by race and ethnicity, disproportionately bear the burden of disability from under- or poorly-treated mental health problems. For example, Hispanics in the U.S. are approximately twice as likely as Whites to die from cirrhosis of the liver, despite lower drinking/heavy drinking prevalence. This is possibly attributable to higher cumulative doses per drinking occasion, the prevalence of hepatitis C which enhances risks to the liver from heavy drinking (NIAAA, 2002), and/or differences in access to early, effective treatment. With regard to mental health services, Satcher stated that "culture counts" in critical ways, and that the nation's diversity has to be addressed in the conduct of basic and applied research, in service delivery, and in the ways that we educate future generations of service providers.

For example, significant disparities in age and ethnicity appear among individuals who are served in, and complete, public sector alcohol treatment programs. Booth and colleagues (1992) found that Hispanic and African American clients were less likely than Caucasians or Native Americans to complete treatment and were more likely to appear in "no alcohol treatment" conditions (about 50% of Hispanic and African Americans versus 25% of Native Americans and 40% of Caucasians). Native Americans were more likely to complete treatment (64.7%) compared to Caucasians (44.7%). The authors conclude that these discrepancies are the result of several important interactive factors, including variable rates of under-diagnosing drinking problems and social class distinctions between the groups in terms of who receives public sector versus private alcohol treatment services.

Health and Safety: African Americans currently have higher rates of alcohol-related medical problems and mortality than Whites, despite having higher rates of alcohol abstinence (Gray, 1995). The general alcohol-induced mortality rates are described as three times higher for African Americans compared to Whites (Clifford & Rene, 1985-86). Among individuals who abused alcohol, more health-related problems appeared among African American than among White drinkers (Caetano & Clark, 1998b). They were three times more likely to develop cirrhosis of the liver and esophageal cancer, one of several alcohol-related cancers. Results from several studies reveal more psychological impairments such as obsessive compulsive behavior, depression, hostility, paranoid ideation, and more stress among African Americans who drink excessively, compared to Whites who drink at the same rate (Pavkov, McGovern, Lyons & Geffner, 1992; Grant & Harford, 1995).

Similar findings have been reported from research with Native Americans who use alcohol. Death from heavy drinking is reported to be more than six times higher among Native Americans compared to the general population, and cirrhosis of the liver is 14 times greater among Native American populations compared to non-Native Americans (Moran & May, 1995). The rate of alcohol-related death among American Indian men is estimated at 27%, and at 13% for women, although rates vary widely among individuals from different tribes (May & Moran, 1995). Rates of vehicular homicide, homicide, and suicide that are attributable to alcohol are higher among Native Americans than the general population (Milbrodt, 2002). Furthermore, American Indians with alcohol use disorders appear to be at a high level of risk for concomitant mental health problems (SAMHSA, 2001).The incidence rate of esophageal cancer in Hawaii is much higher among Native Hawaiians than among Whites, and this may be attributable to a difference in the "drink of choice" between these two groups. Native Hawaiians choose beer and Whites are more likely to choose wine and spirits (Mukuau, 1995). A fair amount of discussion about the drinking patterns among Asian Americans and Pacific Islanders addresses "flushing" reactions to alcohol consumption. This is a physiological response or sensitivity that many individuals experience (to varying degrees) in response to drinking alcohol, and may include a variety of chemically-induced, physically uncomfortable symptoms (Kuramoto, 1995; NIAAA, 2002). While flushing has no apparent long-range health impact, it may or may not be related to the frequencies with which affected individuals choose to drink. Studies indicate that some individuals with this response drink less, while other individuals develop alcohol-related problems despite its presence (NIAAA, 2002). Luczak et al. (2001) concluded that an individual's status with the gene and specific alleles that control this response (ALDH2 gene, ALDH2*2 allele) may serve as a protective factor among some Chinese college students, and as a risk factor among Korean (and White) students when absent.

Mental Health and Other Social Effects: Intimate partner violence (IPV) is one problem that has been associated with alcohol abuse. When sociodemographic and psychosocial covariates are controlled in analyses, previously noted significant relationships between men's drinking problems and their perpetration of IPV disappear among White and Hispanic couples (Cunradi, Caetano, Clark, & Schafer, 1999). This is not true among White women perpetrators; their alcohol-related problems continue to predict the IPV that they perpetrate, but not IPV perpetrated against them. However, among Black couples, alcohol-related problems of men and women continue to be strong predictors of IPV. It should be noted that the key variable is the presence of alcohol-related problems, not the amount of alcohol consumed (Cunradi et al., 1999).

Some authors address the issues of social control and economic incursions that may be tied to alcohol use among members of certain ethnic and cultural groups. For example, Gray (1995) presents an historical framework of alcohol's role in the lives of African Americans. This history reports ways in which alcohol has been used to maintain and preserve an inequitable social order and to reinforce patterns of oppression. Milbrodt (2002) also describes historical roots of alcohol problems among Native Americans that are tied to interactions between Native people and Europeans. Alcohol was recognized by some tribal leaders as a source of their increasing vulnerability, poverty, persecution, and loss of traditional social order and resources (Mancall, 1995).

Ethnic and Cultural Influences on Drinking Patterns

Alcohol consumption is governed, in large part, by the social rules, norms, customs, and traditions acquired through an individual's cultural and ethnic contextual experiences, including immediate family, extended kin, peers, "teachings," and "preachings." Ignoring these influences can lead to misguided judgments about the appropriateness and inappropriateness of alcohol consumption and concomitant behaviors (Heath, 2000). For example, there is a danger that many Native Americans will develop a belief in the stereotype of the "drunken Indian" and that this inaccurate stereotype may lead an individual to conclude that drinking to excess is normative within the group (May & Smith, 1988). This conclusion was based on a set of observations of Navajo Indians. The concept has parallels in studies of individuals' tendency to overestimate the amount of alcohol use/abuse that occurs within their communities or in the population, and the possibility that these misperceptions "normalize" their behavior (Perkins & Wechsler, 1996).

Many interventions are based on assumptions that do not recognize the importance of these norms, practices, and influences on alcohol consumption and abuse. Such a lack of cultural relativity may result in a misinterpretation of intervention outcomes (Heath, 2000). For these reasons, Adrian (2002) cautions researchers to be alert to implicit assumptions about relationships between ethnicity and addiction, particularly in reference to differences in prevalence rates, associated problems, and use-related attitudes.

Cultural Norms and Values

Ethnic and cultural group norms, values, and expectations concerning alcohol vary markedly, as do cultural strengths and resiliency factors (Amodeo & Jones, 1997; Oetting, et al., 1998). Members of different ethnic and cultural groups show preferences for different types of alcoholic beverages, which may, in turn, affect access and relative alcohol content/exposure (Graves & Kaskutas, 2002; Heath, 2000). Individuals who drink in social groups and in situations where there are linked activities, adjust their consumption rates and rhythms to others in the group and/or to the linked activities rather than follow an individually-determined pattern of consumption (Heath, 2000). Some cultures abhor any alcohol use. For example, among non-drinking adolescents, religion often plays a central role in life. Muslim and non-Western immigrant teenagers are very likely to be abstainers-at least among Norway's adolescents (Pedersen & Kolstad, 2000). Unfortunately, this does not guarantee an absence of alcohol-related problems, and when alcohol is a problem, these cultural norms may lead to hiding, minimizing, denial, or exclusion (Abudabbeh & Hamid, 2001; Straussner, 2001b). In cultures that accept some alcohol consumption, norms govern what types are consumed. There are also norms concerning how much is consumed, and what are acceptable forms of intoxicated behavior. "Some cultures reinforce abstinence as a norm; others approve of drinking only as part of religious ceremonies. Drinking, especially if it occurs in a group setting, may symbolize solidarity…" (Amodeo & Jones, 1997, p. 242-243). Thus, any specific type of substance use could be differentially viewed as normative, deviant to some degree, or quite deviant behavior, depending on the cultural context (Oetting et al., 1998). Culture has a powerful influence on alcohol-related behaviors, as well as on belief systems about alcohol among users and among members of the users' support systems (Amodeo & Jones, 1997).

Furthermore, socialization theory explains how specific drinking customs and rituals are transmitted across generations and from one individual to another within a family, ethnic, or cultural group (Oetting et al., 1998). The degree to which cultural norms influence an individual's drinking behavior is determined, in part, by the extent of that person's identification with the group, the degree of consistency in the group's norms, and the presence of confounding or complementary forces, such as gender and age norms (Oetting et al., 1998). Drinking and other drug use behavior are also associated with the perception of risk associated with consumption, and the risk perception may differ among ethnic and cultural groups. White individuals in a general population survey are the least likely to perceive risks for alcohol use (compared to Black and Hispanic respondents), and have the highest prevalence of past month use (Ma & Shive, 2000).

A culture-specific framework for comparing cultures and for understanding individuals' drinking dynamics addresses such factors as:

• Attitudes, values, and behaviors related to using alcohol and to being intoxicated;
• Cultural definitions of alcohol use as problematic and explanations of the problem;
• Type and severity of social sanctions;
• Help seeking;
• Where help is sought and received;
• Meaning and consequences of changing, not changing, and relapsing;
• Types of help that result in success;
• Definitions of success;
• Interaction with other factors and influences (age, gender, social class, sexual orientation, religion, resettlement/immigration/refugee experiences, and degree of acculturation) (Amodeo & Jones, 1997).

Gutmann (1999) urges caution, however, in drawing conclusions about the role of acculturation in shaping alcohol consumption patterns:

Changes in drinking patterns and problem drinking among immigrants to the United States are often mistakenly attributed to acculturation, just as the etiology of alcohol abuse and alcoholism is often erroneously traced to the 'ethnic origins' of these men and women (p. 173).

The process of acculturation alone may not be the primary factor shaping alcohol abuse patterns, but the stress of the acculturation process within hostile environments may influence alcohol use and abuse patterns.

This is of concern, because practitioners and researchers may unwittingly and inadvertently contribute to the problematic drinking patterns through: (1) influencing the perceptions and understandings of individuals with respect to the relationship between their particular ethnic groups and alcohol consumption, and (2) inattention to social conditions and inequitable conditions under which the individuals might live. In fact, a content analysis of empirical studies led to the conclusion that there is no support for a contention that substance use, substance-related problems, or substance-encouraging attitudes differ significantly between representatives of mainstream U.S. society and U.S. ethnocultural subgroups (Adrian, 2002). This is important because misrepresentation and over-inflation of the differences contributes to "further problematizing" the status of individuals from these groups (p. 854). However, it is also difficult to separate the effects of cultural norms and values from other contextual influences, such as unemployment and the loss of status that accompanies the loss of traditional tribal roles of importance. Relevant cultural norms may apply either to the actual consumption of alcohol, or more to the threshold of acceptable behavior while under the influence of alcohol (Draguns, 2000).

The Hispanic community has strong cultural prohibitions about women drinking. This may account for the high number of Hispanic women (70%) who have less than one drink per month, if they drink at all (Barthwell, 1997). These community injunctions do not exist for Hispanic men-a fact that is offered as a potential explanation for their significantly higher drinking rates when compared to Hispanic women. McNeece and DiNitto (1994) describe a culturally specific definition of alcohol (and other drug) problems that exists within segments of the Latino community. There is a perception of such problems as being the result of extrinsic, spiritual intervention, rather than as a phenomenon under individual control. In addition to addressing issues of religion and spirituality, culturally competent practice with Hispanic and Latino individuals should address issues of:

• Stress (e.g., economic conditions, language barriers, racism)
• Family
• Peer groups
• Natural social support systems such as extended family (related and non-related "adopted" members), neighbors, friends, healers, religious and indigenous institutions, local groups, and community leaders (Delgado, 1995).
  

Similarly, the influence of the Confucian and Taoist philosophies has been considered as an explanation for the low rate of alcohol consumption among Asian Americans. The emphasis on peace, congruence, and harmony may serve to moderate alcohol consumption (Caetano, Clark, & Tam, 1998). The degree of acculturation to American cultural patterns may also serve as a means of explaining differences in drinking behavior across Asian and Pacific

Islander groups. Studies of youth and young adults generally associate higher degrees of assimilation with higher levels of drinking, particularly among men (Kuramoto, 1995). Risk factors that have been identified through key informant surveys among Asian American groups include: drinking as an intrinsic part of business transactions (Chinese and Japanese men), waitresses and hostesses encouraged to drink with clients (Korean women), isolated elders (Japanese and Filipino men), recent immigrants experiencing posttraumatic stress (Southeast Asians), young men who engage in "pack" social behaviors, and increasing numbers of young women whose group behaviors reflect their male counterparts (Kuramoto, 1995). Makimoto (1998) suggests that alcohol problems among Asian Americans are often related to struggles with the transition to Western culture. The transition process creates stress, disrupts traditional family structures and the extensive support system provided by extended family members, and can hinder self-identity development. Some individuals use alcohol to cope with the stress associated with these difficulties.

Historically, African Americans who drank did so primarily on weekends and/or as part of celebrations and holidays. West African traditions involved alcohol as an integral part of medicine, religion, and special celebrations, but placed high value on moderate drinking and disapproved of drunken behavior (Gray, 1995). Slavery, emancipation, abolition, and civil rights have since intervened, and one contemporary result is a tremendous degree of variability and ambiguity in attitudes, meanings, norms, and behaviors related to alcohol consumption (Gray, 1995). A large segment of the African American community is characterized by abstinence (Herd, 1990). Many of the African Americans who do drink tend to follow a pattern of group and/or weekend drinking (Dixon, 1991; Goddard, 1993). The cultural-specific approach to understanding alcohol use disorders leads to an awareness of where people seek and receive help with their problems. African Americans very often rely on the church as a critical resource for addressing substance use problems (Amodeo & Jones, 1997). It is important to note that the research concerning drinking patterns among African Americans does not tend to employ ethnographic approaches or to address cultural theories, and therefore is limited in its usefulness for "within group" comparisons (Gray, 1995).

Discrimination and Racism

Frustration, anxiety, anger, and stress that result from an individual's encounters with discrimination, oppression, racism, social injustice, ethnocentrism, and economic instability may be contributing factors to alcohol consumption (Brown & Tooley, 1989; Dixon, 1991; Harvey, 1985). Caetano, Clark, and Tam (1998) indicate that drinking patterns observed among some Native American groups are consonant with the use of alcohol as a means of coping with low self-esteem, anxiety, and feelings of frustration, powerlessness, hopelessness and despair resulting from experiences with discrimination and oppression.

Individuals at all socioeconomic levels experience racism and discrimination, which may explain why alcohol use patterns within some ethnic and cultural groups tend to cross over socioeconomic boundaries. For members of an ethnic or cultural group that is vulnerable to racism and discrimination, and who also experience limited resources, alcohol use may provide escape for those who cannot afford professional services, take vacations, or use other outlets (Mosley, Atkins, & Klein, 1988). Dixon (1991) adds that, particularly among African Americans, alcohol is often valued for the escape it provides, while the problems that its use may create are underestimated.

Access to Alcohol

Another factor that contributes to drinking patterns within an ethnic or cultural group is the extent to which alcohol is easily accessible. Highly segregated, low-income neighborhoods tend to have a high degree of access to liquor and density of liquor outlets (NIAAA, 2002). Neighborhoods characterized by predominately African American or other racial/ethnic "minority" group demographics often have a disproportionately high concentration of liquor stores, bars, and alcohol-related advertising, making alcohol access easy (Alaniz, 1998; Harvey, 1985). Liquor, beer and wine manufacturers and distributors have been shown to aggressively market and advertise their products specifically to members of the African American and other ethnic/cultural groups (Alaniz, 1998; Gray, 1995).

Adolescents from different ethnic and cultural groups differ in the frequency and contexts within which they are offered substances, and in their refusal strategies (Moon, Hecht, Jackson, & Spellers, 1999). For example, among a group of 7th grade White, African American, and Mexican American teenagers, Mexican Americans received the greatest number of substance offers. They were most likely to be offered substances by peers in the family and at parties. White teenagers were more likely to receive offers at friends' homes, on the street, or from acquaintances. African Americans received offers of substances from their dates (especially among girls) and their parents, and were more likely to receive offers in parks. African American adolescents were the most likely to resist the offers and to use explanations in their refusal repertoires. Gender differences also appeared among these variables (Moon et al., 1999).

Prevention and Intervention

The Social Work Code of Ethics directs social work professionals to acquire and adopt culturally competent practices (see Section 1.05 of the NASW Code of Ethics, 1997-2001). Culturally competent practice includes understanding the influences of culture in general, acquiring knowledge about clients' cultures, utilizing client-centered competencies, and gaining awareness about the effects of diversity and oppression. This includes consideration of client language preferences and abilities. It also includes respect for clients' ethnic and cultural norms around aspects of gender- and age-specific roles. There are two general approaches to prevention and intervention of alcohol use disorders among members of specific ethnic or cultural groups. The first involves applying evidence-based practice and adapting interventions that have been empirically tested and proven to work with the general population. The second involves creating culturally specific programs "from the ground up." Of course, some approaches might represent a hybridization of these two strategies.

Direct Practice: Routes to Treatment

Research results indicate that members of various ethnic and cultural groups are less likely to seek and to complete alcohol treatment in comparison to their White counterparts (Nathan, 1986; Williams, Mason, Goldberg, & Culter, 1996). Those who do, often enter treatment for alcohol abuse as a result of seeking treatment for some other problem, such as an alcohol- related medical condition (Booth et al, 1992). Therefore, the initial intervention objective may involve helping the client to enter alcohol treatment. Motivational enhancement therapy
(MET), Motivational Interviewing (MI), and the Transtheoretical/Stages of Change approaches have been identified as strategies that are appropriate for application with a widely diverse population of clients (see earlier modules of this curriculum; DiClemente, Bellino, & Nevins, 1999).

The AOD Cultural Framework outlined by Amodeo and Jones (1997) specifically addresses the cultural dynamics involved with seeking help for problems. The social worker and client explore the culture's values, attitudes, beliefs, communication styles, and behavior patterns around the use of alcohol and other drugs, as well as those surrounding help seeking. As a result, the cultural framework directs the social worker to identify the points and places at which help seeking occurs, the types of individuals from whom help is sought, the type of help sought and provided, the availability of help sought and provided, and the reinforcements (or costs) of changing behavior that are experienced in that context (Amodeo & Jones, 1998).

Screening and Diagnostic Assessment

In a World Health Organization (WHO) study of cross-cultural applicability of diagnostic criteria and assessment instruments, Gureje et al. (1997) concluded that substantial differences across the world's ethnic and cultural groups limit the adaptability of drinking descriptors. These differences are tied to a lack of corresponding linguistic elements for describing and defining alcohol-related behaviors, an absence of cultural applicability of certain core concepts, and distinct differences in the cultural concepts being employed. Considerable differences in access to particular substances and in innately acquired physiological tolerances to alcohol may have an impact on the manifestations of alcohol abuse and dependence (Canino et al., 1999). The cross-cultural applicability of alcohol diagnostic criteria warrants serious empirical attention, since client responses to interview protocols can be affected by differences in the way their cultural groups:
1) recognize symptom severity,
2) "problematize" different states of alcohol use,
3) build assumptions about how alcohol problems develop,
4) hold culture-specific manifestations that are not recognized in official nomenclatures and alcohol classification systems (Schmidt & Room, 1999).

The validity of alcohol screening and assessment instruments has generally been established with populations of White/Caucasian men. Relatively little is known about the applicability of these measures to women and members of various ethnic and cultural groups in the United States (Cherpitel, 1999). A comparison of the CAGE (Mayfield, McLeod, & Hall, 1974) and the TWEAK (Russell et al, 1991) screening instruments was conducted with non-clinical (general population) samples of Hispanic, Black, and White/other respondents. Sensitivity and specificity were determined using ICD-10 and DSM-IV criteria. The CAGE appeared not to differ across gender and ethnic subgroups. The TWEAK, however, was more sensitive among men than women, and sensitivity was highest among White and Hispanic men, although these results were also modified by service type (Cherpitel, 1999). Cherpitel and Borges (2000) compared the applicability of four screening instruments for alcohol use disorders: CAGE, BMAST (Pokorny et al, 1972), AUDIT (Babor et al, 1992), and TWEAK. Their use was compared for patients seen in Mexican and Mexican American emergency rooms. They found that lowering the specific cut points of some instruments for use with these populations, particularly with women, had a great impact on instrument performance as determined by ICD-10 or DSM-IV criteria. Canino et al. (1999) have tested the psychometric properties of the Alcohol Use Disorder and Associated Disability Interview Schedule (AUDADIS) translated into Spanish for use with Hispanic clients. This assessment tool demonstrated good test-retest reliability for the diagnosis of alcohol dependence and major depression. The reliability and validity levels of the Spanish AUDADIS were comparable to findings reported for the interview schedule employed in other studies. Reliability for reports of beer and wine consumption and for reports of usual quantities consumed were higher than for other types of alcoholic beverages or for quantities during periods of heaviest consumption. Overall, the instrument provided good to excellent reliability in diagnosing past year, prior to past year, and lifetime alcohol dependence (and major depression) diagnoses.

Similarly, Zeiler et al. (2002) have explored the appropriateness of administering the Drug Abuse Problem Assessment for Primary Care (DAPA-PC) to White and Black individuals. They found that White respondents were more likely to report use during the past 30 days (68% versus 52%, p<.05) and that Black respondents were almost twice as likely to report a quit attempt within the past 6 months (30% versus 17%, p<.05). Overall scores on the instrument did not differ significantly across the two groups, and the responses were similar with regard to having consumed too much, withdrawal symptoms, loss of recall, problematic consequences of use, and others expressing concern about their use. The team concluded that the overall instrument has applicability for identifying both Black and White individuals with alcohol use problems, but that item differences that were observed indicate that such instruments should be created, tested, and normed separately for different ethnic groups.

In short, the intake procedures that are utilized with individuals who experience alcohol-related problems can "make or break" the helping process. To practice in a culturally competent manner at intake, the social worker must consider the role of alcohol in the client's family, religious, and ethnocultural systems, and seek out the strengths and resiliencies offered by these traditions. In addition, the social worker must review the individual's degree of ethnic/cultural identification, circumstances of migration/refugee status, socioeconomic standing (past and present), language preferences, and previous experiences with treatment systems (Straussner, 2001a; Thurman et al., 2000).

Intake procedures that are utilized with individuals who experience alcohol-related problems can "make or break" the helping process.

Programs

The theoretical models adopted by social work practitioners represent an additional issue for culturally appropriate intervention with individuals whose lives are affected by alcohol. For example, behaviorally oriented methods, rather than insight-oriented methods, may be more effective for intervention within some ethnic and cultural groups (Juarez, 1985; Thurman et al., 2000). This is, in part, because of a focus on the here and now and on contextual factors. But many intervention approaches that are effective when applied to one ethnic or cultural group fail miserably when transplanted into another. For example, Native American populations have rejected intervention and prevention programs that work in non-Native society, because they did not take into account the cultural needs of the community (Milbrodt, 2002). Thus, for evidence-based practice to be appropriate, it is necessary that the research concerning "best practices" be appropriately designed and conducted to explore effectiveness of applications among specific ethnic and cultural groups.

Culturally specific models of relapse prevention appear to have relevance for certain African American clients in substance abuse treatment (Walton, Blow, & Booth, 2001). The African American clients in this particular study reported significantly greater skills in coping and greater self-efficacy than did White clients, as well as possibly a greater expectation of sober leisure activities. However, they also reported greater resource needs for avoiding relapse. African American clients may encounter a greater number and severity of difficult social situations (high stress, low support) that affect post-treatment relapse patterns (Walton, Blow, & Booth, 2001).

Spirituality and ceremonial life must be included as crucial alcohol intervention ingredients for many ethnic and cultural groups, (Milbrodt, 2002; Roland & Kaskutas, 2002; Thurman et al, 1995). For example, the involvement of curanderos (traditional folk healers) may be effective for intervention with Hispanic clients who personally ascribe to these traditions (primarily Mexican and Mexican American individuals). Alcoholics Anonymous programs that are specifically tailored to individual Native American communities have proven successful for individuals who consider themselves to be traditional, as well as more culturally assimilated members (Milbrodt, 2002). These meetings discard aspects of the AA model that are in direct conflict with Native American norms (e.g., anonymity and rules for interaction), and replace them with culturally relevant elements (e.g., social connectedness). A subset of African American clients may benefit from intervention techniques that include spiritual and/or religious aspects. For example, Kaskutas et al. (1999) observed marked differences in the experiences of White and Black clients who attended Alcoholic Anonymous (AA) programs. They found that Black clients were more likely to have felt like a member of AA (64% versus 54% among Whites), and more likely to have had "a spiritual awakening" as a result of AA (38% versus 27%).

Another culturally relevant feature of intervention with individuals from various ethnic and cultural groups is the inclusion of family members in the intervention process. The culturally specific definition of "family member" should be employed; this might include nuclear and extended family members who are related by blood bonds, as well as non-blood relatives. For example, cousins may function as siblings and should be included as brothers and sisters if this is true for a particular client. Another example is the concept of "hijos de crianza" that applies to many Puerto Rican families-reared children who are not blood relations. The importance of extended family and extended networks is a common thread between most U.S. ethnic and racial groups. In addition to the support that group members often receive from these connections, family centered intervention can also help with issues of acculturation. For example, the social worker may help the client and family reconnect family ties that were disrupted as a consequence of acculturation struggles. Alcohol prevention programs that work with populations of inner-city Hispanic and Black adolescents are likely to involve family members in the prevention efforts (Epstein, Botvin, Baker & Diaz, 1999b). Native Americans in alcohol recovery may rely on their cultural connections for strength, meaning, support, and reinforcement of sobriety (Milbrodt, 2002).

d

It is important to assess the extent to which a particular theoretical stance is sensitive and responsive to issues of oppression, discrimination, and racism. All social work practitioners must acknowledge a client's beliefs about, and understanding of, the devastating consequences of these social forces. This is even more important when working with individuals who have alcohol use disorders that might be triggered or exacerbated by experiences of racism, discrimination, oppression, or prejudice. Acknowledgement and empathic responses from the social work practitioner may encourage individuals to investigate less destructive methods of coping with the pain, fear, anxiety, depression, and frustrations of these experiences.

In addition, the social worker should address economic difficulties and issues of self-esteem that are related consequence of oppression experiences. For example, the action of promoting a positive Native American self-image through highlighting the significance of rites of passage, was used effectively in curtailing alcoholism among a sample of Native Americans (French, 1989). African American clients receiving treatment for alcohol-related problems need referrals for economic difficulties as part of the intervention process more often than White clients in similar treatment programs (Walton et al, 2001).

Community Practice

Community characteristics represent one major set of factors affecting the level of stress associated with membership in certain ethnic or cultural groups (de la Rosa, 2002). This includes the possibility that individuals live in neighborhoods with high crime, poverty, and unemployment rates. It also includes the extent to which cultural traditions are valued and the degree to which individuals encounter racial discrimination. Social environments that promote opportunities and minimize these factors can be expected to promote individuals' healthy adaptation and avoidance of substance abuse problems (de la Rosa, 2002). Milbrodt suggests that, "Healing the culture is crucial to the future of alcohol abuse rehabilitation programs for the Native American population." (Milbrodt, 2002, p. 34).

Lee (1994) suggests that community-focused programs should:
1) Provide a consistent message about the risk and protective factors associated with alcohol abuse;
2) Attempt to change community norms, values and policies;
3) Promote conditions for creating community cohesiveness;
4) Create a base of support for those with problems related to alcohol, which include individuals, groups, and organizations;
5) Integrate existing services and activities of preexisting organizations and institutions in the community.

Consistent messages about risk and protective factors, and the benefits of curtailing excessive drinking should be promoted. Messages that might be helpful for African American families and communities dealing with alcohol problems include arguments that individuals and families would have more money, more family stability, and less violence, if alcohol misuse were eliminated (Dixon, 1991). Messages to change community perceptions of alcohol use disorders are critical. Alcohol use disorders are not personal failures, but are problems that may require professional intervention (Gordon, 1994). Attention should also be directed to the vehicles through which messages are delivered. Perea and Slater (1999) discovered that warnings about drunk driving have different levels of credibility among Hispanic and White adolescents, and by gender. "Collectivist" messages that emphasized the risks to friends and family were more believable than "individualist" messages that emphasized risks to self, particularly among adolescent girls and Hispanic youth.

Gaining the support of local or indigenous community leaders can reinforce treatment and prevention efforts from a culturally relevant perspective. Medicine (1982) suggests that by including Native American tribal officials, tribal members can be reminded that alcohol was not a part of traditional Native American culture, and is historically an "introduced evil." Similarly, as a component of intervention and prevention, Asian American community leaders can help members reconnect to Asian traditions and customs surrounding controlled drinking, as well as a focus on interdependence, personal restraint, and group achievement, all of which seem to curb drinking problems among Asian Americans (Caetano, Clark, & Tam, 1998).

One strategy for enhancing service utilization is to engage programs and activities that are already established in the "target" community. After reviewing reports of alcohol abuse prevention efforts that have succeeded in Asian American communities, Ho (1994) proposed using recreational and sports activities, cultural heritage programs, discussion groups, community service activities, and clubs to promote personal growth, self esteem, cultural identity, and a sense of accomplishment. These resources not only serve as vehicles for disseminating alcohol-specific educational information, they also provide alternatives to alcohol use. Soriano (1994) suggests taking advantage of social clubs and religious institutions already established in the Hispanic community. These types of organizations may provide support and space for community-based Alcoholic Anonymous (AA) groups, which have been shown to increase sobriety among members of some ethnic and cultural groups (Roland & Kaskutas, 2002; Tonigan, Connors & Miller, 1998). Having AA services as a part of well known and accepted organizations in the community may provide more support for participation and attendance. In short, employing culturally competent treatment practices may result in better treatment outcomes, including the use of some types of ancillary support services (Campbell & Alexander, 2002).

Classroom Activities

1. The instructor should read the article by Amodeo and Jones (1998), and use the AOD Cultural Framework to view alcohol and drug issues through various cultural lenses. This article for social work educators includes several suggestions for classroom applications, activities, and assignments that apply the framework to training social work students for work with alcohol problems. Included are a case supervision example (p. 395), classroom exercises (p. 396), clinically focused classroom exercises (p. 396), and homework and paper assignments (p. 397). In addition, there are recommendations for instructors on how to prepare course materials and lectures (p. 397), and on how to discuss cases and clinical problems in the classroom (p. 395).
2. Assign students to review and discuss media content related to alcohol use and alcohol problems among various U.S. ethnic and cultural groups. Their observations should at least include advertising, news, fictional television, popular literature, and music.
3. Discuss the ways in which professional literature on ethnic and cultural groups might influence attitudes, stereotypes, assumptions, and practices of social workers. What kinds of "negative" influences should alert social workers? How will they learn to recognize these influences? What are the likely consequences of not being aware of these influences?
4. Discuss the ways in which alcohol (and other substances) have historically been used as means of social control of members of certain ethnic and cultural groups. How has this history affected today's realities for ethnic and cultural groups in the United States? How are these means of social control perpetuated today? What options are available to these groups to counteract this particular influence of alcohol?
5. Have students read the article by May, P. A., Miller, J. H., & Wallerstein, N. (1993). Motivation and community prevention of substance abuse. Experimental and Clinical Psychopharmacology, 1, 68-79. Discuss the parallels and differences between intervening around motivation and around community change.

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Updated: March 2005

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