Skip to main content
SpringerLink
Log in

Cultural competence and derivatives in substance use treatment for migrants and ethnic minorities: what’s the problem represented to be?

  • Original Article
  • Published:
Social Theory & Health Aims and scope Submit manuscript

Abstract

Cultural competence (CC) was introduced to reduce substance use treatment (SUT) disparities among migrants and ethnic minorities. However, outcome reviews report limited evidence for its effectiveness in reducing SUT disparities. This paper applies Bacchi’s “What’s the problem represented to be?” approach and an ecosocial perspective in a narrative review (2007–2017) of CC in SUT. This review qualitatively identifies (1) the origin and (2) nature of CC and derivatives in SUT, (3) the presuppositions, (4) how the concepts are questioned and (5) what is left unquestioned. The literature search yielded 41 studies. (1) CC originated in the USA whereas derived concepts are more common in other continents. (2) Components of CC and derivatives are mostly located at the micro (client–provider) level. (3) The most prevalent presuppositions are situated at the micro service user (language, trauma, shame) and the macro level and to a lesser extent at the provider level (ethical requirements, discomfort) and client–provider interaction (distrust, confidentiality, countertransference, worldviews). (4) The authors of the reviewed papers question whether CC is sufficient, how it relates to generalist treatment approaches and whether CC is sufficiently evidence based. (5) Unquestioned issues concern defining culture, formal treatment access, the ‘prevalence presupposition’ and a lack of macro outcome indicators.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

(adapted from De Kock et al. 2017)

Similar content being viewed by others

Notes

  1. “Disparities are differences in health care services received by the two groups that are not due to differences in the underlying health care needs or preferences of members of the groups” Smedley et al. (2003).

  2. Any person who has changed his or her country of usual residence (IOM 2017, p. 15). About two-thirds of the 3.3% international migrants resided in high-income economies in 2015 (IOM 2017, p. 20). About 10% of this number are refugees and asylum applicants (IOM 2017, p. 32).

  3. Ethnic groups are “Those human groups that entertain a subjective belief in their common descent because of similarities of physical type or of customs or both, or because of the memories of colonization and migration; this belief must be important for group formation” (Weber 1922/1974, p. 18). De Kock et al. (2017) argue that this combined terminology stresses the individual history of migration and ethnic “groupness” as well as the societal denomination and categorization of ethnicity.

  4. For example, early intervention or prevention.

  5. We refer to the included reviews and Table 2 for detailed outcomes.

  6. ‘Problem drug use’ prevalence is one of five key epidemiological indicators used by the EMCDDA to monitor aspects of the drug use phenomena across the European Union. The implementation of this indicator is supported by resolutions of the Council of the European Union. ‘problem substance use’ as a concept is more specific compared to ‘substance use’ which could be perceived as stigmatizing towards recreational users when reporting about problem users. Problem substance use includes temporary increased use as well as varying terms such as substance abuse and misuse. It refers to “recurrent drug use that is causing actual harms (negative consequences) to the person (including dependence, but also other health, psychological or social problems) or is placing the person at a high probability/risk of suffering such harms.” (Thanki et al. 2015).

  7. In our results, proportions (e.g. half, one-third or one-quarter of the included papers) are only mentioned in case codes recurred in at least five papers. When referring to these proportions, all those authors are referred to in-text.

  8. Aboriginal Health Council of South Australia; Aboriginal and Torres Strait Islanders Commission (Australia); American Indian Religious Freedom Act; Assembly of First Nations (AFN) (Canada); First Nations Behavioral Health Association (USA); Health Canada’s First Nations and Inuit Health Branch; Indigenous and Tribal Peoples Convention (Norway); Indigenous Physicians Association of Canada; National Aboriginal Health Organization (NAHO) (Canada, until 2012); Ontario National Native Alcohol and Drug Abuse Program (NNADAP) (Canada); Pacific Substance Abuse and Mental Health Collaborating Council (Pacific Jurisdictions); Sami Act of 1987 (Norway); Sami National Centre for Mental Health and Substance Abuse (SANKS) (Norway); Wharerātā indigenous leaders Group for mental health and addictions (New Zealand, Australia, Canada).

  9. Disproportionately high rates of substance use and substance use related deaths compared to general populations is established among American Indians/Alaska Natives (AI/ANs) (Croff et al. 2014, Greenfield et al. 2012 in Liddell and Burnette 2017), lifetime diagnosis of alcohol and substance use disorder among black and Hispanic populations in the Northern America (Burnett et al. 2013 in Gainsbury 2017) and opioid addiction among remote First Nations communities in north-western Ontario.

  10. e.g. Black and ethnic minorities in the UK, African American, Asian American and Pacific Islanders, Latino, American Indian and Alaska Native, and White in the USA Census.

  11. The articles were screened that did not contain a clear definition of culture (n = 34) for possible reasons for this omission. A tendency was discerned tendency that authors arguing in favour of culture-based interventions (Croff et al. 2014; Greenfield and Venner 2012; King 2011; Dell et al. 2011; Echo Hawk 2011; Leske et al. 2016; Liddell and Burnette 2017; Rowan et al. 2014) describe specific cultures as opposed to dominant cultures but do not give a conceptual definition of culture. Also, authors aiming at extending or critiquing the concept of CC were less likely to give a definition of culture (Whitley 2012; Ida 2007; Gray and Ralphs 2017; Mamakwa et al. 2017, Chan and Yoon 2011).

  12. This is exemplified by the fact that Resnicow and colleagues’ model of surface and deep structure adaptation (2000) is often quoted as a model for cultural adaptation in treatment.

References

  • Alegría, M., G. Canino, P.E. Shrout, M. Woo, N. Duan, D. Vila, M. Torres, C.-N. Chen, and X.-L. Meng. 2008. Prevalence of mental illness in immigrant and non-immigrant US Latino groups. American Journal of Psychiatry 165: 359–369.

    Google Scholar 

  • Alegria, M., N. Carson, M. Goncalves, and K. Keefe. 2011. Disparities in treatment for substance use disorders and co-occurring disorders for ethnic/racial minority youth. Journal of the American Academy of Child & Adolescent Psychiatry 50 (1): 22–31.

    Google Scholar 

  • American Psychological Association’s (APA). 2003. Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. The American Psychologist 58: 377.

    Google Scholar 

  • Bacchi, C. 2009. Analysing policy: What’s the problem represented to be?. Pearson Higher Education: Frenchs Forest.

    Google Scholar 

  • Bacchi, C. 2012. Introducing the “What’s the Problem Represented to be?” Approach. In Bletsas, A, ed. C. Beasly. Strategic interventions and exchanges: Engaging with Carol Bacchi.

    Google Scholar 

  • Bacchi, C., and J. Eveline. 2015. Mainstreaming politics: Gendering practices and feminist theory. Adelaide: University of Adelaide Press.

    Google Scholar 

  • Beresford, B., S. Clarke, and J. Maddison. 2018. The active ingredients of therapy interventions: Professionals’ views Therapy interventions for children with neurodisabilities: A qualitative scoping study. Health Technology Assessment. https://doi.org/10.3310/hta22030.

    Article  Google Scholar 

  • Betancourt, J.R., A.R. Green, J.E. Carrillo, and I. Owusu Ananeh-Firempong. 2003. Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports 118: 293–302.

    Google Scholar 

  • Bhui, K., N. Warfa, and P. Edonya. 2007. Cultural competence in mental health care: A review of model evaluations. BMC Health Services Research 7: 15.

    Google Scholar 

  • Bhui, K., M. Ascoli, and O. Nuamh. 2012. The place of race and racism in cultural competence: What can we learn from the English experience about the narratives of evidence and argument? Transcultural psychiatry 49: 185–205.

    Google Scholar 

  • Blomme, E., C. Colman, and C. De Kock. 2017. De instroom van migranten en etnische minderheden in de drughulpverlening: Een verkennende studie. Panopticon 38: 102–117.

    Google Scholar 

  • Burlew, A.K., V.C. Copeland, C. Ahuama-Jonas, and D.A. Calsyn. 2013. Does cultural adaptation have a role in substance abuse treatment? Social work in public health 28: 440–460.

    Google Scholar 

  • Butler, M., E. McCreedy, N. Schwer, D. Burgess, K. Call, J. Przedworski, S. Rosser, S. Larson, M. Allen, S. Fu, and R.L. Kane. 2016. Improving cultural competence to reduce health disparities, vol. 170. Rockville, MD: Agency for Healthcare Research and Quality (US) Comparative Effectiveness Reviews.

    Google Scholar 

  • Carpenter-Song, E.A., M.N. Schwallie, and J. Longhofer. 2007. Cultural competence reexamined: Critique and directions for the future. Psychiatric Services 58: 1362–1365.

    Google Scholar 

  • Chang, D.F., and P. Yoon. 2011. Ethnic minority clients’ perceptions of the significance of race in cross-racial therapy relationships. Psychotherapy Research 21: 567–582.

    Google Scholar 

  • Croff, R.L., T.R. Rieckmann, and J.D. Spence. 2014. Provider and state perspectives on implementing cultural-based models of care for American Indian and Alaska Native patients with substance use disorders. The Journal of Behavioral Health Services & Research 41: 64–79.

    Google Scholar 

  • Cross, T.L., B.J. Bazron, K.W. Dennis, and M.R. Isaacs. 1989. Towards a culturally competent system of care. A Monograph on effective services for minority children who are severely emotionally disturbed. Washington DC: Georgetown University Child Development Centre.

    Google Scholar 

  • Dagsvold, I., S. Møllersen, and V. Stordahl. 2015. What can we talk about, in which language, in what way and with whom? Sami patients’ experiences of language choice and cultural norms in mental health treatment. International Journal of Circumpolar Health 74: 26952.

    Google Scholar 

  • De Kock, C., and T. Decorte. 2017. Exploring problem use, discrimination, ethnic identity and social networks. Drugs and Alcohol Today 17: 269–279.

    Google Scholar 

  • De Kock, C., T. Decorte, W. Vanderplasschen, I. Derluyn, and M. Sacco. 2017. Studying ethnicity, problem substance use and treatment: From epidemiology to social change. Drugs: Education Prevention and Policy 24: 230–239.

    Google Scholar 

  • Dell, C.A., M. Seguin, C. Hopkins, R. Tempier, L. Mehl-Madrona, D. Dell, R. Duncan, and K. Mosier. 2011. From benzos to berries: Treatment offered at an Aboriginal youth solvent abuse treatment centre relays the importance of culture. The Canadian Journal of Psychiatry 56: 75–83.

    Google Scholar 

  • Domenig, D., J. Fountain, E. Schatz, and G. Bröring. 2007. Overcoming barriers: Migration, marginalisation and access to health and social services. Amsterdam: Foundation Regenboog AMOC.

    Google Scholar 

  • Echo-Hawk, H. 2011. Indigenous communities and evidence building. Journal of Psychoactive Drugs 43: 269–275.

    Google Scholar 

  • EMCDDA. 2013. Drug prevention interventions targeting minority ethnic populations: Issues raised by 33 case studies. Luxembourg: European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).

  • Farkas, L. 2017. Analysis and comparative review of equality data collection practices in the European Union. Report comissioned by the European Comission, Directorate-General for Justice and Consumers: Data collection in the field of ethnicity.

    Google Scholar 

  • Fedorova, O. 2012. Transcultural drug work: A handbook for practitioners working with drug users from different ethnic and cultural backgrounds, Co-operation Group to Combat Drug Abuse and Illicit Trafficking in Drugs (Pompidou Group).

  • Fountain, J., and J. Hicks. 2010. Delivering race equality in mental health care: Report on the findings and outcomes of the community engagement programme 2005-2008. Central Lancashire: University of Central Lancashire.

    Google Scholar 

  • Gainsbury, S.M. 2017. Cultural competence in the treatment of addictions: Theory, practice and evidence. Clinical psychology & psychotherapy 24: 987–1001.

    Google Scholar 

  • Gale, N.K., G. Heath, E. Cameron, S. Rashid, and S. Redwood. 2013. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology 13: 117.

    Google Scholar 

  • Gil-González, D., M. Carrasco-Portiño, C. Vives-Cases, A.A. Agudelo-Suárez, R. Castejón Bolea, and E. Ronda-Pérez. 2015. Is health a right for all? An umbrella review of the barriers to health care access faced by migrants. Ethnicity & Health 20: 523–541.

    Google Scholar 

  • Gough, D., J. Thomas, and S. Oliver. 2012. Clarifying differences between review designs and methods. Systematic Reviews 1: 28.

    Google Scholar 

  • Gray, P., and R. Ralphs. 2017. Confidentiality and cultural competence? The realities of engaging young British Pakistanis and Bangladeshis into substance use services. Drugs: Education Prevention and Policy. https://doi.org/10.1080/09687637.2017.1398714.

    Article  Google Scholar 

  • Greenfield, B.L., and K.L. Venner. 2012. Review of substance use disorder treatment research in Indian country: Future directions to strive toward health equity. The American Journal of Drug and Alcohol Abuse 38: 483–492.

    Google Scholar 

  • Guerrero, E.G. 2010. Managerial capacity and adoption of culturally competent practices in outpatient substance abuse treatment organizations. Journal of Substance Abuse Treatment 39: 329–339.

    Google Scholar 

  • Guerrero, E.G. 2013. Workforce diversity in outpatient substance abuse treatment: The role of leaders’ characteristics. Journal of Substance Abuse Treatment 44: 208–215.

    Google Scholar 

  • Guerrero, E.G., and C.M. Andrews. 2011. Cultural competence in outpatient substance abuse treatment: Measurement and relationship to wait time and retention. Drug and Alcohol Dependence 119: e13–e22.

    Google Scholar 

  • Guerrero, E.G., M. Campos, D. Urada, and J.C. Yang. 2012. Do cultural and linguistic competence matter in Latinos’ completion of mandated substance abuse treatment? Substance Abuse Treatment, Prevention, and Policy. 7 (1): 34.

    Google Scholar 

  • Guerrero, E.G., K. Fenwick, and Y. Kong. 2017. Advancing theory development: Exploring the leadership–climate relationship as a mechanism of the implementation of cultural competence. Implementation Science 12: 133.

    Google Scholar 

  • Guerrero, E.G., and D. Kao. 2013a. Racial/ethnic minority and low-income hotspots and their geographic proximity to integrated care providers. Substance Abuse Treatment Prevention and Policy 8: 34.

    Google Scholar 

  • Guerrero, E.G., and D. Kao. 2013b. Racial/ethnic minority and low-income hotspots and their geographic proximity to integrated care providers. Substance Abuse Treatment Prevention and Policy 8: 1–10.

    Google Scholar 

  • Guerrero, E.G., and A. Kim. 2013. Organizational structure, leadership and readiness for change and the implementation of organizational cultural competence in addiction health services. Evaluation and Program Planning 40: 74–81.

    Google Scholar 

  • Hall, G.C.N. 2001. Psychotherapy research with ethnic minorities: Empirical, ethical, and conceptual issues. Journal of Consulting and Clinical Psychology 69: 502–510.

    Google Scholar 

  • Hodge, D.R., K.F. Jackson, and M.G. Vaughn. 2012. Culturally sensitive interventions and substance use: A meta-analytic review of outcomes among minority youths. Social Work Research 36: 11–19.

    Google Scholar 

  • Hunt, G., T. Kolind, and T. Antin. 2018. Conceptualizing ethnicity in alcohol and drug research: Epidemiology meets social theory. Journal of Ethnicity in Substance Abuse 17 (2): 187–198.

    Google Scholar 

  • Ida, D. 2007. Cultural competency and recovery within diverse populations. Psychiatric Rehabilitation Journal 31: 49–53.

    Google Scholar 

  • IOM. 2017. Migration and migrants: A global overview. In World Migration Report 2018. Geneva: IOM.

  • Jongen, C., J. Mccalman, and R. Bainbridge. 2018. Health workforce cultural competency interventions: a systematic scoping review. BMC Health Services Research 18: 1–15.

    Google Scholar 

  • King, J. 2011. Reclaiming our roots: Accomplishments and challenges. Journal of Psychoactive Drugs 43: 297–301.

    Google Scholar 

  • Kirmayer, L.J. 2012. Rethinking cultural competence. Transcultural Psychiatry 49: 146–149.

    Google Scholar 

  • Knis-Matthews, L., L. Richard, M. Moccia, V. Patel, S. Salomone, and L. Stein. 2012. Cultural lens on mental illness: Four clients share their perspectives. Occupational Therapy in Mental Health 28: 180–196.

    Google Scholar 

  • Krieger, N. 2012. Methods for the scientific study of discrimination and health: An ecosocial approach. American Journal of Public Health 102: 936–944.

    Google Scholar 

  • Leamy, M., V. Bird, C. Le Boutillier, J. Williams, and M. Slade. 2011. Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. The British Journal of Psychiatry 199: 445–452.

    Google Scholar 

  • Lemmens, P., H. Dupont, and I. Roosen. 2017. Migrants, asylum seekers and refugees: an overview of the literature relating to drug use and access to services. EMCDDA: Background paper commissioned by the EMCDDA.

    Google Scholar 

  • Leske, S., M.G. Harris, F.J. Charlson, A.J. Ferrari, A.J. Baxter, J.M. Logan, M. Toombs, and H. Whiteford. 2016. Systematic review of interventions for Indigenous adults with mental and substance use disorders in Australia, Canada, New Zealand and the United States. Australian and New Zealand Journal of Psychiatry 50: 1040–1054.

    Google Scholar 

  • Liddell, J., and C.E. Burnette. 2017. Culturally-Informed Interventions for Substance Abuse Among Indigenous Youth in the United States: A Review. Journal of evidence-informed social work 14: 329–359.

    Google Scholar 

  • Mamakwa, S., M. Kahan, D. Kanate, M. Kirlew, D. Folk, S. Cirone, S. Rea, P. Parsons, C. Edwards, and J. Gordon. 2017. Evaluation of 6 remote First Nations community-based buprenorphine programs in northwestern Ontario: Retrospective study. Canadian Family Physician 63: 137–145.

    Google Scholar 

  • Meyer, O.L., and N. Zane. 2013. The influence of race and ethnicity in client’s experiences of mental health treatment. Journal of community psychology 41: 884–901.

    Google Scholar 

  • Møllersen, S., H.C. Sexton, and A. Holte. 2009. Effects of client and therapist ethnicity and ethnic matching: a prospective naturalistic study of outpatient mental health treatment in Northern Norway. Nordic Journal of Psychiatry 63: 246–255.

    Google Scholar 

  • Nelson, A. 2017. Addiction workforce development in Aotearoa New Zealand. Drugs: Education. Prevention and Policy 24: 461–468.

    Google Scholar 

  • Owen, J.J., K. Tao, M.M. Leach, and E. Rodolfa. 2011. Clients’ perceptions of their psychotherapists’ multicultural orientation. Psychotherapy 48: 274.

    Google Scholar 

  • Palmer, D., and K. Ward. 2007. ‘Lost’: listening to the voices and mental health needs of forced migrants in London. medicine. Conflict and Survival 23: 198–212.

    Google Scholar 

  • Quintero, G.A., E. Lilliott, and C. Willging. 2007. Substance abuse treatment provider views of “culture”: Implications for behavioral health care in rural settings. Qualitative Health Research 17: 1256–1267.

    Google Scholar 

  • Rein, M., and D. Schön. 1996. Frame-critical policy analysis and frame-reflective policy practice. Knowledge and Policy 9: 85–104.

    Google Scholar 

  • Resnicow, K., R. Soler, R.L. Braithwaite, J.S. Ahluwalia, and J. Butler. 2000. Cultural sensitivity in substance use prevention. Journal of Community Psychology 28: 271–290.

    Google Scholar 

  • Rowan, M., N. Poole, B. Shea, J.P. Gone, D. Mykota, M. Farag, C. Hopkins, L. Hall, C. Mushquash, and C. Dell. 2014. Cultural interventions to treat addictions in Indigenous populations: findings from a scoping study. Substance Abuse Treatment, Prevention and Policy 9: 1–26.

    Google Scholar 

  • Saloner, B., and B. Le Cook. 2013. Blacks and Hispanics are less likely than whites to complete addiction treatment, largely due to socioeconomic factors. Health Affairs 32: 135–145.

    Google Scholar 

  • SAMHSA 2000. Cultural Competence Standards in Managed Care Services: Four Underserved/Underrepresented Racial/Ethnic Groups. DHHS Pub. No. (SMA) 00-3457.

  • Shaw, S.J., and J. Armin. 2011. The ethical self-fashioning of physicians and health care systems in culturally appropriate health care. Culture, Medicine and Psychiatry 35: 236–261.

    Google Scholar 

  • Smedley, B.D., A.Y. Stith, and A.R. Nelson. 2003. Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington: National Academies Press.

    Google Scholar 

  • Steinka-Fry, K.T., E.E. Tanner-Smith, G.A. Dakof, and C. Henderson. 2017. Culturally sensitive substance use treatment for racial/ethnic minority youth: A meta-analytic review. Journal of Substance Abuse Treatment 75: 22–37.

    Google Scholar 

  • Sue, S., N. Zane, G.C. Nagayama Hall, and L.K. Berger. 2009. The case for cultural competency in psychotherapeutic interventions. Annual Review of Psychology 60: 525–548.

    Google Scholar 

  • Thanki, E., E. Kalamara, A. Noor, L. Montanari, and J. Vicente. 2015. Problem drug use indicator. Lisbon: EMCDDA.

    Google Scholar 

  • Weber, M. (1922/1974). Economy and society, vol. 1. Berkeley: University of California Press.

    Google Scholar 

  • Whitley, R. 2012. Religious competence as cultural competence. Transcultural Psychiatry 49: 245–260.

    Google Scholar 

  • WHO. 2010. How Health systems can adress health inequeties linked to migration and ethnicity. København: WHO—Regional office for Europe.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Faculty of Law and Criminology, Ghent University, Universiteitstraat 4, 9000, Ghent, Belgium

    Charlotte De Kock

Authors
  1. Charlotte De Kock
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Charlotte De Kock.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

De Kock, C. Cultural competence and derivatives in substance use treatment for migrants and ethnic minorities: what’s the problem represented to be?. Soc Theory Health 18, 358–394 (2020). https://doi.org/10.1057/s41285-019-00113-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1057/s41285-019-00113-0

Keywords

Search

Navigation