Addiction continues to be one of society’s most complex and prevalent problems. Millions of Americans abuse alcohol, drugs and nicotine every year. No culture is exempt from substance abuse--it is an equal opportunity disease that crosses all cultures. Over the past several decades, researchers have come up with many theories on the origins of addiction. But regardless of whether the origin is genetic, neurochemical, psychosocial or political, the devastation that substance abuse spawns is part of our historical and present reality.
The results of the Substance Abuse and Mental Health Services Administration (SAMHSA)’s 2002 National Survey on Drug Use and Health revealed that an estimated 22 million Americans age 12 or older suffered from substance dependence or abuse due to alcohol, illicit drugs or both. According to the American Psychiatric Association, substance abuse disorders are significantly responsible for rising morbidity and mortality rates, especially among men, and approximately 100,000 deaths each year are directly related to the use of illicit drugs or alcohol.
The term “substance abuse” has been defined in many different ways. These definitions range from very concrete to extremely elaborate. A common definition used by Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) is that substance abuse is a progressive disease marked by a state of powerlessness and the inability to manage one’s life. AA and NA further suggest that dependence on alcohol or any other mind-altering drug results from a personal philosophy or mode of thinking that traps the substance user in a downward spiral of addiction and self-destruction.
In my own research, I have defined substance abuse as the unrelenting use of a mood-altering drug that results in a complex tapestry of emotional, psychological, spiritual and physical turbulence, which engages the abuser in a system of consequences that, if not stopped, results in a total demise of one’s being.
Today, substance abuse disorders continue to proliferate in alarming numbers, especially in the African-American community. African Americans comprise approximately 12% of the population in the United States, yet in 1999 they accounted for 23% of admissions to publicly funded substance abuse treatment facilities.1 Consequently, there is a great need for more culturally sensitive and efficacious treatment targeted to the special needs of this minority population.
Although African Americans have made tremendous social and economic advances during the past several decades, the tradition of black Americans being viewed as a racial group--rather than a cultural group--continues to adversely affect their psychological well-being.2, 3 Until recently, white male populations have dominated studies of substance abuse, with little focus on gender, ethnicity and etiologic variations. These cultural biases and the emphasis on majority American values and lifestyles may contribute to the presence of substance abuse behaviors in the African-American community.
Socio-cultural Aspects of Substance Abuse
To meet the treatment needs of the African-American substance abuser in a culturally sensitive manner, care providers must understand the variables that interface with the disorder. There are a number of variables related to socio-cultural factors in substance abuse. Research designs on substance abuse often do not address descriptive variables such as gender, age, income/wealth, geographic locations and cultural patterns. These variables play an essential role in differentiating drug-use patterns, whether between ethno-racial groups or within them.
Socioeconomic considerations are eminent determinants of African-American drug use. Experts on substance abuse disorders agree that poverty and other socioeconomic factors have a great impact on the prevalence of substance abuse in the African-American community. A 1992 study identified poverty, illiteracy, limited job opportunities, poor education, high availability of drugs, and stresses of the urban lifestyle as underpinnings of substance abuse in the black community.4 Other researchers have found that environmental factors, such as the large number of liquor stores in African-American communities, influence the heavy use of alcohol among black Americans.5
In addition, many African Americans have been subjected to violence as a primary oppressor, which robs the community of the resources needed to solve drug problems. Violence does not only present in the form of crime or domestic disputes but also in the context of racial discrimination, lack of access to food and clothing, homelessness, overcrowded living conditions, lack of health insurance, and restricted social welfare policy. Black women have experienced other forms of violence, such as sexual harassment, gender discrimination, and a lack of protection from domestic violence.
Spirituality, as defined by Webster’s Encyclopedic Unabridged Dictionary, pertains to sacred things or matters, religious or devotional. A 1992 research study investigating the role of spirituality in nursing offers a more comprehensive definition: “Spirituality refers to the propensity to make meaning through a sense of relatedness to dimensions that transcend the self in such a way that empowers and does not devalue the individual. This relatedness may be experienced intrapersonally (as a connectedness within oneself) interpersonally (in the context of others and the natural environment) and transpersonally (referring to a sense of relatedness to the unseen, God, or power greater than self and ordinary resources).”6
Although religion is sometimes seen in the nursing literature as interchangeable with spirituality, the two concepts are not the same. Religion refers to belief in God or gods, or a system of worship, with a commitment to practice and worship in faith, which includes attending religious services.7
In recent years, research on spiritually related variables has experienced a paradigm shift and is beginning to generate a body of knowledge about the significance of spirituality and improved well-being as they relate to various health experiences. Previous theories about spirituality and healing postulated a disparity between spiritual and physical dimensions. Spirituality, at times, was regarded as private and internal, while God was viewed as being an external presence, which one related to through specific religious activities.6
Spirituality has also been studied as a coping strategy for responding to stressful life events and experiences. Coping strategies are defined as either external--e.g., support from the religious community--or internal (such as private prayer, reading, and reflection on one’s beliefs). Carla Cooper, PhD, senior vice president of St. Luke’s Health Care Philanthropy at St. Luke’s Episcopal Hospital, has stated that spirituality is far more than any drug or explanation, and that at the heart of spirituality is love, the mysterious force that bears all, believes all, hopes for all and endures all.
Within this emerging paradigm, spirituality is an ever-present, sometimes dominant part of human experience. Therefore, spirituality can be seen as integral to health, not only in terms of a cure for a disease or illness but also as a sense of wholeness or well-being.
It has been well documented that spirituality and religion are key sources of strength and tenacity for African Americans. The results of a recent study on spirituality among African-American women in recovery from substance abuse revealed that spirituality--a key component of African personality and culture--had a significant correlation with positive mental health outcomes for these patients.8
The black church is where many African Americans learn important aspects of socialization, including value transmission, positive modeling by older persons in the congregation, and important lessons in managing life. In the African-American community, the black church is held in high esteem akin with the high levels of religious involvement among elderly blacks, which suggests that religiosity may be an important coping resource for African Americans.9 The fact that religion and spirituality play an important role in the lives of so many older blacks suggests that they may perform just as important a function in the lives of younger African Americans.
From all of the evidence cited above, we can conclude that substance abuse treatment for African Americans must place more emphasis on socio-cultural factors as well as the unique role that spirituality plays in the black community. There is an urgent need for more research in these areas, to build on the knowledge already gained from prior studies on substance abuse in the African American population.
In many cases, limited attention to ethnicity and socio-cultural factors in health research has resulted in beliefs and assumptions that may not fit the experiences of African Americans. Effectively aiding the black community means understanding and appreciating the internal realities of African Americans.
A critical examination of black cultural traditions and the realities of inner city living are important to consider in forming an understanding of substance abuse in this population. Research and treatment that lacks this perspective is less likely to identify key interventions for primary, secondary and tertiary prevention. It takes the art of listening from those in power in the health care system to hear and understand the cultural needs of this twice-special population--individuals who are African Americans as well as substance abusers.
Furthermore, the health care establishment must recognize that the inclusion of spirituality is important to the process of recovery from all illnesses. Research has shown that integration of culturally specific factors such as spirituality into treatment of substance abuse is consistently associated with better outcomes and lower rates of relapse. It can also help negate the hardships in the lives of substance abusers, which often are precursors to addiction and causes of relapse for patients in recovery. In addition, spirituality can help treat cultural pain, which is an emotion that is experienced by a person who is a member of a racial, ethnic or religious group, particularly one that has suffered oppression.10
Segal (1995) defined substance abuse prevention as “efforts to preclude the use of alcohol and other drugs.”11 This research study also stated that primary prevention eliminates the need for secondary and tertiary prevention, and that once a behavior has started, it cannot be prevented. Therefore, there is a crucial need for more primary prevention programs to be made available to the African-American community. Parity of funding is necessary so that money can be allocated for the development of programs to meet the needs of this special population. It is essential that African Americans receive information about drugs and their harmful effects with the intent to change this population’s attitudes about drugs, thereby preventing their use.
We also need to develop culturally sensitive instruments to assess the presence of risk factors and substance abuse patterns in African Americans. To obtain accurate information, the measures used must reflect the target population’s customs and traditions. Standard guidelines for the diagnosis of substance abuse disorders, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), are not universally appropriate for use with all cultures.
A culturally relevant knowledge base addresses factors such as specific cultural behaviors, the extent alcohol and drugs are used to cope with the impact of society’s expectations, and to what extent alcohol and drugs are a reflection of what has been learned by the dominant culture, to name a few.11 Finally, spiritual history-taking can prove to be helpful when planning substance abuse prevention and treatment strategies for a particular community or population.
Identifying and focusing on the unique cultural, social and spiritual issues related to substance abuse in African Americans will enable nurses to provide more culturally sensitive and appropriate care to these patients. Past conceptualizations regarding substance abuse treatment in the black community have guided nursing practice for many years. Today, however, opportunities for nursing to shape new concepts and specific knowledge about the complexity and impact of substance abuse in African Americans could help to improve nursing interventions for this population.
An increase in culturally specific treatment options for African-American substance abusers may also help to strengthen their overall patterns of health. Nurses who understand the cultural needs of this minority population will be better prepared to support these patients’ recovery needs. After all, how can nurses effectively treat their patients without some understanding of where the patient has come from--in every sense of the term? To gain that crucial understanding of where our patients have come from, we must first be able to see them from inside their own culture.
I would like to express my grateful appreciation to the Substance Abuse and Mental Health Services Administration (SAMHSA)’s Minority Fellowship Program (MFP) for its financial support of my progression in academia in the field of psychiatry/mental health and substance abuse treatment. I also want to express my gratitude ad infinitum to the American Nurses Association’s Ethnic Minority Fellowship Program, notably Faye Gary, RN, EdD, FAAN, executive consultant, and Janet Jackson, program director.
1. Substance Abuse and Mental Health Services Administration (2002). The Dasis Report: Black Admissions to Substance Abuse Treatment: 1999. Rockville, Md.: Office of Applied Studies.
2. De La Rosa, M., Vega, R., and Radisch, M.A. (2000). “The Role of Acculturation in the Substance Abuse Behavior of African American and Latino Adolescents: Advances, Issues, and Recommendations.” Journal of Psychoactive Drugs, Vol. 32, No. 1, January-March, pp. 33-42.
3. Kendall, J. (1996). “Creating a Culturally Responsive Psychotherapeutic Environment for African American Youths: A Critical Analysis.” Advances in Nursing Science, Vol. 18, No. 4, pp. 11-28.
4. Clucas, A., and Clark, V. (1992). Module II 7: Drug and Alcohol Problems in Special Populations. In M. A. Naegle (Ed.), Substance Abuse Education in Nursing, Vol. 2, pp. 531-547. New York: National League for Nursing.
5. Williams, R., & Gorski, T.T. (1997). Relapse Prevention Counseling for African Americans: A Culturally Specific Model. Independence, Mo.: Herald House/Independence Press.
6. Reed, P.G. (1992). “An Emerging Paradigm for the Investigation of Spirituality in Nursing.” Research in Nursing & Health, Vol. 15, pp. 349-357.
7. Emblen, J. (1992). “Religion and Spirituality Defined According to Current Use in Nursing Literature.” Journal of Professional Nursing, Vol. 8, pp. 41-47.
8. Brome, D.R., Owens, M.D., Allen, K., and Vevaina, T. (2000). “An Examination of Spirituality among African American Women in Recovery from Substance Abuse.” Journal of Black Psychology, Vol. 26, No. 4, pp. 471-486.
9. Krause, N. (1992). “Stress, Religiosity, and Psychological Well Being among Older Blacks.” Journal of Aging and Health, Vol. 4, No. 3, August, pp. 421-439.
10. Wesley, M.G. (1997). “Community Primary Prevention Intervention of Chemical Dependency for African American Families and Communities: A Collaborative Nursing Facilitation.” Journal of Addictions Nursing, Vol. 9, No. 3, pp. 129-135.
11. Segal, B. (1995). “Prevention and Culture: A Theoretical Perspective.” Journal of Drugs and Society, Vol. 8, Nos. 3-4, pp. 139-147.