Discovering "culturally competent" approaches to treating people with substance abuse problems means more than finding politically correct language to paper over differences between providers and clients, if the reports at a conferences sponsored by the Center for Substance Abuse Treatment (CSAT) last month are any indication. CSAT is part of the federal Substance Abuse and Mental Health Services Administration.

Just what is cultural competence? "There’s no consensus," admitted CSAT’s Chris Currier, "but there’s a common theme: respect." Added her colleague, Dorothy Lewis, "It means you can communicate effectively and understand the other person’s point of view, which in turn helps to improve treatment and outcomes."

As an example, Howard Sampson, director of CSAT’s Division of State and Community Assistance, cited the barriers between American Indians and the substance abuse treatment they desire. The need is clear, said Sampson. In some tribal communities, 87 percent of the people are addicted to alcohol and have related health problems, as well as poor nutrition and diabetes. Half the fathers may be in wheelchairs due to diabetes and can’t work. But what hampers treatment?

"A clinic may be 60 miles away and the treatment not culturally appropriate," said Sampson. "Or there may be no youth services on the reservation, while open treatment slots go begging off the reservation."

After 1993, said Clifton Mitchell, chief of the Treatment and Systems Improvement Branch, some sites began using traditional Indian healing in substance abuse treatment. "Now we have a standing cultural committee for advice," he said, although none in urban areas.

Then there are the jurisdictional issues caused by the tribal communities’ sovereign status and the "confusing mess" of overlapping roles of the Bureau of Indian Affairs, the Indian Health Service, and various state substance abuse agencies, said Sampson. "A big problem is just getting these groups to give up their sense of ownership in order to help people."

Tribal communities, he said, need more than individual or group therapy. "They need community healing. For 100 years Indian children were removed from their culture. But when there’s an increase of traditional practices within a community, violence and drug addiction plummet."

If Sampson has to juggle jurisdictions to provide treatment, consider the task of Bruce Grant, Ph.D., a public health advisor for the Division of State and Community Assistance, which covers the Pacific Island territories of the United States—half a million people scattered over 30 million square miles of ocean.

"Nearly all health indicators are worse there compared with the mainland U.S.," said Grant. "On one hand, they are like developing nations with high rates of malnutrition and infectious diseases like cholera and dengue fever. On the other hand, they also have high rates of diabetes, heart disease, and cancer like developed nations."

In addition, there are also high rates of alcohol and drug abuse and suicide, especially among youth, he said. These, he said, are due to rapid social change, family disruption, and the aftereffects of a colonial legacy.

Working collaboratively with people in the region, CSAT, the State Department, and the White House Asia-Pacific Island Initiative seek to create structures that are "self-reliant and sustainable."

He mentioned four programs now under way. One will provide for counselor and educator development to build a cadre of substance abuse and mental health workers, who will in turn offer leadership in community-college and other programs. A second will assess needs for continuing medical education for medical officers in the region. A third effort will build capacity for epidemiological surveillance training covering drug and alcohol abuse and comorbid conditions, and create collaborative relationships between jurisdictions.

Finally, a policy report will identify gaps in service needs, create treatment plans, and examine human resource development.

Above all, said Grant, these efforts will be overseen by a Pacific Substance Abuse and Mental Health Collaborative Council, which Grant calls "an emerging regional force that will promote sustainable, culturally appropriate services in substance abuse and mental health prevention and treatment."

One twist to working in the Pacific, added Grant, an anthropologist, was that U.S. models of minorities don’t work because the people in question are majorities in their own territory. "So models of cultural competency applied to minority populations in the U.S. do not adequately capture essential notions of a ‘culture’ in the Asia-Pacific region," he said.

There were three cultural models of looking at the health care system, he said. The ethnomedical model examined how people perceive illness and health-seeking behavior. The cultural-ecological model looked at how societies and individuals adapt to the surrounding environment, and a political-economic model that took into account the structural and historical roots of the health care system.

In the Pacific region, said Grant, all three models had to be embraced. His role was to mediate among them. If his work is successful, and the islanders do create their own systems to combat substance abuse, he will, he said, happily put himself out of a job.