ethnic and gender differences in drug users' perceived need for treatment

The International Journal of the Addictions, 28(6), 539-558, 1993

Ethnic and Gender Differences in Drug Users’ Perceived Need for Treatment

Douglas Longshore,* Shih-chao Hsieh, and M. Douglas Anglin

Drug Abuse Research Center, UCLA Neuropsychiatric Institute, 1100 Glendon Ave. #763, Los Angeles, California 90024

ABSTRACT

Little is known about ethnic and gender variation in drug users’ perceived need for treatment or about the predisposing factors that might account for such variation. Among 1,170 drug-using arrestees in Los Angeles, perceived need for treatment is positively related to these predisposing factors: self-reported drug dependence, attitude toward treatment for drug use, and occurrence of drug-related problems other than dependence. Self-reported drug dependence is higher among women and accounts for the greater perceived need reported by women. Hispanics are less likely to perceive a need for treatment. Among daily drug users, both Hispanics and African-Americans are less likely to do so. These ethnic differences are not explained by self-reported drug dependence or any other predisposing factor. Impli- cations for treatment referral, intake, and counseling are discussed.

Key words. Drug use treatment; Perceived treatment need

*To whom correspondence should be addressed.

539

Copyright 0 1993 by Marcel Dekker. Inc.

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.

540 LONGSHORE, HSIEH, AND ANGLIN

INTRODUCTION

Few previous studies have examined ethnic or gender differences in drug users’ attitudes toward treatment for drug use. Moreover, no previous research exists regarding the extent to which such attitudes might account for ethnic or gender differences in need for treatment as perceived by drug users or in their actual treatment experience. The distinction between treatment experience and perceived need is important for two reasons. First, actual experience and perceived need may have different antecedents. Experience with (or demand for) various medical or mental health services is thought to be influenced chiefly by “enabling” factors such as treatment cost or client proximity to treatment providers. On the other hand, perceived need for medical or mental health services appears to be influenced chiefly by “predisposing” factors such as the belief that professional help is relevant to the problem at hand and attitude toward available treatment providers (Andersen et al., 1975; Veroff et al., 1981) (see Note 1). Research that is focused on perceived need, rather than on treatment experience, may therefore suggest strategies by which treatment outreach and referral can be tailored to predisposing attitudes and other factors most strongly related to perceived need within particular ethnic or gender categories.

Second, entry into treatment is often influenced by events such as the threat of incarceration, family pressure, or medical problems. In such cases, clients may not believe that their drug use itself is problematic (Anglin and Hser, 1990; see also Miller, 1985, and Thom, 1986) or that treatment is required. Moreover, clients’ general attitude toward treatment is less favorable, and retention time shorter, when they see little or no real need for treatment (Baekeland and Lundwell, 1975). Research on the factors that predict perceived treatment need in different groups may therefore suggest ethnic- or gender-specific counseling strategies by which initial motives for treatment entry might be “reconfigured” to enhance “the probability that the client will stay in treatment long enough for the therapeutic process to take effect” (Ger- stein and Harwood, 1990, pp. 109-110).

This paper identifies demographic differences in perceived need for treatment among a sample of 1,170 drug-using arrestees interviewed in the city and county jails in Los Angeles. The paper also assesses the degree to which demographic differences in perceived need can be explained by “predisposing” factors such as self-reported drug dependence. Findings provide a basis for recommendations regarding referral, intake, and counseling strategies.

BACKGROUND Ethnicity

In Veroff et al.’s (1981) nationwide survey of perceived need for mental health treatment, African-Americans were less likely than Whites (non-

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.

TREATMENT NEED 54 I

Hispanics) to endorse the view that mental health problems are appropriate for professional care. Similarly, Torres (1983) found that Hispanics were less likely than Whites to believe that professional care is appropriate for problems in mental health. Casas and Vasquez (1989) described in some detail the ways in which the values and techniques of mental-health counseling appear at odds with the values and interaction styles of Hispanics (see also Rogler et al., 1987).

More specifically, many African-Americans and Hispanics appear skeptical of two of the modalities widely available for treatment of drug use. Brown (1985, p. 2 12) noted that methadone maintenance clients, especially African- Americans, are ‘ambivalent, at best, about the use of methadone as a maintenance drug” because that form of treatment has been widely viewed as oppres- sion, not therapy. Espada (1979) described a similar view of methadone maintenance among Hispanics. Tucker (1985) observed that the confrontational techniques used in many therapeutic communities may be unsuited to Hispanic clients. Attitudes toward these treatment modalities could influence perceived need for treatment among African-American and Hispanic drug users, to the extent that the general concept of treatment for drug use is linked with either modality. Austin and Gilbert (1989, p. 13) cited the “extreme reluctance” of Hispanics to enter any treatment, regardless of modality. Jorquez (1984) and Sanchez (1977) ascribed negative views of treatment specifically to the tecuro (heroin addict) subculture.

Gender

Some research suggests that women are more likely than men to report needing treatment for health problems. Perhaps because of sex-role differences, it may be more acceptable for women to recognize such problems and to dis- cuss them with friends, relatives, and health professionals (Corney , 1990; Neighbors and Howard, 1987; Schneider et al., 1980). Surveys of perceived need for mental health treatment have indicated that “women more often define a problem as relevant for professional help.. . .” (Veroff et al., 1981, p. 120). Horwitz (1977) reported that women are more likely than men to recognize psychiatric illness and that women more readily accept the patient role.

These findings suggest that, among heavy users of illicit drugs, women may be more likely to report needing treatment. However, the women in Thom’s (1986) sample of alcoholics were less likely to believe that alcohol use itself was a sufficient reason for seeking treatment. Perceived need among women was linked more to the crisis events that had reportedly triggered their heavy drinking. This pattern emerged despite the lack of any apparent gender difference in degree of alcohol dependence or in the actual occurrence of alcohol-related problems. Moreover, among heavy users of illicit drugs, women often appear significantly more deviant than men, e.g., higher on

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.


psychiatric impairment (Anglin et al., 1990; Worth, 1990) and accordingly may be highly resistant to treatment. Thus, while women may be more likely than men to perceive health treatment needs overall, this generalization may not apply to drug-using women. The link between perceived need for treatment and heavy drug use per se may be weaker among women than among men, and greater psychiatric impairment among drug-using women could make it more difficult for them to recognize the need for treatment.

METHODS

This study is based on a secondary analysis of data collected between April 1988 and January 1990 for the Los Angeles site of the Drug Use Forecasting (DUF) Project. In DUF, face-to-face interviews are conducted quarterly with adult arrestees who have entered Los Angeles city or county jails within the prior 2 days. DUF’s primary purpose is to assess drug-use patterns and trends in “an extremely deviant segment of the population,” i. e., drug-using arrestees (Wish and O’Neil, 1989). Self-report data are collected under a standard DUF protocol and a supplemental protocol for Los Angeles. No monetary incentive is offered for participation. However, arrestees who consent to the interview receive snacks or cigarettes if they choose. Refusal rates have been low, rang- ing from 2 to 3% each quarter.

Between April 1988 and January 1990, a total of 1,579 arrestees were interviewed (excluding 48 cases whose racial identity was not African- American, Hispanic, or non-Hispanic White). The great majority (91%) of these arrestees reported a history of illicit drug use. Complete data are available for 1,170 drug-using arrestees. (The loss of cases is due mostly to the fact that, under the press of time, some arrestees are not asked to complete the Los Angeles interview supplement). Demographic characteristics of these 1,170 arrestees appear in Table 1.

The remainder of this section indicates coding for behavioral and attitudi- nal measures used in this study. Table 2 reports the breakdown on these measures for the sample as a whole and for ethnic and gender subsamples.

Perceived Need. Arrestees are asked, “Do you feel you could use treatment for drug or alcohol use?” Those who have responded affirmatively with regard to drug use, either singly or in combination with alcohol use, were coded 1. Those who have reported no need for treatment were coded 0.

Self-Reported Drug Dependence. Arrestees are asked whether they have ever used any of 18 illicit drugs. Arrestees who report use of any drug are also asked whether they believe they are currently dependent on that drug. For this study we focused on the four “hard” drugs most commonly reported by Los Angeles arrestees: heroin, cocaine (crack or powder), phencyclidine

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.

TREATMENT NEED 543

Table 1.

Demographic Characteristics of Drug-Using Arrestees, Drug Use Forecasting Project, Los Angeles Site (n = 1,170)

Sample Characteristic percentage

African-American Hispanic Non-Hispanic Whites Gender: male Marriedlcohabiting Full- or part-time employed Full-time in school

41 .O 35.9 23.1 67.6 30.5 48.7

1.5

Standard Mean deviation

Years of education 11.6 3.27 Years of age 29.6 8.63

Age at first heroin usea 21.1 6.85 Lifetime number of arrests 8.36 34.02

“Data not available for all sample cases. N = 321 for age of first cocaine use. N = 700 for age of first heroin use.

Age at first cocaine usea 22.2 7.04

(PCP), and amphetamines (Westland et al., 1989). Those reporting dependence on one or more of these four drugs were coded 1; those reportedly not dependent on any of the four drugs were coded 0.

Drug-Related Legal Problems. As noted above, perceived treatment need among women may be based more often on crisis events that are related to drug use rather than on drug dependence itself. DUF does not systematically collect data on such problems, but, of course, all DUF respondents are arrestees. For those held on drug-related charges, their arrest is clearly a direct consequence of involvement with drugs. Hence, charge at intake may serve as a reasonable proxy for the occurrence of drug-related legal problems. The va- lidity of this proxy is limited by the fact that, regardless of charge, arrestees may be experiencing other drug-related problems not reflected in the data. Drug-using arrestees held on drug charges (possession or sale) were coded 1 ; all other such arrestees were coded 0 (see Note 2).

Attitude toward Professional Care. Perceived need for treatment may reflect variation in the degree to which racial or gender subsamples agree with

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.


c- 0 -$ %

0,

v) .E

8

h f c 0

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.

TREATMENT NEED 545

the concept that seeking help from professionals is an appropriate way to cope with personal problems. Working with two nationwide samples, Veroff et al. (1981) reported that attitude toward professional care is consistently and positively related to years of education (see also Wolkon et al., 1973). The authors believe that education reflects both favorable exposure to the concept of seeking professional help and continued reference-group support for help seeking. In this study, we employ high school education as a proxy for attitude toward professional care. Arrestees who have reported completing their high school education were coded 1 (more favorable); those who did not complete high school were coded 0 (less favorable) (see Note 3).

Attitude toward Treatment for Drug Use. Research cited above indicates that attitudes toward treatment for drug use, particularly methadone maintenance and therapeutic communities, may be less favorable among African-Americans and Hispanics than among Whites. Lacking a direct measure of attitude toward treatment for drug use, we adopted experience in such treatment as a proxy. Arrestees reporting prior treatment for drug use, either singly or in combination with alcohol use, were coded 1 (more favorable to treatment); those reporting no such experience were coded 0 (less favorable). It is important to note that age is likely to be correlated with treatment experience (Hubbard et al., 1989). Multivariate analyses with attitude toward treatment as one predictor will include age as another, thus partialing out the variation in treatment experience that is associated with age.

Heroin Use. Two of the most widely available treatment modalities, methadone maintenance and methadone detoxification, are relevant specifically to heroin dependence. Demographic patterns in perceived treatment need could therefore be affected by the ethnic or gender distribution of heroin use (see Note 4). Moreover, as noted above, attitude toward methadone may vary by ethnicity and could affect perceived need, to the extent that treatment for drug use, as a general concept, is associated with methadone. Arrestees who reported any use of heroin within the past 30 days were coded 1. Arrestees who did not report such use were coded 0.

FINDINGS

First, we examine relationships between perceived need and the demographic characteristics (ethnicity and gender) or drug-using arrestees. Second, we determine whether “predisposing” attitudes, such as perceived drug dependence, can account for these relationships. Finally, we repeat this second step for the subset of arrestees who used illicit drugs on a daily basis. Because our measure of perceived need is dichotomous (yesho), logistic regression techniques are employed for each analysis.

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.


Ethnicity, Gender, and Perceived Need

The raw (unadjusted) odds ratios in Column A of Table 3 indicate that Hispanics are significantly less likely than Whites (odds ratio = 0.69) to perceive a need for treatment. In addition perceived need is more likely among female arrestees (odds ratio = 1.49), more likely among older arrestees (odds ratio = 1.31), and more likely among heroin users (odds ratio = 15.38).

These bivariate relationships may be due to, or masked by, differences in the composition of ethnic and gender subsamples. If, for example, the ratio of men to women is higher in one racial subsample than in another, the relationship between demographics and perceived need cannot be specified accurately unless ethnicity and gender are tested as predictors of perceived need in the same equation. Furthermore, as already noted, age and heroin use may be related to perceived need. Subsample differences in age composition or in the proportion of cases using heroin could therefore confound the relationship between ethnicity or gender and perceived need. Accordingly, the second step in the analysis is to test four demographic predictors-ethnicity, gender, age, and heroin use-in a multivariate context. The adjusted odds ratios in Column B of Table 3 indicate the relationship of each predictor to perceived treatment need after other predictors are taken into account.

Table 3.

Relationships between Demographic Factors and Perceived Need for Treatment, Drug Use Forecasting Project, Drug-Using Arrestees, Los Angeles Site (n = 1,170)

A, B, Demographic perceived need, perceived need, factor raw odds p value adjusted odds p value

Ethnicity : Non-Hispanic White African-American Hispanic

Gender: Male Female

Heroin use: No Yes

Age: 18-28 years 29 or older

1 .o 1.06 0.64 0.69 0.04

1 .o 1.49 0.002

1 .o 15.38 o.oO01

1 .o 1.31 0.03

1 .o 0.90 0.54 0.41 o.Ooo1

1 .o 1.21 0.11

1 .o 19.71 o.Ooo1

1 .O 0.86 0.28

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.

TREATMENT NEED 547

The relationship for Hispanics is confirmed. With all demographic predictors in the equation, Hispanics are significantly less likely (odds ratio = 0.41) to perceive a need for treatment. Regarding gender, the odds ratio of 1.27 approaches statistical significance (p = . 1 1 ), with female drug users still more likely than male drug users to report needing treatment. Again, African- American ethnicity does not predict perceived treatment need (odds ratio = 0.90).

Perceived treatment need is much higher among current heroin users (odds ratio = 19.71) than among heroin nonusers. This finding is noteworthy in light of the greater prevalence of heroin use among Hispanics and older arrestees in this sample. Entering heroin use as a predictor strengthens the negative relationship between Hispanic ethicity and perceived need. Heroin use also appears to explain the positive bivariate relationship between age and perceived need, since heroin users tend to be older (see Note 5).

Predisposing Factors

Perceived need can be expected to vary as a function of “predisposing” factors, as noted in the Introduction. The third step in the analysis examines perceived need as a function of four predisposing factors: self-reported drug dependence, occurrence of drug-related legal problems, general attitude toward professional care, and specific attitude toward treatment for drug use. Table 4 reports the bivariate relationship for each predisposing factor. Self-reported dependence has the strongest relationship to perceived treatment need (odds ratio = 48.44). Among the three proxy measures, attitude toward treatment (as indicated by treatment experience) is the strongest bivariate predictor of perceived treatment need (odds ratio = 5.06), followed by attitude toward professional care (as indicated by education) (odds ratio = 1.37). Drug-related legal problems (as indicated by charge at arrest) has marginal but nonsignificant predictive value (odds ratio = 1.32, p = .14). It is notable that, despite the relative weakness of proxy measures in general, two of the proxies in this analysis are signficantly related to perceived treatment need in the expected direction. Perceived need is more likely among arrestees with more favorable attitudes toward treatment and among arrestees with more favorable attitudes toward professional medical or mental-health care.

Following the priority indicated by the strength of biviate relationships, we added predisposing factors to the multivariate demographic analysis in stepwise fashion. Self-reported drug dependence, the strongest predisposing factor in bivariate analyses, was entered first. The adjusted odds ratios in Column A of Table 5 show that, after self-reported dependence is taken into account, women are no longer more likely than men to report needing treatment (odds ratio = 1 .18). Thus, self-reported dependence seems to account for the earlier relation-

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.


Table 4.

Relationships between Predisposing Factors and Perceived Need for Treatment, Drug Use Forecasting Project, Drug-Using Arrestees, Los

Angeles Site (n = 1,170)

Predisposing factor

Perceived need, raw odds p value

Perceived drug dependence: No Yes

Attitude toward treatment: Less favorable More favorable

Drug-related legal problems: No Yes

1 .o 48.44 o.oO01

1 .o 5.06 O.OOO1

1 .o 1.32 0.14

Attitude toward professional care: Less favorable 1 .O More favorable 1.37 0.01

ship (marginally significant) between gender and perceived need. However, net of self-reported dependence, Hispanics remain less likely to perceive treatment need (odds ratio = 0.54). Both heroin use and self-reported dependence retain their strong positive associations to perceived need for treatment (odds ratio = 4.96 and 30.97, respectively).

After self-reported dependence, attitude toward treatment was entered next, then attitude toward professional care, and finally drug-related problems. Findings are reported in Columns B to D of Table 5. The strength of most predictors changes very little at each step. We focus accordingly on results for the full equation (Column D). Self-reported dependence remains consistently and positively related to perceived treatment need (odds ratio = 29.65), as does heroin use (odds ratio = 4.31). Positive associations emerge for attitude toward treatment (odds ratio = 1.85) and the occurrence of drug-related legal problems (odds ratio = 2.10) but not for attitude toward professional care. Net of these predictors, Hispanics continue to be less likely to percieve a need for treatment (odds ratio = 0.60).

Daily Drug Users

As a final step, we reexamine these findings within a critical subset of drug-using arrestees: those reporting drug use every day for at least the past 30

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.

Tab

le 5

.

Rel

atio

nshi

ps b

etw

een

All F

acto

rs a

nd P

erce

ived

Nee

d fo

r Tr

eatm

ent,

Dru

g U

se F

orec

astin

g Pr

ojec

t, D

rug-

Usi

ng A

rres

tees

, Los

Ang

eles

Site

(n

= 7

,7 7

0)

4

;a rn 3 6 z 1 z

A,

B,

C,

D,

perc

eive

d ne

ed,

perc

eive

d ne

ed,

perc

eive

d ne

ed,

perc

eive

d ne

ed,

% Fa

ctor

ad

just

ed o

dds

p va

lue

adju

sted

odd

s p

valu

e ad

just

ed o

dds

p va

lue

adju

sted

odd

s p

valu

e

Ethn

icity

: N

on-H

ispa

nic

Whi

te

Afr

ican

-Am

eric

an

His

pani

c G

ende

r:

Mal

e Fe

mal

e H

eroi

n us

e:

No

Yes

A

ge: 18-2

8 ye

ars

29 o

r old

er

No

Yes

A

ttitu

de to

war

d tre

atm

ent:

Less

favo

rabl

e M

ore

favo

rabl

e

prof

essi

onal

car

e:

Less

fav

orab

le

Mor

e fa

vora

ble

Dru

g-re

late

d le

gal

prob

lem

s N

o Y

es

Perc

eive

d de

pend

ence

:

Atti

tude

tow

ard

u I .o

0.

76

0.23

0.

54

0.01

1 .o

0.81

0.

36

0.59

0.

03

1 .O

0.81

0.

36

0.60

0.

03

1 .o

0.87

0.

60

0.53

0.

05

1 .o

1 .o

1.18

0.

40

1 .o

1 .O

1.18

0.

38

1.18

0.

38

1.07

.7

3

o.OOO

1 1 .o

I .O

4.

96

O.OO

O1

1 .O

I .o

4.21

O.

OOO1

4.

31

4.27

o.O

OO1

1 .O

0.78

1 .o

0.

81

0.27

1 .o

0.

76

0.14

1 .O

0.

76

0.14

0.

20

o.OOO

1 1 .o

30

.91

o.OOO

1 I .o

28

.37

O.OO

O1

1 .o

28.3

7 o.O

OO1

1 .o

29.6

5

1 .o

I .82

0.00

7 I .o

1.

83

0.00

7 1 .o

1.

85

0.00

7

I .o

0.97

0.

86

1 .o

1 .o

1.00

VI s

0.00

5 1 .o

2.

10

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.


days. While not an unambiguous indicator of actual need for treatment, daily use of hard drugs quite strongly suggests physiological or psychological dependence and is likely to be associated with a range of functional problems that can also be addressed in treatment, e.g . , crime involvement, impairment social relationships, and employment difficulties (Anglin and Hser, 1990). In the sample of 1,170 drug-using arrestees, 287 reported daily use. Multivariate analyses based on those arrestees are reported in Table 6.

Table 6.

Self-Reported Dependence and Perceived Need for Treatment, Drug Use Forecasting Project, Drug-Using Arrestees (daily users),

Los Angeles Site (n = 280)

Perceived need, Factor adjusted odds p value

Ethnicity : Non-Hispanic White African-American Hispanic

Gender: Male Female

Age: 18-28 years 29 or older

Heroin use: No Yes

Perceived dependence: No Yes

Attitude toward treatment: Less favorable More favorable

Drug-related legal problems: No Yes

Attitude toward professional care: Less favorable More favorable

I .o 0.37 0.33

1 .o 1.10

1 .o 1.17

1 .o 1.70

1 .o 5.31

1 .o I .73

1 .o 0.74

1 .o 1.25

0.07 0.07

0.80

0.68

0.24

o.oO01

0.18

0.57

0.56

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.

TREATMENT NEED 55 1

With all predictors in the equation, perceived treatment need is significantly associated with self-reported dependence (odds ratio = 5.3 1). Predictive value is also indicated for two other variables. African-American daily users are less likely to report needing treatment (odds ratio = 0.37). The significance level is marginal ( p = .07) but noteworthy, given the small number of cases availble for analysis. Furthermore, Hispanic daily users are, again, less likely than Whites to report needing treatment (odds ratio = 0.33, p = .07).

It is possible that some degree of error is introduced by measuring fre- quency of drug use solely by self-reports. That is, the findings could be dis- torted if a nonnegligible percentage of arrestees who reported daily drug use were in fact not using daily. To guard against this possibility, we checked self- reported drug use against the results of DUF uring tests for the presence of any of the four hard drugs. Only nine arrestees (3% of self-reported daily users) tested negative on all four drugs. With these nine arrestees excluded, findings in Table 6 do not change (data not shown). Thus, reliance on self-reports introduced no detectable bias in the analysis of perceived treatment need among daily users.

DISCUSSION

Predisposing Factors

Among the factors we were able to test, self-reported dependence was most strongly related to perceived need for treatment. This finding is probably due in part to methodology; dependence and need were both assessed by self- report, not by proxy. Despite the use of proxies to measure three other predisposing factors, two were related to perceived need in the expected direction. Perceived need was greater among drug-using arrestees most favorably disposed to treatment (i.e., those with treatment experience) and arrestees faced with drug-related problems other than drug use itself (i.e., those charged with drug possesion/sale).

Variation in the proxy used to measure attitude toward treatment (prior treatment experience) presumably reflects the influence of enabling factors (e.g., treatment cost) as well as predisposing factors. However, we believe that this proxy is serviceable for our purpose because treatment experience probably reflects, and may even promote, agreement with the idea that seeking professional help is an appropriate way to cope with personal problems. Support for this assumption appears in research by Torres (1983), who found a strong correlation ( r = .42) between Hispanics’ approval of self-disclosure to mental health professionals and prior exposure to mental health services (see also Baekeland and Lundwell, 1975). This assumption is supported also by the per- sistence of a positive relationship in our data between past treatment experience

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.


and perceived current need for treatment. It seems unlikely that past experience would predict current perceptions of need if past experience were simply a matter of access and not predisposition as well.

Demographic Differences

Perceived need for treatment was more common among women than among men. This finding is consistent with previous research on gender differences in perceived need for various health care services, but it is not consistent with the expectation that women who use illicit drugs might be less likely to report needing treatment for drug use. Though female drug users gen- erally appear more deviant than male drug users (Anglin et al., 1990), the women in this study remain more inclined than men to see their drug use as a problem appropriate for treatment.

In Thorn’s (1986) study of alcoholics, perceived treatment need among women was explained more by crisis events than by drug dependence per se. However, in this study of drug-using arrestees, the gender difference in perceived treatment was explained by self-reported dependence, not by drug- related legal problems (one form of crisis event). It seems quite possible that perceived dependence is one mechanism through which sex roles exert an influence on perceived treatment need. That is, traditional malelfemale sex roles may make it easier for women to accept the idea that they are not in control of their drug habit and that professional help is needed. The discrepancy between Thorn’s results and ours could be due to many factors, including, of course, the fact that her sample included alcohol users while ours focused on users of illicit drugs.

Hispanics appear less likely than Whites to report needing treatment. This finding is consistent with some previous research in which Hispanics appeared less inclined to see their personal problems as appropriate for mental health services. However, unlike the gender difference discussed above, this ethnic difference was not explained by self-reported drug dependence. Nor was it explained by any other predisposing or demographic factors available for analysis. In analyses focused on daily users, perceived need was lower among both African-Americans and Hispanics after self-reported dependence and all other factors were taken into account. This finding is tentative, given marginal significance levels in the analysis of perceived need.

We noted above that negative views of treatment among African- Americans and Hispanics may be specific to heroin users and/or to treatment modalities for heroin use (methadone maintenance and detoxification). How- ever, findings for both African-Americans and Hispanics persisted when heroin use was added as a predictor of perceived treatment need. Thus, negative attitudes toward treatment are neither confined to the tecaro (Hispanic heroin addict) subculture nor specific to methadone.

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.

TREATMENT NEED 553

IMPLICATIONS

Hispanics and African-Americans may be less comfortable with self- disclosure in therapeutic contexts or more skeptical of the idea that personal problems are best handled with the help of professionals. But there is danger in reifying such broad cultural patterns and in assuming that any disinclination to seek treatment reflects problems that reside in the prospective client rather than in the nature of available services (Casas and Vasquez, 1989; Desmond and Maddux, 1984). Hence, this review of implications focuses explicitly on the interaction between drug users and treatment providers.

First, initial commitment to treatment may be more tenuous among African-American and Hispanic drug users. It may therefore be advisable to place special emphasis on the engagement of African-American and Hispanic clients at each step of the treatment entry process-outreach, referral, and intake. This emphasis may be especially important for clients who seek treatment because of family pressure, legal coercion, or other external motivators, inasmuch as clients whose treatment entry is less than voluntary may be most likely to believe that they do not really need it and most likely to drop out prematurely.

In concrete terms, how can engagement in treatment be promoted? One key may be the delivery of referral and intake services inways that are culturally congruent. For example, early interaction between treatment staff and Hispanic clients may be more productive if staff are able, or trained, to adopt interaction styles that reflect Hispanic cultural values such as respeto (maintenance of personal integrity) and confianzu (trust and intimacy). These styles might serve to overcome Hispanic dissatisfaction with therapeutic encounters that otherwise seem impersonal and nonreciprocal (Austin and Gilbert, 1989; Valle and Vega, 1980). Staff/client interaction may, in addition, be more productive if staff are bilingual and thus able to accommodate the language prefer- ence of their clients, including those who speak English well but who prefer Spanish when discussing personal matters. Similarly, attention to spirituality, communalism, and African heritage might be expected to raise the engagement of African-American clients (Amuleru-Marshall, 1991 ; Grills, 199 I ) .

Second, treatment perceptions might improve in African-American and Hispanic communities if closer ties are established between treatment providers and community care-givers, such as staff at neighborhood health clinics, clergy, and consejerm (nonprofessional counselors). One way to strengthen such ties is to invite community care-givers into treatment programs as in- service trainers or Advisory Board members. Another is to broaden the scope and purpose of treatment intake so that, when appropriate, potential clients are routinely referred to specific community-based resources (e.g., the address, phone, and contact person) as alternatives or adjuncts to formal treatment. A comprehensive set of such resources would include, for example, culturally-

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.


specific self-help groups, social service agencies, crisis centers, and religious leaders or groups. Conversely, if community care-givers are in closer contact with local treatment programs, it is more likely that drug users who do meet treatment intake criteria will be referred to treatment by community care- givers. Reciprocity is probably a key to sustained communication between treatment providers and community care-givers and to more favorable perceptions of treatment among drug users who are members of ethnic communities.

Third, findings on perceived need among daily drug users suggest that denial, in the clinical sense, may be higher among African-Americans and Hispanics. However, an alternative interpretation is that, even when using on a daily basis, African-American and Hispanic drug users are indeed more able to handle the demands of their habit (see Beschner and Walters, 1985; Morris, 1985). Further research will be required to determine the extent to which group differences in perceived need reflect denial as opposed to drug-use competence. In the meantime, the success of outreachheferral and treatment strategies targeted to African-American and Hispanic drug users may depend largely on how issues of denial versus competence are handled. If outreachheferral staff and counselors accept a drug user’s claim that hidher habit is under control, they may reinforce the denial that inhibits treatment entry and retention. On the other hand, efforts to break through denial may be counterproductive among drug users whose habit is intensive but nonetheless under control. Such users may be more influenced by arguments based on social rather than personal motivations (e.g., racialkommunity concerns and the importance of serv- ing as a role model for one’s children). Counselors who are more aware of such issues may be more successful in “reconfiguring” the motives of drug users who at first perceive little or no need for treatment.

ACKNOWLEDGMENTS

The data on which this report is based were collected under National Insti- tute of Justice (NU) Contracts 88-IJ-CX-K005, 89-IJ-CX-R007, and 89-IJ-R- 007. Analyses were supported by NIJ grant 90-IJ-CX-0044 and National Insti- tute on Drug Abuse Grant KO2 DA00146.

1. Predisposing factors and enabling factors can be interrelated. For example, place of residence (urban versus rural) may reflect normative influences on the predisposition to seek treatment as well as degree of access to treatment providers. The distinction between treatment experience and perceived need remains important, however, because antecedents common to both may nonetheless vary in their power to predict treatment experience and perceived need. Because income-generating crimes (e.g., burglary, forgery, and possession of stolen property) may be motivated by the cost of purchasing illicit drugs, we examined four alternative proxy

2.

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.

TREATMENT NEED 555

measures of drug-related legal problems. In all four measures, persons arrested for drug possession/sale or for income-generating crimes (both coded 1) are compared with persons arrested on all other crimes, e.g., assault, weapons charges. and homicide (coded 0). The four alternative measures reflect different procedures for handling prostitution and robbery, two of the more common charges. Though often categorized as violent crime, robbery can also be considered income-generating. Similarly, persons may engage in prostitution as a means of obtaining money for illicit drugs. In one measure, prostitution is included among income- generating crimes while robbely is not. A second measure reverses this classification. In the third measure, each of the two charges is counted as income-generating; in the fourth, neither is. Analyses indicate that relationships between perceived treatment need and drug-related problems are similar, regardless of whether drug-related legal problems are defined strictly on the basis of drug possession/sale or on any of the alternative broader measures. Analyses reported below are based on the original measure, which distinguishes drug possession/sale arrestees from all others. To examine alternative cut-points for this variable, we tested some college experience versus no college experience, and college graduates versus nongraduates. In other analyses we treated education as a continuous variable. None of these alternatives produced findings different from those reported here. In Los Angeles, heroin use is more common among female arrestees than among male arrestees, as indicated by self-reports as well as urine testing, and Hispanic arrestees are more likely than non-Hispanic arrestees to report heroin dependence (Westland et al., 1989). With heroin use as a dependent variable, the adjusted odds ratio for Hispanic ethnicity is I .58; for age, 3.00. If heroin use is excluded from the analysis, the predictive strength of age remains significant (adjusted odds ratio = 1.17, p = .03).

3.

4.

5.

REFERENCES

AMULERU-MARSHALL, 0. (1991). African-Americans. In J . Kinney (Ed.), Clinical Manual of Substance Abuse. St. Louis, Missouri: Mosby Year Books, pp. 146-164.

ANDERSEN, R., KRAVITS, J., and ANDERSON, 0. (1975). Equiry in Health Services: Empiri- cal Analyses in Social Policy. Cambridge, Massachusetts: Ballinger.

ANGLIN, M. D., DESCHENES, E. P., and BOOTH, M. (1990). Ethnic and gender differences in legal supervision effectiveness in controlling narcotics use and crime. Paper in submission.

ANGLIN, M. D., and HSER, Y. (1990). Treatment of drug abuse. In M. Tonry and J. Q. Wilson (Eds.), Crime and Justice: Drugs and Crime, (Volume 13). Chicago: University of Chicago Press, pp. 393-460.

ANGLIN, M. D., HSER, Y., and BOOTH, M . W. (1987). Sex differences in addict careers: Treatment. Am. J . Drug Alcohol Abuse 13(3): 253-280.

AUSTIN, G. A., and GILBERT, M. J. (1989). Substance Abuse among tatino Youth, Prevention Research Update No. 3 . Los Alamitos, California: Southwest Regional Educational Labora- tory.

BAEKELAND, F., and LUNDWELL, L. (1975). Dropping out of treatment: A critical review.

BESCHNER, G. M., and WALTERS, J. M. (1985). Just another habit? The heroin users perspective on treatment. In B. Hanson, G. M. Beschner, J. M. Walters, and E. Bovelle (Eds.), Life with Heroin: Voices from the Inner City. Lexington, Massachusetts: Lexington Books, pp.

BROWN, B. S. (1985). Federal drug abuse policy and minority group issues- Reflections of a

CASAS, 1. M., and VASQUEZ, M. J . (1989). Counseling the Hispanic client: A theoretical and

Psychol. BUN. 82(5): 738-783.

155-173.

participant-observer. Int. J. Addict 20( 1): 203-2 15.

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.


applied perspective. In P. B. Pedersen, J. G. Draguns, W. J. Lonner, and J. E. Trimble (Eds.), Counseling Across Cultures. Honolulu: University of Hawaii Press, pp. 153-175.

CORNEY, R. H. (1990). Sex differences in general practice attendance and help seeking for minor illness. J. Psychosom. Res. 34(5): 525-534.

DESMOND, D. P., and MADDUX, J. F. (1984). Mexican-American heroin addicts. Am. J. Drug. Alcohol Abuse lO(3): 317-346.

ESPADA, F. (1979). The drug abuse industry and the “minority” communities: Time for change. In R. L. Dupont, A. Goldstein, J. O’Donnell (Eds.), Handbook on Drug Abuse. Rockville, Maryland: National Institute on Drug Abuse, pp. 293-302.

GERSTEIN, D. R., and HARWOOD, H. J . (1990). Treating Drug Problems. Washington, D.C.: National Academy Press.

GRILLS, C. N. (1991). Do Student Assistance Programs Adequately Serve African-American Sru- dents? An Africentric Analysis. Paper presented at Conference on the Drug Abuse Challenge to the Black Community’s Healers, Morehouse School of Medicine.

HORWITZ, A. (1977). Pathways into psychiatric treatment. J. Healrh SOC. Behav. 18(2): 169- 178.

HUBBARD, R. L., MARSDEN, M. E., RACHAL, J . V., HARWOOD, H. J., CAVANAUGH, E. R., and GINZBURG, H. M. (1989). Drug Abuse Treatment: A National Srudy of Eflectiveness. Chapel Hill: University of North Carolina Press.

JORQUEZ. J. S. (1984). Heroin use in the barrio: Solving the problem of relapse and keeping the gusano asleep. Am. J. Drug Alcohol Abuse lO(1): 63-75.

MILLER, W. R. (1985). Motivation for treatment: A review with special emphasis on alcohlism.

MORRIS, R. W. (1985). Not the cause, nor the cure: Self-image and control among inner-city Black male heroin users. In B. Hanson, G. M. Beschner, J. M. Walters, and E. Bovelle (Eds.), Life with Heroin: Voices from the Inner City. Lexington, Massachusetts: Lexington

NEIGHBORS, H. W., and HOWARD, C. S. (1987). Sex differences in professional help seeking among adult Black Americans. Am. J . Commun. Psychol. 15(4): 403417.

ROGLER, L. H., MALGADY, R. G., COSTANTINO, G., and BLUMENTHAL, R. (1987). What do culturally sensitive mental health services mean? Am. Psychol. 42(6): 565-570.

SANCHEZ, A. F. (1977). Drug abuse and treatment of the “tecato” or Mexican-American junkie. In D. E. Smith, S. M. Anderson, M. Buxton, N. Gottleib, W. Harvey, and T. Chung (Eds.), A Multicultural View of Drug Abuse. Cambridge, Massachusetts: G. K. Hall, pp. 574-579.

SCHNEIDER, L. J., LAURY, P. D., and HUGHES, H. H. (1980). Ethnic group perceptions of mental health providers. J. Couns. Psychol. 27(6): 589-596.

SINGH, B. K., and WILLIAMS, S. J . (1983). Chronological maturation and attempts at deaddic- tion: An extension of the maturation hypothesis. Adv. Alcohol Substance Abuse 2(4): 91-101.

THOM, B. (1986). Sex differencs in help-seeking for alcohol problems: The barriers to help- seeking. Br. J. Addict. 81: 777-788.

TORRES, W. (1983). Puerto Rican and Anglo conceptions of appropriate mental health services. Adv. Descriptive Psychol. 3: 147-170.

TUCKER, M. B. (1985). US. ethnic minorities and drug abuse: An assessment of the science and practice. Inr. J. Addict. 20(6&7): 1021-1047.

VALLE, R., and VEGA, W. (1980). Hispanic Natural Suppon Systems: Mental Health Promotion Perspectives. Sacramento: State of California.

VEROFF, J., KULKA, R, A,, and DOUVAN, E. (1981). Menral Health in America: Patterns of Help-Seekingfrom 1957-1976. New York: Basic Books.

WESTLAND, C., ANGLIN, M. D., and WANG, J . (1989). Annual Epidemiological Analysis of L o s Angeles County DUF Data. Unpublished paper, Drug Abuse Research Group, University of California, Los Angeles.

Psychol. Bull. 98(1): 84-107.

Books, pp. 135-153.

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.

TREATMENT NEED 557

WISH, E. D. , and O’NEIL, J . A . (1989). Drug Use Forecasting research update. Research in Acrion: Drug Use Forecasting. January to March 1989. Washington, D.C.: National Institute of Justice, pp. 2-8.

WOLKON, G . H. , MORIWAKI, S . , and WILLIAMS, K . J. (1973). Race and social class as factors in the orientation toward psychotherapy. J. Couns. Psychol. 20(4): 3 12-316.

WORTH, D. (1990). Minority women and AIDS: Culture, race, and gender. In D. A . Feldman (Ed.), Culture and AIDS. New York: Praeger.

THE AUTHORS

Douglas Longshore, Ph.D., earned his doctorate in sociology from UCLA in 198 1. He is currently prin- cipal investigator at the Drug Abuse Research Center, Neuropsychiatric Institute, University of California, Los Angeles. Before joining UCLA, he was a social science analyst at the Program Evaluation and Methodology Division of the U.S. General Accounting Office in Washington, D.C., and a project director at the Studies and Evaluation Department,

System Development Corporation, Santa Monica, California. His research interests include HIV risk among drug users, treatment evaluation, treatment utilization patterns, and equity issues in criminal justice.

Shih-chao Hsieh, M.P.H., earned her master’s from the University of Illi- nois at Chicago in 1989. She is currently programmerlanalyst at the Drug Abuse Research Center, Neu- ropsychiatric Institute, University of California, Los Angeles. She form- erly worked under Dr. Richard Cooper at Cook County Hospital. Her research interests and publications concern the measurement of AIDS- related knowledge and attitudes, treatment utilization patterns, and statis-

tical applications in social science research.

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.


M. Douglas Anglin, Ph.D., earned his doctorate in social psychlogy from UCLA in 1979. Since then he has been involved in research projects pertaining to the evaluation of community treatment and other interventions for heroin and cocaine users. His work has brought nationwide recognition and invitations to serve as an advisor for many local, state, and federal organizations. He is author or coauthor of over 70 articles for scientific publications and holds memberships in the American Psychological Association, the Evaluation Research Society, the American Association for the Advancement of Science, and the Society of Psychologists in Addictive Behaviors.

Subs

t Use

Mis

use

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

Uni

vers

ity o

f B

ritis

h C

olum

bia

on 1

1/18

/14

For

pers

onal

use

onl

y.

ethnic and gender differences in drug users' perceived need for treatment

Documents