Description of a Case of Drug Addiction Treatment in a Lesbian - Essay Example

?Scientist-Practitioner Approach to Treating Substance Abuse of an Asian American Lesbian Woman This paper presents a case of an Asian American lesbian woman with a substance abuse problem. The case details the significant life events of the client that contribute to her current situation. The diagnosis and proposed treatment plan is based on the presenting case and takes on a scientist-practitioner approach. This approach advocates that trained professional psychologists are knowledgeable in both research and clinical practice, to be able to deliver effective psychological services (Jones & Mehr, 2007). Evidence-based practice (EBP), as part of the scientist-practitioner approach, utilizes evidence in making clinical decisions about a case. Chen, Kakkad & Balzano (2008) describes EBP as: concerned with promoting effective practice through integrating the best available research evidence with clinical expertise in the context of client characteristics (e.g., values, religious beliefs, worldviews, goals, treatment preferences) and sociocultural factors (p. 1261-1262) Chwalisz (2003) enumerates the steps in EBP as follows: The first is the raising of specific clinical questions regarding the client’s reported problem case followed by the search for evidence to answer such questions. Such evidence is evaluated for its usefulness in the attempt to solve the problem. Next, the findings are applied to the client’s problem and finally, the outcome of the intervention or therapy is evaluated. In this paper, the presenting case provides the details surrounding the main problem which is the client’s substance abuse. Evidence is searched in the case and evaluated using all five axes of the DSM-IV-TR to come up with a speculative diagnosis. This step is important in gaining credibility of the evidence. Feltham (2005) contends that evidence-based practice is set apart from other “anything goes” therapy practices he describes as “spurious”. He also claims that therapies that are unable to show documentation of empirical support dissuade prospective clientele from availing of such therapies. The multi-axial evaluation of the case dictates the design of the treatment plan appropriate to the client. The interventions in the plan likewise follow a scientist-practitioner approach, as they are selected to address the client’s problems after careful study of the case details. The interventions are based on both research and clinical experiences with cases similar to the client’s. Finally, as part of the scientist-practitioner approach is the analysis of countertransference factors that may affect the therapeutic process between the therapist and the client. In this analysis, specific characteristics of the client shall be analysed with regards to the therapist’s treatment approach. It will also validate if the intervention is culturally responsive to the client’s circumstances (Aisenberg, 2008). Case Study: Pam, aged 27 Pam is a twenty-seven year old Chinese-born Asian American woman who had difficult relationships with her parents as a child living in China. Her parents often engaged in domestic squabbles that ended with her father physically abusing her mother. Pam’s father eventually abandoned the family leaving her mother as the primary care giver for her and her three siblings. When Pam turned ten years old, a rich aunt living in the United States paid for her go to the states to live with her. The aunt took care of Pam sending her to school amongst other forms of support. As a recent immigrant Pam struggled with the English language and as a result, she had a difficult time in school. She was often teased because of her ethnicity and lack of language skills. Pam became withdrawn and claims not to have had a friend until her junior year in high school. During her junior year of high school a girl named Lauren made an effort to befriend her. Pam was eager to have a friend and did everything to please her new fried, Lauren. Pam admits she became so attached and overly possessive and became jealous whenever Lauren would interact with other friends. This instigated their many fights. Pam continued this behaviour until one day Lauren could no longer deal with Pam’s incessant interference. At this point Lauren stopped being Pam’s friend altogether. Pam’s obsession with Lauren was perceived by Pam as arousing a deep attraction for her. As an adolescent, she became very confused with her sexual orientation. She would find some boys attractive, but when they came close to her and attempt to communicate, she would freeze. Pam cultivated a fear that they might suddenly beat her up. Pam’ s personal experience with abuse came solely from her observing her father’s abuse of her mother. This translated to a fear of becoming close to men in general (including this therapist). With the exception of observing her father’s abuse of her mother experience of her at the age of 19, she was sure that she was a lesbian and came out to her aunt and her small world. At 24, Pam got involved with a Hispanic woman named Betina, who was addicted to drugs. Betina was instrumental in introducing Pam to cocaine and a life of drug addiction. To justify the drug use Betina told Pam that, “misery loves company”. Betina stated that as both women are outcasts, being lesbians with ethnic backgrounds, they had to stick together. The drugs numbed the pain of being negatively viewed by other people in addition to numbing Pam’s insecurities and questions about her life including her sexuality. The constant drug use rendered Pam inefficient at her job as an office clerk. Pam began to have a record of being often tardy or absent and did not complete the tasks assigned to her. Her inability to concentrate on work affected her supervisor and colleagues in their work and eventually compromised her job. As Pam’s addiction continued in time, her funds dwindled rapidly due to her drug use and she became crabby and defensive. Her change of personality was remarkable, and her co-workers were often the target of her outbursts and temper tantrums. Eventually, Pam was fired from her work. As Pam's addiction continued, she did not seem to learn from being fired. Betina was also a resource as to how to be an addict. After losing her job, Pam purchased her drugs with the proceeds from selling her possessions and stealing from her aunt. Eventually Betina helped her get on welfare, which also was a funding source. Betina would sometimes supply her with the drugs. Betina usually had some stock left over from those she sold to other users. Two years after being fired and becoming a full time addict, Pam's aunt got tired of being a victim to Pam’s thefts and other manipulations. In addition to informing Pam's mother in China of the changes in her daughter, the aunt gave her the number of our clinic and told her not to contact her again. Pam attempted to quit the life she had especially since it was making her suffer physical pain, which she was unaccustomed to. Once her aunt, her only family connection in the United States, cut her off, Pam realized that Betina was someone who was unhealthy for her and that she had to get away from her. Betina must have noticed a change in Pam and in an attempted to keep Pam in her life as an addict and lover Betina attempted to exert her power over Pam by offering her free drugs, the profits of her drug dealing. It was at this point that Pam entered our program fulfilling the three months of clean time required to participate in the therapy and housing services we offered. Diagnosis Multiaxial Evaluation (from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Axis I: Substance Abuse/ Dependence Pam’s manifested symptoms are suspected as Substance Abuse/Dependence. Under DSM-IV-TR (text revision of 2002). Following are the usual behaviours exhibited by substance abusers/ dependents: SUBSTANCE ABUSE:             Manifests one or more of the following behaviour:  (1) Failure to fulfill major obligations: Pam’s constant tardiness and inefficiency at work were the reasons why she was eventually fired. She was unable to concentrate on her tasks and has developed an antagonistic personality. Still unemployed, she does not manifest the drive to find employment. (2) Use when physically hazardous: In spite of the awareness of the negative outcomes of drug use on her health, Pam continues to engage in it. (3) Recurrent social or interpersonal problems: Pam’s social skills have not fully developed since childhood, and her inadequacy in human interaction persists to the present. Her change in personality and demeanour has affected her harmonious relationships with her co-workers due to her work inefficiency.   “With SUBSTANCE ABUSE the user has a choice: he/she uses in spite of illegal, unsafe consequences, or inappropriateness of the drinking/drugging experience.” (APA DSM-IV-TR, 2002). Pam continues to use drugs despite her awareness of its harmful consequences to herself.  SUBSTANCE DEPENDENCE: Manifests three or more of the following behaviour: Tolerance: Pam’s prolonged use of drugs may have made her so immune to the ‘high’ that it provides so she needs to take increased dosage in order for her body to achieve the same effect she had on the first few times she got “hooked” into the habit. This heightens her tolerance for the drug effects. Large amounts over a long period: Pam’s intake of drugs/ illegal substances depends on its availability. The more drugs available for the taking, the more she can consume. This has gone on for the past three years, and the fact that she has a constant supplier in the person of Betina, she has access to more drugs. Unsuccessful efforts to cut down: Despite her numerous attempts announcements to stop and reform her life by avoiding drugs, she would usually fall back into the drug habit. Time spent in obtaining the substance replaces social, occupational or recreational activities: Pam’s numerous commitments have usually been missed due to her drug problem. Continued use despite adverse consequences: Pam has gotten herself in dire circumstances because of her substance abuse/ dependency. Axis II:  Developmental Disorders/ Personality Disorders From the data gathered, Pam seems to present a number of developmental disorders. From childhood, it was shown that she was socially withdrawn and a slow learner due to her migration from China. Her inadequate language and literacy skills have led her to troublesome consequences such as teasing and bullying from her peers. Pam’s over-possessiveness of her first friend, Lauren has caused her to breakdown in fits of jealousy, and this was the reason why she lost Lauren. Pam manifested fear of the threat of boys hurting her. She goes into panic attacks when they get close to her, possibly, as a result of her childhood trauma, witnessing her father abusing her mother. Axis III: Physical Conditions Pam’s prolonged substance abuse/dependency has caused the client physical illnesses such as memory loss, body pains, seizures, general malaise and the threat of HIV from sharing needles when injecting substances to the body. Such illnesses have made Pam progressively weaker physically confining her to her bed when any of these symptoms occur. Axis IV: Severity of Psychosocial Stressors Pam is unable to interact and relate well to people, especially men, due to her early trauma with her violent father. However, society does not segregate men from women, and she is faced with the constant stressor of encountering men in her daily affairs. Her social skills have not been fully developed, as seen from her history of being withdrawn from her peers. She has a tendency to be attached to a significant person in her life, and she seems content with being with that person alone. This would serve as a stressor when other people would show interest in being part of her life since she does not seem to be open to other human relationships other than Betina and her aunt. Engaging in a lesbian relationship with Betina became another psychosocial stressor for Pam. Add to the fact that their relationship was not considered “normal” by most people around them. This is one major cause of her feelings of being an outcast of society. The environment where she lives in is another source of stress for Pam. Living with Betina encourages her continuous engagement in the drug use because of Betina’s easy access to it, being a drug pusher herself. Axis V: Highest Level of Functioning Overcoming her lack of English language skills as a child was difficult for Pam but she needed to do it in order to survive. Although considered a low performer, she was able to complete high school. She was able to find a job in the summer after she graduated and proved to be a good worker. Considering her painful childhood, Pam has been portrayed as a survivor in the context of her personal situation. When things are carefully explained to her and made sure that she understood the consequences of her behavior, Pam does the necessary action to normalize her life and become drug-free for a certain period of time. Her weak will may be made stronger with careful scaffolding of reminders and even threats to her safety Proposed Treatment Plan In coming up with an appropriate treatment plan for Pam, many factors are to be considered. Like in most cases, treatment needs to combine psychological therapy with the treatment of the physical addiction. Before any treatment plan is attempted, Pam’s intrinsic desire to be reformed must be expressed and reinforced. The decision to be free of her addiction should help her commit to being cooperative with the concrete vision that she can indeed be free from the bondage of the addiction. Detoxification To cleanse her body of the chemicals she has ingested, Pam needs to go through detoxification. “While detoxification alone is rarely sufficient to help addicts achieve long-term abstinence, for some individuals it is a strongly indicated precursor to effective drug addiction treatment.” (National Institute on Drug Abuse, n.d.). Change of Environment Since her immediate environment is one factor that encourages her addiction, she must be moved to an environment that promotes well-being and where the triggers of her addiction can be reduced if not eliminated. Removing the client from her toxic relationship where her addiction is enabled is one immediate positive attribute to inpatient care. Our inpatient treatment plan provides a conducive environment including individual and group therapy that can facilitate introspection, planning and skill building needed for the long-term success over addition. The treatment team will assist the client to develop a realistic action plan to pursue a drug-free and positive lifestyle after the treatment process. This is what our housing services offered and is the ideal transition residence for Pam while she undergoes treatment. Cognitive Behaviour Therapy The most important element in the treatment plan is Pam’s psychological therapy. Psychotherapy will help in treating Pam’s emotional wounds. The need to understand why things turned out the way they are should be met so the individual is equipped to resolve the situation and empowered to move on (Gutierrez, DeLouis, & GlenMaye,1995). Aaron Beck, proponent of Cognitive Behaviour Therapy, claims that much of our psychological problems are caused by “cognitive distortions” due to our acknowledged human fallibility. In depressed people, these belief systems, or assumptions, develop from negative early experiences. These negative experiences lead to the development of dysfunctional beliefs about the world, which are triggered by critical incidents in the future (Field, 2000). In Pam’s case, her initial negative experiences were from her dysfunctional childhood. Being a close observer to her abusive father who then abandoned the family, her early separation from her family and her struggles to adjust in a totally new environment in addition to growing up “without friends” all contributed to her pathology. Thus, she currently harbors negative feelings of self-worth. CBT teaches Pam to reframe her negative thinking to more positive thoughts and to empower her to behave appropriately to support such positive views. In using Cognitive Behaviour Therapy (CBT) with clients with problems with substance use (PSU), the specific aims are to help clients broaden their perspective on their dependence on substances such as drugs and alcohol either for pleasure and/or relief from discomfort. It also aims to reduce the intensity and frequency of the individual’s cravings or urges to get ‘high’ by lowering his beliefs in the substance use. CBT teaches the client techniques in managing his cravings in order to reduce the risk of relapse. Likewise, CBT helps combat depression, anxiety, anger and other negative emotions that usually trigger substance use (Stallard, 2003). The goal of therapy is to help Pam realize that reorganizing the way she views her present solution to stressful situations (drug use) will call for a corresponding reorganization in her behavior. In therapy, clients are taught Thought Catching or the process of recognizing, observing and monitoring their own thoughts and assumptions and catch themselves especially their negative automatic thoughts when they dwell on it. Once they are aware of how their negativity affects them, they are trained to check if these automatic thoughts are valid by examining and weighing the evidence for and against them (Corey, 2005). Pam will learn to assess the advantages and disadvantages of her drug using behaviour as well as evaluate why she keeps holding on to her substance related beliefs. More importantly, therapy helps her distinguish her behaviour from her own person, that what she does is not necessarily a judgment of who she really is. A CBT therapist uses a variety of therapeutic strategies depending on what he decides will work on a particular client. He also delegates responsibility to his client by expecting him to do homework outside the therapy sessions. Homework or Task Assignment is aimed at positive behavior that brings about emotional and attitudinal change (Corey, 2005). Therapists also engage in Socratic dialogues with the clients, throwing questions that encourage introspection with the goal of the client arriving at his own conclusions. Reality Testing lets the client do tasks to disprove negative beliefs such as phoning a friend to disprove the belief that no one wants to speak to him. (Field, 2000). With substance abuse problems, craving management is included in the therapy as the client understands why he craves drugs and manage it by identifying what triggers his craving and normalizing the craving until it ceases. Since the clients’ emotions play a key role in triggering and maintaining substance use, CBT helps to understand and normalize emotions, identifying links between emotions and substance use, identifying and labeling emotions and it also teaches strategies to manage emotions. For instance, Pam feels threatened that Betina (who may be the only person giving Pam positive feedback) will reject her if she does not give in to Betina’s demand to take drugs. Pam, fearing being alone more than any repercussion the drugs may have, takes the drugs. This feeling of “threat of rejection” can be identified as a trigger. The therapist than may help Pam to recognize this trigger and making her understand that giving into Betina’s whims will damage them both especially Pam. The therapist may draw a picture to Pam of the pros and cons of giving in to Pam’s whim and letting her choose the better alternative. After undergoing intensive CBT, relapse prevention is essential. All throughout treatment, clients are encouraged to integrate the techniques they have learned in therapy in their daily lives with the goal of keeping CBT effective even when therapy ends (Roth, Eng and Heimberg, 2002). However, clients are also warned that they might still encounter difficult times in the future even after successful treatment but their newly acquired skills at dispelling negative thoughts and reactions to triggers must be at their disposal to use whenever they might need them. Clients are reminded that the belief that a single difficult event is not a failure on their part. “An important goal of therapy should be to ensure that clients can apply cognitive and behavioral techniques on their own, with less reliance on the therapist over time, thus facilitating relapse prevention efforts.” (Roth, Eng and Heimberg, 2002, p. 453). Being able to manage her fear of men will also help her in dealing with stressful situations. This can also be added to the goal of CBT for her. CBT offers hope for the seemingly hopeless substance abusers who want to be free from their addiction and finally lead better, productive, clean and drug and alcohol-free lives. Family Therapy Family therapy is essential in the healing of Pam’s affliction. Since her only proximally available family is her aunt, she can be called in to support her niece in therapy. She can provide the necessary information and advise to help Pam develop an empowered sense of self and responsibility. Emphasis on Client’s Strengths Pam’s strengths should be used in the treatment plan. Among these are her potentials to secure a good job and her resilient personality. Her survivor skills may be called upon whenever she feels tempted to relapse into her addiction after treatment. She may find ways and means to avoid anything that would trigger her urges to take illicit drugs like old co-drug dependent friends, drug dealers, or even places she associates with her former life in the drug trade. The most potent temptation would be her relationship with Betina who is the source of her drug use. Therapy must address how she can break free from her and manage her life on her own. Vocational Rehabilitation Vocational rehabilitation such as engaging in arts and crafts, gardening, cooking, etc. will not only keep her mind off her addiction but also equip her with more skills. Such skills will help her find appropriate, decent and gainful employment to start her off in her reformed life. Assertiveness Training Pam is also recommended to get into assertiveness training to enable her to non-defensively express her emotions. This will help her not to be easily taken advantage of people, specifically, Bettina. She will likewise be empowered to think of herself positively, and even contest the societal norms and beliefs she grew up on, which were partly responsible in lowering her self-esteem. An effective treatment plan attempts to administer to her medical, psychological, vocational and social needs. As Pam gets better in her treatment plan, consistent monitoring of her progress must be assessed continually and modified as necessary to ensure that the plan meets her changing needs. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term abstinence and fully restored functioning. Participation in self-help support programs during and following treatment often is helpful in maintaining abstinence. (National Institute on Drug Abuse). Countertransference Factors The concept of countertransference was first introduced by Freud in 1910. He noted that there are some factors in the patient that can influence the analyst’s unconscious feelings and these can interfere with the treatment. However, more contemporary therapists see such therapist’s reactions to patients may also have diagnostic and therapeutic relevance which can contribute rather than inhibit treatment (Bethan et al., 2005). Pam’s case involves several factors that may cause countertransference in therapy. Considering her therapist is a white male practitioner who is experienced with drug addiction and mental health issues, possible countertransference factors may be the following: Gender differences, as Pam has manifested a fear of being close to men. The fact that her therapist is male also brings about the possibility of sexual attraction from the side of the therapist. Cultural differences, as Pam is Asian-American while therapist is Caucasian. The therapist must be adept at the cultural norms of Asian Americans to understand Pam’s value system better. Pam’s sexual orientation, as she claims to be a lesbian, being in a relationship with a woman. Pam’s ambivalence in dropping the drug addiction, as her resolve to quit usually disintegrates with Betina’s temptation of available drugs. Although the therapist is experienced with drug-related cases, Pam’s complicated profile may serve as a challenge to him. Analysis of Combined Countertransference Factors The identified possible countertransference factors have been dissected individually. However, the therapist needs to take in the individual factors as a combination of all because Pam’s case essentially presents a woman belonging to an ethnic group who claims to be a lesbian addicted to drugs. The inherent countertransference factors need to be keenly studied by the therapist in order to be able to manage them well so they will not negatively influence the therapy sessions. As a heterosexual male Caucasian, the therapist needs to be conscious of his persona in relation to his client who is a homosexual female Asian American. The ‘White privilege’ concept (McIntosh, 1990) may be an unconscious state of mind that is triggered when the therapist comes face to face with a client with Pam’s profile. This concept suggests that the white race claims superiority over other races and in the case of the therapist, the fact that he is a man further strengthens the claim of dominance over a non-white woman. The therapist should keep an open mind and control pre-conceived notions about his client. The fact that the countertransference of being of opposite genders may initially be awkward for Pam, due to her fear of men should remind the therapist that her unresolved issues should come first. Pam’s profile has been vulnerable to various stereotypes from the time she was young. Possessing characteristics that are prone to judgment such as being a woman, an Asian and a lesbian, Pam has developed an insecurity that has caused her withdrawal from social circles. Steele (1997) explains that stereotype threat is an external factor that greatly affects an individual’s confidence about his own abilities due to his identification with the domain and the resulting image it projects about him. It is likely that Pam still shirks away from situations that may expose her to stereotype threats for fear of being labelled negatively, thus further diminishing her already low self-esteem. It is also possible that she has grown immune to such stereotypes that it defines her “self-fulfilling prophecies” to be manifested (Rist, 2000). The therapist should project to Pam that he is non-judgmental and the therapy sessions are stereotype threat-free. Maintaining a warm and sincere disposition will help the therapist eventually gain Pam’s trust. Although avoiding stereotypes to cloud his judgment of the client, the therapist should also be aware of the common characteristics that have been proven by research to be true for certain cultural groups. Phinney (1996) notes that Asian Americans are typically subdued and obedient, and try to maintain harmony in relationships usually through submitting to the interest of others over one’s own (Uba, 1994). They also emphasize the importance of family and the fulfilment of obligations to the family. The therapist may be able to use this countertransference information to understand that Pam may have the tendency to just keep quiet when she disagrees with him because of her concern for harmony. In such situations, it is the therapist’s role to encourage Pam to speak out her mind. To encourage her, he can lead her by disclosing some of his fears to Pam himself. The therapist may also call on Pam’s aunt, her only family in the US, to join in some therapy sessions as she may provide pertinent information about Pam and how she can be helped with her problems. Pam’s Asian value of family may prove helpful in this case. Greene (1994) contends that Asian-Americans are known for “unquestioning obedience to one’s parents and their demand for conformity, consistent with the respect accorded elders and the sharp delineation of gender roles” (p. 245). Pam’s resolve to quit her substance abuse was strengthened by the knowledge that her aunt confessed to her mother back in China of her problematic situation in the US. The therapist should acknowledge that Pam’s family expectations of her serve as an additional motivation for Pam to amend her dysfunctional lifestyle. This may include her confrontation of her sexual orientation as being a lesbian is deemed to bring shame to the family. It must also be considered by the therapist that Pam is a biencultured individual (Ho, 1995). This means that raised as a child in China and grew up in America from her adolescence made her internalize cultures of both countries. She has not totally forgotten her Chinese origins, as she lived with her Chinese aunt for a long time and was continually exposed to both cultures as she was growing up. Thus, the therapist could not totally rely on his knowledge of Asian influences on Pam nor apply his own American cultural influences in understanding her nature. Ho (1995) advises therapists to transcend their own internalized culture through self-introspection in order to steer free of culturocentrism and egocentrism. This makes them focus better on the client as an individual embedded with the influences of various cultures she encounters in her life. Pam’s sexuality is a strong countertransference factor. Her perception of being a lesbian may come from inexperience in being with men. This has been identified to be caused by her negative view of men formed from her traumatic experience with her father. The therapist, being a man, may see the possibility that Pam may not really be a lesbian. The countertransference in this case may be to prove it. However, should Pam develop her trust in the therapist who is there to help her, she may realize that not all men may be as violent as she thought. This realization may open her to the possibility of taking interest in men instead of women and abandoning the perception that she is a lesbian. However, if Pam is sure of her sexual orientation, the countertransference for the therapist may be the difficulty in understanding and accepting the full consequences of racism and homophobia in Pam’s life (Greene, 1994). To cope with such difficulty, the therapist may fail in processing the issues by moving too quickly past the communication about the homosexuality and racism issues, thus minimizing its importance to the client. It must be remembered that it may be overwhelming for Pam to carry such a burden, and the gravity of her issues can lead her to succumb to deep depression or even suicide (Proctor and Groze, 1994). Such life stressors should not be underestimated and should equally warrant respectful attention in the therapy as the problem of substance abuse. Much is expected from the therapist in the treatment plan of Pam. Having experience with drug-related cases, he is equipped with skills to help her in the planned interventions. Mangrum & Spence (2006) emphasize the need for more intensive training of therapists involved with substance-abuse cases due to the growing considerations necessary in various cases. It would also be ideal if the therapist is adept with mental health treatment, as severe substance abuse may lead to co-occurring mental health disorders (Mangrum & Spence, 2006). Likewise, the therapist should be adept in empowerment practices (Gutierrez, DeLouis, & GlenMaye,1995), as Pam and other clients suffering from substance abuse are in dire need of assurance that they have the power to turn their lives around if they are truly determined to do so. References Aisenberg, E. (2008). Evidence-based practice in mental health care to ethnic minority communities: Has its practice fallen short of its evidence? Social Work, 54 (4), 297-306. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, D.C. Betan, E., Heim, A.K., Conklin,C.Z.& Westen, D. (2005) Countertransference Phenomena and Personality Pathology in Clinical Practice: An Empirical Investigation. Am J Psychiatry 162:890-898, Chen, E.C., Kakkad, D., & Balzano, J. (2008). Multicultural competence and evidence-based practice in group therapy. Journal of Clinical Psychology: In Session, 64 (11), 1261-1278. Chwalisz, K. (2003). Evidence-based practice: A framework for twenty-first-century scientist-practitioner training. The Counseling Psychologist, 31 (5), 497-528. Corey, G. (2005) Theory and Practice of Counseling and Psychotherapy, 7th ed. Brooks/Cole, a division of Thomson Learning Inc. Feltham, C. (2005). Evidence-based psychotherapy and counselling in the UK: Critique and alternatives. Journal of Contemporary Psychotherapy, 35 (1), 131-143. Field, A. (2000) Cognitive Therapy, retrieved on July 22, 2011, from http://www.sussex.ac.uk/Users/andyf/depression.pdf Greene, B. (1994). Ethnic-minority lesbians and gay men: Mental health and treatment issues. Journal of Consulting and Clinical Psychology, 62 (2), 243- 251 Gutierrez, L.M., DeLouis, K.A., & GlenMaye, L. (1995). Understanding empowerment practice: Building on practitioner-based knowledge. Families in Society, 76 (9), 534-544 Ho, D.Y.F. (1995). Internalized culture, culturocentrism, and transcendence. The Counseling Psychologist, 23 (1), 4-24. Jones, J.L. & Mehr, S.L. (2007) Foundations and Assumptions of the Scientist- Practitioner Model. American Behavioral Scientist 50 (6) 766-771 Mangrum, L.F., & Spence, R.T. (2008). Counselor and client characteristics in mental health versus substance abuse treatment settings providing services for co-occurring disorders. Community Mental Health Journal, 44, 155-169. McIntosh, P. (1990). White privilege: Unpacking the invisible knapsack. Independent School, 49 (2), 31-37. National Institute on Drug Abuse (n.d.) Principles of Drug Addiction Treatment: A Research-Based Guide. Retrieved on July 22, 2011 from http://www.whitehousedrugpolicy.gov/treat/bestpractice.html Phinney, J.S. (1996). When we talk about American ethnic groups, what do we mean? American Psychologist, 51 (9), 918-927. Proctor, C.D., & Groze, V.K. (1994). Risk factors for suicide among gay, lesbian, and bisexual youths. Social Work, 39 (5), 504-513 Rist, R.C. (2000). HER classic: Student social class and teacher expectations: The self- fulfilling prophecy in ghetto education. Harvard Educational Review, 70 (3), 257-301. Roth, D.A., Eng, W. & Heimberg, R.G., (2002) Cognitive Behavior Therapy, Encyclopedia of Psychotherapy Vol. 1 Elsevier Science (USA). Steele, C.M. (1997). A threat in the air: How stereotypes shape intellectual identity and performance. American Psychologist, 52 (6), 613-629. Uba, L. (1994). Asian Americans: Personality patterns, identity, and mental health. New York: Guilford Press. Read More