**11. Cultural competence in SUD treatment**

Latinos have become the fastest-growing population entering SUD treatment, reaching 12% of the total treatment population in the past 10 years [8, 77]. It is important to highlight the need for culturally competent practices and for providers to understand and use clients' cultural backgrounds, including immigration and acculturation experiences, to support their recovery from SUD. For instance, studies have suggested that among Mexican Americans in the United States, an extended period of residence contributes to a higher prevalence of SUD [78, 79]. Cultural competence may play a critical role in reducing the impact of structural racism in enhancing access to and engagement in the prevention and treatment of Latino substance use [19, 80, 81]. For instance, Latino clients are influenced by individual, program, and community characteristics when facing decisions about substance use and seeking help [7]. As is common with other cultural groups, it is important to establish trust and effective communication to foster positive health outcomes for Latino clients [7]. Engagement occurs through understanding and accepting cultural distinctions, speaking the client's language, and addressing sociocultural and economic issues related to the problem. In turn, structural racism creates policies, systems, structures, and norms to deny and/or minimize cultural strengths and disempower culturally diverse groups and their attempts to invest in their wellness.

Increasing cultural competence in prevention or treatment improves SUD problems among individuals from various cultural backgrounds [19]. Sociocultural beliefs can influence an individual's approach to substance use and abuse and further shape treatment options. For Latinos and other racial and ethnic minorities, language barriers and unavailability of bilingual interpreters can also add to long waiting periods to receive treatment [80–82]. Even further, Latinos and other racial and ethnic minorities experience more difficulties in navigating the health care system as compared to Whites [80]. These findings suggest that it is vital for SUD treatment programs to address the cultural and linguistic needs of their Latino and other minority clients by tailoring services and practices to help achieve better treatment outcomes. Specifically, with diverse populations continuing to increase in the United States, it becomes vital to assess an individual's substance use and abuse based on his or her racial and ethnic background.

### **12. Organizational cultural competence**

Culturally responsive policies, institutions, communities, and programs can become an intervention to address, decrease and eliminate the creation and use of structural racism. The Office of Minority Health helped in developing standards for healthcare providers to abide by 14 standards (practices) to respond to the cultural and linguistic service needs of diverse populations [83]. Many of the culturally responsive practices have been associated with positive SUD prevention and treatment [80, 84, 85]. For instance, structural, policies, and practices that discriminate against certain groups may be a significant risk of dropout. For culturally and linguistically relevant service outcomes to improve, it is important to identify the methodological flaws of the practices [86]. Cultural competence has been correlated with improved communication, positive therapeutic alliance (e.g., providerclient trust), and higher client satisfaction [80, 87–89]. In particular, Latinos as well as other racial and ethnic minority clients are more likely to remain in treatment when the services they receive are responsive to their cultural and linguistic needs.

Considering the initial evidence suggesting cultural competence can increase the quality of care in SUD prevention and intervention, it is critical to developing nuanced, cost-effective interventions.

#### **13. Training SUD treatment providers in cultural competence**

Training staff members to practice cultural competence in SUD treatment is vital to dismantle mechanisms from structural racism that limit clients seeking treatment and improve outcomes. As recently noted in the *Diagnostic and Statistical Manual of Mental Disorders*, it is important for clinicians and staff members to be aware of the cultural differences of each client [90]. Staff composition is crucial to the implementation of treatment programs, specifically concerning access and retention [91]. In fact, appointing qualified staff members who share similar racial and ethnic backgrounds as clients dramatically increases the likelihood of patients entering treatment [91]. The central goal of the staff should be focused on making patients feel welcomed to help improve treatment outcomes [90]. Staff members can learn about the history of vulnerable groups that may be connected with stress and other factors associated with substance use, such as immigration and acculturation experiences. This is a clear outcome for training staff members that can increase the success of treatment programs and organizations by not only fostering an environment of acceptance but also making the patient feel capable of completing treatment [91].

It is equally important to instill cultural competence in the organization because this will influence policies and programs and integrate cultural empowerment values and beliefs in the system [92]. A culturally competent organization thrives on bringing diverse individuals together to alter their practices and make them more acceptable across various groups [93]. The organizational outcomes and benefits associated with increasing cultural competence in the organization include improving respect, increasing participation, improving trust and collaboration, and promoting equality [92, 93]. Organizations can become culturally competent by seeking collaboration with individuals from various racial and ethnic backgrounds and further identifying the needs of these groups [94]. Identifying those needs provides a space to better adapt and learn how organizations can meet the demands of their diverse clients.

#### **14. Cultural competence applied to different treatment modalities**

The importance of applying cultural competence to various settings and organizations is increasing. It is becoming the norm to request that professionals be culturally competent in the health care system [95]. Culturally competent environments are rapidly growing in organizations. For instance, culturally competent models are being applied to cognitive behavioral therapy as a means of improving outcomes in treatment among minority groups, such as Latinos [96]. This is achieved by providing bilingual translators and programs to Latino clients and training staff members to be respectful of their cultural backgrounds. This has led to the development of mutually respectful and cooperative relationships between clients and their providers.

Cultural competence has been applied to interventions that focus on individuals with depression to improve treatment outcomes among racial and ethnic minority groups [97]. In fact, culturally competent adaptations to psychotherapy have been found to be more effective in reducing symptoms of mental conditions (e.g., depression)

as compared to a wait-list control group [97, 98]. Professions that have focused on including cultural competence in their work environment include business, social work, psychology, public relations, education, and health care [99–102].
