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ADDICTION: A MULTICULTURAL PROBLEM IN NEED OF MULTICULTURAL SOLUTIONS

Just as addiction is a global, rather than a national or regional, phenomenon, so addiction problems in the United States are multicultural. The whole fabric of successful treatment needs to be woven around cultural realities. In this society, twelve-step fellowships, such as ALCOHOLICS ANONYMOUS (AA), NARCOTICS ANONYMOUS, and COCAINE ANONYMOUS, are increasingly seen as the primary means to ensuring long-term abstinence and sobriety through addiction recovery.

Outside the United States there is strong professional resistance to both the DISEASE CONCEPT and twelve-step recovery. In France, for example, where the toxicomanes, physicians dealing with chemical dependency, are heavily invested in a psychotherapeutic approach, there is professional denial that twelve-step programs exist or, if they do, are effective with French clients. Several toxicomanes maintained that even if they, themselves, championed twelve-step recovery and attempted to refer clients to such programs, the French, with their heritage of individual freedom and idiosyncratic behavior and beliefs, would never abridge their freedom by joining such fellowships as AA.

Health professionals in such wine-producing and-consuming countries as ITALY, Spain, and France also express concern over the issue of addicts needing to abstain from all psychoactive substances. Wine, they maintain, is a food, and should not be included in such a blanket prohibition.

It has been suggested that twelve-step fellowships and their success provide credibility to addiction treatment as the bridge between active addiction and active recovery. While this may be increasingly true for the mainstream of white, European-American cultures, it may be less true for other cultures.

Countering the Perception That Twelve-Step Fellowships Have an Exclusively White, Male, Christian, Middle-Class Focus. From its beginnings, elements within the "group conscience" of AA began working to broaden the scope and flexibility of their fellowship. AA may have had its specific beginnings in the Christian Oxford Movement and the personal interaction between its cofounders, Bill W. and Doctor Bob, but its basic tenets reflect a spectrum of cultural antecedents. Throughout history and within various cultures, attempts have been made to deal with addiction and associated human problems. The most generally successful of these have involved in some way the development of individual spiritual maturity within a supportive environment. In that context, the Twelve Steps developed by AA and adapted by other twelve-step fellowships can be seen as a blueprint for developing spiritual maturity, which is similar in intent to the Buddhist Four Noble Truths and Eightfold Path, the Hindu Vedas, and the Zen Oxherding Panels.

Individuals with certain religious backgrounds may have particular problems relating to certain tenets of the Twelve Steps. Many Buddhists, for example, venerate the Buddha as a fully enlightened being to be followed and emulated, but do not see him as a "higher power." Not utilizing a concept of God or a higher power in their cultural background, they see their faith as a philosophy and a way of life rather than as a religion. Points of reference need to be established in order for twelve-step recovery to become meaningful for these individuals.

Culture and Spirituality in Twelve-Step Fellowships. While there are many meetings that have a distinct Christian orientation that goes far beyond joining hands and reciting the Lord's Prayer, there are many others that do not. Definitions of God and a "higher power" can and do include an open range of options. Essentially, a belief in God as represented in any particular religion is unnecessary for the workings of twelve-step recovery. However, belief in a power outside oneself that is capable of bringing one to sanity in terms of one's addiction is necessary, even if this power is characterized as the meeting group.

From a recovery standpoint, addiction can be seen as a disease of self-centered fear that depends on isolation and deeply held convictions regarding the nature and effects of the addicts' drugs of choice; that isolation renders the addict incapable of understanding the disease and its personal effects, which is the basis of denial. So long as the addict attempts to fight the addiction through personal willpower alone, he or she is fighting a losing battle, trapped in emotional gridlock in a state of "white knuckle sobriety," where increasing anxiety from the stress will inevitably result in relapse. The reason for this is that the convictions about use are buried within the individual's spiritual belief system, where they can be reached only if the addict is willing to accept that there is something outside his or her own immediate being that can lead him or her to sanity—a power higher than oneself.

Surrender and Powerlessness. The concept of surrender, given its many war-related connotations of occupation, rape, loss of freedom, and so on, is hard enough for anyone to accept, but it is particularly hard for cultural groups that have, over time, suffered more than their share of occupation, rape, loss of freedom, and so on. African-Americans and Native Americans, for example, may feel that they have been in a state of individual and cultural powerlessness for many generations, and have no desire for further surrender. Native Americans also have difficulties with that aspect of twelve-step recovery because it runs counter to tribal mores of self-reliance and stoicism. Adolescents, although their cultural cohesion is transitory, are in the process of developing their own individuality and are often loath to appear to be giving up something they have so recently gained. Muslims may have the least problem with the concept of surrender. "Islam" literally means "submission to God's will."

In explication, and to some degree expiation, of the term "surrender" as it is used in recovery, members of the community speak in such terms as "joining a winning team," and urge newcomers to "hang out with the winners." In admitting powerlessness over the disease, addicts are in effect gaining the power, through enlisting the support of their higher power and the fellowship itself, to be responsible for their own recovery. A misunderstanding of this process can lead to an interpretation that people in twelve-step recovery are somehow "copping out" from personal responsibility. The point is that while the addict may not be responsible for having a disease that involves physiological and possibly genetic, psychological, and environmental components, in twelve-step fellowships the addict is most certainly responsible for his or her own recovery.

The African-American Extended Family Program is a good example of how the precepts of twelve-step recovery can be adapted to the needs a specific community. In it, African-American cultural mores and traditions are taken into consideration and made primary to recovery. Culturally, African-Americans strongly value communalism, or a collective identity (Longshore et al., 2000). In many treatment modalities targeted to African-American populations, drug addiction and use are related to slavery. For example, many African-Americans see methadone, a common treatment for opiate addictions, as a type of chemical slavery (Longshore et al., 1998). The HAIGHT ASHBURY FREE CLINICS, Inc. (HAFCI)/Glide Memorial Methodist Church African-American Extended Family Program (AAEFP), described in detail in Reverend Cecil William's book, No Hiding Place, represents an important collaboration that has made possible an effective intervention in the inner-city crisis of CRACK-cocaine use.

The key to this intervention has been the adaptation of TWELVE-STEP principals of supported recovery to the AFRICAN-AMERICAN inner-city culture. In the HAFCI/Glide program, the basic practicalities of recovery are utilized in a model that is uniquely meaningful in terms of the African-American experience.

The "Big Book" of ALCOHOLICS ANONYMOUS uses the terms "spiritual experience" and "spiritual awakening," manifesting in many different forms, to describe what happens to bring about a personality change sufficient to induce recovery. While some of these may involve an "immediate and overwhelming God consciousness," most are what William James called an "educational variety" of revelation, developing slowly over time. According to a "Big Book" appendix titled "Spiritual Experience," the core of this process is the tapping of an "unexpected inner resource" by members who identify this resource with "their own conception of a Power greater than themselves."

Many members of the African-American community afflicted with crack-cocaine addiction have been raised in the church. There is a tradition of revelation; many who have been "saved" now believe they are sinners because they have used and sold crack-cocaine to their own people. God has been described in a strict denominational sense. Spiritual awakening in a recovery model within a church program may produce conflict with traditional religious definitions, particularly the third step: "Made a decision to turn our will and our lives over to the care of God as we understood him." Religious leaders, such as Reverend Williams, have played a role in presenting a model of recovery theology that helps mobilize the church as a sleeping giant to better respond to the nation's drug epidemic. In his model, Williams employs self-definition within a spirituality of recovery.

In keeping with the IBCA's African-American cultural approach, it was generally agreed that the best site for the new program would be a church. In a Glide conference panel debate on religion and spirituality, Richard Seymour pointed out that under the best of conditions, religion equals spirituality plus culture. This is particularly true in the African-American community, within which the church provides a point of cohesion and a center for both spiritual and community values and, thus, a common ground for positive community activity. For a number of reasons, the clear choice was Glide Memorial Methodist Church in San Francisco's Tenderloin, a neighborhood that, though it includes a number of ethnic minorities, is predominantly African-American, low-income, and hard hit by the onslaught of dealing and abuse of crack-cocaine.

Under the leadership of Reverend Williams, Glide had been providing services for indigent and homeless residents, including addicts, for 25 years. Because of his growing concern over the crack-cocaine problem, Reverend Williams and his wife, Jan Mirikitani, executive director of Glide, attended a twelve-step recovery conference conducted by David Smith and Millicent Buxton. Following this conference, they decided to develop a culturally specific recovery program at Glide Church because of the resistance of people of color to participating in the twelve-step process.

Specific problems of the African-American target population as identified by various studies (HAFCI, 1990; Jackson, 1995; Longshore et al., 1998 and 2000) include the following:

• Low self-esteem
• Late introduction into recovery
• Focus on short-term abstinence rather than long-term recovery
• Dialect of African-Americans
• Institutionalized racism
• Internalized racism
• A unique, often dysfunctional family structure: many classical African cultures have been matrilineal, and look to the "grandmother" for spiritual direction and values. African-Americans developed a matriarchal family structure to survive during slavery, but this structure has proved unable to address problems of alcohol and other drug addictions. America is based on a patriarchal family structure, the opposite of the African-American model. It is therefore difficult for African-Americans to relate to systems and to address dysfunctional families when their model is not the norm. The most extreme injury is seen in children being taken from mothers by the system.
• Women's meetings: For those who have lost children, the comparison between now and the capture of children in Africa during the slave trade is made. Particular emphasis is placed upon the role of women in the more matriarchal African-American family. For many the most positive role model is a grandmother who passed on the traditions of the family and represents a "higher power."

The first and foremost priority is bringing to intervention and recovery an approach and nature that members of a target culture can identify and live with. Culturally responsive activities need to be identified and developed. Most research to date has been conducted with African-American populations, but the treatment models developed in conjunction with these studies can be transliterated to other ethnic and cultural populations.

Implicit within these modalities is the recognition that treatment is more than the prescribing of medication or the providing of basic and generic counseling based on a homogeneous model of what constitutes addictive disease.

Does establishing culturally congruent treatment produce results? Another example of a treatment intervention designed to be congruent with the cultural values and mores of the group process is the Engagement Project developed by Longshore et al., which is used for the purposes of scientific measurement of the effects of cultural congruency. Treatment began with a traditional African-American meal of fried chicken, ribs, greens, potatoes, and red beans and rice, to establish a culturally-specific framework for the intervention. The participant shared this meal with a counselor and a former drug user, called a "peer." This group then together watched a video featuring still photos, footage, and clips from commercial films about African-Americans. The third and final phase of the intervention consisted of a counseling session to review the participant's commitment to recovery. By situating drug abuse as both an individual problem and a community problem seated in power inequalities between the African-American community and dominant institutions, the intervention proved statistically effective in terms of participants reporting being drug abstinent one year afterwards.

Cultural Characteristics of Other Ethnic Groups.

Asian Americans. Asian Americans have been traditionally treated as a conglomerate group, a "model minority" whose drug problems have often been overlooked (Nemoto, 1999). However, this is patently not the case, as Japanese Americans, Filipinos, Vietnamese Americans, and Chinese Americans all come from differing cultural backgrounds and retain variant attitudes toward substance abuse, illness, and disease. Some cultural constructs that are shared among most Asian Americans regarding the use of drugs and alcohol are a fear of addiction, fear of injecting drugs, and a strong stigma attached to drug users in the community (Nemoto, 1999). Immigrant Asian Americans are more likely to use drugs than American-born people of Asian descent (Nemoto, 1999); such cultural factors often inform a user's response to treatment. It is necessary that treatment providers be not just bilingual, but also bicultural, in the sense that they are equipped to understand the unique family structure and pressures present in Asian American culture.

Native Americans. The traditionally tribal orientation of Native American society is in stark contrast to dominant institutional norms. For many Native Americans, an effective approach to the treatment of drug and alcohol problems involves a strong spiritual component. A 1998 report by Christine T. Lowery asserts that four broad concepts comprise an intellectual understanding of "healing the spirit" for Native Americans. These concepts, addressing the concepts of spiritual health and wellness, are:

• Balance and wellness.
• The colonization experience and addiction as a crisis of spirit.
• Issues of abuse (including sexual abuse).
• A time of healing.

Careful consideration of these principles illustrates the unique spiritual perspective Native Americans have on addiction and recovery. The intersection of the concepts outlined above should be the focus for intervention in these communities. For Native Americans, healing is traditionally a multidimensional, spiritual, relational, and inter-generational endeavor.

Hispanic Americans. Studies indicate that there is a positive correlation between length of time in the United States and drug usage among Hispanic Americans (Ma et al., 2000). Moreover, degree of acculturation and immigration status may affect treatment-seeking behaviors (Amodeo, 1997). An illegal immigrant is less likely to seek drug or alcohol treatment intervention because of the perceived threat of deportation.

Acceptance of disease-concept-related treatment and recovery outside the United States has differed from culture to culture, from country to country, in some cases from community to community. In Scandinavia, for a studied example, Finland, Iceland, and SWEDEN have experienced phenomenal multiplication of AA groups since the 1970s, whereas Denmark and Norway have experienced a decline in groups over the same period. With the advent of glasnost, narcologists in the former Soviet Union discovered AA. Since that time, treatment has been increasingly linked with recovery in Russia and other republics.

Overcoming Points of Resistance and Concern. The distance between cultures may seem like a chasm at times, but it is being bridged by such projects as the AAEFP that provide both recovery and a means to developing cultural parity. Society is changing rapidly, and fortunately, recovery has the flexibility to change along with it. Many groups within AA have learned that if there is no meeting that fits their special need, they can form their own meetings. The challenge is to adapt the process of treatment and recovery to all cultures and races, to counter stereotypes that recovery works only with certain groups.

(SEE ALSO: Chinese Americans, Alcohol and Drug Use among; Ethnicity and Drugs; Hispanics and Drug Use; Rational Recovery; Sobriety; Treatment; Women and Substance Abuse)

DAVID E. SMITH

RICHARD B. SEYMOUR

REVISED BY SARAH KNOX