By William L, White, MA and Mark Sanders, LCSW, CADC
Abstract
Communities of color have been ill-served by acute care models of treating severe alcohol and other drug (AOD) problems [including addiction] that define the source of these problems in idiopathic (biopsychological) terms and promote their resolution via crisis-elicited episodes of brief, individual interventions.
This article explores how approaches that shift the model of intervention from acute care (AC) of individuals to sustained a sustained recovery management (RM) partnership with individuals, families and communities may be particularly viable for historically disempowered peoples.
The advantages of the RM model for communities of color include: a broadened perspective on the etiological roots of AOD problems (including historical/cultural trauma); a focus on building vibrant cultures of recovery within which individual recoveries can be anchored and nourished; a proactive, hope-based approach to recovery engagement; the inclusion of indigenous healers and institutions with the RM team; an expanded menu of recovery support services; culturally-grounded catalytic metaphors and rituals; and a culturally- nuanced approach to research and evaluation.
Introduction
Addiction has been characterized as a “chronic, progressive disease” for more than 200 years (White, 2000a), but interventions into severe alcohol and other drug (AOD) problems continue to be based on serial episodes of self-encapsulated, acute intervention (O’Brien and McLellan, 1996; Kaplan, 1997).
Recent research has confirmed the chronic nature of severe AOD problems (Simpson, Joe, & Lehman, 1986; Hser, Anglin, Grella, Longshore, & Pendergast, 1997) and compared such problems to other chronic health disorders (e.g., type 2 diabetes mellitus, hypertension and asthma) in terms of their etiological complexity, variability of course, and recovery and relapse rates (McLellan, Lewis, O’Brien, & Kleber, 2000).
Calls for shifting addiction treatment from an acute care (AC) model to a model of sustained recovery management (RM) are increasing (White, Boyle, & Loveland, 2002, 2003; Compton, Glantz, & Delaney, 2003; Edwards, Davis, and Savva, 2003; Moore & Budney, 2003), and components of such models are currently being evaluated with adolescents (Godley, Godley, Dennis, Funk, & Passetti, 2002) and adults (Dennis, Scott & Funk, 2003).
The emerging model of recovery management has been defined as:
…the stewardship of personal, family and community resources to achieve the highest level of global health and functioning of individuals and families impacted by severe behavioral health disorders.
It is a time-sustained, recovery-focused collaboration between service consumers and traditional and non-traditional service providers toward the goal of stabilizing, and then actively managing the ebb and flow of severe behavioral health disorders until full remission has been achieved or until recovery maintenance can be self-managed by the individual and his or her family (White, Boyle, Loveland and Corrigan, 2003).
This article contrasts the application of AC and RM models of intervention into severe AOD problems within communities of color.1
We will focus specifically on those American Indian/Alaskan Native2, African American, Hispanic/Latino and Asian and Pacific Islander communities whose members present unique obstacles and resources as they enter publicly funded treatment for severe AOD problems.
Our contrast of AC and RM models is drawn from the pioneering work of McLellan, Lewis, O’Brien and Kleber (2000) and from the descriptions of the RM model set forth by White, Boyle and Loveland (2002, 2003).
We argue that historically disempowered persons, and, in particular, communities of color, have been illserved by acute, biomedical models of intervention into AOD problems, and that models of recovery management hold great promise in providing more effective solutions to AOD problems within communities of color.
We will explore elements of RM that tap deep historical traditions within communiti es of color and that are highly congruent with contemporary, abstinence-based religious and cultural revitalization movements within communities of color.
Great care must be taken that discussions of the needs of ethnic communities do not inadvertently contribute to stereotypes about communities of color. To determine whether RM models of intervention hold greater promise than AC models within communities of color, we will need to explore those characteristics of communities of color that have relevance to the viability of these models.
Given the enormous differences within and between ethnic communities and the changes in communities over time, we would ask readers to keep all observations, ideas and strategies set forth in this article on probation pending their validation within particular communities and with particular individuals and families.
“People of color” and “communities of color” do not constitute a monolithic group to which any single explanatory or intervention model can be indiscriminately applied. We also recognize that the concepts set forth here may not be limited to communities of color and may also apply to particular white communities.
Testing components of the RM model will need to be conducted in all ethnic communities and across multiple subpopulations within those communities.
---------
1 While we have limited our discussion to communities of color, many reviewers (including Hennessey and Simonelli) of early drafts of this paper were struck by how applicable the ideas and strategies set forth in this paper are to women of all ethnic backgrounds.
2 All future references to American Indians or Native Peoples are intended to include Alaskan Natives.
--------
To achieve this will require redesigning addiction treatment in light of new recovery management models and doing this within the larger framework of cultural competence.3
We hope this introductory paper will stand as an invitation for such sustained exploration. Our vision is the development of culturally competent models of recovery management within all communities and the dynamic evolution of RM principles and practices based on experience within and dialogue between communities.
We will begin by contrasting how AC and RM models conceptualize the sources and solutions to AOD problems and then explore the RM model’s emphasis on proactive engagement, the use of indigenous healers and institutions, catalytic rituals and metaphors, new technologies of monitoring and recovery support, a sustained recovery management partnership, and the need for culturally-nuanced approaches to recovery research and evaluation.
AC and RM Models: The Source of AOD Problems
American Indians experienced massive losses of lives, land, and culture from European contact and colonization resulting in a long legacy of chronic trauma and unresolved grief across generations. This phenomenon,…contributes to the current social pathology of high rates of suicide, homicide, domestic violence, child abuse, alcoholism and other social problems among American Indians. --Brave Heart and DeBruyn, 1998
When people are taught to hate themselves, they will do bad things to themselves. -- Sanders, 1993.
Acute care (AC) models of intervention have assumed that the sources and solutions to AOD problems reside within the individual, and that brief interventions to alter an individual’s physical, cognitive and emotional vulnerabilities can produce a permanent resolution of these problems.
When the AC model fails to resolve AOD problems, the root of that failure is viewed as residing inside the individual.
The professional response, in practice if not in theory, is to prescribe additional repetitions of the failed intervention. Of people admitted to publicly funded addiction treatment in the U.S., 60% have been in treatment before (including 23% 1 time, 13% 2 times, 7% 3 times, 4% 4 times, and 13% 5 or more times) (OAS, 2000).
An aggressive system of managed behavioral health care has lowered the intensity and duration of these treatment episodes, further lessening the viability of addiction treatment for persons within communities of color who present with high problem severity and chronicity.
Awareness of this inadequacy has triggered the rise of indigenous recovery movements, including the Wellbriety Movement in Indian Country (see www.whitebison.org) and Afrocentric frameworks of recovery, e.g., faith-based recovery ministries (Glide Memorial Church, One Church—One Addict, Free N’ One, African American Survivors Organization, Turning Point) (Sanders, 2002).
Recovery within these movements is seen not as a singular goal but a therapeutic byproduct of participation in larger cultural and religious revitalization processes.
-----------
3 Cultural competence has been defined as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations.” Cross, T., Bazron, B., Dennis, K., & Isaacs, M., (1989). Towards A Culturally Competent System of Care Volume I. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center.
---------------
The premises of the RM model contrast sharply with those of the AC model. RM models posit that AOD problems spring from multiple, interacting etiologies; unfold (suddenly or progressively) in highly variable patterns; ebb (remission) and flow (relapse) in intensity over time; and are resolved at different levels (from full to partial) via multiple long-term pathways of recovery.
This opening proposition has particular relevance to communities of color. It suggests that people of color may be at risk for AOD problems but that these risk factors differ between and within ethnic groups (Matsuyoshi, 2001).
It suggests that historical, political, economic, and socio-cultural circumstances can also serve as etiological agents in the rise of AOD problems.
Client discussions about cultural pain (e.g., slavery, the loss of land, attempted extermination, epidemic diseases, the purposeful break-up of tribes and families, the loss of families and culture via immigration or forced deportation, forced internment as prisoners of war, other forms of physical sequestration, immigration distress, acculturation pressure, racism and discrimination) are viewed, not as defocusing or acting out, but as a medium of a consciousness raising and catharsis that can open doorways to personal and community healing and transformation (Green, 1995).
This approach is much more congruent with beliefs within communities of color that their AOD problems result as much from historical trauma4, economic and political disempowerment, and cultural demoralization as from biological vulnerability (Manson, 1996; Brave Heart & DeBruyn, 1998; Brave Heart, 2003).
This view recognizes that historical trauma and cultural oppression elevate risk factors for substance use problems and erode resiliency factors that operate as a protective shield against AOD problems and speed their natural resolution (Brave Heart, 2003).
Culturally nuanced models of RM reflect an understanding of the effects of intergenerational trauma (grief, rage, self-hatred, self-medication) upon whole communities.
Positing multiple pathways of long-term recovery also opens up the potential for culturally prescribed frameworks of AOD problem resolution (abstinence-based religious and cultural revitalization movements, e.g., Nation of Islam) as well as cultural adaptations of existing recovery support structures (e.g., the “Indianization” of Alcoholics Anonymous and the adaptation of A.A. within Hispanic/Latino communities) (Womak, 1996; Hoffman, 1994).
RM models assume that severe AOD problems constitute complex, chronic disorders that require sustained individual, family, community and cultural interventions for their longterm resolution.
In this view, treating severe and persistent AOD problems via AC models of intervention is as ineffective as treating a bacterial infection with half the effective dose of
antibiotics.
While providing temporary symptom suppression, such treatment results in the subsequent return of the problem, often in a more virulent and treatment-resistant form.
In the RM model, the treatment of severe and persistent AOD problems is best done within a sustained recovery management partnership that provides on-going recovery support and
consultation and anchors the recovery process in indigenous supports within the client’s natural environment.
-------
4 Maria Yellow Horse Brave Heart (2003) has defined historical trauma as “cumulative emotional and psychological wounding over the lifespan and generations, emanating from massive group trauma experiences.”
-----------
From longer article with references at
http://www.bhrm.org/papers/peopleofcolor.pdf
From site of Behavioral Health Recovery Management
http://www.bhrm.org/
Excerpt published here thanks to author William L. White, MA, a Senior Research Consultant at Chestnut Health Systems, and the author of Slaying the Dragon: The history of Addiction Treatment and Recovery in America.