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CULTURAL
COMPETENCE IN ADDICTION MEDICINE.
INTRODUCTION I wrote that poem in commemoration of a Navajo artist who was knifed to death over a bottle of cheap wine. The artist killed had averaged over 200 days a year in the local detoxification facility. I worked with Native Americans in the southwest for ten years–between 1986 and 1996. I’ve also traveled back since my return east to consult and provide training to therapists and counselor’s who work with Native Americans. I have worked as a therapist, trainer, and consultant with Native Americans and other cultural groups in the United States for over thirty years. I have found that the most significant therapeutic interventions one can make with people from cultures different than ones own arise from the processes of engagement and deep empathy. I have found treatment outcomes are significantly affected [adversely] when the practitioner carries preconceptions, judgements, criticisms, intolerance or righteous thinking into the diagnostic/treatment encounter. Deep engagement with the patient can, many times, be a healing experience in and of itself. It certainly contributes significantly to the healing process and the receptiveness of the patient to the therapeutic/diagnostic experience. Sensitivity to the patient yields sensitivity for the culture, the individual’s place in it, and their cultural needs. One of the major challenges I have faced as a trainer for health professionals has been to effectively convey the importance of rapport and open-mindedness to fellow practitioners in a way which creates receptivity to learning the essential elements and skills of engagement and empathy. Intellectually, it is understood. In practice, it is sadly lacking. This perspective is culturally universal, not specific. Research has continuously demonstrated that the effectiveness of the healing interaction is more a function of the qualities of the healer and the relationship established with the patient, than of any specific technique or methodology employed (Peck, 1997). When working with people from cultures different than ones own, establishing a meaningful and potent patient relationship can become more difficult–it doesn’t have to. In fact, it can be more fun Our interventions and communications must make sense within the symbolic context of the patient’s culture. We can achieve this, to a large extent, through engagement. Engagement requires us to listen and ask questions so that we understand the personal meaning of the constructs they present. Through this process our patients feel understood and heard–two of the most essential ingredients required for a person to feel valued and worthwhile in the context of the relationship with a healer/health care provider. Engagement contributes significantly to the healing process and the receptiveness of the patient to the therapeutic/diagnostic experience. Sensitivity to the patient yields sensitivity for the culture, the individual’s place in it, and their cultural needs. I’ve learned some things about some Indian tribes and some other cultures. I’m certain you have to. What I know, more than any specific tribal pattern or cultural fact, is that It is very easy to work intimately and meaningful with peoples from other cultures and that it doesn’t take a whole lot of cultural knowledge or factual information in order to do that. The knowledge certainly can be helpful. However I don’t believe it is essential. I believe the essential ingredients include remaining curious and open to ways of perceiving and interacting with the world and a rudimentary understanding of some culturally important symbolic processes–without necessarily knowing the specifics (more on this later). Behavior occurs within a cultural context, and knowing that context helps us understand behavior. However, even then, understanding the culture may not help us understand the individual. I grew up in Brooklyn, New York where it was not uncommon to hear young children admonished to "stop acting like a wild Indian." One of my earliest lessons in cultural relevance happened when my wife and I traveled with a Navajo couple and their two small girls to a conference in Tucson, AZ. After checking into the hotel, we were in our respective rooms unpacking. I heard a lot of noise in the hallway and opened the door to see the two girls running up and down the hall and screaming as only little girls having fun can do. Dad soon opened his door and said in a loud voice… "Stop acting like a wild white man." I. The Importance Of Recognizing And Honoring Cultural Differences In Treatment A large company in attempting to build team spirit within its multi-national workforce hosted a lavish buffet lunch--but failed to take cultural differences into account. Employees from cultures that don't follow the Western practice of lining up to wait turns jostled their way to the front and took all the food before the others could get to it. Though the employees eventually worked out the problem, very little team spirit resulted from this particular attempt. (Joinson, 1995) Alcoholism is the most serious health and social problem facing Native Americans. Addictive behavior is learned within a cultural context and treatment, in order to be as effective as possible, must acknowledge, understand, and honor this context–or our treatment, no matter how lavish–as the buffet–will eventually fail. One of the primary symptoms of addictive behavior–denial–may present itself strengthened by the justifications and blaming accusations towards the treatment provider, of cultural insensitivity or ignorance. We must extend empathy and interest and withhold our judgments and criticisms. Otherwise our patients will feel unsafe and call forth even more defense mechanisms than we otherwise might encounter. Honoring and acknowledging culture and it’s traditions enables us to better understand the cultural context within which addictive behavior occurs, while simultaneously lowering the walls of denial that surround the patient and reduces their resistance to treatment and recovery. Insensitivity to cultural values, traditions, and differences can only serve to increase denial and further alienate patients from the recovery process. In many Native American traditional cultures it is impossible to separate healing from the overall cultural context. Healing, spirituality, religion, and art are all inextricably interconnected. Furthermore, healing itself is rarely viewed as an isolated activity or directed toward an isolated symptom or body part. Healing is often viewed, as in the Navajo tradition, as a return to balance, and thus involves the person in relationship to all of the natural and supernatural forces surrounding them (Sandner, 1979). Though Western Scientific medicine can diagnosis and repair a myriad number of conditions irregardless of culture, race, or local (i.e., low blood sugar, or a thyroid imbalance, kidney stones or the flu can be diagnosed knowing nothing about a patient’s culture.) However, for many native peoples, this healing does not satisfy the individual’s striving for harmony or balance–often viewed as the cause of the disease or condition in the first place. True balance or harmony is restored through ceremony and ritual. It is part of the myth and supernatural cultural context of the individual. This form of healing is thus culture specific. The patient and healer must share the same basic beliefs, or this type of healing cannot occur (Sandner, 1979, 1991). Sharing the belief I have found, does not necessarily mean knowing the ritual/custom/tradition in all its elaborate manifestations, simply understanding the importance of the belief and supporting the patient in their own inner congruence with the belief may be enough. Incorporating the beliefs into your prescription or treatment plan can also help accelerate healing, the depth and meaningfulness of which might surprise you. C. Creating A Therapeutic Alliance: Putting The Ingredients Together
Alcohol and Other Drug Abuse (AODA) related deaths for Native Americans aged 15-32 are 11 times higher than for any other group of Americans. A third of all Native American deaths are individuals under the age of 45– with accidental death being the number one cause. AODA account for 46% of IHS outpatient visits and 73% of inpatient days (Muldoon, 1994) Where alcohol sale, possession or consumption is illegal on a reservation, use requires driving to obtain the substance. DWI then becomes a significant problem and is usually exacerbated by long travelling distances, poor roads, low economics conditions. During the period 1973-1993, the City of Gallup, NM operated a protective custody system through their Police Department. Protective custody amounted to police pick up of public inebriates and placing them in the local jail. Gallup, with a population at that time of 22,000, had an annual average of 32,000 protective custody pick-ups for public intoxication. The vast majority of the these pick-ups were Native Americans who couldn’t drink at home and came to Gallup for their alcohol (Daw and Mosher, 1995). Leaving the reservation to drink may create further complications in the addictive cycle. Traditional values become forsaken and identity problems develop which affect the individual’s ability to function in prescribed roles. The chasm between the generations becomes intensified as does the split between those individuals practicing native values and traditions and those lost in the "white man’s world." These generational gaps become intensified through addiction and it becomes harder for the addict to return to their family and their culture. The alienation that ensues may further intensify the development of the addictive behaviors. Years of persecution may have resulted in guilt and self-loathing, an inability to cope with anger, chronic depression, impoverished object relationships, and long-term personality changes, as well as distress and apathy…. Rage, and an inability to express the rage at the intended object because of real or fantasized threats of retribution may also be experienced. (Beane, et. al.,1980 cited by Muldoon, 1994). The rage or anger is internalized and acted out against self or family members. Alcoholism is a common manifestation of this internalization process and an escape from the feelings described. The legal status of alcohol sale, possession and use greatly determines patterns of use and abuse within a tribe. Border towns in the Southwest which are located near reservations following prohibition become the center of alcohol activity. Family, job, craft, or trade are dramatically effected by use since the consumer must leave home and travel to obtain the alcohol. When alcohol is legal and available, the family and other disruptions, though also severe, possibly manifest more slowly and in a different manner. When alcohol use is legal off reservation grounds vast quantities of alcohol are consumed at one time–the body becoming the only legal container. The Chronic stage of alcoholism becomes quickly reached with this type of drinking. Other devastating drinking patterns may then emerge to quell the daily cravings for alcohol. In some towns of the Southwest mouthwash and hairspray become popular items of purchase on days when the liquor stores are closed. Hairspray mixed with water becomes the drink "Ocean"–quickly intoxicating and quickly damaging to the body. The prevalence of alcoholism among tribes with different cultural, economic and physical environments has created speculation about the etiology of alcohol abuse among Native Americans. To date, research has not consistently yielded any conclusive evidence for correlation between the metabolism of Native Americans and their unhealthy patterns of alcohol usage (Hall, 1986). And remember altered states of conscious are not strange states to many Native Americans. Peyote use with the Native American church and other ritualistic use of hallucinogens have a long history among native peoples as do the vision quest experiences which also lead to altered states of consciousness. We may need to consider the desire for these states in our discussions and prescriptions for sobriety.
While 12 Step programs work for millions of addicts we must bear in mind that the foundational admission of "powerless" required by Step 1 is an admission of cowardice to many Native people. However this too can be contaminated by the Denial process as a way to avoid the 12-Steps in general, and their own addiction in particular. As treatment providers, we may unwittingly fuel denial and avoidance of effective treatment modalities by our ignorance or insensitiveness to cultural traditions and values. Many native Americans have been in and out of treatment with no or limited sustained progress in recovery. The Navajo and other native people are of the opinion that western interventions and assessments are not responsive to the needs of the Indian people. Western therapists think linear, as compared to the circular or clockwise methods of native. Assessment tools and interventions are viewed as western in nature and linear in thought–alien and missing the mark. (Dine¢ Center for Substance Abuse Treatment - personal communication)
The Bureau of Indian Affairs (BIA) stated that the 312 Native American tribes differ from themselves and from the traditional middle class in value preferences regarding major life concepts (relationship with nature, family, time orientation, work, extended family, material possessions, etc.). The large number of tribes and the years of migration contribute to diversity amongst the tribes themselves and highlights the need to communicate with all peoples as individuals. We seem to return again and again to the need to meet with all people where they are, listen to their reality, remain open to their reality and their way of experiencing their reality–judgment and value free.
Clearly the world is too diverse and the patient population too large for us to match patients with healers of the same culture. Others believe that because the cultural factors each client brings to counseling are so diverse, matching is not practical. Even when we share primary cultural identification, there are other significant differences. For instance, although healer and patient may be Native American, one may have grown up in poverty on a reservation, while the other may have been raised in the middle-class suburbs of San Diego. Those who believe cultural matching is not necessary say that a good counselor can be successful at "crossing cultures" by recognizing and learning about various cultures, by being aware of the singularity of each background, and by counseling to bridge cultural differences. (Tighe,1990) Healing in any context requires the healer to suspend their judgments of patients so that the patient feel accepted and free to talk about their concerns. Practitioners who are successful in this approach are likely to inspire confidence and facilitate communication.
Herein lies possibly one of our strongest allies. I invite you to learn some of the foundational belief systems that underlie cultural history. Native Americans share some commonalties about the significance of natural processes–without necessarily sharing the same belief or interpretation. Find out about the importance of the following:
We prescribe medications, therapy, homework, and other regimes we believe will assist our patients in reaching a higher state of health and wellness. Working with Native Americans in the field of addictions I have worked with many who have never learned their traditions, or have left them behind in favor of the alcoholic road. Prescribing a return to traditional values, ceremonies and rituals addresses the healing element Carl Jung spoke to Bill Wilson about many years ago when he stated his belief that alcoholism was a spiritual crisis and required a spiritual approach for recovery. Inviting patients to experience a sweat lodge ceremony, or have a healing ceremony performed by a medicine man may well help them embrace, or re-connect with an important spiritual domain and add a powerful force to their recovery and their lives. I have personally listened to many patient dreams whose meaning was clearly pointing the patient back to their culture and their traditions. I suggest reconnecting and re-associating in as many ways as I can. Sometimes a suggestion has been met with refusal because the lone individual may feel s/he is violating cultural law or custom by utilizing sacred symbols (colors, grasses, etc) improperly. These are important considerations and one must remain open to them. An elder or medicine man may be culturally necessary for certain processes. Furthermore, I suggest you refrain from utilizing any cultural ritual you yourself are not comfortable with or do not understand. Don’t burn cedar or sweet grass if you can’t stand the smell. Don’t suggest drinking sacred water from a certain well in order to supercharge the healing process if you think that idea is malarkey. Furthermore it doesn’t help to assume affiliation with a culture that is not ours’ or to "act as if" I know rituals and traditions I am incapable of knowing. Remain congruent to yourself. Anything else will be a sham. Become aware of barriers to effective communication and tear them down. In the stress of daily work with addictive behaviors and the physical, emotional, family and spiritual devastation that we see it may become all to easy to forget the basic foundations and the essential ingredients of communication and rapport building. We may have to work hard to separate our anger at the disease from becoming displaced upon the patient. Obviously stereotyping is destructive and is readily perceived as prejudice. Observing and honoring cultural differences makes it difficult to force solutions where they don’t fit. However, here too, over zealous needs to heal or anger at the disease may contribute to our own denial and manifest itself in these behaviors. Yes, Native cultures are different. All cultures other than my own are different. And even within my own culture there are vast differences. So cultural competence really means people sensitivity. People are not puppets of their cultures and though we need to understand the cultural context of behaviors and attitudes, we need to not lose sight of our need to understand the individuals we treat (Satel, 1997). Healing is about individuals and their infinite complexity. Culture effects this complexity in varying degrees and we must remain mindful of that. Scott Peck (1999) has stated that… "the best psychotherapists eventually learn, if they hang in there long enough, to stop trying to heal their patients. What they can realistically set their sights on is building the best possible relationship–within that relationship, healing will naturally occur without their having to ‘do’ anything." This means engaging with each person with an open mind and heart.
Bibliography Covey, Stephen, First Things First Simon & Schuster. (1994) Draw, Raymond and Mosher, Herb, The Bridges of McKinley County: Building Rural recovery Coalitions. Treating Alcohol and Other Drug Abusers in Rural and Frontier Areas. Substance Abuse and Mental Health Services Administration. Technical Assistance Publication Series. DHHS Publication No. (SMA) 99-3339. 1995 (TAP17) Hall, Roberta, A. Alcohol Treatment in American Indian Populations: An Indigenous Treatment Modality Compared with Traditional Approaches. In Alcohol and Culture: Comparative Perspectives From Europe and America. Thomas F. Babor (Ed). New York Academy of Sciences, New York, 1986. Pp. 168—178. Hester, Reid K. & William R. Miller (Editors) Handbook of Alcoholism Treatment Approaches: Effective Alternatives. Allyn & Bacon (1995) Joinson, Carla, Cultural Sensitivity Makes Good Business Sense. HR Magazine, November 1995 Miller, William, R. Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin. 1985. Vol. 98 No. 1. 84 - 107 Muldoon, Anne. Cultural Diversity as a Positive Force in the Treatment of Native American ALCOHOL AND OTHER DRUG ABUSE. Rural Issues in Alcohol and Other Drug Abuse Treatment. PAY 10DHHS Publication No. (SMA) 96-3099. 49-55. 1994 Peck, M. Scott. The Road Less Travelled and Beyond: Spiritual Growth in an Age of Anxiety. Simon and Schuster. New York. (1997) Sandner, Donald, Navaho Symbols of Healing. Healing Arts Press. Rochester, VT. (1979) Satel, Sally and Greg Forster. Multicultural Mental health: Does your skin color matter more than your mind? Executive Summary. Center for Equal Opportunity. Washington, DC. http://www.ceousa.org/health.html
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Richard
I Jontry, Ph.D., MAC, CAC Diplomate |
