EL PROCESO DE REFORMA PROCESAL PENAL.

Restoringlostculturaltiesorprovidingasense ofculturalbelongingcanbeapowerfulthera- peuticforceinsubstanceabusetreatment,and inimportantways,substanceabuseisintimate- lyintertwinedwiththeculturalcontextin whichitoccurs.Culturalprohibitionsagainst substanceuseandculturalpatternsofpermis- sibleusedefine,inpart,whatisreasonableuse andwhatisabuseofsubstances(Westermeyer 1995).Riskfactorssuchasculturaldisplace- mentordiscriminationcausesubstanceabuse ratestorisedrasticallyforagivenpopulation. Problemsthatpervadeparticularcultures, suchasracism,poverty,andunemployment, haveanimpactontheincidenceofsubstance abuseandareappropriatefocusesforinter- ventioninsubstanceabusetreatment(Taylor andJackson1990;ThorntonandCarter1988). Communalandculturallyspecificwellness activitiesandgroupsincludeawiderangeof activitiesthatuseaspecificculture’shealing practicesandadjusttherapytoculturalvalues. Forinstance,Hispanics/Latinosgenerallyshare avalueofpersonalismo,apreferenceforper- son-to-personcontact.Effectivesubstance abusetreatmentprovidersthusbuildpersonal relationshipswithclientsbeforeturningtothe tasksoftreatment.Also,attheoutsetoftreat- ment,personalrelationshipsdonotyetexist. Atthispoint,aclient’shesitationshouldnot bemistakenforresistance(MillanandIvory 1994).

Threecommonwaystointegratesuch strengths-focusedactivitiesintoasubstance abusetreatmentprogramare

•Culturallyspecificgroupwellnessactivities maybeusedinatreatmentprogramtohelp clientshealfromsubstanceabuseandprob- lemsrelatedtoit.

•Culturallyspecificpracticesorconceptscan beintegratedintoatherapeuticgroupto instructclientsorassisttheminsomeaspect ofrecovery.Forexample,apsychoeducation- algroupformedtohelpclientsdevelopabal- anceintheirlivesmightuseanAmerican Indianmedicinewheeldiagramortheseven principlesofKwanzaa.Themedicinewheel representsfourdimensionsofwellness: belonging,independence,mastery,andgen- erosity.Thesefourconceptspromotewellness fortheindividualandcollectivegoodofthe American-Indiantribalgroupandhumani- ty/environments.Kwanzaaisbasedona valuesystemofsevenprinciplescalledthe NguzoSaba.TheKwanzaaparadigmisa nonreligious,nonheroicritualthathasbeen widelyembracedbythenationalAfrican- Americancommunity.TheNguzoSabaand otherKwanzaasymbolsandpracticescanbe usedtherapeuticallyintheregroundingand reconnectingprocessforAfrican-American clients.

•Culturallyorcommunity-specifictreatment groupsmaybedevelopedwithinaservices programorinasubstanceabusetreatment programservingaheterogeneouspopulation withasignificantminoritypopulationofa specifictype.Examplesmightincludea groupforpeoplewithcognitivedisabilities, orabilingualgroupforrecentimmigrants. Suchgroupstypicallyareprocess- orsup- port-oriented,thoughtheyalsomayhave psychoeducationalcomponents.Thegroups helpminoritygroupmembersunderstand

theirownbackground,copewithprejudice, andresolveotherproblemsrelatedtominori- tystatus.GroupsdescribedinthisTIPfall intothiscategory.

Groupsandpracticesthataccentuate culturalaffinityhelpcurtailsubstanceabuse byusingaparticularculture’shealingpractices andtappingintothehealingpowerofacom- munalandculturalheritage.Manyhave commentedontheusefulnessofthesetypesof groups(Trepperetal.1997;Westermeyer 1995),andclinicalexperiencesupportstheir utility.AsthisTIPiswritten,littleresearch- basedevidencehasaccumulatedtoconfirmthe effectivenessofthisapproach.Researchis neededtoevaluatetheeffectivenessofcultural- lyspecificgroupsandascertaintheprimary indicationsfortheiruse.

Differentcultures havedevelopedtheirownviewsofwhatconsti- tutesahealthyandhappylife.Theseideasmay provemorerelevantandunderstandableto membersofaminorityculturethandotheval- uesofthedominantculture,whichsometimes canalienateratherthanheal.Allculturesalso havespecificprocessesforpromotingwellness amongtheirmembers.

Inusingaculture’shealingpracticesorgroup activities,whetherinheterogeneousorhomoge- neousgroups(thatis,allonecultureoramix ofcultures),treatmentprovidersshouldbe carefultoshowrespectforthecultureandits healingpractices.Aslongasrespectand awarenessareevident,theuseofsuchprac- ticeswillnotharmthemembersofaparticular culture.

Group leadersalwaysneedtostrivetobeculturally competentwithmembersofthevariouspopula- tionswhoentertheirprograms.1 _Substance

1 _{See chapter 3 of this TIP and the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment} (SAMHSA in development a) for more information on cultural competence. TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998b), contains information on being sensitive and respon- sive to the needs of people with disabilities, and A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals (CSAT 2001) has information on working with gay and lesbian populations.

Types of Groups Commonly Used in Substance Abuse Treatment 32

abusetreatmentcounselorsfirstneedtobe awareofthedemographicsintheirprogram areas,andtobeawareaswellthatthereare manypeoplefrommixedethnicbackgrounds whodonotnecessarilyknoworrecognizetheir culturalheritage.Cliniciansshouldactively avoidstereotypingclientsbasedontheirlooks, andinsteadallowthemtoself-identify.Clients shouldbeaskedwhatitmeanstothemto belongtoaparticulargroup.Cliniciansalso shouldbesensitivetoself-identificationissues suchassexualorientation,genderidentifica- tion,anddisability.Whenindoubt,clinicians shoulddiscusstheissueprivatelywiththe client.

Agroupleaderforaculturallyspecificgroup willneedtobesensitiveandcreative.How muchauthorityleaderswillexerciseandhow interactivetheywillbedependsonthevalues

andpracticesoftheculturalgroup.Thegroup leadershouldpayattentiontoanumberoffac- tors,allofwhichshouldbeconsideredinany groupbutwhichwillbeparticularlyimportant inculturallyspecificgroups.Cliniciansshould •Beawareofculturalattitudesandresistances

towardgroups.

•Understandthedominantculture’sviewof theculturalgrouporcommunityandhow thataffectsmembersofthegroup.

•Beabletovalidateandacknowledgepastand currentoppression,withagoalofhelpingto empowergroupmembers.

•Beawareofaculturalgroup’scollectivegrief andangerandhowitcanaffectcounter- transferenceissues.

Figure 2-7 The SageWind Model for Group Therapy

Inprogramsthathavetheresources,thecapacitytoofferavarietyoftypesof groupsaddressingarangeofclientneedsispreferred.SageWindinReno, Nevada,offersmorethan100groupseachweek.

Toassesseachclient’suniqueneeds,SageWind’scomprehensivebiopsychosocial assessmentevaluatestheseverityofaclient’ssubstanceabuse.Inaddition,the clinicalteam,theclient,andanyothersconcerned(suchasprobationorparole officers,parentsorlegalguardians,orsocialworkers)determinethebestcourse ofgrouptherapyformats.

Groupinterventionrangesinintensityfromonegroupperweektomorethan 20.ThelargenumberofweeklygroupsofferedinSageWind’smenuofoptions coversacontinuumoftreatmentoptionsfrompsychoeducationaltoskills-build- ingtoexperientialtoprocess-oriented.Inastructuredprogramsimilartothat ofauniversity,wherefundamentalcoursesarerequiredbeforemoreadvanced onesmaybetaken,clientsattendthegroupstheyneed,thenchangetoothers andprogressthroughtheprogram.Clientscompletegroups,movingtomore advancedformatsuntiltheyhavemetdischargecriteriabasedontheAmerican SocietyofAddictionMedicine(ASAM)PatientPlacementCriteria-2R(PPC-2R) (ASAM2001).

•Focusonwhatisheldincommonamong membersofthegroup,beingsensitiveto differences.

TheSageWindModelforgrouptherapy, discussedinFigure2-7(seep.33),provides individuallytailoredinterventionsforits clients.

Differentcultureshavespecific activitiesthatcanbeusedinatreatment setting.Somecommonelementsintreatment includestorytelling,ritualsandreligiousprac- tices,holidaycelebrations,retreats,andrites ofpassagepractice(thesemaybeparticularly usefulforadolescentclients).

Culturallyspecificgroupsworkbestifallmem- bersofthepopulationbecomeinvolvedinthe activity,eventheclientswhoarenotfamiliar withtheirculturalheritage.Infact,thereasons forthatlackoffamiliaritycanbecomeatopic ofdiscussion.Helpingclientsunderstandwhat theyhavelostbybeingseparatedfromtheir culturalheritage,whetherbecauseofsubstance abuseorsocietalforces,canprovideonemore reasontocontinueinsobriety.