Vivencias de la familia con paciente en UCI

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.

0URPOSEæGroupsandpracticesthataccentuate culturalaffinityhelpcurtailsubstanceabuse byusingaparticularculture’shealingpractices andtappingintothehealingpowerofacom- munalandculturalheritage.Manyhave commentedontheusefulnessofthesetypesof groups(Trepperetal.1997;Westermeyer 1995),andclinicalexperiencesupportstheir utility.AsthisTIPiswritten,littleresearch- basedevidencehasaccumulatedtoconfirmthe effectivenessofthisapproach.Researchis neededtoevaluatetheeffectivenessofcultural- lyspecificgroupsandascertaintheprimary indicationsfortheiruse.

0RINCIPALæCHARACTERISTICSæDifferentcultures 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.

,EADERSHIPæCHARACTERISTICSæANDæSTYLEæGroup leadersalwaysneedtostrivetobeculturally competentwithmembersofthevariouspopula- tionswhoentertheirprograms.1_Substance

1_{Seechapter3ofthisTIPandtheforthcomingTIPImprovingCulturalCompetenceinSubstanceAbuseTreatment}

(SAMHSAindevelopmenta)formoreinformationonculturalcompetence.TIP29,SubstanceUseDisorderTreatment

forPeopleWithPhysicalandCognitiveDisabilities(CSAT1998b),containsinformationonbeingsensitiveandrespon-

sivetotheneedsofpeoplewithdisabilities,andAProvider’sIntroductiontoSubstanceAbuseTreatmentforLesbian,

Gay,Bisexual,andTransgenderIndividuals(CSAT2001)hasinformationonworkingwithgayandlesbianpopulations.

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.

4ECHNIQUESæDifferentcultureshavespecific 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.