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Alcoholism Treatment Quarterly Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/watq20
Applying a Cultural Competency Framework to Twelve Step Programs a
Lori K. Holleran PhD & Samuel A. Macmaster PhD
b
a
School of Social Work , The University of Texas , Austin, TX, USA b
College of Social Work , The University of Tennessee , Nashville, TN, USA Published online: 22 Sep 2008.
To cite this article: Lori K. Holleran PhD & Samuel A. Macmaster PhD (2005) Applying a Cultural Competency Framework to Twelve Step Programs, Alcoholism Treatment Quarterly, 23:4, 107-120, DOI: 10.1300/J020v23n04_08 To link to this article: http://dx.doi.org/10.1300/J020v23n04_08
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PERSPECTIVES
Applying a Cultural Competency Framework to Twelve Step Programs Lori K. Holleran, PhD Samuel A. MacMaster, PhD
ABSTRACT. It is important for clinicians to develop cultural competency skills in any cross-cultural setting where a working knowledge of the client’s culture is important to the delivery of services. Twelve Step recovery programs represent a distinct culture, where members have developed their own set of norms, behaviors and even language. An understanding of this culture is important to any clinician working with clients who may be referred to and/or are members of a Twelve Step group. This article defines cultural competency, applies this to the culture Lori K. Holleran is affiliated with the School of Social Work, The University of Texas, Austin, TX. Samuel A. MacMaster is affiliated with the College of Social Work, The University of Tennessee, Nashville, TN. Address correspondence to: Lori K. Holleran, PhD, The School of Social Work, The University of Texas at Austin, 1925 San Jacinto Boulevard, Austin, TX 78712 (E-mail:
[email protected]). The authors would like to thank J. D. Chesire, PhD, LISW, Assistant Professor at the University of Kentucky College of Social Work, and Dr. Young-Mi Kim, a graduate of the The University of Texas at Austin School of Social Work doctoral program, for their assistance on this manuscript. Alcoholism Treatment Quarterly, Vol. 23(4) 2005 Available online at http://www.haworthpress.com/web/ATQ 2005 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J020v23n04_08
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that has developed around Twelve Step groups, and provides information to familiarize clinicians to these cultural norms. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2005 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Cultural competency, Twelve Step programs, culture
The “culture of AA” is vital to the members’ transformation of identity. –Jensen, 2000, viii
INTRODUCTION Issues of cultural competency have become increasingly important for social work practitioners. While cultural competency has traditionally been viewed as it relates to issues of race or ethnicity, e.g., African Americans (Ervin, 2001; Solomon, 1976), Asian Americans (Lu, Lum, & Chen, 2001), Latinos/as (Bean, Perry & Bedell, 2001), it is important for clinicians to develop skills in any cross-cultural setting where a working knowledge of the client’s culture is important to the delivery of services. The NASW Standards for Cultural Competence in Social Work Practice (2001) define culture as “the integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group.” Twelve Step recovery programs represent a distinct subculture, where members have developed their own set of norms, behaviors and even language. An understanding of this culture is important to any clinician in working with clients who may be referred to, and/or are members of a Twelve Step group. This article defines cultural competency, applies this to the culture that has developed around Twelve Step groups, and provides information to familiarize clinicians to these cultural norms. DEFINING CULTURAL COMPETENCE Cultural competence warrants a concise, practical definition. Cultural competence is a set of congruent behaviors, attitudes, and policies
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that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations (Cross et al., 1989; Isaacs & Benjamin, 1991). Operationally defined, cultural competence is the awareness and incorporation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings, thereby facilitating positive outcomes (Davis & Donald, 1997). The word culture is used because it implies the established patterns of human behavior that includes thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups (NASW, 2001). The word competence is used because it implies having the capacity to function within the context of culturally integrated patterns of human behavior defined by a group. Being competent in cross-cultural functioning means learning new patterns of thought and behavior and effectively applying them in the appropriate settings. Intra-group differences, such as geographic location or socioeconomic background, call for awareness and avoidance of oversimplifications. Culturally competent individuals have awareness of communication modes and cues such as tone of voice, choice of words, and body language. Being culturally competent means having the capacity to function effectively in varied cultural contexts. Cultural competence has been conceptualized as a developmental process that occurs along a continuum. It is a process, never fully achieved (NASW, 2001). There are six possibilities on this continuum, starting from one end and building toward the other: (1) cultural destructiveness, (2) cultural incapacity, (3) cultural blindness, (4) cultural pre-competence, (5) cultural competency, and (6) cultural proficiency. (Cross et al., 1989). This spectrum elucidates the process that clinicians undergo in moving towards cultural competence. OPERATIONALIZING CULTURAL COMPETENCE Cultural competence means (1) valuing the needs and nuances of social groups and (2) being willing to learn about, modify, and adapt to the populations’ unique issues. One necessary ingredient for cultural competence, honoring diversity, means accepting and respecting differences. A second indispensable ingredient is obtaining an accurate understanding of these differences. Neither of these ingredients alone
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will result in cultural competency without the other. For example, someone may value an ethnic or racial difference, but without education about the particular culture, they cannot interact competently. In the same vein, someone may know quite a bit about a culture and not value it–this also would not be cultural competence. Diversity between cultures, in this case those inside and those outside of Twelve Step programs, must be recognized. It is equally important to note the diversity within groups. Assimilation and acculturation can create kaleidoscopes of subcultures within groups. Other factors such as gender, geographic locality, and socioeconomic status can also be powerful aspects of groups. When examining Twelve Step culture, it is important to note that not only are individuals diverse within groups, but groups within programs, and programs within the larger umbrella of Twelve Step programs in general. For example, AA and NA have their own basic texts that they refer to which dramatically distinguish the two programs from each other. Recognizing intra-cultural differences helps to illuminate the complexities of diversity. Clinicians must examine their own backgrounds, assumptions, and values in order to become culturally competent (NASW, 2001). In light of addiction recovery programs, it is important to recognize that clinicians have feelings, thoughts, and values around substances, addictive behaviors, and recovery that must be explored and understood in order to be effective in rapport building and intervention with individuals in Twelve Step programs. This is particularly important given the stigma that is often attached to addiction and substance abuse.
TWELVE STEP PROGRAMS AS CULTURE The marked prevalence of Twelve Step programs is evident. Twelve Step programs began with Alcoholics Anonymous in 1935. Alcoholics Anonymous has grown to a membership of 2,160,013 internationally (AA World Services, 1998). Presently, there are over two hundred programs known to AA world service that utilize the twelve steps (see http://www.onlinerecovery.org/12/) ranging from NA (Narcotics Anonymous), CA (Cocaine Anonymous), and OA (Overeaters Anonymous) to such programs as DA (Debtors Anonymous), SLAA (Sex and Love Addicts Anonymous) and EA (Emotions Anonymous). Twelve Step programs also exist for family and friends of program members in-
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cluding Alanon (associated with AA), Naranon (associated with NA), Alateen (for children of alcoholics), and O-anon (associated with OA). While much of the literature about Twelve Step programs refer to them as “self-help groups” and focus on “therapeutic effects,” other studies recognize the more pervasive psychosocial implications of Twelve Step programs referring to their members as a “mutual help community” (Davis & Jansen, 1998, 171; Tonigan, Conners, & Miller, 1998, 281), “social world” (McCormick & Dattilo, 1995; Smith, 1993), “community of healers” (Wilcox, 1998), and “culture of recovery” (Rapping, 1997, 56). Tonigan, Ashcroft, and Miller (1995) distinguish between the “program” (i.e., the literature and core ideas of what members need to do) and the “fellowship” (i.e., a sense of mutuality among members in a shared past and common future). Twelve Step programs have a set of principles called the 12 traditions on which the “Society” has been built. These traditions consist of concepts including bars against exclusion of any man or woman in need of help, leaders as servants rather than governors, groups as autonomous, no fees or dues, public relations based on “attraction rather than promotion” (AA World Services, 1976), and a primary purpose “to carry its message to the alcoholic who still suffers” (AA World Services, 1976, 564). By virtue of these parameters, AA maintains what Davis and Jansen call, “a remarkably subtle and, in some ways, counter-establishment worldview that challenges dominant cultural expectations” (1998: 172). This paper provides a conceptual framework for understand the Twelve Step program as a unique culture, not only impacting the members’ addictive behavior(s), but impacting multiple domains of their existence and identity, within and outside of the program. It is important for clinicians to recognize such programs are far more than “resources” or post-treatment recommendations, as clients may be communicating in culturally bound ways that will not be interpreted correctly by non-competent clinicians. Culture consists of the distinguishing patterns of behavior and thinking that people living in social groups learn, create, and share (Bodley, 1994). Culture includes such aspects of living as beliefs, rules of behavior, language, and rituals. Groups of people who share a common culture–and in particular, common rules of behavior and a basic form of social organization–constitute a society. Thus, the terms culture and society are somewhat transposable. The people of a society collectively create and maintain culture. Culture has several distinguishing characteristics: (1) It is based on symbols and the ability to communicate using language, (2) people in the same society share common behaviors
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and ideology through culture, (3) it is learned or socially inherited, and (4) people use culture to flexibly and quickly adapt to changes in the world around them. People in recovery are members of a distinctive cultural community. In light of the characteristics noted above, Twelve Step programs demonstrate the construction of a shared reality through language, narrative, principals, actions and values. Twelve Step Symbols and Language Beliefs cannot be held without language-based propositions (Goodenough, 1990). Members of Twelve Step Programs start with immersion into the “fellowship” by learning the language. Words and phrases such as “recovery,” “powerlessness,” “turning it over,” “Higher Power,” “step work,” “sponsor,” “inventory,” “anonymity,” which initially have little meaning and may be fraught with misconceptions must be learned, understood, and integrated into a new belief paradigm for living. The new set of propositions and meanings are repeated in Twelve Step meetings. Meeting attendance is crucial to a member’s enculturation (i.e., adoption of the behavior patterns of the surrounding culture) into the program. Attendance at meetings is not a clear indicator of commitment (Emrick, Tonigan, Montgomery, & Little, 1993) and those that do not attend regularly do not tend to accept the program and fellowship dimensions of Twelve Step programs (Caldwell & Cutter, 1998). Less than weekly participation is no more effective with regard to abstinence than nonattendance (Fiorentine, 1999). Clearly, there is a difference between attendance, participation, and membership. For those that attend regularly, slowly but surely, information is reordered within the category structures of the individual thus shifting their behaviors and symbolic actions concurrently (Wilcox, 1998). As stated by Wilcox, “As members learn to manipulate this new referential system, they acquire a radically different foundation for the symbolic representation of reality” (1998: 110). All behavioral actions in Twelve Step programs have an underlying symbolism–for example, getting a sponsor symbolizes willingness, writing an inventory represents honesty and acceptance, and service related actions symbolize gratitude. These principles and actions transform the individual within the Twelve Step culture and in the larger societal contexts.
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Common Behaviors and Ideology Twelve Step programs foster a human view of existence on this planet that is very familiar to anthropology and to traditional human social organization (Wilcox, 1998). The literature of Twelve Step programs concurs that a “shared ideology” (i.e., a particular system of teachings disseminated through group interaction) plays in important role in members’ change processes (Wright, 1997). Frank and Frank (1991) add that the Twelve Step worldview is a safe refuge of acceptance for the addicted person where the social norms of the group teach new coping mechanisms both in and outside the group. Responsibilities and duties are shared by members and structured by an egalitarian ideology. Human relations are defined by reciprocity. Members adopt a “home group” which they commit to attending on a regular basis and take service responsibilities within the group including chairing meetings, sponsoring other members, putting their phone numbers on lists for newcomers, attending group business meetings, and perhaps taking inter-group service responsibilities such as group general service representative (GSR) at the meta-level. The Twelve Steps, which are the backbone of Twelve Step culture, essentially consist of the following: admission of a problem, acknowledgement that help is needed from a power greater than self, deciding to turn for help, making a moral inventory, sharing the findings with another person, acknowledging defects of character, addressing the defects spiritually, listing those who were harmed, making direct amends where needed, taking daily inventory and making amends quickly, improving conscious contact with a Higher Power, and carrying the message and practicing the principles in all daily affairs. The steps are continually addressed in the ongoing transformative process. Twelve Step ideology has been viewed as iatrogenic (potentially detrimental) from the perspective of social scientists that have labeled it as a “cult” (Alexander & Rollins, 1984). This is based on the perspective that Twelve Step programs impose “thought reform techniques” (Lifton, 1961) such as “mystical manipulation” of spiritual beliefs, control over members’ contacts outside the group, and the unconditional love offered by group members. While the efficacy of these arguments is not relevant to this paper, the very existence of the arguments speaks to the tenet of this manuscript, being that Twelve Step programs are a culture in and of themselves.
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It is important, however, to note that Twelve Step programs’ unique spiritual aspect is not characterized by a set of beliefs but instead by an emphasis on the individuality of spiritual beliefs. Consequently, recovery programs can be embraced by those of varied religions and denominations, not excluding atheists or agnostics. One study even reports counter-intuitive findings that show that spiritual coping style was unrelated to progress through the Twelve Steps (Horstmann & Tonigan, 2000). Learned and Socially Inherited Reality Twelve Step programs are rooted in the concept of “pass it on.” AA and other Twelve Step programs that have grown out of AA, like most cultures, have documented their history and evolution. Twelve Step literature is built on the stories of the founders and the experiences of the first members (hence, the “Big Book” of Alcoholics Anonymous.) Most Twelve Step programs utilize a basic text particular to their issues. The Twelve Step culture is built on historical narratives (Jensen, 2000). This literature serves as the foundation for the content and structure of recovery programs. The meetings provide the grounds for the sharing of beliefs and actions of the community. New members are welcomed and taught about the culture by “old timers” and other newcomers who are acclimating to the society. For the most part, they are valued immediately as the most important person in the group, since the belief is held that “you cannot keep what you do not give away.” As long as they continue to espouse the membership requirement (i.e., “a desire to stop drinking”), they begin to transform, conforming to members’ expectations, gaining a new capacity for healthy social existence. The practice of the twelve steps leads to a sense of competence, not only regarding abstinence, but also in functioning in everyday life. Beyond abstinence, to succeed, the recovering person must achieve a positive belief in their own value, efficacy, and interdependence with others. This may not be in congruence with American ideals of individualism and achievement, due to the Twelve Step emphases on interdependence rather than autonomy (Wilcox, 1998). Twelve Step program members are encouraged to attend many meetings to acquire a new vision of reality in which they are intrinsically no better or no worse than others and in which responsibilities over-ride self-serving actions.
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Another perspective is the intergenerational impact of the culture passed on through families. Parents in recovery raise their children within the worldview that they learn in Twelve Step programs (Wallen, 1993). Family members of people in Twelve Step programs often get involved in Twelve Step recovery programs of their own. This strengthens recovery networks by extending the culture to support system members. Whether the children have addictions or not, the beliefs and actions of the program members often influence their own perspectives and actions. Twelve Step Program Cultural Adaptiveness What members learn in Twelve Step culture allows them to function and adapt to the larger surrounding culture. From an ecological “micro” point of view, the above noted integration of new language, beliefs, and actions help the individual productively exist in larger domains such as family, work, and community. Twelve Step culture also can be viewed from a broader ecological perspective. Research demonstrates that Twelve Step programs starting with AA have adapted to meet the needs of cultures around the world (Makela, 1993). Twelve Step recovery programs have been cited as a growing mechanism of influence for underprivileged groups (Makela et al., 1996). In fact, once a Twelve Step program is established in a particular linguistic region, local members often support its spread to other countries that share their language. For example, Latin America has a system of international sponsorship in which AA groups in different Spanish speaking countries formally support each other (e.g., Mexico sponsors Spain, Colombia sponsors Panama, Ecuador, and Peru, and Argentina sponsors Bolivia, Chile and Paraguay) (Makela, 1993). Interestingly, although Twelve Step programs started as a primarily middle-class phenomenon, recent meta-analysis found no consistent relationship between SES and AA affiliation (Emrick et al., 1993). Socioeconomic composition of program membership varies from country to country relating to the history of the programs’ development and growth in the country rather than the relationship to the class structure of the surrounding society (Makela, 1993). While Levinson (1983), an advocate of behavioral interventions, erroneously assumes that Twelve Step programs strip members of cultural identity, replacing it with the identity of an addict/alcoholic or other concern, it is more accurate to note the “biculturality” of members
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with distinct cultural backgrounds. Members are more likely to view their program association as complimentary to their membership in American culture, religion, or other important ethnic or other cultural groups (Wilcox, 1998). Culturally Competent Social Work with Twelve Step Program Members The first step to establishing a framework for cultural competence with Twelve Step program members is augmenting awareness of the culture among clinicians. Members of recovery cultures seek understanding and acceptance from those they choose to work with in their recoveries. They desire helpers who have knowledge of the program and who know the culture and its nuances. The mistake many clinicians make is referring clients to Twelve Step programs and recovering counselors without considering enhancing their own comfort and knowledge of Twelve Step culture. This knowledge, awareness and sensitivity can be learned. Similar to the issue of cultural competence and racial matching (cf. Gitterman, 1991), research is split with regard to whether a person needs to be a member of the subculture to be competent, i.e., a recovering people versus nonrecovering as clinicians (McGovern and Armstrong, 1987). In a recent study, the majority of respondents believed that recovering and nonrecovering counselors do not differ in diagnostic ability, empathy, or effectiveness; most saw education and experience as being more important than alcohol/drug status (Anderson & Wiemer, 1992). Results of a study by Savage and Stickles (1990) indicate that adolescent subjects preferred recovering counselors and saw them as more effective than nonrecovering clinicians. Thus, in the literature, there appears to be an emphasis on competency and a preference for recovering clinicians by some clients. As noted previously, people seek Twelve Step programs for difficulties that are often stigma laden. Consequently, clients seek workers who are aware, knowledgeable, and nonjudgmental. Thus, when a client inquires whether a clinician is in recovery, they are likely asking whether or not the clinician is culturally competent with people in recovery.
IMPLICATIONS Cultural competency involves changing awareness and activities to fit cultural norms. Cultural practices can be adapted to develop cultur-
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ally grounded tools for treatment (e.g., integration of Twelve Step paradigm into practice, common language, practices congruent with Twelve Step recommendations). It would appear that interventions grounded in salient cultural values and beliefs related to (a) spiritual recovery, (b) fellowship, and (c) the relationship between addiction recovery and transformation, would engage recovering people in the clinical work of clinicians and build on their own belief systems. Knowledge of these factors of Twelve Step existence would enhance social work intervention including rapport building, problem solving, advocacy, and empathic, client centered connections. Perhaps Twelve Step programs work because they are culturally grounded in the personal experience of its members and have components that enable unique successes for some individuals. It is, in fact, possible that they are not better than anything that happens in professional mental health or substance abuse treatment, but simply more culturally competent. It is important to note that there are individuals who cannot integrate into the Twelve Step culture for whom clinicians, on their own, are the treatment providers. There are populations who may have more difficulty thriving in the culture, for example, some clients designated as “dually-diagnosed.” Thus, clinicians can also serve to help clients bridge the complex interactions of the multiple cultural realms that they exist. Recommendations to the Field Clinicians working in the alcohol and drug field should recognize that cross-cultural understanding must include knowledge of Twelve Step programs as a complex and dynamic culture with a profound impact on its members. Practitioners should note that all Twelve Step program members who have inculcated into a recovery program are, by definition, bi- or multi-cultural. Therefore, in order for interventions to be effective, clinicians must work to enhance their cultural competency to address the unique needs and strengths of individuals in Twelve Step programs. This can be achieved with the following actions: attend and witness a variety of open 12-Step meetings, pursue critical dialogue with diverse program members, and maintain a balance of power, especially considering recovering clients “experts” in their life experience, values, and beliefs. Maintaining a “teachable” stance with regard to program-based cultural nuances and mores will benefit the client-clinician relationship and enhance the client’s capacity for successful recovery.
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