Introduction

Bridges to Recovery
by Jo-Ann Krestan

At last, a book that defines a new language for treating substance abuse in an increasingly culturally diverse population. Until now, therapists, counselors, and teachers who treat addiction within the context of the whole family have had to make do with outdated one-size-fits-all theories and treatment programs.

Bridges to Recovery is the first book to bring together experts from three major fields within psychotherapy — family therapy, addiction counseling and multicultural treatment — to provide a practical and flexible framework for working with families within their individual cultural contexts. Drawing upon case studies, clinical anecdotes and proven treatment methods, Bridges to Recovery provides practitioners with a unique insight into the individual cultural nuances that make addiction recovery a very personal journey.

Jo-Ann Krestan, co-author of the classic book The Responsibility Trap: A Blueprint for Treating the Alcoholic Family, and her contributors integrate the latest ideas and research to offer a foundation for addiction treatment that brings to the forefront the cultural thinking that affects alcohol and drug use/abuse among Native Americans, Jewish Americans, African Americans, West Indians, Asian Americans, Mexican Americans, Puerto Ricans and groups of European origin. This book will be an invaluable asset to teachers and students in clinical social work, psychology and substance abuse counseling programs, setting the standard for education and treatment at the beginning of the 21st century.

This book really began in the early nineties, on an icy, rain-soaked January day. I had been invited to the Roberto Clemente Guidance Center, in New York City, to teach a seminar on the family systems model of treatment first elaborated in The Responsibility Trap(Bepko and Krestan, 1985). This model included three sets of contructs central to the understanding and treatment of addiction in family systems: over- and underresponsibility; pride, shame, and power; and the role of alcohol as a mediator of gender role constriction.

I met Miguel Hernandez that day. I was excited by his creativity; his passion for helping people. I was also struck by the creativity of the Guidance Center's multicultural group of clinicians in applying these ideas to largely poor, ethnic minority, immigrant families. Our ideas on gender and addiction signified fairly innovative scrutiny of the interfaces between the family system, the addictive system, and the larger social system as they are embedded in gender role socialization. However, what I came away with on that cold January day was a recognition of the degree to which our ideas were culture bound as well as gender bound. For instance, I had long been fascinated by Bateson's view of power in his essay on the epistemology of alcoholism, yet it had never before occurred to me that power, in the sense of "power over," might not be universally valued, which is the case in the Native American Indian culture. At the conference I listened to African American clinicians discuss overresponsibility partially as a function of the differing work potentials for African American women and men, and I recalled a conversation I had had the previous year in Santa Fe when a Navajo clinician told me that overresponsibility was not as problematic in her Nation as in the Anglo culture, because the centrality of women is overt, not covert.

After the conference, I scribbled notes for a project that would translate the ideas in The Responsibility Trap into more culturally relevant terms.

I spent the next few years more absorbed with other professional issues, other projects, but each time Monica McGoldrick published a work on ethnicity, or Celia Falicov wrote or talked on systemic views of culture, or the American Family Therapy Academy, where I was privileged to serve as a board member for three years, struggled with diversity, the impulse to develop my idea of a project on multiculturalism and addiction reappeared.

So here we are: Bridges to Recovery: Addiction, Family Therapy, and Multicultural Treatment.

Since my presentation at Clemente, there has been an explosion of writing on multiculturalism, addiction, and family systems thinking. All of us are embedded in diverse ecological contexts. Workforce 2000, a report by the Hudson Institute, tells us that the population of the United States is changing at a quickening rate; it claims that women, immigrants, and non-Whites will constitute more than five-sixths of the additions to the workforce between now and the year 2000. The 1990 Census Bureau statistics tell us that minorities will be the numerical majority in the United States population by the year 2056. As we enter the new millennium, health experts tell us, substance abuse remains one of the largest and most costly health care problems in America.1 Moreover, our most basic concepts are changing: family systems thinking has been redefining the very idea of family.

Multicultural competence and the acknowledgment of class, gender, and sexual diversity are critically relevant dimensions of effective treatment in the fields of addiction and marriage and family therapy in the diverse postmodern world in which we live, teach, and practice. This book offers a framework that will help practitioners elicit and understand the specific ecological story that is needed to adequately treat addictive families. It describes those characteristics of different ethnic groups that are relevant to addiction, characteristics mediated by such relevant sociological variables as gender, class, and generation.

Addiction treatment and family therapy have in some ways grown up together. Both professions have seen tremendous growth and change since the mid-sixties. Family therapy has spawned several different theoretical and clinical models for optimal family functioning. Addiction treatment has expanded from the treatment of alcoholism and heroin addiction to include treatment for polydrug addiction, chemical dependency, and other addictions, such as addiction to sex, food, gambling, and spending.

Addiction treatment and family therapy have also influenced one another. Today substance abuse treatment and what we have come to call the "recovery movement" have broadened to include community support and residential treatment for the families of addicts, for codependents (see, for example, Krestan, 1990), and for adult children of alcoholics. The term dysfunctional family refers to at least sixty different maladies, all with related family problems. Addiction recovery books and articles make frequent reference to and have popularized many of the concepts in family therapy. Claudia Black, Sharon Wegscheider-Cruz, Janet Woititz, and Timmen Cermak were among the first addiction specialists to look at family roles, family rules, and the intergenerational effects of substance abuse. The PBS series Focus on Family, with John Bradshaw, was one of the most successful television series in recent years. Unfortunately, however, the addiction recovery movement has presented family therapy ideas in a highly hybridized and often inaccurate way in order to make them more palatable for popular consumption.

Family therapists did not write extensively on alcohol and drug addiction and the recovery movement until the mid-eighties. Steinglass, Bennett, Wolin, and Reiss formulated the concept of the alcoholic family. Coleman, Stanton, and Todd introduced creative ideas on the relationship of drug abuse to loss. Berenson, in his articles and teaching, opened a dialogue on spirituality. Elkin analyzed the relationship between power and addiction. Treadway, tirelessly teaching around the world, raised consciousness about alcoholism. Bepko and Krestan, in The Responsibility Trap: A Blueprint for Treating the Alcoholic Family, provided the first substantive clinical bridge between family systems approaches to addiction, the twelve-step programs, and the recovery movement. The Responsibility Trap also introduced the idea of addressing gender differences in socialization as a major emphasis in treatment. Bepko and Krestan's treatment model has been clinically useful with all types of substance abuse, including eating disorders and the noningestive addictions, such as gambling.

The family therapy profession has attempted to make theory and treatment of addiction and families relevant to issues of class, gender, and ethnicity. Minuchin's work paved the way for a school of family therapy that dealt with class. The feminist critique of family therapy began with Hare-Mustin's classic article "A Feminist Approach to Family Therapy." McGoldrick, Giordano, and Pearce's Ethnicity and Family Therapy(released in 1996 in a second edition) pioneered family therapy's consideration of cultural variables, as did Falicov's many articles. Only in the past few years, however, has family therapy as a whole dealt with issues of cultural diversity. Despite these initial efforts to bring theory and practice into the postmodern world, family therapy professionals still need a ready resource that will help them successfully treat the diverse families that come to them in crisis. The substance abuse literature is beginning to address issues of class, culture, "race," and sexual orientation. Feminism and Addiction(Bepko, 1991) was the first serious attempt to make the family treatment of substance abuse relevant to women.

Research and writing on multiculturalism and diversity have also increased dramatically. However, studies of ethnic and "racial" variation have gone in and out of favor and fashion with the changing political climate.

This book is a first of its kind. My hope is that we will move forward in integrating family therapy with addiction treatment and that this book will be a resource that will increase cross-cultural and interdisciplinary collaboration and spark further research. In writing our chapters, my contributors and I faced a number of challenges, including the following:

• A growing belief that the very categories we were using — not just gender but "race" and class as well — were social constructions. (Although I felt stuck with the language of categories, I feel so strongly about the social construction of the concept of "race," while recognizing its political utility, that the word race is frequently used in quotes in this introduction.)

• A recognition of the tremendous heterogeneity within cultural groupings.

• Concern over issues of inclusion and exclusion. (For example, who are the African Americans? The descendants of slaves? The Caribbean Islanders? The Muslims? The Baptists?)

• Problems with terminology. (Is it Native American or American Indian or Native American Indian? Latino or Hispanic? Lippard, 1990, an art writer and activist, says, "Three kinds of naming operate culturally through both word and image" [p. 19]. The three kinds of naming are "self-naming,... the supposedly neutral label imposed from outside, which may include implicitly negative stereotyping and is often inseparable from the third, explicit racist namecalling" [p. 20]. The authors of the chapters in this book have named in different ways, for different reasons.)

• Concern for consistency between chapters. (Should the chapters be "Krestanized," or should the editor's role be to edit only for clarity while keeping the diverse voices and styles of the contributors?)

So here we are: A diversity of styles and voices won out. I have insisted on little, only that the contributors write what they truly believe. I have encouraged speculation and opinion, reasoning that this is not a work tied to empirical research (although research is extensively reviewed and cited) but a clinical work — in some cases from a somewhat anthropological and historical perspective. Several of the contributors have also made extensive use of personal interviews and communications in supplementing their other data.

Organization and Content of This Book

Part One: Perspectives

The first chapter, on power and shame, explores the dominant treatment paradigm for alcoholism by deconstructing ideas of power as they have evolved from the Western Eurocentric ideas that spurred the initial colonization of the North American continent. In this chapter I introduce the concept of "values of origin" to capsulize the belief systems of different groups as they relate to addiction and recovery. Values of origin encompass not only beliefs about family, spirituality, power, and external and internal loci of control but also beliefs about alcohol and other drugs. Gender practices, spiritual belief systems, and choice of rural versus urban living also relate to values of origin. It is my belief that the concept of values of origin, if operationalized, might yield yet another lens through which we can view individuals, families, and groups instead of resorting to our socially constructed categories.

In the cross-cultural literature on alcohol studies, cultures and nations have long been classified by their attitudes toward drinking, that is, by whether they are abstinent, ambivalent, or temperate. They have also been compared on measures such as per capita alcohol consumption, alcohol and drug policies, annual deaths by cirrhosis per 100,000, epidemiology of alcohol dependence, and the social consequences of alcohol and drug addiction. They have been categorized by beverage preference (that is, as wine-, beer-, and spirit-drinking cultures) and by reasons for drinking and using drugs (that is, whether utilitarian, celebratory, ritualistic, or spiritual). They have been compared on demographics, notably social class, gender, religious denomination, and age. (Heath, 1995; Ninth Special Report to the U.S. Congress, 1997). Values of origin (Krestan) are key in determining a family's "ecological niche" (Falicov, 1995) with respect to addiction.

Cable starts her chapter on adult children of alcoholics (ACOA) by writing, "Once upon a time North American children learned to read with Dick and Jane. The White, Christian, blond-haired children lived with their mother, father, cat, and dog in a clean house on a tree-lined street." Placing the ACOA movement in historical context, Cable applies Falicov's multidimensional comparative approach to an exploration of the research literature and to the self-help traditions within the ACOA movement. Enunciating various themes as organizing principles for the material, she challenges the "tyranny of normality," celebrates resilience, and relates postmodernism to the clinical treatment of adult children of alcoholics.

Copyright © 2000 by Jo-Ann Krestan

About the Author

Jo-Ann Krestan is a leading marriage and family therapist and addiction counselor who has appeared on such shows as Oprah and 20/20 and is co-author of The Responsibility Trap: A Blueprint for Treating the Alcoholic Family. Her other books include Singing at the Top of Our Lungs and Too Good for Her Own Good. She lives in Surry, Maine, and Castle Valley, Utah.