Introduction

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 inThe 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 inThe Responsibility Trapinto 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 termdysfunctional familyrefers 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 seriesFocus 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, inThe 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 Trapalso 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'sEthnicity 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 wordraceis 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.

Part Two: Ethnic Ecologies

Part Two of this book integrates what we know about ecological contexts, addiction, and family systems in ways that are immediately useful for clinicians.

Most of the contributors struggled with the need for a dialectical process between an ethnic-focus approach and Falicov's multidimensional comparative approach (Falicov, 1995). Ellias-Frankel, Oberman, and Ward quote an old joke: "Two Jews meet and there are three opinions." Rather than holding three opinions, they speak in terms of "ethnic themes" that do not "determine a particular response but rather [pose] an overt or covert question to which members of the group may have dissimilar responses." Dispelling the myth that Jews don't drink or have other addiction problems, they insist, "The most important fact to grasp about Jewish addiction is that it exists and is significantly underdiagnosed and undertreated."

Chang explores major commonalities among Asian Americans and Pacific Islanders while integrating highly particular and useful information about a wide range of groups. The compassionate depth of his work is reflected in discussions of the Asian historical background, especially migration and loss, and his analysis of families, relationships, gender roles, communication, harmony, and addictions. His clinical explications are extremely specific and practical. His thoughtful explorations of values and the poignancy of his depiction of the migrant's experiences of loneliness and loss stayed with me from my first reading of his first draft.

Hudak uses an ethnic-focus approach to groups of European origin. It is interesting that when I decided to treat European groups as an ethnic category, we found that there was more anthropological than clinical literature available. This presents new questions about assumptions inherent in a dominant discourse that was largely formed by the early settlers from European countries (see chapter 1). The richness of Hudak's case studies teaches us much about treatment and compensates for the lack of literature. The anthropological information that is available suggests that these individual groups do in fact have significant ecological differences that impact on addiction patterns and treatment.

Reid, a social worker, trained family therapist, pastoral counselor, and Baptist preacher, writes on African Americans with an immediacy that joins expression with commitment. According to Knox (1985), "the organized church is by far the most profound instrument available to Blacks when it comes to coping with the multiplicity of problems that beset their lives" (p. 35), and, as Harrison Pipes (1997) says, "undoubtedly, the old-time Black preacher is the Black leader today; it is to him that the great majority of Blacks in this country look for guidance" (p. 64).

Reid's chapter, which reflects her pastoral calling, is consistent with Pipes' formulation of old-time religion: it uses words familiar to her audience; a narrative voice meant for listening more than reading; a figurative style with heavy use of metaphor, often drawn from the Bible; and rhythmical, sometimes elliptical, sentences. It appeals to emotion as much as to reason.

In the chapter by Hernandez and in the one by Bibb and Casimir, our attention is directed to how U.S. foreign policy and the international drug trade closely affect addiction among Puerto Rican and West Indian immigrants, respectively. Since I do not believe we ever speak apart from context, I have no difficulty with material that some readers may consider highly politicized. As Almeida, Woods, Messineo, and Font (1998) point out, family theory has too frequently considered the systems in the "interior" of family life while neglecting the larger social systems. Even feminist theory, while introducing an analysis of power inequities, has paid insufficient attention to multiple levels of oppression. Hernandez' approach directly deconstructs addiction in the Puerto Rican population as a multilevel systemic phenomenon that is often rooted in racism, classism, and oppression. I believe that there is a place in clinical work for the acceptance and encouragement of linear rage, as well as for systemic responsibility.

Clinically, Hernandez, true to the creativity that first struck me, applies Stivers' (1976) idea of a group adopting a dominant group's stereotype when he writes, "The central theme I try to discuss is how by losing control and becoming addicted the client has fallen into the trap of acting out the stereotyped view that the dominant group has about Puerto Ricans. I tell my clients that every time they lose control, they become another number in the statistics that proves to 'them' that Puerto Ricans are 'spiks who don't do nothing but get high'. Talking about the impact that poverty, migration, and ethnic minority reality have on our lives is done to contextualize addiction within a sociopolitical context."

Bibb and Casimir state in the opening to their chapter, "Holding individuals personally accountable must be balanced with knowledge of the powerful social, geographic, and economic forces that created and now maintain the flow of alcohol and drugs abroad and in North America. It is important to attend not only to the psychological and clinical dilemmas that substance abusers face but also to their social and community context. Addiction is extremely personal and yet extremely global." Their discussion of addiction and West Indians includes specific clinical issues, suggestions for needed research agendas, and comments on the international drug trade.

Baron meets the challenge of writing about the enormous complexity of our largest immigrant group, the Mexican Americans. This group is burdened by heavy substance abuse. Baron focuses on a way of assessing a particular family at a particular moment in time. He synthesizes several models (notably those of Falicov, Sue and Sue, and Jones) in a methodology that pays particular attention to acculturation, ethnic identity development, and worldview. He also offers an extremely comprehensive review of the literature. Of the enigmatic character of the Mexican, the late Octavio Paz (1985) wrote, "It is revealing that our intimacy never flowers in a natural way, only when incited by fiestas, alcohol or death" (p. 70) and "There is nothing so joyous as a Mexican fiesta, but there is also nothing so sorrowful. Fiesta night is also a night of mourning" (p. 53).

"Mitakuye Oyasin" (Lakota for "All Our Relations")

Don Coyhis, director of White Bison, is a man I wanted to connect with for several years. I knew that Don, following a vision quest, had exchanged his corporate life for a path of bringing substance abuse recovery to his own people. In a series of "coincidences" involving a stranger in Las Cruces, New Mexico, I finally did track Don down. After much discussion he and his staff, notably Richard Simonelli, shared a series of Don's talks, originally given in the oral tradition of Don's people and transcribed by Richard. The addiction recovery program for Native Americans described in chapter 3 represents a unique blend of the wisdom of the medicine wheel and a twelve-step approach to sobriety. One of the beauties of White Bison's approach to the "red road of sobriety" is its ability to transcend the heterogeneity of Indian nations and traditions by synthesizing symbols and rituals that are common to all.

Future Directions

Several ecological contexts deserve more exploration in relationship to addiction recovery in the twenty-first century:

1. The Role of Gender

It is a consistent finding across every group that the most prevalent risk factor for addiction, other than having an alcoholic parent, is gender -- that is, being male. The Ninth Special Report to the U.S. Congress on Alcohol and Health (1997) concludes, "Studies confirm that women drink less and report fewer alcohol-related problems than men do" (p. 27). Heath (1995), an anthropologist, concurs: "One measure of status that is recognized everywhere is gender (what many consider to be the sociocultural implications of the biological category of sex differentiation)...men drink more, and more often, than do women. (This is almost a cultural universal with only two peculiar instances -- both small migrant groups in novel settings -- known where the opposite holds)" (p. 337). The Ninth Special Report also concludes that future research on women and alcohol use should pay particular attention to "childhood and adult violent victimizations, depression, sexual experience, and the influence of husbands' or partners' drinking" (p. 28). It seems significant that these factors, which are predictors of women's drinking, have as much to do with the women's relationship to men as to the women themselves.

2. The Role of Spiritual/Religious Belief Systems

It is a consistent finding that religious belief systems are often predictors of drinking behavior, and yet little attention has been paid to religion as a demographic variable since Cahalan, Cisisn, and Crossley did the original research in 1969. Alcoholism is often considered a disease of the mind, body, and spirit; Chappel (1997) and Royce (1995) consider it a spiritual disease. There appears to be considerable cultural resistance to this idea. Relatively little research has been done on the relationship between alcoholism recovery and spirituality despite studies that identify spiritual healing as a major contributor to the overall health of individuals (Benson, 1976; Borysenko, 1988; Michaud, 1998; Ornish, 1995).

3. Adolescence

Adolescence in different groups (particularly Latino), with its potential for engendering cross-generational conflict, its heavily researched risk factors, and its vulnerability both to addiction and to early intervention deserves a book of its own. The literature on risk and protection factors in adolescence is extensive. As a start I recommend Jose Szapocznik's work on prevention of alcohol and drug abuse among Latino youth, particularly his work on multicultural effectiveness training.

4. The Rural Context

An excellent resource, published by the National Institute of Drug Abuse, isRural Substance Abuse: State of Knowledge and Issues(1997), which decisively dispels the myth of rural insulation from drug problems. Although one quarter of Americans live in rural areas and although among some groups (for example, African Americans) there seems to be increasing migration to rural areas from urban areas, rural America has rarely been the focus of concern about substance use and abuse. The tremendous economic downturns in rural areas create special vulnerabilities to psychosocial problems and addiction, and since the agricultural community is moving more toward hiring single, male migrant workers, instead of families, we might expect alcohol and drug use within the migrant populations to escalate.

5. Groups of European Origin

We have not talked about Franco-American concentrations in New England, the legacy of high suicide rates in the Nordic countries and their relationship to alcoholism in Nordic populations in the upper Midwest, the role of vodka as a medium of exchange in a crumbling Russian economy and our increasing population of Russian immigrants.

As Lippard (1990) says, "We have not yet developed a theory of multiplicity that is neither assimilative nor separative -- one that is, above all, relational" (p. 21).

What we have done is to begin.

Jo-Ann Krestan

November 1998

Surry, Maine

and

Castle Valley, Utah

References

Almeida, R., Woods, R., Messineo, T., & Font, R. (1998). The Cultural Context Model: An Overview. In M. McGoldrick (Ed.),Re-Visioning Family Therapy.New York: Guilford Press.

Bateson, G. (1972).Steps to an Ecology of Mind.New York: Chandler.

Benson, H. (1976).The Relaxation Response.New York: Avon Books.

Bepko, C. (1991).Feminism and Addiction.New York: Haworth Press.

Bepko, C., with Krestan, J. (1985).The Responsibility Trap: A Blueprint for Treating the Alcoholic Family.New York: The Free Press.

Black, C., (1987).It Will Never Happen to Me.New York: Ballantine Books. (Originally printed 1981, Denver: M.A.C.).

Borysenko, J. (1988).Minding the Body, Mending the Mind.New York: Bantam.

Cahalan, D., Cisisn, I. H., & Crossley, H. M. (1969).American Drinking Practices: A National Study of Drinking Behavior and Attitudes.New Brunswick, NJ: Rutgers Center of Alcohol Studies. New Haven, CT: College & University Press.

Chappel, J. N. (1997) Spirituality and Addiction Psychiatry. In N. S. Miller (Ed.),Principles and Practice of Addictions in Psychiatry(pp. 416-421). Philadelphia: Saunders.

Coleman, S. B. (1985).Failures in Family Therapy.New York: Guilford Press.

Elkin, M. (1990).Families under the Influence: Changing Alcoholic Patterns.New York: W. W. Norton.

Falicov, C. J. (1995). Training to Think Culturally: A Multidimensional Comparative Framework.Family Process,34, 181-193.

Hare-Mustin, R. T. (1978). A Feminist Approach to Family Therapy.Family Process,17, 181-193.

Hudak, J., Krestan, J., & Bepko, C. (1999). Alcohol Problems and the Family Life Cycle. In B. Carter and M. McGoldrick (Eds.),The Expanded Family Life Cycle: Individual, Family, and Social Perspectives(3rd ed., pp. 455-469). Boston: Allyn and Bacon.

Inclan, J. & Hernandez, M. (1992). Cross-Cultural Perspectives and Codependence: The Case of Poor Hispanics.American Journal of Orthopsychiatry,62(2), 245-255.

Knox, D. H. (1985). Spirituality: A Tool in the Assessment and Treatment of Black Alcoholics and Their Families. In F. L. Brisbane and M. Womble (Eds.),Treatment of Black Alcoholics in Alcoholism Treatment Quarterly,2(3 and 4), 31-44. New York: Haworth Press.

Lippard, L. R. (1990). Mixed Blessings:New Art in a Multicultural America.New York: Pantheon Books.

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Middelton-Moz J. & Dwinell, L. (1986). After the Tears: Working Through Grief, Loss, and Depression with Adult Children of Alcoholics. In R. J. Ackerman (Ed.),Growing in the Shadow: Children of Alcoholics.Pompano Beach, FL: Health Communications.

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Paz, O. (1985).The Labyrinth of Solitude.New York: Grove Press.

Pipes, H. (1997) "Old-Time Religion: Benches Can't Say "Amen." In H. P. McAdoo,Black Families(3rd ed.). Thousand Oaks, CA: Sage.

Roberston, E. B., Sloboda, Z., Boyd, G. M., Beatty, L. & Kozel, N. (1997). "Rural Substance Abuse: State of Knowledge and Issues." Monograph No. 168, NIAAA, U.S. Dept of Health and Human Services, National Institutes of Health, Rockville, MD.

Royce, J. E. (1995). Effects of Alcoholism and Recovery on Spirituality.Journal of Chemical Dependency Treatment,5(2), 19-37.

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Szapocznik, J. (Ed.) (1994).A Hispanic/Latino Family Approach to Substance Abuse Prevention.Rockville, MD: Center for Substance Abuse Prevention.

Szapocznik, J., & Kurtines, W. (1989).Breakthroughs in Family Therapy with Drug Abusing Problem Youth.New York: Springer.

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Chapter One: Addiction, Power, and Powerlessness

Jo-Ann Krestan

The ecology of addiction in a multicultural society requires us, as family therapists and addiction counselors, to re-examine two core ideas that have historically guided our treatment of addiction in the United States: power and powerlessness. Pride, false pride, and shame are closely related concepts and must also be viewed in a multicultural context.

Power and powerlessness are concepts laden with multiple meanings. Understanding the ecology of addiction as it relates to a particular individual or group requires us to first think about these concepts in a generic way and to then particularize them to the individual or group. The founders of Alcoholics Anonymous and family systems thinkers like Gregory Bateson based their beliefs about the nature of addiction on the Western European view, which is primarily "power over." I will address the concept of "power over" at some length, because traditional addiction treatment in the United States, often wedded to a twelve-step approach, evolved from this Western European view. It is in the context of this view that addicts are asked to embrace the idea of powerlessness over their addiction. Only then, we tell them, can they regain power over their life. The first step in recovery in Alcoholics Anonymous, the dominant paradigm for most addiction treatment in the United States, occurs when addicts recite, "[We] admitted we were powerless over alcohol, that our lives have become unmanageable." This admission of powerlessness that AA insists on is key to the shift in the addict's belief system and crucial to dismantling what Karen Horney (1937) calls "neurotic pride." In his concept of the symmetrical structure of "alcoholic pride" Gregory Bateson (1972) too recognized the necessity for addicts to shift their stance from one that asserts domination over the self, others, and the environment to one that accepts the reality of limitation, a concept that is foreign to our Western culture.

It is necessary to broaden our thinking about what it means to have power or to be powerless and examine what it is about these prevailing views of power that can set the stage for addiction.

Kinds of Power

In her bookUnderstanding Race, Ethnicity, and Power, Pinderhughes(1989) wrote:

People experience the presence or absence of power in many areas of life. For power is a systemic phenomenon, a key factor in functioning....Internal power is manifest in the individual's sense of mastery or competence. The power relationships between people determine whether their interactions are characterized by dominance-subordination or equality. These styles of interaction are, in turn, affected by the status and roles assigned within the group or the larger society.

There are four related kinds of power:

Individual

Interpersonal

Socio/Cultural

Spiritual

Let us first deconstruct these kinds of power and posit how addicts think of each of them. I believe that addicts, in their addiction, identify with the dominant discourse of "power over" and that they must learn to view this discourse as "power to" if they are to recover from their addictions.

Individual Power

Individual "power to" is synonymous with empowerment and includes feelings of self-control, subjectivity, and the ability to define one's own life. It is the power to choose. For example, although we have no say about the family of origin we are born to, we can learn to make choices about family relationships that empower rather than victimize us. For the addict, "power to" is the power to surrender, a paradox I examine later in this chapter.

Individual "power over" may extend to total control of one's feelings or to the illusion of total control over one's life. Gender-linked messages about the control of feelings, such as the suppression of male vulnerability or of female anger, teach people that they have individual power over their feelings, thereby constricting normal emotional behavior. Individual "power over" denies the need to act in a context with others. Those who insist on having this kind of power will have difficulty submitting to authority. Any absence of control is viewed by them as being controlled and therefore out of control. For example, being a member of the crew on a sailboat rather than the captain may be experienced as being powerless, rather than simply as being a team player. The individual who must have "power over" will have difficulty relinquishing control when cooperation is needed. For example, the addict says, "I can control my habit. I have power over my addiction."

Interpersonal Power

Interpersonal "power to" is the power to be heard in a group, perhaps to become the leader. It is the power to make choices and take positions about what one will or will not do, rather than just react to situations in relationships. For the addict, "power to" means the ability to leave bar friends and go to an AA meeting. It empowers addicts to exercise a healthy choice, such as to amend their relationships in sobriety.

However, interpersonal "power to" can lead to "power over." One's power to enlist in a cause may become institutionalized leadership, a legitimized form of "power over." Although "power over" may start benignly, it is vulnerable to becoming a power over others that denies equality and becomes exploitative, unjust, and even violent. There can be no "power over" without relative inequality (Sebastian, 1992). Our institutionalized "power over" that emanated from the Eurocentric subjugation of what became these United States is White, male, Protestant, and heterosexual.

The addict, desperate to hold on to "power over," says, "I will overpower your efforts to control my chemical use.Iwill controlyou."The addict's expression of "power over" might be annoying manipulative behavior or actual physical coercion.

Culture, like power, is a systemic rather than a static process. Falicov (conversation with author, 1998) points out that it is a dialogical process, with certain cultural attributes being highlighted in interaction with others.

Sociocultural Power

Sociocultural power is group power. For a group, "power to" may mean a centralized position (rather than marginalization), access to resources, or political power. That is, "power to" is the right to define the rules, control the discourse, select the language. For the addict, sociocultural "power to" means becoming part of a reference group that values sobriety.

Sociocultural "power over" is power that privileges certain groups at the expense of others, as demonstrated by race and class discrimination. A group that exerts "power over" creates inequality among groups. For example, immigrants come to the United States to find the "good life" portrayed in the media, but their success often depends on which race or class they belong to. It is clear that success and power in the United States are synonymous with material comfort. Immigrants of color are frequently denied access to the better-paying jobs. These people may be highly skilled, well-educated individuals who were relatively well compensated for their work in their country of origin. It is a shock for them to come in search of the "good life" only to experience a profound loss of status inflicted by a more powerful sociocultural group (Espiritu, 1997).

The original European colonists decimated the American Indians and warred with the Mexicans who once were in possession of much greater territory; their descendants interned the Japanese during World War II, despised the first Catholic Irish and Italian immigrants, and were, in general, intolerant of difference. Those addicts whose sociocultural reference group has "power over" feel more powerful than do those whose group lacks such power. This encourages the illusion in the former that they have power over their addiction.

Spiritual Power

Spiritual power comes from how we think about our relationship with the world around us. This larger picture includes self and others, spirit (in AA terms, "Higher Power"), the natural world, destiny or fate, the meaning of death. Spiritual "power to" is the ability to transform the self. It gives us courage and compassion when we meet our existential edges. spiritual "power to" is the power of Gandhi and the Dalai Lama. For the addict, it is the ability to, in the face of powerlessness, find the spiritual strength to exert power to obtain a whole, healthy, sober life.

Spiritual "power over" stems from the belief that one has a direct line to God, a relationship that ultimately privileges one to have power over others. Such a belief may be inflicted by a leader, doctrines of the church, laws of state, or cultural expectations. Spiritual "power over" is demonstrated by our efforts to control the natural world with technology. As I write this, there is a summit in Kyoto to address a result of power over nature -- global warming. The U.S. Army Corps of Engineers has dammed rivers and flooded whole towns, overgrazing has decimated vast grasslands, and altering the landscape has caused houses on hillsides in California to slide into mud. The Eurocentric values held by the early colonists in this country encouraged them to subdue the wilderness, tame the rivers, and conquer indigenous peoples. Man's persistent efforts to control nature are demonstrated everywhere.

For the addict, spiritual "power over" is invincibility, perfection. The addict says, "I am my own Higher Power. No God has power over me. I am the master of my fate. I can control my own destiny."

Whatever their "values of origin" on power, addicts entering the treatment system in the United States will be exposed to the hegemony of the twelve-step approach to recovery. This approach has created widespread belief that recovery begins with admission of powerlessness over a drug, but what powerlessness means to each of us is intimately tied to our ideas about power. We must understand the sometimes equivocal uses of power in our dominant discourse.

Power and the Dominant Discourse

A dominant discourse is the central story of a culture as it arises from assumptions about what is normative. It is sustained by language. Discourses are not equally privileged. According to Hare-Mustin (1994), "The dominant discourse is the one that supports and reflects the prevailing ideology of those in power" (p. 20).

The dominant discourse on power in the United States is "power over" as opposed to "power to." Hayton (1994) asserts that it evolved from European beliefs and traditions that came with the colonization of North America.

The traditions that Europeans brought to America were:

an attitude of moral superiority,
a belief that the universe was created to serve the needs of man,
an intellectual and religious intolerance,
advanced military equipment, and
a natural inclination to be violent toward one another. (P. 105)

These beliefs and traditions became the framework for the dominant discourse on power, by those in power, in the United States today.

Language and Induction into the Dominant Discourse

Language constructs reality in ways that marginalize or centralize, because of the assumptions of power inherent in the dominant discourse. Social lines are often constructed between sexual orientations, races, classes, and genders. In the United States these lines translate to institutionalized "power over." Although we have supposedly shunned the assimilationist ideology of the melting pot, we still attempt to induct newcomers into our values.

Race

We use the word race as though it were an objective reality instead of a social construction. Race is historically a biological term referring to physical characteristics of different peoples. However, as Zack (1995) points out, "There are no genetic markers for race....The ordinary concept of race has dialectically ridden on an assumption of racial purity that has been used to racialize dominated groups as it suited dominant interests" (p. xvi). Pinderhughes (1989) concurs: "Over time, race has acquired a social meaning in which these biological differences, via the mechanism of stereotyping, have become markers for status assignment within the social system...a status assignment based on skin color" (p. 71).

Historically, the dominant discourse on race in the United States placed "Whiteness" at the center, largely unexamined. Racism was studied for years in terms of its effects on Black identity rather than its effects on White identity; that is, the dominant discourse has portrayed racism as a problem for people of color rather than as a problem for all. Fine, Weiss, Powell, and Wong (1997) point out that "White standpoints, privileged standpoints, are still generally taken as the benign norm or, in some cases, the oppressive standard -- either way escaping serious scrutiny" (p. viii). McIntosh (1998) examines the context that defines a White person's experience:

As a White person, without even consciously defining myself as White, there are dozens of ways in which my skin color privileges me in everyday life, and I may barely realize them.

When I am told about our national heritage or about "civilization," I am shown that people of my color made it what it is.
I can remain oblivious to the language and customs of persons of color who constitute the world's majority without feeling in my culture any penalty for such oblivion.
I can easily buy posters, postcards, picture books, greeting cards, dolls, toys, and children's magazines featuring people of my race. (P. 149)

It is Whites, however, who are most often unconscious of race. People of color are always conscious of it. Toni Morrison (1997) says, "I have never lived, nor has any of us, in a world in which race did not matter" (p. 3).

Gender

Language creates gender as dichotomous: heterosexual or homosexual; male or female. The centrality of White male heterosexuality is at the center of our discourse on gender. Building on McIntosh's work, Crowfoot and Chesler (1996) built their own list of White male privileges and behaviors, which often remain just below our level of consciousness. Here are two examples:

We [White males] feel and act freer than others to deviate from group ground rules, expectations, and "appropriate" group behavior (e.g., sitting outside a circle, coming late to a meeting, announcing alternative pressing tasks, etc.)
We can afford to limit our efforts to talk with, seek out, and work with women and people of color to those with whom we agree or feel comfortable. (Pp. 210-211)

Although other cultures value power differently in some spheres, male heterosexual power is almost universally valued:

Our response to the idea of power cannot be separated from what women have known about power, not only from being powerless but from watching the powerful. As we explore the issue of power, we necessarily use language and concepts which contain the assumptions of a destructively power-using, power-seeking culture, and these are reflected in the choices we see for ourselves. (Goodrich, 1991a, p. 4)

The powerful who are being watched by Goodrich's women are those who enlist in the White, male, heterosexual Euro-American worldview of who has power and why. The women are watching, and so are the indigenous peoples in the United States, who have historically been overpowered, enslaved or colonized, and the immigrants, who have been pressured to assimilate, acculturate, abide by, and even emulate this Euro-American dominant discourse about power. When people from other cultures move to this country, they are expected to conform to the dominant discourse. Part of the acculturation process includes the gradual acquisition of views about what power is and who has it. Those who acquire these views of "power over" may soon despair of having it.

The results of women's socialization are pathologized. The inflammatory Moynihan Report in the 1960s pathologized female heads of household among African Americans, shifting, many scholars feel, the responsibility for Black poverty to the Black family rather than to the institutionalized structures of oppression. In the 1980s, the addiction recovery movement used language to define a whole syndrome, namely, codependency (Beattie, 1987); the idea subtly reconstructed women's experience (Krestan and Bepko, 1990).

It is significant that the universal risk factor for alcoholism, across all cultures, is gender. That is, men are more at risk for addiction than women. Women are at risk for addiction primarily consequent to their relationships with men.

Sexual Orientation

Sexual orientation is another example of how the lens of the dominant discourse distorts our vision and privileges one group at the expense of another while allegedly creating static categories between people.

The lyrics of a song inKiss of the Spider Woman(Ebb, McNally, & Kander, 1992), a musical that depicts two men, a political rebel and a gay drug addict, sharing a jail cell, express the divisiveness between categories of sexual orientation. Valentin, the Marxist revolutionary, angrily sings to Molina, the homosexual:You're making me sick, that prissy whine. Watch me now, I draw the line. So you stick to your side, and I'll stick to mine. Never, ever cross this line!The dominant discourse on individual sexual preference has drawn lines, and the assumptions both creating and deriving from those lines serve to perpetuate the discourse on sexual preference as clear, divisive, and necessary.

Class

The dominant discourse on class in America is that anyone with enough will can achieve the upward mobility of the American dream. Those who share this attitude about achieving "success" insidiously punish those who don't acquire, or aspire to acquire, it. People of color, women, the less educated, those for whom English is a second language, the differently abled -- all are frequently prevented from acquiring "success" and are then shamed or held back because they are not "successful." McGoldrick and Giordano (1996) state, "Class increasingly organizes the United States in very insidious ways, including structuring the relationships among ethnic groups" (p. 16).

Of the relationships between class and other demographics, Kliman (1998) writes as follows:

Class involves multiple relationships to economic and other social structures: race, ethnicity, religion, gender, sexuality, physical and mental well-being, and geography. It also involves relationships between classes. One's economic and social circumstances exist in relation to those of others. (Pp. 50-51)

Definitions of class shift with context...as economic And other forms of domination operate together. (P. 51)

The media creates and promotes the language and images that support a dominant discourse on class.

The Broadway musicalMiss Saigondepicts a seventeen-year-old Vietnamese orphan girl who falls in love with an American GI during the fall of Saigon in the Vietnam War. (This production created a huge controversy about casting when it was originally cast with mixed-race actors.) The "Engineer" is first her pimp and later her hope when he sees that her mixed race child, Tam, can be their ticket to America. This fictional love story accurately depicts how people from other cultures frequently view living in the United States. The pimp sings:

What's that I smell in the air,

the American dream?

Sweet as a new millionaire,

the American dream!

Luck by the tail! How can you fail?

And best of all, it's for sale!

The American Dream! (Boublil, Maltby, & Schönberg, 1990)

The American dream the Engineer sings about promises a life of freedom, freedom to own land, start a business. The American dream includes the promise that if you work hard enough, you can, with a little luck, succeed in the United States. It is the promise that has lured immigrants since the discovery of America. Hayton (1994) claims that the first people to come were "dissenters, misfits, criminals, adventurers, indentured servants, and other risk-takers...[they had] the characteristics that helped the settlers survive in the wilderness, and these are the characteristics that stimulated invention and creativity and accounted for material progress throughout American history" (p. 105). People come to America to find material wealth and freedom from a repressive government.

Differences Among Differences

One difficulty with understanding difference is the human predilection to promote personal differences as so unique that no one else can understand them. Kliman and others demonstrate that it is the intersections between class, race, gender, and other demographics that construct "hierarchies" of oppression and shape family life. Almeida's (1994) hierarchy of oppression is created by demographics that describe collective consciousness and the external experience of self-power. Shame, in contrast, is the internalized experience. For example, a White, middle-class lesbian who is not "out" may be externally located higher up on the hierarchy of oppression. Her internalized experience, however, may place her somewhere else. Although one may claim that one's oppression is worse than another's, no one totally knows another's shame. In the United States, African Americans as a group are more oppressed externally than are Jews. However, a Jew may be more oppressed or internally feel more shame than an African American.

Whether one tells Polish jokes or queer jokes, language creates difference, and the resulting relationships of equal or unequal power. The perceived right to use language to make a joke at the expense of another illustrates an attitude of "power over."

Values of Origin in Western Culture

In describing her concept of ecological niche, Falicov (1995) writes, "Multiple contexts and the borderlands that result from the overlapping of contexts call to mind ecological spaces where access is allowed or denied, locations of partial perspectives where views and values are shaped and where power or powerlessness are experienced" (pp. 377-378).

Whatever ecological niche describes a particular family at a particular point in time, it is the values that extend across the parameters of that niche, that are, in my view, most relevant as risk or protection factors for addiction.

I am indebted to a friend (Lacy, personal communication, Feb. 12, 1997) for first using the phrasevalues of originto signify the range of values that relate to the other ecologies as class, religion, and education, among others, but that derive from one's country of birth or ancestry.

In the United States the values of origin derive from European colonization and prize "power over" in all spheres: individual, interpersonal, sociocultural, and spiritual. These values of origin assume superiority. The induction of immigrants into this dominant discourse is so thorough that it disrupts the original values of immigrant groups. In general, "power over" is a Western value. It is maintained by those in power to protect their power. The dominant discourse on values in the United States today promotes competition, individuality, mastery, youth, health, ability, and material success. It allows one person, or a few, to exert all four kinds of power.

A notable example of this is one man, Bill Gates, CEO of Microsoft, who allegedly has said, "There won't be anything we won't say to people to try and convince them that our way is the way to go."

Gates, who is, according toUSA Today(Mar. 4, 1998, p. 1), "...the nation's richest, most powerful businessman," is also the first business leader to defend himself before Congress. Gates was testifying in response to charges from his business rivals that Microsoft competes unfairly. The Senate is investigating whether to create new anti-trust legislation. Microsoft is "accused by competitors of ruthlessness. It is generally getting a public image as a greedy company out to control the world (p. 2A)."

The natural way these power holders think about their world was created and is supported by our country's dominant discourse. Those who have "power over" may not be conscious of their position, because it is their context, their difference, that predominates. It is only natural that the corrective context for recovery from attitudes dominated by Eurocentric idealization of "power over" -- of excess and exploitation -- and from the addictions they spawn is one of "power with."

Values of Origin in Other Cultures

Other cultures, compared to our Euro-American culture, have a very different discourse on power. For example, American Indians do not believe in power over the natural world. They strive for harmony with the environment and with nature. "A traditional Indian lives in harmony with the forces of life." (Simonelli, personal correspondence, January 15, 1998). As Coyhis puts it in chapter 3, "Indians look at it differently: you work with nature or the situation you are in; you understand that everything is interconnected. One of our values is to 'share the deer.' This value is the opposite of control; it's about sharing, it's about flow, it's about balance, and it's about rhythm."

Hispanic cultures view competition very differently from Euro-American culture. "White middle-class Americans stress individualism and actually value the individual in terms of his ability to compete for higher social and economic status. The Hispanic culture values those inner qualities that constitute the uniqueness of the person and his goodness in himself. To the Hispanic, family (familism) is more important than the individual" (Ho, 1987, p. 125).

Spirituality and religion are central to African Americans. Pinderhughes, Knox, McAddoo, and Boyd-Franklin emphasize the role of spirituality in the lives of African American clients and their families. Concepts of alcoholism among Whites, Blacks and Hispanics in the United States show widespread support for the concept of alcoholism as a disease, independent of ethnicity (Caetano, 1989). However, Blacks and Hispanics are more likely to think that alcoholism results from a violation of spiritual values and that addiction represents moral weakness. "Hispanics value the spirit and soul as much more important than the body and worldly materialism. A Hispanic person tends to think in terms of transcendent qualities such as justice, loyalty, or love. He is not preoccupied with mastering the world" (Ho, 1987, p. 127).

Spirituality is also central to the many different Indian nations in this country. Although belief systems vary widely among the more than five hundred federally recognized tribes, there are commonalities. These include a desire for harmony, a belief in the unseen world, and a belief in the interconnectedness of all life (Fleming and Manson, 1990).

Asian American and Pacific Islander communities have their own view of spirituality, one that is based on a history influenced by Confucianism and Buddhism. The tenets of their belief system include moderation in behavior, self-discipline, and harmony in relationships, derived from mutual loyalty and respect (Ho, 1987).

Interestingly, one of the most significant predictors of addiction -- religious affiliation -- is less studied than other demographic variables. Yet religious proscriptions regarding drinking, gambling, and other potential addictions are often highly correlated with drinking patterns.

The dominant discourse in the United States overtly prescribes equality for men and women, but covert power relationships between men and women are far from equal. African Americans are more likely than Whites to practice interpersonal gender equality. In her review of the literature on power relationships between Black spouses of varying social classes, Boyd-Franklin (1989) concludes that Black families appear to be more egalitarian than White couples. However, a high incidence of domestic violence suggests that this claim may represent more of an ideal than a reality.

Other countries with majority White populations also have different values of origin on some parameters as compared to the dominant discourse in the United States. TheUnited Nations Development Report(1994) states:

Traditionally, women in Europe have enjoyed greater equality with men than have women in any other region. For example, Sweden, Norway, Finland, Denmark and France top all other countries in having women's health, education and income levels approach those of men....Today, however, the gaps between men and women in Eastern Europe and the Commonwealth of Independent States are widening as a result of recent changes that have taken place in these countries...i.e., the rapid transfer from centrally-controlled to market economies.

Power and Addiction

The dominant discourse on "power over" in the United States creates a context in which those with this power inevitably fear losing it and those without it experience shame for not having it. Fear and shame are extremely uncomfortable feelings. Most of us spend our lives trying to avoid them. They are the demons that make our knowledge and acceptance of human limitation so painful.

Pinderhughes (1989) has noted a paradox in relation to power and vulnerability: "Paradoxically then, power can create greater vulnerability to powerlessness....Those in positions of power can also develop a tendency to deny their own personal pain and ignore their experiences of powerlessness" (pp. 122-123).

Different ecological contexts have different levels of significance in the evolution of, an individual's addiction and in his or her recovery from it. Different ecological contexts also produce differing experiences of power and powerlessness in people, experiences that may seemingly contradict one another. Someone with a strongly developed sense of spiritual "power to" may sustain relative powerlessness in the socio-cultural arena without feeling powerless, and one whose sense of power is diminished interpersonally within the family may invoke race, class, or heterosexual privilege in order to feel powerful. Almeida (1994) suggests that there are hierarchies of oppression, but a person seemingly high on the objective hierarchy (e.g., being male) may still feel oppressed if he is low on another (e.g., class) in a context where gender is less important than class.

Understanding addiction requires us to recognize power and powerlessness on all levels and in all their complexities. I have worked with clinicians who believed that "objective" powerlessness causes addiction and that recovery from addiction is irrelevant to those who are socially oppressed; these clinicians claim that their clients have "nothing to get clean and sober for." I have also worked with clinicians who failed to realize the ravages of addiction in families who appear to be powerful (e.g., White, materially successful, and well educated). Power can make one peculiarly vulnerable to feelings of powerlessness, and power comes with a high price (e.g., the price of power that is attached to male privilege).

Celia Falicov stresses the

About the Contributors

Moises Barón, PhD, Director, Counseling Center and adjunct faculty, School of Education, University of San Diego, California

Amy Bibb, MSW, Family Institute of New Jersey and private practice in Metuchen and Red Bank, New Jersey

Laura Chakrin Cable, MSW, LICSW, Co-Director of the Family Institute of Providence and private practice in Providence, Rhode Island

Georges J. Casimir, MD, Chief, Outpatient Mental Health Services, Kingsbrook Jewish Medical Center, Brooklyn, and Associate Professor of Psychiatry, SUNY Health Science Center, Brooklyn, New York

Peter Chang, PhD, Associate Professor, California School of Professional Psychology and private practice in Oakland, California

Don Coyhis, Director and Founder, White Bison, Inc., Colorado Springs, Colorado

Jeffrey Ellias-Frankel, PhD, Colts Neck Consulting Group, Colts Neck, New Jersey

Miguel Hernandez, MSW, Program Coordinator, Roberto Clemente Center and faculty, Ackerman Institute for Family Therapy, New York, New York

Jacqueline Hudak, MEd, Director, Family Therapy Associates of Monmouth County and faculty, Family Institute of New Jersey, Metuchen, New Jersey

Jo-Ann Krestan, MA, LMFT, LSAC, Visiting Faculty, Family Institute of New Jersey, Metuchen, New Jersey, and consultant, Surry, Maine and Castle Valley, Utah.

Alan Oberman, MSW, CADC, CCGC, Catholic Charities and Colts Neck Consulting Group, Colts Neck, New Jersey

Deniece J. Reid, MSW, LCSW, MATS, CDA, Director of Pastoral Counseling, The Cathedral/Second Baptist Church, Perth Amboy, New Jersey

Richard Simonelli, writer and advocate, Native American issues; Director, Mountain Sage Publishing, Boulder, Colorado

Kelly Ward, LCSW, CADC, Assistant Professor, Department of Social Work, Monmouth University and Colts Neck Consulting Group, Colts Neck, New Jersey

Excerpted from Bridges to Recovery: Addiction, Family Therapy, and Multicultural Treatment by Jo Ann Krestan
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