Treatment of Substance Abuse

Psychosocial Occupational Therapy Approaches

Diane Gibson

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781317839712
• Edition: 1
• Topic: Medicine
• Subtopic: Occupational Therapy

This timely volume fills a long-standing gap in the professional literature by providing an overview of contemporary assessment and rehabilitation of alcohol and chemical dependent substance abusers. Although many occupational therapists and other activity therapy staff work in substance abuse programs, few articles in occupational therapy literature address this relevant topic. Treatment of Substance Abuse: Psychosocial Occupational Therapy Approaches provides a unique overview of contemporary assessment and rehabilitiation of alcohol and chemical dependent substance abusers. The highlights of this insightful book include behavioral and educational frames of reference as well as specific treatment modalities such as stress management, activities of daily living, and leisure counseling. Contributors examine current polemics regarding programs that use methadone versus abstinence and theoretical concepts including the psychodynamic model with emphasis on the defensive structure underlying the abuser's personality, as well as leveled conceptual framework for considering treatment. A number of practical techniques are discussed within the overall context of each article; hence the reader will find usable guidelines for establishing boundaries of treatment as well as discreet ideas about methods and practice. Roles and functions of varying disciplines are reviewed in an effort to discriminate role clarity and provide implications for practice in relation to different models. This issue is valuable to the OT who seeks an understanding of the varying viewpoints and current practice in the substance abuse field.

Ethnographic Interview: An Occupational Therapy Needs Assessment Tool for American Indian and Alaska Native Alcoholics

Barbara K. Lange, MOT

Barbara K. Lange is affiliated with the Occupational Therapy Department, University of Utah Hospital, 50 N. Medical Drive, Salt Lake City, UT 84132.

The author would like to thank the following for their encouragement, support, and patience: Juli Evans, George Tomlin, and George Guilmet; David Whitehead; and the staff of the Puyallup Tribal Treatment Center. The author would also like to acknowledge her deepest appreciation and respect for the American Indians and Alaska Natives who so carefully taught her not to ask Why but to instead observe How.

This paper was submitted in partial fulfillment of the requirements for the degree of Master of Occupational Therapy from the University of Puget Sound, Tacoma, WA.

SUMMARY. For an occupational therapist unfamiliar with a culturally diverse treatment population, ethnographic interview is described as an appropriate method for assessing client group needs. This study describes the use of ethnographic interview as a tool which was culturally sensitive to the occupational behaviors of American Indians and Alaska Natives of the Northwest involved in drug and alcohol treatment. Results of the interviews helped the researcher identify sociocultural factors in the acquisition and maintenance of maladaptive behaviors. Recurring themes of the extended family network, the strength and complexity of social norms and codes, and the pervasiveness of alcohol use among this population are described in review of the literature and results of the interviews. Results of the Tennessee Self-Concept Scale revealed an overall measure of self-esteem significantly lower than that of the normed population, and generally supported rehabilitation issues originally identified by the literature and expanded on in the interviews. Implications for treatment discuss acceptance of the therapist by members of the culture, the concept of noninterference, the role of purposeful activity, cultural identification and assimilation, and the use of group work.

Assessing the needs of diverse cultural groups, such as the American Indians and Alaska Natives of the Northwest, is an important skill for any therapist entering an unfamiliar cultural setting, attempting to define and address the occupational issues of that culture.

Needs assessment will help the therapist respond to the actual needs of the client and not just to treatment needs as perceived by the health care professional (U.S. Dept. Health, Education, and Welfare, 1977). Standards of what is good or healthy may be unconsciously biased by the dominant cultural values of the health care worker (Clark, 1983; Leininger, 1978; Murillo-Rhode, 1979).

For an occupational therapist unfamiliar with a culturally diverse treatment population, ethnographic interview is an appropriate tool for assessing client group needs. Ethnography is the work of defining a culture. Unlike standard research, ethnography does not collect data from people for the purpose of testing an imposed hypothesis. Instead, ethnography seeks to understand the meaning people assign to objects and events in their daily lives. For health professionals, ethnography provides a method for examining health and disease from the patient’s point of view, regardless of cultural background.

Since occupational therapy “… seeks to promote maximum competence in occupational performance” (Rogers, 1982, p. 34) therapists need to understand the values and traditions of their American Indian and Alaska Native clients to assess accurately their needs and provide culturally appropriate treatment. Anthropological studies have shown that patients may temporarily abandon their own health care practices and beliefs to satisfy health care workers, but will ultimately reject imposed treatment regimes which run counter to internalized cultural values (Leininger, 1978).

PURPOSE OF THE STUDY

The purpose of this study was to implement an occupational therapy needs assessment which was culturally sensitive to the occupational behaviors of Northwest American Indians and Alaska Natives involved in drug and alcohol treatment. This assessment fulfills two purposes: it describes a process which any occupational therapist, newly challenged by an unfamiliar cultural setting, can use to help identify issues of cultural and treatment relevance, and; having been applied to a large group of Indians recently involved in alcohol treatment, offers a broad base of knowledge about a peer group, from which a therapist can identify or compare individual client dysfunction.

REVIEW OF THE LITERATURE

Native Values, Beliefs and Practices

In an attempt to describe a few of the more salient traditional American Indian and Alaska Native values and practices, the author acknowledges the risk of stereotyping. Because of cultural diversity among historically distinct tribal groups, “the value orientations related to productivity, self-maintenance, and leisure are culturally specific to some degree” (Skawski, 1987, p. 38). Concepts of sharing, cooperation, family, noninterference, time, learning style, and spirituality should be considered a characterization of typical group values and corresponding behavior.

“The concept of sharing is deeply ingrained among Native Americans who hold it in greater esteem than the white American ethic of saving” (Lewis & Ho, 1975, p. 379). Indians derive little status from the permanent accumulation of material goods. Historically in the Northwest culture area the Indian potlatch, a festive gathering of friends and neighbors in which an individual would distribute his accumulation of food, blankets or other useful items, is an example of the importance of sharing (Jilek-Aall, 1981).

Cooperation, patience, and nonaggression are important values among Native Americans. Unlike members of the white majority, Indians and Eskimos do not publicly emphasize individual achievements, and often do not feel as comfortable when encouraged to compete with peers (Weiringa & McColl, 1987). Skills tend to be used to contribute to the well-being of the family and tribe, and not for personal gain.

“To be really poor in the Indian world is to be without relatives” (Primeaux, 1977, p. 92). The extended family and the tribe are of foremost importance to the traditional Indian. Children are highly valued, loved and wanted. Elders are respected for their wisdom and expertise in traditional matters, and are valued for their ability to pass down their knowledge through myth, legend and folklore (Primeaux, 1977; Weiringa & McColl, 1987). Within the family, independence is encouraged. Children often eat, sleep, and play without seeking permission of their parents. They are usually free to explore their surroundings and are rarely told they cannot do something. Young children are protected from danger by having the danger removed. Older children are told about possible consequences of an act or decision, but are then “left free to make their choice” (Backrup, 1979, p. 22).

Freedom to explore the environment is also an essential component of Indian learning style. Guilmet’s review of the literature describing American Indian learning styles contrasts the way Indian children learn at home or within their native cultural environment, with teaching strategies typically used in white school systems (1985). Historical and contemporary evidence indicates that when learning technical knowledge or skills Indian children may receive verbal guidance from elders or teachers only after a lengthy period of observation of the task. Indian children may then experiment with trial and error to master the task independently, before presenting their skill or product for approval. For non-Indian children the long period of observation may be replaced by elaborate verbal instructions which describe the task in detail. Indian children, for whom sharp observational skills are culturally prominent, are at a specific disadvantage in white school systems where language is the primary teaching/learning modality. Also at odds with the white classroom emphasis on competition, verbalization, and individual achievement, are the Indian values of cooperation, nonaggression, and patience.

Patience is taught early to Indian children. They may play in the midst of a group of adults, but know not to interrupt their conversation. Indian adults may not respond to tantrums or outbursts by children, who are taught at a young age to control their emotions. Indian children are treated with the same respect and consideration they are taught to show others (Good Tracks, 1973). Child-rearing practices of Native Americans are largely based on the important concept of noninterference.

In American Indian society attempts to persuade or counsel another person, even to keep that person from doing something dangerous or foolish, are considered rude and will not be tolerated. White health care workers, teachers, and social workers are taught to “help” others through advising and counseling. These actions may be interpreted by Indians as “meddling,” and they will usually not respond to such interference (Lewis & Ho, 1975).

Traditional Indians also differ from white Americans in their concept of time. Time, as structured by a twenty-four hour clock, traditionally had no objective value to Indians. Their concept of time was a cyclical one based on naturally recurring phenomena; sunrise, sunset, days, nights, moons (months), and seasons (Lewis, 1975). A difference in time orientation also applies to orientation to the future. Whereas the white middle class is preoccupied with “saving for the future” and the “future of their children,” many Indians are oriented to the present. In their earlier subsistence lifestyle, work was done to satisfy a present need, rather than long term future security (Jilek-Aall, 1981). The mother earth provided all that was needed, and maintaining balance with nature by using only what was needed and saving for the next winter was in itself enough of a consideration for the future (Baker, 1982).

“American Indians have a profound spiritual relationship with nature and mother earth” (Backrup, 1979, p. 22). Maintaining harmony with spiritual forces which underlie and pervade nature and the perceived world is seen as the basis of health. “To the American Indian, ‘medicine’ means more than just the treatment of diseases and healing of injuries. There is little distinction between medicine and religion; they are aspects of the same thing” (Primeaux, 1977, p. 91). A primary purpose of Indian religions is to support a balance between the individual, other people, nature, and the spirit world. Traditionally, illness was treated in part by a shaman whose behaviors encompassed those of the contemporary physician, psychiatrist, and spiritual leader. The shaman, or medicine man possesses supernatural powers obtained through contacts with the “underworld” or communication with a guiding spirit (Jilek, 1982). Although shamanistic healing rituals vary from tribe to tribe, medicine men and medicine women consider the health of the individual to include his/her mind, body, and a personal relationship with the environment. They do not dichotomize the world into mental versus physical illness. The treatment process, which could include the ritualistic use of herbs, as well as ceremonial dancing or praying, is geared toward restoring the person’s harmony and oneness with the natural and spiritual world. Tribal religions provided a code for acceptable behavior, social organization “which contributed to an understanding of the meaning of life” (Mitchell & Patch, 1986, p. 129), and the means (ceremonies, rituals, and treatments) for preventing and dealing with individual or social dysfunction.

It must be understood that what has just been presented is a very general, brief description of a few traditional American Indian and Alaska Native beliefs and values. Although many tribal values and traditions are intact (to various degrees) and are expressed through individual and group behaviors, the problems of contemporary American Indians and Alaska Natives closely reflect the plight of the urban poor in America.

On many reservations, boredom, the absence of traditional roles, and the lack of opportunity to obtain white society’s well-advertised “good life,” exacerbate and perpetuate alcohol abuse, dissolution of the family, and general hopelessness among Indians. Rural Indians who do obtain an education or career opportunity off the reservation may experience conflict in trying to balance their two roles (Jilek-Aall, 1981).

American Indians living on urban reservations experience high unemployment, inadequate housing, and high rates of alcohol and drug abuse. Child neglect, spouse abuse, and high divorce rates indicate a general breakdown of the family unit (Guilmet, 1984). Urban Indians who have moved off their rural reservations are often deprived of supportive extended family networks. They may feel equally alienated from both their native culture and the white majority culture. Walker (1981) points out that in view of the steadily increasing migration of Indians into cities such as Los Angeles, Chicago, Minneapolis and Seattle, urban Indian alcohol programs must be designed to help Indians synthesize the values of the two cultures in which they live.

It is important for the occupational therapist to acknowledge the cultural traditions of American Indian and Alaska Native clients. The history and traditions of the aboriginal Indian are the basis for many of the occupational behaviors of contemporary urban and reservation-based American Indians. Because the health needs of each ethnic minority are unique, the therapist who has knowledge of various cultural groups is in a better position to communicate effectively with and treat his or her minority clients.

Scope of the Problem

To say that alcohol abuse is the number one health problem of American Indians and Alaska Natives (Baker, 1982; Beauvais & LaBoueff, 1985; Levy & Kunitz, 1974; Weibel-Orlando, 1984) understates the extent of the problem. The effects of alcohol abuse are far-reaching and perpetuate a cycle of family dissolution, economic depression, and community anomie. Indian people die younger than any other ethnic group in the country, with five of the ten leading causes of death directly related to alcohol. Alcohol is involved in 75% of all fatal accidents, 80% of all suicides, and 90% of all homicides (Kauffman, 1986). Mail (1985) reported that alcohol abuse is a main factor in the removal of Indian children from their homes, marital problems, spouse and child neglect, increased rates of infant morbidity caused by fetal alcohol syndrome, employment instability, and “complications in one’s spiritual life” (p. 3). In their survey of Indian youth attending rural reservation schools, Oetting, Beauvais and Goldstein (1981) found that drug and alcohol use is well-established among children in the 4th-7th grades.

The almost overwhelming scope of the Indian alcohol problem is compounded by notoriously ineffective alcohol treatment programs designed for and by white people (Kivlahan, Walker, Donovan, & Mischke, 1985; Query, 1985; Weibel-Orlando, 1984; Weibel-Orlando, Weisner, & Long, 1984). In response to a specific need, cultural identification and prevention strategies are currently being emphasized by many federally funded, tribally operated Indian alcohol treatment programs (Albaugh & Anderson, 1974; Hall, 1986; “Self Help,” 1974).

Ceremonial use of the sweat lodge is a cleansing and healing ritual once used by most aboriginal North American tribes. Although use of the sweat lodge had lapsed in many parts of the country, Hall (1986) found it to be an alcohol treatment modality popular among tribal treatment programs. This was particularly true of multitribal programs that also provided client access to the Native American Church, or employed a medicine man on a regular basis. Hall suggested that renewed popularity of the sweat lodge is part of a nativist reform movement which emphasizes Indian self-sufficiency, a return to the spiritual concepts of the pre-European past, and abstinence from alcohol.

Jilek-Aall (1981, p. 156) notes that, “as does the Coast Salish spirit-dancer, the Indian A.A. member...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• ABOUT THE EDITOR
• Foreword
• The Implementation of an Occupational Therapy Program in an Alcohol and Drug Dependency Treatment Center
• Occupational Therapy Intervention in the Treatment of Alcoholics
• An Organizational Framework for Occupational Therapy in the Treatment of Alcoholism
• Abstinence-Oriented Inpatient Treatment of the Substance Abuser
• Ethnographic Interview: An Occupational Therapy Needs Assessment Tool for American Indian and Alaska Native Alcoholics