Biopsychosocial Assessment

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Journal of Social Work Practice in the Addictions

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Applying an Ecological Framework to Understanding Drug Addiction and Recovery

Holly C. Matto PhD and LCSW-C

To cite this article: Holly C. Matto PhD and LCSW-C (2004) Applying an Ecological Framework to Understanding Drug Addiction and Recovery, Journal of Social Work Practice in the Addictions, 4:3, 5-22, DOI: 10.1300/J160v04n03_02

To link to this article: https://doi.org/10.1300/J160v04n03_02

Published online: 12 Oct 2008.

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Applying an Ecological Framework to Understanding Drug Addiction

and Recovery

Holly C. Matto

ABSTRACT. A new conceptual model of drug addiction and recovery, the Acculturation Model, is presented, with “addiction” and “recovery” understood as distinct sociocultural phenomena with their unique pre- scribed behaviors, rituals, symbols, and language that serve to construct and consolidate a cultural identity. The model suggests that individuals in recovery from drug addiction will need to make a cultural transforma- tion in order to maintain sobriety. Examples of specific rituals that may help facilitate movement from addiction to recovery are detailed. [Arti- cle copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Web- site: <http://www.HaworthPress.com> © 2004 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Culture, drug addiction, recovery, ritual, substance abuse

INTRODUCTION

One of the most widely recognized conceptual models of drug addic- tion endorsed by researchers, practitioners and clients is the medical model derived from Jellinek’s (1960) “disease” model of alcohol use.

Holly C. Matto, PhD, LCSW-C, is Assistant Professor at Virginia Commonwealth Uni- versity School of Social Work (E-mail: [email protected]).

Journal of Social Work Practice in the Addictions, Vol. 4(3) 2004 http://www.haworthpress.com/web/JSWPA

© 2004 by The Haworth Press, Inc. All rights reserved. Digital Object Identifier: 10.1300/J160v04n03_02 5

The disease concept is the predominant framework across most sub- stance abuse treatment programs and is the fundamental philosophy of 12-step self-help groups, which are nearly universally recommended for clients during and after participation in a formal treatment program (Jung, 2001).

The medical model has provided an important foundation from which to understand addiction, and may serve to reduce societal stigma associated with addiction, to the extent that extricating “disease” from “person” reduces bias against the individual. Contextualizing sub- stance-related behaviors from the medical model has helped profession- als working in the field, individuals struggling with addiction, and family members who have loved ones wrapped in the throes of sub- stance abuse to understand the biological processes that undergird ad- dictive behaviors. It also helps in eliminating the notion that substance abuse results from a deficiency in willpower or lack of moral strength (Jung, 2001). In addition, continued earmarking of substantial federal funding for bio-behavioral research initiatives in substance abuse etiol- ogy, progression and treatment is further testimony to the widespread recognition and adoption of the disease concept of addiction, and the so- cietal value placed on preventing, mitigating, and managing illness.

However, coinciding with the advantages and benefits brought by the medical model, there are distinct disadvantages that have been well ar- ticulated by social workers working in the field of substance abuse (Amodeo, 1997; Okundaye, Smith, & Lawrence-Webb, 2001). Specifi- cally, cultural and social factors implicated in causing, maintaining, and perpetuating drug addiction are not given due attention in the medical model (Amodeo, 1997). Moreover, the central focus on illness, deficit and powerlessness can compromise a client’s sense of worth, dignity and self-determination. Often, clients will begin to see themselves se- lectively through this lens of disease (Castro, Proescholdbell, Abeita, & Rodriguez, 1999).

While this selective approach might be necessary and appropriate as an initial step in matching treatment response to how clients have lived out their drug addiction–acknowledging that the disease has taken over the entirety of their lives, identity, and relationships–a more holistic framework is needed in working with clients over the long term. Impor- tant new directions in this area can be found in recommendations being promulgated by national health science institutions. For example, the National Institutes of Health (NIH) has presented a long-term research agenda that seeks to incorporate social and cultural factors into health research. Multilevel analyses are recommended that will include the so-

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cial/environmental context as well as psychological/behavioral and bio- logical contexts (Anderson, 1998). This multidimensional approach is particularly exciting for substance abuse researchers and practitioners who have traditionally viewed addiction as a biopsychosocial disease that requires multilevel treatment interventions.

In beginning to develop new biopsychosocial practice models, social workers have begun to challenge the deficit paradigm associated with an insular medical model in favor of a more inclusive strengths perspective that is more compatible with the profession’s values and ethics (Brun & Rapp, 2001; Gray, 2001; Okundaye, Smith, & Lawrence-Webb, 2001). Recent literature suggests that strengths-based concepts (e.g., “em- powerment,” “suspension of disbelief,” “dialogue and collaboration,” “membership,” and “regeneration”) be incorporated into existing addiction paradigms (Okundaye, Smith, & Lawrence-Webb, 2001, p. 71-72).

Over the past decade, scholars working in the field have advanced the exploration of sociocultural implications related to substance abuse. For example, recent investigations have focused on culturally competent addictions practice (Bush & Sainz, 1997; Hodge, Cardenas, & Montoya, 2000; Markward, Dozier, Hooks, & Markward, 2000; Taylor, 2000; Woll, 1996) and treatment needs of special populations (Castro et al., 1999; Cruz & Peralta, 2001; Isralowitz, 2001; Shedlin & Deren, 2002; Straussner, 2001; Waters, Fazio, Hernandez, & Segarra, 2002; Westermeyer, 1984). However, examining addiction and recovery as transactional processes using an ecological lens has not been explored to date.

This paper presents a new conceptual model of drug addiction and re- covery from an ecological framework, the Acculturation Model, which conceptualizes addiction and recovery as transactional processes that take place within a larger sociocultural context. The model incorporates both internal (motivational readiness and perceptional factors) and ex- ternal (sociocultural, environmental, and ecological) factors in explain- ing where a client is in the addiction-recovery process, with the individual viewed as inseparable from and in transaction with the envi- ronment. Individuals entering into recovery are, therefore, faced with making a significant sociocultural transformation as part of the path to sobriety.

CULTURE AND CULTURAL IDENTITY

“Culture” is a multifaceted construct representing social group affili- ation or attachment, social influences, personal identity development,

Holly C. Matto 7

participation in prescribed behavioral practices, and shared sociocul- tural interactions. Culture has been defined as a social group’s behavior patterns and customs, and as “a set of traditional, explicit and implicit beliefs, values, actions, and material environments that are transmitted by language, symbol and behavior within an enduring and interacting group of people” (Saarni, Mumme, & Campos, 1998, p. 247). A sense of community found in cultural membership is relationally formed through emotional commitment and a newly forged identity (Etzioni, 2001).

According to Westermeyer (1984), cultural elements are learned and can be classified into four domains:

1. Technology: transportation, housing, tools (e.g., stories, songs, beliefs, artifacts)

2. Social Institutions: family, neighborhoods, organizations, fellow- ship

3. Psychosocial Factors: identity, beliefs, norms, roles, status, ritual, ceremony, symbols

4. Communication: language, nonverbal behavior (p.12)

In this article, elements from two of these four domains–psychosocial factors and communication–are described and applied to addiction and recovery cultures.

Cultural Identity

Cultural identity is a composite of skills, behaviors, values, relation- ships, and social competencies that reflects one’s membership within and commitment to a given community. Acculturation represents the process by which individuals acquire the requisite psychosocial proper- ties that fit with a particular cultural identity, facilitating movement into a prescribed social environment (Parke & Buriel, 1998). Such cultural identity construction emerges through the developing memberships and commitments to addiction and recovery communities. As pointed out by Amodeo (1997): “The addiction process is viewed as one that pro- foundly changes identity” (p. 566).

Indeed, contemporary research has shown that individuals must ne- gotiate both a new social as well as personal identity as they move into new relationships or social context attachments during the recovery process (Koski-Jaennes, 2002). Of interest to practitioners and re- searchers are the nature of these sociocultural adaptations and the iden-

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tification of specific sociocultural elements that help move clients from addiction into recovery.

Identity transformation is critical in the acculturation process, and con- structing a new cultural identity becomes an essential component of re- covery as clients explore “Who am I now?” “How do I act?” “What do I do?” in negotiating through acute social status confusion. In addition to individual and treatment facility components implicated in identity trans- formation and cultural socialization, ecological variables (e.g., employ- ment opportunities, perceived societal stigma, community sustainability, niche-construction) significantly influence a client’s cultural transforma- tion.

THE ACCULTURATION MODEL

The proposed Acculturation Model recognizes that behaviors, atti- tudes, perceptions and sociocultural attachments are influenced by both the addiction and the recovery contexts (or communities), i.e., an indi- vidual’s strength of attachment to addiction or recovery communities is influenced by the social context such as family, friends and neighbor- hood. The Acculturation Model posits an interactive process across time, with movement through addiction and recovery communities viewed as fluid and flexible rather than rigid and dichotomous. Similar multidimensional or pluralistic acculturation models have been pro- posed in the sociological literature to explain ethnic identity develop- ment (Porter & Washington, 1993).

Table 1 provides a matrix that conceptualizes this interactive rela- tionship between addiction and recovery membership over time, sug- gesting that cultural identity also develops and changes through these relationships. The matrix shows the dynamic nature of cultural mem- bership and identity construction, whereby movement among quadrant pathways is influenced by an individual’s social, behavioral, psycho- logical transaction within the larger social context.

Quadrant one shows that individuals may be highly engaged in ad- diction behaviors while simultaneously not being influenced by the re- covery community, indicating that the individual is at high risk for continuation of substance abuse and the associated negative conse- quences. These individuals may experience strong attachment to the ad- diction community through relationships with social context agents (e.g., friends, family, neighborhood connections) who are also highly

Holly C. Matto 9

attached to this community and, simultaneously, may have few social connections with context agents committed to the recovery community.

Quadrant two shows individuals who are high in both addiction and recovery cultures. People struggling with high membership across two cultures with vastly disparate values, beliefs, and behavioral norms may experience a state of psychological and social disequilibrium or anomie. Thus, individuals in this quadrant are likely to experience extreme feel- ings of ambivalence. These may be individuals who struggle with a

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TABLE 1. Matrix of Addiction and Recovery Cultures

Quadrant 1 Addiction Culture (high) Recovery Culture (low)

• Strong fit between drugs/alcohol and self-image

• Weak fit between recovery and self-image

• High congruence in favorable attitude towards drugs/alcohol between client and other agents in client’s social context

• Low congruence in favorable attitude towards recovery between client and other agents in client’s social context

• Attachment to social context strongly influenced by addiction community

• Attachment to social context weakly influenced by recovery community

Quadrant 2 Addiction Culture (high) Recovery Culture (high)

• Strong fit between drugs/alcohol and self-image

• Strong fit between recovery and self-image • High congruence in favorable attitude

towards drugs/alcohol between client and other agents in client’s social context

• High congruence in favorable attitude towards recovery between client and other agents in client’s social context

• Attachment to social context highly influenced by both addiction and recovery communities, and clients may be characterized by extreme ambivalence and repeated relapse

Quadrant 3 Addiction Culture (low) Recovery Culture (low)

• Weak fit between drugs/alcohol and self-image

• Weak fit between recovery and self-image

• Low congruence in favorable attitude towards drugs/alcohol between client and other agents in client’s social context

• Low congruence in favorable attitude towards recovery between client and other agents in client’s social context

• Attachment to social context is not determined or influenced by addiction or recovery communities

Quadrant 4 Addiction Culture (low) Recovery Culture (high)

• Weak fit between drugs/alcohol and self-image

• Strong fit between recovery and self-image • Low congruence in favorable attitude

towards drugs/alcohol between client and other agents in client’s social context

• High congruence in favorable attitude towards recovery between client and other agents in client’s social context

• Attachment to social context weakly influence by addiction community

• Attachment to social context strongly influenced by recovery community

strong desire for sobriety, have a past experience with recovery, and yet continue to feel the compulsion and pull of active addiction. Despite their expressed strong commitment to a recovery program, they may find themselves in and out of treatment programs due to chronic relapse.

Quadrant three shows individuals who are low in both addiction and recovery communities. Individuals who are low in attachment to addic- tion communities experience weak commitment to the behaviors, social affiliations, rituals and technologies of addiction, and yet are not ac- tively connected to a recovering community. For some, this may mean that they were only brief engaged in both active substance abuse and re- covery efforts, while for others, such as those with long-term sobriety, it may mean that their cultural identities are fully integrated and that they are not actively involved in either culture (e.g., do not attend 12-step meetings, provide sponsorship, or work in a substance abuse treatment facility). Such individuals are generally at low risk for relapse.

Quadrant four represents individuals who have made a strong com- mitment to sobriety, demonstrated by a high involvement in recovery culture, such as taking on 12-step meeting responsibilities (e.g., coffee making, literature committee, chairing meetings) and low addiction pat- terns. This quadrant may include individuals with long-term sobriety who devote their occupational, recreational, and relational time to re- covery-related activities (e.g., working in a drug rehab, opening a half- way house, continuing sponsorship responsibilities).

Treatment needs to focus on this “acculturation” across cultural mem- bership, to explore how, why, and under what circumstances grid move- ment occurs. Of specific treatment concern is understanding cultural identity deconstruction and reconstruction processes, and to identify and strengthen individual and treatment facility elements associated with client socialization into the recovery culture, strengthening client cultural engagement.

Reconceptualization of the change process from current individual behavioral-based stage-sequential processes (McConnaughy, Prochaska, & Velicer, 1983; Miller, Tonigan & Montgomery, 1990; Prochaska & DiClemente, 1983; 1986) to recognizing contextual factors can frame the individual struggle within a larger ecological context. There can be much power gained in viewing oneself as a member of a sociocultural group for whom the symbols, social artifacts, language, customs, and rituals are shared. Applying an ecological framework to understanding substance abuse and recovery processes can also facilitate changes in how society views the addicted individual, with a goal of continuing to fight against addiction stigma.

Holly C. Matto 11

Relapse

The Acculturation Model does not conceptualize relapse as an event that propels an individual from one status to another (from “sober” to “drug-using”); rather, “relapse” is viewed as a sign of significant ten- sion existing between the confluence of two competing cultural mem- berships. A relapse, then, is the behavioral consequence or expression that an individual’s cultural memberships are strained, indicating move- ment and transition along the matrix pathways.

Such transitions are marked by an increase and/or decrease in spe- cific sociocultural practices; individuals may experience heightened so- ciological ambivalence or cultural cognitive dissonance. The associated feelings that this disequilibrium brings can foster growth and change (e.g., a recommitment to a previous level of membership by entering treatment) or, alternatively, can lead an individual toward a more rigid, linear cultural practice (e.g., deeper into active addiction).

Ritual

Rituals are important aspects of culture and of the acculturation pro- cess. “Every culture has its own system of healing. All over the world, healing involves calmness, beautiful places, kind people, simple rou- tines, rituals, and temporary protection from everyday problems” (Pipher, 2002, p. 104). The concept of “ritual” is not new to people struggling with addiction; rather, ritualistic behaviors are manifest in destructive ways during active substance use as compulsive behaviors that perpetuate the addiction. For example, ritual behaviors that collec- tively structure addictive patterns include illicit activities to obtain drug money; procedures associated with obtaining the drug, “cooking” and drug preparation; and the consequential high and repeated cycle of withdrawal. Addictive rituals organized around the commitment to the high include activities such as locating transportation to get the drugs, maneuvering through culturally prescribed spatial arrangements with designated social roles and statuses (e.g., “lookouts”; “runners”; “money handlers”), and the adoption of a common language with its unique semiotics.

Persons struggling with recovery also participate in ritualistic behav- iors. The 12-step program operates from this framework, creating com- mon rituals and language that encourages community membership, affiliation, and social bonding, as do methadone maintenance programs. Much can be learned from exploring the functional elements of recov-

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ery-related ritual. Rituals function to provide consistency, structure, predictability and guidance with a population for whom these very at- tributes are essential and often missing. Two psychosocial functions of ritual include reaffirming a social and spiritual structure and managing collective stress. Rituals can provide safety, containment, meaning, and connection (Scheff, 1979), and can put suffering and pain into a mean- ingful context.

Rituals also connect time dimensions, offering continuity in life eras (past, present, future), and provide a sense of “rootedness” and future promise (Van Gennep, 1960). Van Gennep’s (1960) three stages of the ritual process parallel the recovery process, and can be understood as el- ements of acculturation into recovery: (1) separation (preparing for rit- ual); (2) transition (forming new roles/identities); and (3) reintegration or aggregation (moving into stable experience). Thus, rituals can facili- tate client socialization to the recovery community when entering into treatment, leaving treatment, and transitioning among phases of recov- ery, and serve to organize and regulate behavior.

Imber-Black (1999) discusses three categories of rituals found in the family therapy literature: transition, healing and identity redefinition rituals.

1. Transition rituals. Such rituals confirm a process of normative change and transition. In recovery, transitional rituals open up opportunities and space for transformation, healing, and redefinition to occur. Transition ritu- als mark new life phases and initiate members into new roles. Rituals may function to mark developmental changes as they occur in the recovery pro- cess, and hold significance in validating strong emotions, mitigating anxi- ety associated with change.

For example, in a hospital-based substance abuse treatment setting, the “stripping down” process that requires the discarding of street clothes in exchange for blue hospital scrubs upon intake, symbolizes the transitional space that serves as antecedent to emerging identity trans- formation. Another example of transitional rituals is the key chain and anniversary ceremonies that traditionally take place at 12-step meet- ings, publicly marking an individual’s length of time in recovery.

2. Healing rituals. These rituals facilitate physiological, cognitive, emo- tional, spiritual and relational change. Shared social meanings are transmit- ted through customs and traditions. Healing rituals can be transformative, create bonding, and make space sacred. “Private rituals can engender recommitment to the society at large, as do public shared rituals” (Etzioni, 2001, p. 127). For example, sharing one’s story or giving public testimony

Holly C. Matto 13

to a group of recovering witnesses can powerfully connect members and strengthen a collective commitment to the recovery process.

3. Identity redefinition rituals. These rituals function to decrease stigma brought on by constructed labeling, and help clients to find a sense of place in a new social structure. For example, taking on a new role in sponsorship or taking on a new job at 12-step meetings can create change in an individ- ual’s social identity within the recovery community.

Over time, rituals can aid in integrating disparate parts of one’s self, bridging disparate cultural memberships. Ritual, as a cultural exchange process that facilitates movement between addiction and recovery com- munities, is an important sociocultural element for treatment providers to attend to in aftercare transitioning.

PRACTICE APPLICATION OF THE ACCULTURATION MODEL

This paper illustrates one transitional pathway in the matrix–those high in addiction and low in recovery transitioning into high recovery and low addiction–and describes the social context processes that facili- tate this transition, using case examples from clinical work at a short-term hospital-based substance abuse treatment facility.

An underlying practice tenet of the Acculturation Model is that sub- stance abuse treatment needs to allow for the creation of new recov- ery-related rituals, language and symbols. For example, the serenity prayer,1 used to open and close many 12-step self-help group meetings, is a healing ritual that unifies social interactions through a structured common language that strengthens bonds among members and restores both a personal and collective commitment to recovery principles. Other self-help group rituals enacted to structure, guide, and renew re- covery commitment at each meeting include reading the 12-steps and 12-traditions and performing meeting duties such as sponsorship solici- tation, recognizing “home group” members and educating on program literature.

In addition, prescribed scripts are generally followed by meeting par- ticipants during introductions and story sharing. They tend to include the following format: “Hi, I’m (first name). I’m an addict/alcoholic” with the group responding “Hi (first name). Keep coming back.” The group re- sponse following each story that is shared is “Thanks for sharing.” Recog- nition for clean time is signified by participation in a key chain ceremony that acknowledges each meeting participant with 30 days, 60 days, 90 days,

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one year, two years, multiple years, and 24 hours or less of “clean time,” re- iterating that “the most important person in the room is the newcomer.” Residential treatment settings may include morning meditations and daily check-in and close-outs that require residents to express physical, mental and spiritual feelings, contribute to solidifying structure and routine through ritual.

The Goodbye Ceremony

One example of a cultural recovery ritual that stimulates healing in an inpatient setting is the Goodbye Ceremony. Membership and celebra- tion are specific ritual functions illuminated in the Goodbye Ceremony. The community forms a circle around the departing member, symboli- cally enclosing the member in a supportive web of affiliation. A key chain, a symbol of program completion, is passed around to each mem- ber of the community and is ultimately given to the departing client as a gift from the group to mark his/her successful completion of the pro- gram. During this social exchange ceremony, each group member is in- vited to share significant memories about the parting member and, in turn, the parting member is asked to share something significant about his/her relationship with each group member and about the group as a whole. Clients share that the key chain is viewed as an artifact repre- senting closure, accomplishment, and pride. Rituals like this one allow the tension between holding on and letting go to become palpable, and affirm transition through celebration and social exchange.

The Goodbye Letter

Another transition ritual incorporated into inpatient settings is the Goodbye Letter. This ritual allows for the mourning of drug addiction behaviors as a necessary antecedent to developing new recovery-related rituals. Members are asked to construct a goodbye letter that expresses his/her relationship with the drug and the related feelings about the ter- mination process. Clients will often include in their letters metaphors about how they perceived their relationship with heroin, alcohol, crack-cocaine or other drugs, and share feelings about what they will miss and what will not be missed in letting go of their drug relationship. Clients read their letters to the group, participating in a symbolic “let- ting go” process. Group members offer feedback to help the client sus- tain recovery commitment and to explore the often intense, exposed emotions. The following are excerpts from different goodbye letters:

Holly C. Matto 15

Dear Mr. Al Cohol, with your help I have lost it all–my health, family, house, self-respect, and admiration from everyone I love. Your departure is long over due. Although your personality was addicting, fond memories will not remain. Parting is not sweet sor- row.

This scene has been played out many times; society chooses to look the other way. People are lost in destruction. Reconstruction is necessary. Self-inflicted disaster. Amends are to be made.

She was the love of my life. She soothed me and my pain. I wel- comed her. She had many mates. When she died, all the feelings she soothed had to be replaced.

Drawings

Art experiences can powerfully evoke emotional expression through symbolic action, and can serve as significant transitional, healing, and redefinition rituals (see Tables 2 and 3). Art products will often depict addiction and recovery cultural symbols coexisting together, represent- ing the experienced reality of dual membership and the resulting ambiv- alence. Some examples of recovery and addiction cultural symbols found in residential treatment art productions include pictures of skele- tons, gravestones, broken hearts, and the inner city. One drawing very poignantly detailed a man immersed in a cluttered room, scrounging around on the floor in abject desperation. The drawing was entitled “Looking for the Rock.”

Art as symbol gives validation, meaning and coherence to one’s cul- tural memberships, and can aid in the redefinition process of expanding one’s current identity. Art can be transformative through process (ac- tion) and product (art content), and can symbolically mark significant transitions. One specific art directive asks clients to illustrate what they need to “leave” in treatment (e.g., old attitudes, social affiliations, thoughts, behaviors), and what they need to “take” with them into their next environment as they leave treatment (e.g., new hope, courage, ac- cess to and development of support networks, empowerment). One cli- ent illustrated the importance of control over memories as an internal capacity that bridges both “inside” and “outside” treatment processes. This client saw memories as a transitioning factor in leaving treatment; as a unifying tie to past and present identity constructions; and as com-

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Holly C. Matto 17

TABLE 2. Client Artwork Representing Addiction Culture

Cultural Symbol Cultural Message

Empty skis

Skeleton

Swimming in a bottle

Fish trapped in a bag

Mirrored image

fighting self

Monster

Junk yard

Chained to the bottom

of a water bed

Solo oboe

Frozen hand in the

snow

Skull and crossbones

Map

Dangling from the

cliff's edge

Broken-down car

Gas gauge on empty

Feeling “out of my skis”

“Me, when I came into treatment”

“My escape”

“Trapped in a sea of pain”

“I’m my own worst enemy”

“This is me when I’m using”

“The wreckage of my life”

“I’m trapped and I can’t get up for air”

“I can’t play with the rest of the band”

“I’m reaching for help; hoping to thaw out”

“Always drawn toward poison”

“I’m at the crossroads”

“Barely hanging on”

“Spiritual depletion”

“I can’t go on”

TABLE 3. Client Artwork Representing Recovery Culture

Cultural Symbol Cultural Message

Hope chest

Oyster

Turtle

Puzzle

Nature scenes

Swimming in a pool

“Take what you need, leave the rest for later”

“You have the pearls of wisdom inside you”

“Sometimes you have to leave the protective shell”

“Trying to piece it all together”

“Peace, serenity, freedom, inspiration”

“Seeing things with clear eyes”

forting resource she could draw from in the future (e.g., the social sup- port and relationships formed during treatment).

Another directed art experience that facilitates transformation is the therapeutic gift exchange. Clients are paired with a partner and are asked to create a recovery-related “gift” for their partner based on what they think their partner needs in order to maintain sobriety. Clients en- gage in the symbolic act of creating an art product. Symbolic action, however, is also realized through the social exchange process of gift giving and gift receiving. During the sharing process clients become aware that it is often easier to identify what others need than to take re- sponsibility for meeting one’s own needs and self-changes.

Out of the drawn form arise client narratives, or sociocultural stories, related to their lived experiences. This language, embedded in client narratives elicited through the artwork, reflects a significant cultural component that serves a partializing function. For example, recov- ery-related slogans are quite prevalent in both formal treatment and self-help settings, and help to distill information and direction into man- ageable pieces that allow messages to be readily accessed at vulnerable times. One example of this can be found in recovery-related slogans that parallel the longer standardized version of the first three steps of the 12-step program:2 “I can’t; He can; I’ll let Him”; “awareness; accep- tance; and action.”

Slogans provide for simplicity and, therefore, power in the message that gives direct advice for action. Examples of such slogans include “You’re either working towards recovery or working towards relapse”; “There are only three outcomes to continued drug use: Jails, institu- tions, and death”; “One day at a time”; “Honesty, Openness, and Will- ingness”; “Meeting-makers make it”; “FEAR is Forget Everything And Relapse, or Face Everything And Recover”; or the African proverb: “When death finds me, I hope it finds me alive.” A few of the more memorable indigenous or client-derived slogans include “Flock with like fliers”; “Fly above your surroundings”; and “Stay out of the woods, hunting season is open all year.”

Sociocultural Transitions

“Becoming involved in an environment requires the navigation of border points between groups, organizations, or institutions. Barriers may exist at these border points that may increase the difficulty of gain- ing needed assistance or services. The transition between treatment en-

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vironments may be affected by the fit between a person and the new environment, impacting how easily and to what degree the person is able to navigate this transition” (Mankowski, Humphreys, & Moos, 2001, p. 539).

Transition in addictions treatment has traditionally been defined as the point at which an individual leaves one phase of recovery for an- other phase, often indicated by a physical move (e.g., from an inpatient hospital-based setting to a longer-term treatment facility; from a 28-day residential program to a halfway house). Much of the transitioning fo- cus in the practice community has been on case management and con- crete discharge planning. What is often missed is the sociocultural transition that simultaneously takes place, not as an event but as a multi- dimensional process of transformation.

This is precisely why careful attention to the reintegration process of aftercare transitioning is so critical in drug addiction treatment, as at the very time a client has begun the healing process of symbolically and concretely changing one’s cultural membership, the client is charged with reentering a society for which his/her addiction membership has already been firmly established. Society welcomes the client into old roles, niches, practices, and relationships. The onus, then, is on the cli- ent to seek access to a new culturally compatible environment that pro- motes a positive and healthy transactional fit with one’s new membership.

Certainly the client is in need of much support at this time to negoti- ate this transition and to find societal access for continued nurturing and growth. This is one reason why many treatment protocols offer client mandates to “commit to 90 meetings in 90 days,” “get a sponsor,” and “work the 12-step program.” This ritual process, initiated in the inpa- tient treatment milieu, can be extended in practice into a client’s new re- covery-saturated social world upon discharge. A client’s personal and social identity transformation, with associated changes in social roles, can help solidify commitment, solidarity, and continuity of one’s new cultural attachment.

CONCLUSION

While the treatment literature recognizes the multidimensional and complex consequences of addiction (e.g., housing, legal, economic, health, mental health, interpersonal relations), current practice models do not comprehensively include the social context. The Acculturation

Holly C. Matto 19

Model as presented from an ecological framework gives new direction to expanding the existing practice models. Understanding the socializa- tion processes implicated in sociocultural transitioning and how ritual might be used to facilitate movement through recovery phases should be the focus of future research inquiries. The model offers a contextualized base for assessment and intervention, positing a dy- namic change matrix that enables clients and practitioners to explore where the client is embedded socioculturally and, thus, to identify the individual’s specialized treatment needs.

Research initiatives need to examine the specific sociocultural ele- ments involved in such transitioning. Specifically, studies that examine the function of specific rituals in strengthening attachment to the recov- ery community via social context relationships are needed. It is impor- tant to identify the specific factors that influence movement and transition from one grid quadrant to another; for example, from an am- bivalent position of high addiction and high recovery to low addiction and high recovery. In beginning to understand the sociocultural factors that facilitate this transitional movement, treatment providers can better meet the unique needs of their clients.

NOTES

1. “God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

2. Step one: “We admitted we were powerless over drugs/alcohol–that our lives had become unmanageable”; Step two: “We came to believe that a power greater than our- selves could restore us to sanity”; Step three: “We made a decision to turn our will and our lives over to the care of God as we understood Him.”

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RECEIVED: 06/20/02 REVISED: 09/05/03

ACCEPTED: 03/01/04

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