This article was downloaded by: [University of Tennessee, Knoxville] On: 16 April 2015, At: 11:18 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Social Work Practice in the Addictions Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wswp20
International Social Work: Experiences and Implications Regarding Substance Abuse a
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Christine Fewell PhD LCSW CASAC , Dorie J. Gilbert PhD , Sam c
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MacMaster PhD , Todd Maison MSW , Lori Holleran Steiker PhD e
ACSW & S. Lala Straussner DSW CAS
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Adjunct Assistant Professor, School of Social Work , New York University , New York, New York, USA b
Associate Professor, School of Social Work , The University of Texas , Austin, Texas, USA c
Associate Professor, School of Social Work , University of Tennessee , Nashville, Tennessee, USA d
CSR Coordinator, The Center for Students in Recovery , The University of Texas , Austin, Texas, USA e
Assistant Dean for Undergraduate Programs and Associate Professor, School of Social Work , The University of Texas , Austin, Texas, USA f
Professor, School of Social Work , New York University , New York, New York, USA Published online: 16 Nov 2011. To cite this article: Christine Fewell PhD LCSW CASAC , Dorie J. Gilbert PhD , Sam MacMaster PhD , Todd Maison MSW , Lori Holleran Steiker PhD ACSW & S. Lala Straussner DSW CAS (2011) International Social Work: Experiences and Implications Regarding Substance Abuse, Journal of Social Work Practice in the Addictions, 11:4, 398-407, DOI: 10.1080/1533256X.2011.622652 To link to this article: http://dx.doi.org/10.1080/1533256X.2011.622652
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Journal of Social Work Practice in the Addictions, 11:398–407, 2011 Copyright © Taylor & Francis Group, LLC ISSN: 1533-256X print/1533-2578 online DOI: 10.1080/1533256X.2011.622652
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International Social Work: Experiences and Implications Regarding Substance Abuse CHRISTINE FEWELL, PHD, LCSW, CASAC Adjunct Assistant Professor, School of Social Work, New York University, New York, New York, USA
DORIE J. GILBERT, PHD Associate Professor, School of Social Work, The University of Texas at Austin, Austin, Texas, USA
SAM MACMASTER, PHD Associate Professor, School of Social Work, University of Tennessee at Nashville, Nashville, Tennessee, USA
TODD MAISON, MSW CSR Coordinator, The Center for Students in Recovery, The University of Texas at Austin, Austin, Texas, USA
LORI HOLLERAN STEIKER, PHD, ACSW Assistant Dean for Undergraduate Programs and Associate Professor, School of Social Work, The University of Texas at Austin, Austin, Texas, USA
S. LALA STRAUSSNER, DSW, CAS Professor, School of Social Work, New York University, New York, New York, USA
The trip was to the shrine of the Virgin of Guadalupe outside Mexico City. People go there to swear to the Virgin (in front of family and the priest) that they will give up alcohol, and then receive a certificate to that effect. Our guide said that in Mexico this was often a much more powerful a force for stopping drinking than AA, which has difficulties dealing with class differences in this society. The guide pointed to a separate building in the huge complex of the Shrine where a line of very sheepish, nervous looking people waited to see the priest, say what they
Address correspondence to Lori Holleran Steiker, School of Social Work, University of Texas at Austin, 1925 San Jacinto Boulevard, Austin, TX 78712, USA. E-mail: lorikay@mail. utexas.edu 398
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are swearing to give up and for how long before signing the papers. If someone goes to a party and is offered a drink and says I can’t drink because “Estoy jurado” (I have sworn), people will respect that and leave the person alone. This whole procedure speaks to the importance of the Virgin of Guadalupe in Mexican life. People are supposed to make a pilgrimage there once in their lifetime, similar to the way Muslims are supposed to go on a pilgrimage to Mecca. The people walk, sometimes for a week or more to get to the church. —Christine Fewell, PhD
Lori Holleran Steiker: This story clearly highlights the impact of culture when examining international social work and substance abuse. This dialogue will explore this topic from a variety of perspectives with a number of social workers. Let’s start this dialogue by discussing where and in what capacity have you practiced social work internationally? S. Lala Straussner: My focus has been on international social work education, with specialization in addictions. I have been a visiting professor (including a Fulbright Scholar) in a number of different countries including: Israel, Poland, Germany, Russia (Siberia), Ukraine, and Czech Republic. During 2007 and 2008, I was a Visiting Professor at the Summer Institute on Alcohol, Drugs and Addictions, International School for the Humanities and Social Sciences, University of Amsterdam, The Netherlands. Obviously, each of these countries has its own unique history and views regarding substance abuse and its treatment approaches and we can certainly learn from each of them. Todd Maison: I practiced international social work in Capetown, South Africa, as part of completing my field work for my master’s degree in social work (MSW-Interpersonal Practice, Mental Health). I went to Capetown to specifically work with people with a variety of addictions, mental illnesses, and physical disabilities. My first field placement was at a school for children with special needs. I did a needs assessment with the school psychologist and we determined how I could best help the school. We identified a group of 10 boys who ranged from 10 to 12 years old. These boys had been in detention weekly for the past year for their behavior and were on the verge of getting expelled. They had different disabilities, mostly related to fetal alcohol syndrome, while some had cerebral palsy or other genetic condition. Drug use was suspected in most of the boys, specifically alcohol or “tic” (crystal meth). I worked with these boys individually and in the group setting for 3 months. My second field placement was at a mental hospital working in group settings with adult males and females with serious and persistent mental illness and addictions. My third field placement was a community detox/recovery housing program providing group and individual sessions
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for adult males who were either detoxing from drugs and alcohol or who where in the early stages of the recovery process. Dorie J. Gilbert: I am the Chair of the International Social Work committee in my school and have served as the faculty liaison for students completing international internships in Ghana, South Africa, and Mexico. Mostly, I have supervised and consulted on community-based development projects and research in Ghana, West Africa. My work has centered around planning and consultation with nongovernmental organizations (NGOs) on various projects that would be implemented by students in partnership with community-based agencies or schools. The various needs of the country (poverty reduction, empowerment, health education, peer leadership programs, etc.) are consistent with social work goals. The potential for indigenous leadership and “inside-up� approaches to social work service delivery was encouraging. Sam MacMaster: My international social work has been on the meso- and macrolevels. I have somewhat limited experience in providing direct services internationally, but have been involved with planning and developing substance abuse treatment services in sub-Saharan Africa, the Caribbean, and Latin America. Lori Holleran Steiker: What are some of the skills and qualities needed to address substance abuse internationally? Sam MacMaster: Two aspects of self-awareness are prerequisites to working internationally: First, it is necessary to always be aware that you are a guest and may not have complete understanding of the nuances of the general culture toward substance use and are almost certainly somewhat blind to the various subcultures of substance users. It is always important to be mindful that although you may have some expertise, it does not make you an expert in how substance use occurs in the host country. Second, it is important to always recognize that services domestically are based on the American disease model. Twelve-step-based programs, while available in almost every country, are an American intervention and do not always translate seamlessly in other countries. It is particularly important to always be aware that the assumptions that we make about substance use and treatment are often made based on this paradigm. S. Lala Straussner: I absolutely agree with Dr. MacMaster and would build on his second point. We need to be aware of our tendency to think ethnocentrically—that our own country knows more than others and that our treatment approach is the best. The growing harm reduction approach originated in Europe (particularly in The Netherlands) and it took many
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years for Americans to recognize its value as an important approach that can be integrated with the more traditional 12-step approach. There is much we can learn from other countries if we keep an open mind. Todd Maison: I agree with Drs. Straussner and MacMaster as well. From an addictions clinician’s perspective, humility and acceptance are key qualities in working in this area abroad. I think striving for cultural competency is a great goal as long as one remains “teachable� and recognizes that individuals are always the best expert in their own lived experience. I think compassion and hope are at the heart of what is needed to address substance abuse internationally and in building strong, healthy human relationships. Self-care helped me immeasurably during my international work in the substance abuse field. Treating my mind, body, and spirit (e.g., processing experiences, running and exercising, and meditation) on a daily basis helped me tremendously with acceptance of both myself and others. Lori Holleran Steiker: What principles do you feel are critical to embrace for effective international social work especially in the areas of drugs and alcohol? S. Lala Straussner: What comes to mind was my trip to teach at a university in Siberia, Russia, a number of years ago. I came prepared to talk about alcoholism treatment, but very quickly realized that my U.S. framework to treatment made no sense in a country with a tremendous alcohol problem, but very few (close to none) treatment resources. Nonetheless, they had their own local approaches and a great desire (at a nongovernmental level) to try to help people who were suffering. So I threw away all my prepared lecture notes, and spent time talking to the students, other faculty, and later city officials about what they see as problems and their solutions. The notion of alcoholism as a disease was not something they were ready to hear, but they were concerned about their teen children dying from alcohol poisoning and the growing heroin and homemade drugs problem. While at that time I was not familiar with the term harm reduction, this approach instinctively made sense given the lack of other options. Sam MacMaster: It has also been my experience that, internationally, there is more of an openness to all possible solutions to substance use issues (e.g., harm reduction models are more widely embraced abroad and related treatments are more widely utilized than in the United States). The converse of the lack of strict adherence to the disease model is the opportunity for other solutions to be employed based on relative effectiveness. Issues of gender inequality, ethnocentrism, and relative poverty and class are often in play, forcing anyone working in this area internationally to be embrace basic social work principles related to working with and advocating for oppressed
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populations. It also seems that regardless of the setting and the evidence to the contrary, it is almost the norm that substance use problems are almost always attributed to outsiders. Drug issues are almost always assumed to be brought into the area by someone else from another area or country. Cultural denial of substance use issues is almost normative. It is important in these situations to always stay in the here and now, and focus on the issues at hand. Dorie J. Gilbert: Interesting question. I think that the principles for effective social work (i.e., commitment to service, social justice, integrity, competence, etc.) are the same whether we’re working abroad or in our own backyards, so to speak, which is why I prefer the term intercultural social work. In addition, with any cross-cultural work, social workers need to have knowledge of the historical and socio-political background of the group. Cultural differences are everywhere and so intercultural maturity may best describe what is needed to be an effective social worker cross-culturally. This draws on some of the work by Patricia King and Marcia Baxter Magolda, who describe the process of sociocultural development that a person goes through as he or she strives to make sense one’s own identity and belief systems and how to negotiate those within the context of relationships with others. For social workers, that’s critical because those relationships involve helping others without allowing our own values and identity to get in the way. Todd Maison: I agree with what the others have shared. I would like to highlight that, especially in the field of substance abuse, the principles of dignity and worth of the person and the importance of genuine human relationships are critical to embrace for effective international social work, especially regarding drugs and alcohol. My experience in South Africa was extremely powerful both personally and professionally. When I think back on what stood out for me most, it was the quality of the human relationships that I built. The young boys that I worked with did amazing work and by the time I left all of the boys had gone 2 months straight without being sent to detention once. When I first met this group of boys they wanted to name the group “The Good Group,” even though they were sent to me for behaving badly. I was fortunate enough to spend time with these boys. Lori Holleran Steiker: What other skills and qualities does a social worker best exhibit when working internationally? Dorie J. Gilbert: I would say that a large part of intercultural maturity is critical thinking informed by self-awareness and awareness and nonjudgmental acceptance of cultural differences. It is becoming aware of one’s own values and self-identity and then learning to incorporate different, sometimes
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conflicting, worldviews of folks from various cultural backgrounds and socio-political environments. I always try to push students to think critically about the unforeseen consequences of addressing a problem from one’s own cultural worldview rather than the sociocultural perspective of the person or group in need of a service. One humorous example is influx of huge quantities of used clothes into Ghanaian communities. In the United States, when folks need clothes, we send them to a clothes bank or provide a way for them to receive used clothes. Yet, the Ghanaian term for used clothes is “Broni waa wu” (translated means “white man is dead”). Why? In their minds, what other reason would there be for people to give away good usable clothes? That’s the humorous side of it. From an intercultural competence perspective, one has to understand the person-in-environment perspective from the specific culture. This donation of clothing has critically undermined local textiles and garment industries in terms of production, employment, and cultural expression, not to mention diminishing rather than improving women’s empowerment, because women are a large part of the garment production industry. Sam MacMaster: I appreciate Dr. Gilbert’s emphasis on critical thinking and intercultural maturity. I also would say that flexibility and humility are two of the most important qualities for international work. Clearly self-awareness is important, but beyond that it is important to be aware that in many areas of the world substance use problems are related to, or perceived to be related to, the international drug trade. For years, most residents in such parts of the world could not afford the drugs that were being trafficked through their countries on their way to North American or Western Europe. As standards of living have been raised, there appears to be a rise in domestic drug problems in many of these countries. There is some frustration with American drug policy and drug consumption. It is important to always tread softly in these areas. I have consistently had the experience as an outside “expert” of being incredibly humbled in any international situation as I have become aware of what I do not know, or what I learned about possible solutions here. Lori Holleran Steiker: What do you think social workers in the United States can learn from other countries? S. Lala Straussner: There is a lot of folk wisdom that sometimes can be very useful, especially when we are working with immigrants from foreign countries. Given the current economy, we can also learn how to offer treatment that may not be based on a great deal of financial resources and how to make greater use of family-based approaches. Sam MacMaster: As mentioned earlier, there is a lack of adherence to the disease model. While I personally am a strong advocate for diseasemodel-based treatment, it is not the only possible solution. Various forms
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of harm-reduction-based services clearly have provided our service systems with a host of examples of innovations. Particularly in underresourced areas, it is amazing to see what can occur with more limited resources. Due to the lack of external governmental or private funding alluded to by Dr. Straussner, many programs are self-supporting out of necessity and either provide participants with work opportunities or become creative in how services are delivered. Particularly for long-term substance abuse treatment services, there is therapeutic value in sheltered or supported work experiences, halfway jobs to go along with halfway housing. In many areas these work experiences support the program. Todd Maison: I appreciate both the researcher and clinical perspectives shared. I would like to add a student or intern perspective. I think social workers can learn a tremendous amount of knowledge and personal experiences from other countries. I think my field placement in South Africa was the most important piece of my education. I learned more about the human relationship and social work values during my international field placement than I ever did in a college course in the United States. Lori Holleran Steiker: If one of our readers is considering international social work, what would you consider the key issues, evidence-based and delineated practices, recommendations, resources, or other relevant factors to take into account? Todd Maison: My recommendation is to carefully research your location of interest for appropriate fit and especially research where you will be living and with whom. For example, I stayed at an organization that brought in roughly 30 new volunteers/field workers every 30 days from all over the world (the majority were from the United States). Even though the university praised the organization that I would be staying with and had a good relationship with them, there were some serious issues that occurred with quite a few of the volunteers. Many of them were young college students, mostly females, ages 18 to 25. I was shocked and saddened to witness how much binge drinking and substance abuse was occurring every night. It became a huge problem as some of these students wouldn’t go to their placements on time and others sometimes never even showed up. At one point the organization had to kick out 15 people due to the drinking. The bottom line is that international work should be taken seriously and not be looked at as a party. Dorie J. Gilbert: I might add that having a strong knowledge base of the “inside-up� approach to knowing what works is imperative. Interculturally competent social workers look for local experts on the front lines of the issue to help design the best strategy, rather than entering the community with a blueprint for change already in hand. For example, the push to
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integrate indigenous healers or traditional health practitioners within a conventional health-care delivery system represents an enormous opportunity for a collaborative strategy of international social work. Sam MacMaster: I smile when I read Dr. Gilbert and Mr. Maison’s recommendation to do solid research prior to committing to international social work. I agree there is value in this, but I also believe in a sink-or-swim approach; quite honestly, just jump out and do it. The opportunities to step out of our culture and see other possible solutions can alter and improve an individual’s practice in many ways. While good preparation is important, be prepared to unlearn or let go of many of the practice principles that may have worked previously. As long as someone remains true to basic social work principles and is focused on being client centered, they will make a difference both in the other country, but also on their return. Lori Holleran Steiker: Can you describe some specific anecdotes (with deidentified case descriptions) that might illustrate some examples of unique international social work situations? Do you have any particular stories that capture the dilemmas or demonstrate successes? Sam MacMaster: I am always struck by my own naivete of the complete lack of resources that individuals in other parts of the world often face. For instance, I remember women in South Africa who would head out to “the bush” to rest up after heavy drug-using episodes. I assumed it was a euphemism for a return to a more rural area. But it was literally a bush, where women would stay under and rest up. While we certainly have our own issues within the criminal justice system, I am also often struck by the brutality of police and prison officials toward substance users in many other areas of the world. On the other hand, there is a common bond that translates cultures and resource differences between people who are actively pursuing recovery from substance use. I have never been in an international situation and not been struck by the depth of the commonalities that hope and recovery can bring. Dorie J. Gilbert: There are a number of good examples of rural community development gone wrong in developing countries because of a lack of intercultural competence. Several center on the theme of misguided attempts at gender empowerment. In rural Ghanaian villages, for example, women are the primary farmworkers and a great deal of time and energy is spent on walking up to 5 to 6 miles to the farm and back carrying heavy loads of produce on the head and often a child on the back. In one particular village, a project was initiated to provide retrofitted donated bicycles for women to haul their produce. While this worked for a while, before long, the bikes became the property of the men in the households. In some regions, bicycles
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are seen as more appropriate for the male gender and furthermore, within a family system where men are expected to be the providers, the man is also the one to distribute and allocate the resources.
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Lori Holleran Steiker: Did you experience or learn anything about substance use or abuse during your international work? Sam MacMaster: ASAM [American Society of Addiction Medicine] recently came out with a new definition of addiction based on brain circuitry. My international experiences have only reinforced this belief for me. Despite cultural differences and drugs of abuse, the addiction process is the same and people tend to use whatever is most readily available. The details may be different, the consequences may be different, and the resources available for recovery may be different; but the process is always consistent. Dorie J. Gilbert: It is difficult to document the actual magnitude of the substance abuse problem in Ghana simply because of a lack of surveys and population assessments of the problem. Several years ago the World Health Organization published baseline data on substance abuse in Ghana, specifically among the youth in order to develop evidence-based models for substance abuse prevention programs. Misuse of alcohol, cigarettes, cannabis, cocaine, tranquilizers, and heroin were noted as particular concerns. In Ghana, substance abuse is very much frowned upon by the society at large, a society that tends to be highly religious with most identifying as strong Christians and actively engaged in regular church attendance. There is no separation between church and state; thus, often religion is readily integrated into prevention of social problems, including substance abuse. This can be seen in an example of a school-based substance abuse prevention program that I attended recently at a high school in the country’s capital city of Accra. The program incorporated biblical scripture, religious song, and a brief church service addressing the sinful nature of drug use. Now, such a strategy may not pass the acceptability standard for one culture but fits perfectly within the sociocultural structure of another. It would be helpful to study the long-term impact of such school-based programs on drug use prevention efforts with youth in various communities. Lori Holleran Steiker: What do you believe are important areas for related work, research, and interventions that social workers can help with in the future internationally? Dorie J. Gilbert: I would say working within the existing program and intervention structures to add evaluative components and supporting the inside-up approach by providing resources for evaluating effectiveness. It really comes down to fully understanding what resources already exist from
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an intercultural perspective and then finding out what pieces are needed that we can provide to fulfill the goal of reciprocity in our work. Sam MacMaster: And in the field of substance abuse, sometimes we are the resource. As standards of living are raised throughout the world, I strongly believe that there will continue to be a rise in substance use, abuse, and dependence; and the need for social workers to address these needs. I believe that due to our experience and expertise in assisting individuals with substance use problems, social workers in the United States are uniquely situated to help meet these needs. Providers in other countries have the opportunities to learn from both our successes and the many mistakes we have made in providing these services. Lori Holleran Steiker: Is there anything else from an international perspective that is important for our readers to know? S. Lala Straussner: Not specifically about substance abuse, but I’m delighted to see that more and more social work students are interested in traveling to other countries as part of their education. Right now I’m preparing a course on trauma that will be taught to U.S. graduate social work students in Israel in conjunction with an international conference on trauma. I strongly believe that having students exposed to professionals, and clients, in other countries will make them better professionals back home. Lori Holleran Steiker: If readers would like to contact any of the authors, feel free to e-mail me at E-mail: lorikay@mail.utexas.edu and I will be happy to connect you.