Special Feature 2



Volume 48 Number 2
Spring 2015

Special Feature

Insider Forbidden Knowledge of a “Culturally Integrated” Treatment Program: From Field Observation to the Confession Booth

Written by Izaak L. Williams (izaakw@hawaii.edu), University of Hawaii at Manoa

This article is the culmination of three years (2011-2014) of field notes as an addiction counselor at a publicly funded “Hawaiian culture-based” drug treatment program on Oahu’s Leeward Coast in Hawaii (referred to here by the pseudonym “Aloha Aina” [AA]). A Goffmanesque picture of AA’s organizational structure is drawn from the triangulation of direct observation, commentary from program participants (i.e., clients or patients), and interviews with former and current program staff on the contexts and overall interactions with AA’s brand of Native Hawaiian (NH) cultural integration. The phrase “culturally integrated treatment” can be expressed and understood with varying interpretations at the level of surface change versus deep structural change.  The former is concerned mostly with appearance and involves matching program staff and patient characteristics (e.g., race/ethnicity) (Resnicow, Soler, Braithwaite, Ahluwalia, & Butler, 2000). Yet another example of surface integration is the holidays a program honors. AA, for instance, honored the annexation and overthrow of the NH Kingdom (Sai, 2004) by commemorating the anniversary of Hawaii Statehood Day, hardly culturally sensitive to Native Hawaiians. Additionally considering the majority of patients were referred by the judicial system and represented a politically disaffected, marginalized social group (Office of Hawaiian Affairs, 2010), it would seem apt for any program to pay homage to Election Day and encourage patients to vote or achieve some level of political engagement, but that was never so with AA’s version of cultural sensitivity.  

AA’s “cultural-based” programming is heavily influenced by an overbearing fiscal structure premised on cost-containment and bottom-lines, perforating surface level accommodations (e.g., adopting a few NH words to the program’s lexicon, i.e., “humana” [participant], “kokua” [helpfulness], “lokahi” [togetherness], kuleana [responsibility], pono [balanced, righteous]) to secure funding and maximize profit: a spirochete infecting the body politic of AA’s treatment program in general and cultural integration in particular.

The Political Economy of NH Cultural Integration

In the treatment industry a culture of corporatization and consumer capitalism prevails in programs that readily adopt surface level cultural messages and NH themes to compete for a limited pool of state and federal funds. In this vein, and with substantive fiscal rewards on the line, AA operated a political economy of NH cultural integration that reproduced processes of colonization in its service delivery (Leanui, 2000) (see Table 1).

Table 1. Stages of Colonization in Aloha Aina’s Program Service Delivery

                             Stages of Colonization    

     Reproduction of Colonization In “Culturally Integrated” Treatment

1) Denial and Withdrawal: This stage is characterized by cultural paternalism and is premised on the colonizer denying the moral legitimacy and value of Indigenous modes of existence.

This extrapolated to program delivery in (a) the form of ignoring within and between group differences in the patient population, (b) implementing “cultural” practices without pretesting interventions to determine their suitability, and (c) disregarding input from the treatment population by failing to heed patient complaints about “NH activities” nor accommodate or survey patient feedback.

2) Destruction/Eradication: Here the colonizer attempts a cultural onslaught to wipeout both tangible and immaterial cultural products (language, customs, indigenous knowledge) and symbols of the Indigenous social system. Indigenous persons are co-opted to participate in breaking down their own cultural models via the colonial strategy of divide and conquer.

This came through in the creation of “cultural” and “clinical” program staff—a false dichotomy— that created contention as an “us” versus “them” mentality   encouraged culturally and clinically divisive treatment. Such an interpretive frame of treatment incentivized contempt for evidenced–based treatment practices that AA despairingly regards as “Western ideology”. This NH/Western binary paradigm defined AA’s program identity and NH program rhetoric.    

3) Denigration/Belittlement/Insult: This is achieved through establishment of institutions (legal, medical, religious, educational, etc.) that legitimize colonial rule via the normalization of belief systems and values that invalidate Indigenous practices, customs, morals, etc.

This stage manifested in a ‘moral model’ of conceptualizing addiction that viewed clients from different cultural backgrounds as possessing characterological defects and moral failings, which yield, pathologies and dysfunction that only NH culture can remedy.

4) Surface Accommodation/Tokenism:  With remnants of indigenous culture posing no threat to the colonial status quo, the colonizer gives the appearance of tolerance and benevolence by showing Indigenous culture token regard (e.g., using NH spiritual practitioners to perform a Native Hawaiian blessing as a stand-in for priest).

This was illustrated in (a) declaring ohana (family) an organizational value but contrarily family systems therapy and patient-family approaches are nonintegral, (b) passive resignation to impression “cultural integration” which led to insensitivity and nonspecificity to ethnocultural differences of patients, and (c) preaching NH culture from a relationship of convenience to patient-centric treatment in service delivery.  



5) Transformation/Exploitation: The colonizer capitalizes upon Indigenous cultural signifiers through assimilating vestiges of indigenous iconography (exhibiting Indigenous art, using a few NH terms) into the institutional framework. Popular Indigenous culture is appropriated and redefined by the colonizer for capitalistic consumption (e.g., Waikiki Hula).

This applied when (a) NH ‘cultural’ totems are used to distinguish the agency as ‘unique’ to opportunistically reap fiscal rewards and favorable program audit reviews, (b) reducing the meaning and value of “NH activities”, e.g., hula to a generic form of commoditized entertainment in which patients engaged in its performance for treatment graduation and the consumption of tourists to generate revenue, and (c) administrators/management staff using the NH ‘race card’ to persuade funders and auditors under subterranean threats of discrimination.


Themes of colonization were further perpetuated in AA cutting fiscal corners (e.g., underinvesting in properly training staff; manufacturing a climate of job insecurity based on fearmongering to freeze wages; nurturing exploitive and predatory organizational culture to grossly underpay — comparable to any other treatment program in Hawaii— and overwork staff, paying most staff as little as (legally) possible), hence its inability to achieve quality control standards via CARF accreditation since January 1987. In effect, nickel-and-diming the quality of overall service delivery and shortchanging “NH program activities”. For example, genuine program investment in the basic idea of Malama ‘Aina (“steward of the land” and its conservation) would entail not only hiring but paying bona fide NH practitioners to incorporate oral tradition centered on storytelling related to NH history, legends, cultural figures, and contributions to civilization to enhance resiliency (Johnson & Beamer, 2013). This further instills a strong sense of pride in NH identity and genealogy (Tengen, 2008). However, AA’s pretentious and insincere commitment to honor the integrity of Malama Aina resulted in a deeply flawed method of service delivery with non-specialized and non-credentialed program staff (self-proclaimed “healers”) resigning Malama Aina to conscripting clients to cost-containment activities such as cleaning bathrooms, picking up trash, pulling weeds, planting vegetables and growing flowers. Additionally, under the guise of psychosocial growth, physical labor was promoted by AA to (re)habilitate criminal offenders, while gardening was touted by AA to “heal” patients with neurological disorders, mental illnesses, and drug addiction. Yet there virtually is no evidence in the extant literature to validate or robustly support these bold therapeutic claims. Still AA fashioned  “Malama Aina” as the primary focus of its service delivery to yield substantial revenue from insurance billing and other funding sources (Department of Health Alcohol and Drug Abuse Division [ADAD], First Judicial Circuit) despite the formation of this program component not being wrought from empirical study, let alone foundational literature.

Moreover, AA’s version of Malama Aina strongly encouraged patients to become field laborers, underemphasizing actual therapy and cognitive behavioral interventions, academic opportunities, and career-building skills via vocational rehabilitation. Clients disinterested in physical labor were still mandated to spend one-third to half of their “treatment” engaged in menial labor. This, despite the reality that nearly all patients expressed employment aspirations beyond farming and gardening in light of possessing strengths, talents, and skills transcending the old colonial trope that NHs are only smart enough to work with their hands. As a result, patient experiences of Malama Aina, and, by extension NH culture, engendered perceptions that stressed negative sentiment through words such as “exploitation” and “manual labor”—a perennial source of chronic grievances with a cross-section of the treatment population.

Moreover, AA claimed that NH cultural values were universal across the treatment board and therefore applicable to all patients irrespective of their cultural background, personal history, or clinical needs.  While this logic might hold at face value for patients embracing their NH heritage, it runs the risk of being insensitive to patients who have little understanding of NH history and culture or who harbor internalized negative messages and sentiment around their NH identity. Simply asserting a one-to-one correspondence between a “universal NH culture” and heterogeneous patient population is highly problematic (see Helm & Baker, 2011, on human services delivery with the ethnic/racial diversity of the Hawaiian population). That is, mandating patients to participate in program practices (hula), traditions (donning a NH malo or loincloth as a requirement for treatment “graduation”), and aspects of service modalities (oili or ‘chanting’), without fully understanding the individual patient can inculcate and exacerbate negative feelings toward NH culture. As Resnicow et al. (2000) point out, “culture-based programs and messages, while potentially salient, must be carefully pretested as some segments of the population may find them irrelevant, inflammatory, or offensive (if they don’t place a high priority on ethnic identity)” (p. 279).

Another assumption contained in AA comes from its treatment philosophy expressed in the belief that the underlying basis of drug addiction resides in a cultural identity dispossessed of “NH cultural values” such as “ohana” (family).  This is subverted to mean that patients are without family-orientated values prior to drug addiction and in treatment recovery. However, because patients already possessed family values as part of their established belief system, this reasoning is warped in service delivery, becoming a narrative of addiction declaring patients immoral and badly skewed in character. The resultant affect further compounds the stigma and shame “addicts” commonly experience given the devastating effects of addiction and criminalization of drug use.               


This article is based on ‘forbidden knowledge’ as AA’s organizational structure is known for externalizing blame and insulating itself from the unacceptable reality of warranted critique vis-à-vis denial-infused suppression of disagreement and censuring critical appraisal. Forbidden knowledge, irrespective of how it is presented and delivered, is stamped out because it raises a threat to the self-representational institutional image and program status quo, rather than regarded as a necessary and pragmatic exchange as part of an ongoing process of improving the efficacy of service delivery. The political economy of AA’s service delivery resulted in an overgeneralized and parallel treatment process rather than a truly integrated and culturally rooted one. The colonizing framework of AA’s service delivery was characterized by: (a) engaging in a narrowly focused and superficial approach to cultural integration using a reductionist method of program service by resigning “cultural practices” to generic NH “activities” (canoeing, hula, working in the lo'i (taro patch) that fail to illuminate or contextualize existing legacies of colonialism, (b) maintaining the “preservation” of NH culture in such a simplified, yet unintelligibly abstract way in program practices as to impression program participants that NH culture is irrelevant in its application to treatment recovery, and (c) Ho omau Ke Ola (“to perpetuate life as it was meant to be”) refusing to recognize that ancient NH ontology, epistemology, cosmology, and contextual contexts (see McCubbin & Marsella, 2009) are not automatically transferable in any meaningful and legible way merely because one self-identifies as NH in the contemporary sense. 

Granted, surface level change is one step forward in the direction of cultural sensitivity (Resnicow et al., 2000), in theory, as cultural sensitivity increases, it can be expected that the program structure operating outside of the political economy will deepen its structure of service delivery. At least one example entails adopting a complex and dynamic biopsychosocial model of addiction that acknowledges colonial legacies and accommodates program philosophy oriented around decolonization processes (see Laenui, 2000, on program formulation as a political approach for NH’s, and on Muller’s, 2014, adaption that broadens the framework focusing primarily on reestablishing and strengthening indigenous knowledge).  This includes a unified and coherent model incorporating the framework of historical trauma (Mohatt, Thompson, Thai, & Tebes, 2014; Pokhrel & Herzog, 2014) that recognizes the enduring social-environmental and psychological impact of colonialism  (Irwin & Umemoto, 2012; Trask, 1999). Needless to say, the particular brand of “innovative Hawaiian culture-based” drug program that AA is invested in will require deconstruction of its colonial model of service delivery before it can envision and commit to deep structural change that manifest in culturally integrated treatment. 


The author dedicates this article to the memory of former and current program participants of “Aloha Aina”


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