Grassroots Interventions for Alcohol Use Disorders in the Mexican Immigrant Community: A Narrative Literature Review

Abstract

This narrative literature review addresses grassroots interventions for alcohol use disorders as practiced in Mexican immigrant communities. These organic efforts are 24-hour AA groups, or anexos, fourth and fifth step AA groups, juramentos, and curanderismo. Literature was identified using PubMed and CINAHL and limited to works published from 2000 to 2018. In all, three publications on 24-hour groups were found, two on fourth and fifth step groups, four on juramentos, and one on curanderismo use. The review offers insight on their practices and concludes that the interventions’ cultural resonance provides advantages over cultural competency AUDs programs developed in public health.

I. Introduction

Few research or public health efforts have examined the use of grassroots interventions to treat alcohol use disorders (AUDs) within Mexican immigrant or Mexican American populations, despite the important need that they fill. Mexican immigrants, regardless of their immigration status, have limited or no health care (Ortega et al., 2007; Vargas Bustamante et al., 2012) and nearly no formal AUDs interventions and treatments (Pagano, 2014). Leading treatment researchers, such as Alvarez and her colleagues (2007, 2009) and Alegria et al. (2006), have called for studying community-based and alternative recovery efforts used by Latino populations, with attention to their cultural context and use of community resources.

We use the term grassroots interventions to describe treatment modalities that exist outside of formal, institutionalized medical settings, and that arise naturally from the community that utilizes them. To qualify as a grassroots intervention, a therapeutic effort must 1) be created and practiced by members of a given community, 2) address a health concern that is generally agreed-upon as a problem and has been observed in a community, either broadly or in specific members, and 3) rely on resources available within the community to provide the recommended therapy, whatever it may entail. Frequently, but not necessarily, grassroots interventions draw from non-biomedical or religious traditions. They are intrinsically organic and rooted in culture, which makes them familiar to participants and informs the intervention’s understanding of the disorder and recovery from it. Across varied contexts, grassroots therapeutic efforts often appeal to their users because of their accessibility to marginalized populations and their cultural resonance.

This literature review explores a specific subset of grassroots interventions: while there are a variety of grassroots interventions existing in Mexico to treat AUDs, there is evidence that Mexican immigrants bring certain grassroots interventions established in Mexico to the United States, where they are further adapted to serve a Latino immigrant population. We focus on the latter - interventions developed by Mexican immigrants from pre-existing examples in their country of origin. The aim of our review is two-fold: (1) to provide an overview of what is known about the interventions, especially regarding how they contribute to recovery, and (2) to learn how the interventions draw on culture to promote recovery. We examine only studies that deal with these interventions as practiced in the United States, given that the same interventions in Mexico and elsewhere are practiced differently because of different sociopolitical contexts in the countries that determine the manner in which they are implemented. We find that the grassroots interventions for AUDs used in the United States are 24-hour AA groups, also known as anexos (the two terms will be used interchangeably), fourth and fifth step AA groups, juramentos, and curanderismo (Garcia, Pagano, Recarte, & Lee, 2017; Garcia, Anderson, & Humphreys, 2015; Garcia & Gonzalez, 2009; Ortiz & Torrez, 2008). Further, the immigrant experience, which includes factors like living in the United States without U.S. government authorization or not being eligible for low-cost, publicly-funded health care, shapes how these interventions develop and contributes to their use.

Knowledge about these grassroots interventions will be beneficial to public health professionals, especially practitioners in Federally Qualified Health Centers (FQHCs) and other community providers who provide health care to Mexican immigrants regardless of their immigration status in the country. It will expand intervention options at their disposal beyond incorporating cultural competency in treatment programs delivered in clinical settings. Too often, cultural competency programs are designed around cultural ideals that do not reflect culture as practiced and lived daily and missed altogether is the immigrant experience (Garcia et al., 2017; Pagano, Garcia, Recarte, & Lee, 2016). Additionally, learning about these interventions and their contributions to recovery opens the door to possible collaborations between public health professionals and practitioners and grassroots recovery efforts. Preventing and treating substance use disorders (SUDs) requires a partnership that includes as many community partners as possible.

II. Methods

This narrative literature review adopts the narrative approach as described by Green and his colleagues (2006). For each intervention, we examined only literature that addresses practices based in the United States. Publications on 24-hour groups, fourth and fifth step groups, and juramentos were located using PubMed and CINAHL, and only works published from 2000 to 2018 were included. Depending on the intervention, the following search words were used: Mexicans, Hispanics, Latinos, immigrant, 24-hour AA groups (grupos de 24 horas in the Spanish language), anexos, fourth and fifth step AA groups (grupos de cuatro and quinto pasos in the Spanish language), juramentos, alcohol use, alcohol use disorders, binge drinking, problem drinking, and alcoholism. They were used in different combinations to obtain maximum search results.

For curanderismo, we built on the literature review by Favazza Titus (2014) on the utilization of curanderos in the United States. The review included publications from 2000 to 2012 and was not just limited to Mexican immigrants. We examined the sources in the review to see if any addressed AUDs or alcohol use and conducted our own literature search, picking up where Favazza Titus (2014) left off. The same search words, with the addition of AUDs, alcohol use, binge drinking, problem drinking, and alcoholism, were used to search the same databases previously discussed. We limited our search of curandero-related literature to resources published from 2012 to 2018. We then created a master bibliography of all literature on three types of grassroots interventions, which listed full citations of each article accompanied by an abstract (either the one provided by the authors, or, if the article lacked an abstract, prepared by us).

Each article on an intervention was summarized with attention to the research problem, sample and methods, and findings. We used the summaries to prepare a detailed report on each intervention. The report included the way the intervention was implemented and practiced, and the demographic characteristics of the participants, including their immigration status, if available. Codes were developed around the general questions identified earlier and were used to code pertinent text of the reports. New codes were also developed with additional reads. NVivo 12 was used to code text and to store, sort, and retrieve relevant text in a single report and across reports. The texts were analyzed using thematic analysis; recurrent themes were identified as they emerged through repeated review of the textual data. The practices of each intervention were among the themes and subthemes identified in the analysis, as were the cultural beliefs and traditions behind each intervention and the immigrant experiences that shape them. The themes and subthemes were used to write lengthy descriptive reports of each intervention, which are only summarized in this literature review.

III. Findings

III.A. Twenty-four hour and fourth and fifth step AA groups

Twenty-four hour groups, or anexos, and fourth and fifth step groups are grassroots interventions that draw from the traditions of Alcoholics Anonymous. They emerged in Mexico in the 1980s to meet the recovery needs of individuals suffering from severe alcoholism and in need of residential and intensive therapy (Garcia et al., 2015; Pagano et al., 2016). Despite identifying as AA groups and holding daily traditional AA meetings around the 12 steps and traditions, neither 24-hour groups nor fourth and fifth step groups are recognized by U.S. General Service Office of Alcoholics Anonymous, or Mexico’s equivalent, La Central Mexicana de Servicios Generales de Alcohólicos Anónimos. Still, both types of group have emerged in Latino immigrant communities to address AUDs and other substance use.

III.A.1. 24-hour groups (anexos)

Pagano et al. (2016, 2018) and Garcia et al. (2017) published the only articles on 24-hour groups, or anexos, in the United States. One of the three articles (Pagano et al., 2018), focuses on the methodology used to study the anexo, and as such is not reviewed. All three articles are based on the same two-year (2014–2016) ethnographic study of three anexos conducted in a single city in northern metropolitan California, in which the objective was to examine the program and the help-seeking pathways of its residents. The combined sample of three anexo groups in the study is 50—42 residents, three directors, two former directors, and three assistant directors—all of them with origins in Mexico or Central America. Of the residents, the majority were poly-drug users, with only two that suffered solely from alcohol abuse. The mean of the residents’ age is 40.5, ranging from 20 to 75 years old. Twenty-six percent have an elementary school education or less, 36% at least some high school, and 22% some college. Only 8% are married. Sixty-three percent are first-generation immigrants, 37% are either 1.5 or second-generation immigrants, and 58% of all participants are in the country without proper immigration documentation.

In the first of the two reviewed publications, Pagano et al. (2016) find that California-based anexos involve greater self-direction for residents than do their Mexican counterparts, and they attribute these differences to sociopolitical contexts. A prominent example of such differences is the absence of corporal punishment in the United States. Unlike in Mexico, where psychological and/or physical violence is practiced in the anexos, there is no evidence of these behaviors in the anexos in the study; U.S. laws do not permit it. For similar reasons, U.S. anexos do not feature coercive stays, which are common in Mexico. In this research site, the men are not in residence against their will. They can come and go as they wish during work hours of the day and can leave the program when they want to. The anexos in the study are also self-supporting, as the seventh AA tradition promotes: men work outside of the anexo and pay for their own room and board, and, as migrants and immigrants, they also work to continue providing for their families in the United States and Mexico. In contrast, the anexos in Mexico are primarily supported with family donations of the interned. Furthermore, the three anexos are not authoritarian like the ones in Mexico with respect to decision-making about the program. Decisions are made by the directors in consultation with their advisory boards.

The second publication (Garcia et al., 2017) offers greater descriptive detail on their recovery program. The three anexos operate from old commercial buildings situated in or near Latino communities, with varied floor plans and living arrangements. At the time of the study, they had been in operation for 7 years, 13 years, and the oldest, 17 years. The three are independent entities, but they support one another by attending each other’s AA meetings and group anniversaries, and they make referrals to each other’s facilities when their own residence is at capacity. They are managed by directors and their assistants, which are all volunteer positions that are filled by former anexo residents with several years in recovery. The director and an advisory board made up of ex-residents and current assistants keep track of the finances, resolve issues (such as conflicts among the residents), and organize sobriety anniversaries, including the anniversary celebration of the anexo’s founding date. All of the anexos are self-sustaining. The residents pay for their room and board, and they give donations during the collections at evening AA meetings.

The AA program at all three of the anexos is similar. The program begins with detox, if needed, which takes place either in a secluded space on site, or, in acute cases, at a local hospital. After detox, new arrivals are assigned a dormitory and are watched over by one of the assistant directors. They remain on the premises alone for a few weeks, until they have started to work on the 12 steps, but they can quit the program and leave when they want to. All residents work the AA program in a highly structured residential setting with specific times for sleeping, waking, consuming meals, and performing daily chores. There are set rules of behavior for strife-free and drug-free cohabitation and for working the recovery program. Individuals who break the rules are warned, and if the behavior persists, are asked to leave. Every evening, they attend mandatory AA meetings open to any AA member or anyone interested in joining AA. Lively testimonials, delivered in the Spanish language, spark self-reflection and a process of personal transformation that helps the men to reach a catharsis. More often than not, the testimonials touch on the immigrant experience and the need to provide for family, not only in the United States but in their country of origin. The residents also perform service at the anexo, such as coordinating a meeting or serving as a reader, in order to promote responsibility. The men remain in the anexo as long as they want, although a recommended stay is from six months to one year. After leaving the anexo, there is no formal aftercare, other than attending AA meetings and providing AA service.

The article goes on to compare the anexo format to other recovery residences using criteria of the National Alliance for Recovery Residences (NARR). The authors found that the anexos did not fit any of the four levels of recovery houses identified by NARR—Level I, Peer-Run; Level II, Monitored; Level III, Supervised; and Level IV, Service Provider. They have characteristics and practices found in more than one NARR level, in part because they are not part of any recovery residence association in the United States. They are rooted in a different cultural tradition—the 24-Hour AA Movement in Mexico—and reflect features associated with that tradition, but, as the authors point out in their first publication, do not entirely replicate it.

III.A.2. Fourth and fifth step groups

Garcia et al. (2015) and Anderson and Garcia (2015) published the only two articles on fourth and fifth step groups in the United States. The two articles are based on ethnographic findings from a single study conducted over two years, from 2013 to 2014, in five cities in California. Data was gathered using observations at 22 meetings and one therapeutic retreat and interviews with 10 group members. The immigration and demographic characteristics of the interview participants are not given, and as a result, their immigration status, gender, and age are unknown.

Garcia, Anderson, and Humphreys (2015), respectively a medical anthropologist, physician, and psychologist, discuss the origins of fourth and fifth step groups in Mexico and California and their therapeutic practices. They refer to these groups as CQs, after their Spanish language name, grupos de cuatro y quinto pasos. Like traditional AA groups, these groups are organized around the principles of AA, but their program starts with and emphasizes the fourth and fifth steps. Respectively, these steps are the compilation of a “moral inventory” and “admitting to God, to ourselves, and to another human being the exact nature of our wrongs”. Proponents of fourth and fifth step groups believe, as the authors found, that starting with these two steps helps to uncover the origins of AUDs and SUDs in an individual early in the recovery process.

As described in their publication, working the fourth and fifth steps program starts with a week-long preparation for a three-day therapeutic retreat, away from the community, called la experiencia, or the experience. In the preparation, the participants undergo a series of evening meetings that introduce them to AA and the cathartic nature of the fourth and fifth steps program. The therapeutic retreat is intense, and little time is devoted to eating and sleeping. The participants of the retreat, or escribientes (writers), put into practice the fourth step by responding in writing to a series of questions about major challenges in their lives and traumas that contribute to drinking. They do this with the support of apoyos, or aides, who encourage and help the participants to answer the questions and to stay awake during this important activity. The aides are individuals who have previously undergone the experience themselves. After the retreat, the participants are paired with a sponsor and an oyente (“listener” or sponsor-in-training) who make suggestions on how to work the fifth step. The retreat is cathartic, as shared in the following: “The majority of escribientes who participated in this retreat characterized it as challenging, life-changing, and something to which they would like to introduce their loved ones” (Garcia et al., 2015, p. 240). The participants return home but continue the fourth and fifth steps program by attending daily AA meetings with the group. The meetings are open to the public and held in Spanish, but some are also offered in the English language.

The authors conclude their article with a call for additional research on the fourth and fifth step groups, given that these groups serve the needs of the Latino community. More importantly, as they point out, fourth and fifth step groups are culturally tailored to this population and emphasize “spirituality, embrace of participants with different patterns of substance abuse, encouragement of family participation, and efforts to reach Latinos who cannot regularly attend face-to-face meetings due to migration, lack of transportation, or other issues” (Garcia et al., 2015, p. 241).

In another article, Anderson and Garcia (2015) address the spiritual aspects of the fourth and fifth steps program and its attraction to Latinos. Their article focuses on activities in only one fourth and fifth step group—Grupo Popular. The authors argue that individuals who seek help with their AUDs at fourth and fifth step groups are treated like enfermos emocional, or emotionally ill. An enfermo emocional is an idiom of distress “that signifies a ‘spiritual’ ailment thought to be at the root of addiction, depression and other ‘neuroses’” (Anderson & Garcia, 2015, p. 191). This kind of ailment requires a form of ‘spiritual healing’ pursued in fourth and fifth steps—one based on a “dramatic, cathartic style of testimony” (Anderson & Garcia, 2015, p. 191).

After describing the recovery program of fourth and fifth step groups, particularly the spiritual retreat, Anderson and Garcia (2015) discuss why these groups are “culturally adapted to Latinos” (p. 194). They argue that in part “…the kinds of dramatic public testimony, group prayer and healing and rebirth practices in CQ resemble those of the Pentecostal and Charismatic Catholic movements, which are currently quite popular in Mexico” (Anderson & Garcia, 2015, p. 194). Cultural acceptance is also the result of the “illness myth” around the spiritual nature of being an enfermo emocional. The authors make this clear in the following:

The highly ‘spiritual’ nature of being enfermo emocional has further implications for CQ’s acceptance by Latinos that become even clearer when we consider how 12-step programmes are often criticised for disempowering their members by encouraging them to submit to a higher power and to identify as sick addicts who will forever be in recovery. In CQ, the enfermo emocional takes this a step further and is not only eternally in recovery, but they are also intermittently ‘mad’. CQ members sometimes describe their spiritual experience as a form of locura (madness) … (Anderson & Garcia, 2015, p. 194)

III.B. Juramentos

Drawing upon religious traditions instead of AA and other self-help traditions, juramentos are another grassroots intervention for AUDs found in both Mexico and in U.S. communities of Mexican immigrants. Fundamentally, they are prayers to a saint, made in the presence of a priest, that request divine assistance in overcoming an alcohol or other substance abuse problem, although the particulars of the practice vary according to local tradition. This literature review identified four articles that examine juramento use in the United States. Three articles describe research that was conducted in the United States, while one discusses data collected in both the United States and Mexico.

Garcia and Gonzalez (2009) address juramentos within the context of Mexican immigration to the United States. The authors’ findings are from an ethnographic study on problem drinking among immigrant and migrant farmworkers in southeastern Pennsylvania. Although juramentos were not the focus of the study, the researchers found them important enough to describe in an article. The sample of the study consisted of 21 immigrant and migrant Mexican farmworkers, but, apart from one juramento case study, the number who made a juramento is not identified.

As the authors discuss, juramentos are deep-rooted religious and cultural traditions found in the homeland and Pennsylvania communities of Mexican immigrants. In Mexican Catholicism and Catholicism in general, it is believed that saints are close enough to God to prompt an intercession, including a miracle. Prayers are often made to a saint associated with a need, situation, or country. Juramentos are a specific, ritualized prayer, used strictly for a drinking or another substance abuse problem. They are made in the presence of a priest, alone or in the company of a family member, usually a spouse. The ritualized process starts with a counseling session at the priest’s office to discuss the reason for making the juramento and to convey the seriousness of making a pledge of abstinence to Our Lady of Guadalupe. Next, a juramento card is prepared. On one side of the card is the image of Our Lady of Guadalupe and on the other, a juramento prayer with the name of the individual, the abstinence period (up to, but no more than one year), and the signature of both the jurado and the priest. Besides helping the individual to recite the prayer, the juramento card also symbolizes the commitment and serves to ward off peer pressure to drink. The last step is the pledge—reciting the juramento prayer, preferably in front of the image of Our Lady of Guadalupe—and a blessing afterwards. The juramento is renewable, when the pledge is fulfilled, and may be renewed as many times as deemed necessary.

Based upon their findings, Garcia and Gonzalez (2009) posit that the juramento is a sacred commitment and a source of a religious-based catharsis that releases the individual from feelings of shame and guilt. It sets the right frame of mind for recovery. The juramento also creates a sense of hope in both the individual who made the pledge and his family that the drinking will stop, together with the problems that come with it. Communication is reestablished between them, and families are reunited. These key components - finding peace within oneself and restoring social and familial relationships - are similar to the premise of AA-based programs, and undoubtedly contribute to the recovery of individuals who successfully complete juramentos.

Juramento use is also addressed in a six-month bi-national study, conducted in Mexico and the United States in 2003, by Cuadrado and Lieberman (2011). The authors gathered their data from interviews with individuals who made a juramento and treatment providers in Mexico and from a survey with priests in the United States. The overall objective was to examine how Mexicans overcome treatment barriers involved in seeking help for substance abuse. In Mexico, the authors learned of the widespread use of the juramento for abstaining from substances. Insights on this practice were gathered from a single case study of an individual who made juramentos over a 15-year period. Unlike the description by Garcia and Gonzalez (2009), here the juramento is made in groups, not individually and in private, and is made to El Sagrado Señor de Chalma (Sacred Lord of Chalma), not to Our Lady of Guadalupe. Social pressure also appears to be a larger factor in the making of a juramento in Mexico. This is evident in how jurados think about what they stand to gain, personally, from the intervention:

There are three perceived benefits of Juramento according to Jurados: (1) reinforcement of will power (I can stop any time I want and remain abstinent as long as I want); (2) control of external community (I can get the people who do not like my drinking off my back); (3) safe harbor with Church & community support (Everyone wants to help when I am a Jurado). (Cuadrado & Lieberman, 2011, p. 926)

And yet, its therapeutic effects extend beyond the individual drinking problem:

There also appears to be three serendipitous benefits emerging from Juramento: (1) with repetitive abstinence self-control often increases in length of time; (2) the Jurados become more aware of the community as a significant other; (3) there is increasing cohesion with wife, family, and community. (Cuadrado & Lieberman, 2011, p. 926)

These benefits - strengthening of both self-control and social ties - that occur as a result of the juramento - are similar to those described by Garcia and Gonzalez (2009), despite differences in how the intervention is practiced.

However, these authors do not have corresponding first-person accounts of juramento use in the United States. Instead, Cuadrado and Lieberman (2011) surveyed Catholic priests in Florida (selected as a research site for its large Latino population). The sample consisted of 162 priests in parishes in counties with a Hispanic population of at least 10%; there were 15 counties in total, including Miami-Dade, Osceola, and Seminole. In all, 40% of the priests were Hispanic, and 61% of all the priests, regardless of ethnicity, were fluent in the Spanish language. A mail-survey around a questionnaire “asked whether the priest had heard about or participated in Juramentos, the length of pledge, who the pledge was made to, and family involvement” (Cuadrado & Lieberman, 2011, p. 927). Almost half (45.7%) of the priests reported “having heard about Juramentos or something similar”, over a third, 35.8% (58) reported having heard specifically about juramentos. Of the priests who were familiar with the juramento or something similar, 59.5% (44) had served as a witness in at least one. The number witnessed ranged from 1 to 50, with a mean of 14.3. While this data from Florida does not demonstrate how, exactly, juramentos are practiced there, it does show that, like in Pennsylvania, the juramento has spread to communities with significant Latino immigration.

Two other articles, by Cuadrado (2014, 2018) alone, present major findings of a 2012 survey of 196 priests along the U.S.-Mexico border in California, Texas, Arizona, and New Mexico. This version expands on her survey used in Florida and includes many of the same questions. In the 2014 article, Cuadrado reports that 72 priests reported having witnessed a juramento at least once, and the number of juramentos witnessed ranged from 1 to over 100, with an average of 17 per priest. Priests who spoke the Spanish language were almost four times as likely to have witnessed a juramento than others; and Hispanic priests were over twice as likely than their non-Hispanic counterparts to report witnessing a juramento. Seventy percent of the individuals making the juramento were men with an average age of 35 years. Most of the pledges were made to our Lady of Guadalupe (51.3%) and others were made to God and Jesus. Alcohol was the major substance behind making a juramento. The length of abstinence was “10–12 months” (34.2%), followed by “more than 1 year” (32.9%), and then “4–9 months” (23.3%). Only 9.6% requested 3 months or less. Nearly 67% of the priests believed that the juramentos were effective.

Cuadrado’s 2018 publication, drawing from the same survey data, describes the AUDs referral practices of Catholic priests along the U.S.-Mexico border and their willingness to work with different recovery resources in the community. She discovered high levels of willingness to make referrals and to work with family, and less willingness to work with treatment or self-help groups. Two-thirds of the priests would make referrals to self-help groups, but less than half of them would work with them directly. Self-help groups are preferred over other community resources because the priests are the most familiar with them, particularly Alcoholics Anonymous. Another significant finding is that priests fluent in the Spanish language were most likely to recognize the importance of family and working with them. They preferred to work with the families directly than with treatment or self-help groups. The author believes that the preference of the priests to work with families may be due to the priests’ concern about lack of assistance for the families with a substance abuser family member.

Cuadrado’s two latter publications (2014; 2018) show that the juramento is also practiced in states along the U.S.-Mexico border, a region with many Mexican immigrants. While Hispanic priests generally had more experience with juramentos than non-Hispanics, fluency in the Spanish language was the most significant correlation with priests’ likelihood of being involved in the juramento process. Furthermore, the articles demonstrate that priests are an important first contact for alcohol abuse problems. Cuadrado (2014) suggests that Latino men are willing to confide in priests because it avoids the feeling of public shame that is associated with seeking help for substance abuse in other venues. She goes on to document the referrals that priests may make as a follow-up to a juramento, and notes that they are very willing to work not only with the individual with an AUD, but also with their family and, to some extent, with other community programs (Cuadrado 2018).

III.C. Curanderismo

Curanderismo is a type of traditional medicine practiced in Mexico and other parts of Latin America, as well as in the United States. It is based on a mix of pre-Columbian and Old-World diagnostic and healing practices. Curanderos, or practitioners of this medicine, offer the same services in the United States as they do in Mexico and treat chronic diseases, pain, folk illnesses, work injuries, and alcoholism (Favazza Titus, 2014; Ortiz & Torres, 2007). There are several studies on the use of curanderismo among Mexican Americans and Mexican immigrants, as a literature review by Favazza Titus (2014) and our own investigations reveal. However, only one study, by Ortiz and Torres (2007), documents how curanderismo is used specifically to treat alcohol use. For this reason, we review this work although it does not directly address use of curanderismo and AUDs in the Latino immigrant community.

Additionally, we consider the work of Ortiz and Torres because many of the remedies discussed are also covered for other illnesses in the literature on curanderismo use in the United States. Their data is from a single focus group conducted in a folk healing and curanderismo course at the University of New Mexico. The sample consisted of six curanderos: five women and one man. All six practiced traditional medicine in Mexico and taught at La Tranca Healing Institute located in Cuernavaca, Mexico. The authors served as moderators and used open-ended Spanish-language questions to discuss the curanderos’ experience in treating “alcoholics.” As Favazza and Titus (2014) and Sanchez (2018) make clear, curanderos in the United States practice their medicine for the same illnesses and diseases as in Mexico. Given this account of curanderismo practice in Mexico for alcohol abuse, we can infer that similar practices are also used for the same reasons in the Latino population.

The focus group identified what the authors labeled “major treatment modalities,” which includes the following:

• Liver Detoxification and General Detoxification: This treatment helps in two ways: to cleanse the liver and to help the drinker with withdrawal symptoms. It consists of saline solutions and vitamin regimens and includes herbal remedies. The protocol also includes diluted amounts of alcohol that the drinker was abusing; it helps with withdrawals.

• Temescal (Sweat Lodge): The temescal is considered a sacred place. The treatment starts with a preparation designed to get the individual to think about the emotional journey to be embarked on. While in the sweat lodge, an emotional awakening is encouraged, and traumas and fears are revisited, all under the guidance of a curandero. The heat and darkness inside facilitate an emotional release, and the perspiration helps to release toxins from heavy alcohol use. The process may include prayer and the seeking of forgiveness. A ritual rinsing is performed at different points and at the end.

• Limpias (Spiritual Cleansings): Limpias are rituals for restoring a state of emotional balance in an individual suffering from despair, fears, and traumas that may contribute to alcohol use. Limpias come in different forms. The ritual may involve “an egg which might be used to absorb and remove destructive and negative energies; it may involve brushing the body with fragrant herbal brushes, or fire, or water might be utilized for this cleansing treatment” (Ortiz & Torres, 2007, p. 85). Limpias work holistically and cleanse the body, mind, and spirit.

• Platicas (Counseling): Platicas, literally translated as talks, are a safe dialogue between the curandero and an individual seeking help for alcohol use. It helps the individual to explore emotional issues. Some are for family members who may need support. They help the family with the distress caused by a family member who will not stop drinking or who has stopped and needs to be reincorporated.

• Sobadas (Massages): Sobadas, or massages, are therapeutic touch. They release endorphins and help counter cortisol, a stress hormone, useful in alcohol withdrawal. The massages may make use of clay poultices.

• Spiritual Treatments: Prayer is also used in conjunction with other approaches. Curanderos pray on behalf of the individual in their presence, and they also pray with them.

Curanderos also make use of biomedicine to treat alcoholism and make referrals to biomedical providers. In fact, some of the curanderos in the focus group had formal medical training. As Ortiz and Torres (2007) inform us, curanderismo has a comprehensive approach when treating alcohol abuse: it addresses the different phases involved, from detoxification to the use of different therapies aimed at causes behind AUDs, such as traumas, and includes family members.

IV. Discussion

For nearly half a century, grassroots intervention efforts for AUDs have emerged from within minority communities across the United States and draw on local support and resources. Evans and his colleagues (2012) point out that behind these efforts were what they call “addiction recovery mutual aid organizations” (p. 2). These mutual aid groups make use of culturally indigenous recovery support resources (CIRSR), described as “… recovery mutual aid efforts organized by and on behalf of members of particular ethnic cultures. CIRSR mobilize distinctive cultural features (e.g., history, language, values, symbols, rituals) to buttress successful recovery from addiction” (Evans et al., 2012, p. 4). By its very nature, CIRSR emphasizes culture. CIRSR considers culture “an agent of healing” and advocates for its use, including the renewal of lost cultural traditions, in recovery. CIRSR also includes facilitators, including cultural indigenous healers, with “… experiential knowledge (lived knowledge of the problem and its solution) and experiential expertise (the ability to translate personal knowledge into skills in helping others within the community)” (Evans et al., 2012, p. 7). CIRSR also makes use of “catalytic metaphors” associated with the culture of the group. That is, it “encompass[es] words, ideas, and stories that, by creating dramatic breakthroughs in perception of self and the world, spark and anchor processes of personal transformation” (Evans et al., 2012, p. 7). In all, culture and nonprofessional recovery expertise in ethnic-specific grassroots efforts are indispensable towards achieving recovery.

To one extent or another, the grassroots interventions described in this literature review have many features and practices of the ethnic-specific recovery mutual aid groups, as described by Evans and colleagues (2012). In fact, 24-hour AA groups, or the anexo, and fourth and fifth step AA groups do qualify as ethnic-specific recovery mutual aid groups. Juramentos and curanderismo do not, but they, too, make use of facilitators and CIRSRs. Many features of these cultural recovery resources are similar across the interventions with some, such as religious symbols and beliefs, being stressed over others.

Mexican and Central American immigrants establish and operate anexos and fourth and fifth step AA groups, and their fellow compatriots make use of them. Despite their different national origins, the members of these AA groups share a common Latino culture and immigrant experience in the United States and use Spanish in their AA meetings and other activities. The anexo and fourth and fifth step groups also make use of cultural facilitators—directors and assistant directors in the anexos and sponsors, and oyentes (sponsor-in-training) in the fourth and fifth step groups—who are like indigenous cultural healers in ethnic-specific recovery mutual aid groups. They not only share a culture with those seeking help with their SUDs, but they also have important experiential knowledge and expertise needed for recovery. The anexo and fourth and fifth step groups also make use of culturally indigenous recovery support resources, particularly their common immigrant stories, values, and rituals in their daily AA meetings. Powerful catalytic metaphors that result in a personal transformation are used in both groups, in their testimonials at the meetings, and, in the case of fourth and fifth step groups, the retreats or las experiencias.

The juramento is both a religious and cultural practice and, as such, draws on the faith and culture of Mexican immigrants. The priests facilitate this practice, and, as the work of Cuadrado (2018) reveals, they also provide support to the families. Culturally indigenous recovery support resources, around saints, religious symbols and rituals are powerful tools in this intervention. Mexico is a predominantly Catholic country devoted to Our Lady of Guadalupe, as are Mexicans living abroad. For nearly five centuries, she has been seemingly the most commanding religious, cultural, and national symbol from the colonial to contemporary era. The pledge is a source of a religious-based catharsis that results from making it—one that, with the help of Our Lady of Guadalupe, releases the individual from feelings of shame and guilt so that he can stop drinking and start healing. A sacred dyadic relationship with an important saint is established when making a juramento. The individual receives support from Our Lady of Guadalupe, and in return, he reciprocates with gratitude, which often involves leaving a votive offering at the church, giving a donation to the parish, or making a pilgrimage to her shrine in Mexico City. In Latin America, dyadic relationships in general are important to building and sustaining networks of individuals and entities for individual, family, and community well-being and includes establishing and maintaining relationships, exchanging resources, and collaborating in social and religious activities (Brandes, 2010; Espinoza, 1999). As such, the structure of a juramento invokes fundamental tenets from both the cultural and religious background of Mexican immigrants and employs them for a therapeutic purpose.

Curanderismo is embedded in Mexican culture and society, and curanderos are indigenous cultural healers in Mexico and Mexican immigrant communities. Historically, it has been a major source of health care in Mexico, especially for the poor. Today, despite the availability of biomedical services, it remains a popular source of care (Ortiz & Torres, 2007; Sanchez, 2018). Like the other interventions, curanderismo makes use of its own culturally indigenous recovery support resources, such as religious symbols, herbs, and non-biomedical healing knowledge. They include several centuries-old remedies for AUDs, among them, herbal remedies, massage, platicas (counseling), temescales (sweat lodges), limpias (cleansing rituals), and prayer to Our Lady of Guadalupe and other saints. These remedies are based on cultural beliefs that attribute illness and disease, including substance abuse, to supernatural (malevolent) forces, strong emotional states (such as rage, fear, an envy), the presence or absence of harmony with one’s environment, and soul separation from the body (loss of soul).

Besides drawing on culture, all of the grassroots interventions in this review also make use of spiritual reawakening, as sparked in the testimonials of the 24-hour groups, the retreats of the fourth and fifth step groups, the pledge of the juramento to a sacred saint, and the temescales and limpias of curanderismo. As Heinz and his colleagues (2010) found in their study on spirituality and substance abuse treatment, religion and spirituality is a source of strength, hope, solace, and comfort during recovery. Research on AA (Cahn, 2005; Roland & Kaskutas, 2002; Sifers & Peltz, 2013; Wade, 2013) reveal the same. In one study, individuals who, at year three in recovery, had a spiritual awakening reported a greater likelihood of continuous abstinence in the previous year (Kaskutas, Turk, Bond, & Weisner, 2003), while spiritual change was a partial mediator in the “relationship between increases in 12-step involvement and better treatment outcomes (here, total abstinence) 1 year postbaseline” (Zemore, 2007, p. 78S). Carter (1998) also found in their study that those who had “increased spiritual practices have fewer relapses and longer-term recovery” (p. 412). This evidence indicates that religion and spirituality have positive implications for staying sober and in recovery after treatment. Furthermore, interventions that include religious and spiritual features may be particularly helpful for Latino immigrants, for whom the use of religious coping strategies correlates with lower rates of substance abuse (Sanchez et al. 2015; Ai & Lee, 2018) and appears to temper the consequences of acculturation stress on mental and behavioral health more broadly (Silva et al. 2017).

V. Conclusion

The larger literature on culturally-based recovery efforts across different racial and ethnic groups document their importance in addressing substance abuse and promoting recovery. Some researchers recommend incorporating them into biomedical or psychosocial treatment programs (Abbott & Chase, 2008; White, Evans, Lamb, & Achara-Abrahams, 2013), while others advocate for using them independently of other programs (French, 2008; Gone, 2011). We contend that, given the need for SUDs interventions and treatments in the Mexican immigrant community, both approaches should be considered. However, for this to occur, healthcare practitioners must become informed on how grassroots interventions, especially the ones examined in this literature review, contribute to recovery. These interventions may have an advantage over formal cultural competence AUDs programs used and promoted in public health. They consider the culture of the immigrants, as it is practiced daily, and their experiences in the country. As such, these grassroots interventions address, in an organic way, the concerns addressed in cultural competence programs. As examined in the work of Guerrero and his colleagues (2010, 2011, 2012, 2013), they include language congruence, race-ethnic matching of treatment providers to ethnic clientele, and culture sensitivity around a homogenized set of cultural ideals. Using culture in this way, in a piecemeal fashion, to connect culturally with clients minimizes culture’s powerful impact in treating SUDs, and failing to consider the many challenges that immigrants face ignores a major health care determinant in the immigrant population. Moreover, the grassroots interventions are not delivered in clinical settings but in familiar places in the immigrants’ communities, such as in their neighborhoods and churches, and are delivered by priests, traditional healers, and the immigrants themselves. To make use of these advantages, more research is needed to understand the variations found in each intervention, their complementary nature, and their potential for long-term recovery.