Experiences of Power and Violence in Mexican Men Attending Mutual-Aid Residential Centers for Addiction Treatment

Abstract

Fundamental elements of hegemonic masculinity such as power and violence are analyzed through characteristics of 12-step programs and philosophy immersed in Mutual-Aid Residential Centers for Addiction Treatment (CRAMAAs). CRAMAAs are a culturally specific form of substance abuse treatment in Mexico that are characterized by control and violence. Fifteen interviews were carried out with men of varied sociodemographic characteristics, and who resided in at least two of these centers. Results identify that power is expressed through drug abuse and leads them to subsequent biopsychosocial degradation. Residency in CRAMAAs is motivated by women, but men do not seek the residency and are usually admitted unwillingly. Power through violence is carried out inside CRAMAAs where men are victims of abuse. From a 12-step philosophy, this violence is believed to lead them to a path of recovery but instead produces feelings of anger and frustration. The implications of these centers on Mexican public health are discussed.

Introduction

The use of drugs in Mexico is considered a public health problem. The National Survey on Addiction reports that drug use has slowly gone up during the past years. Of particular concern is drug use among men. In comparison with women, men between the ages of 18 and 65 years showed a statistically significant increase in their use of any type of drug: In 2008, 3.4% of men had used any drug while 4.7% did so in 2011; and 3.3% of men had used marihuana in 2008,and 4.2% in 2011. On the other hand, only 1.1% of women have used any drug, and 0.4% had used marihuana. The same trend is reported in alcohol use; in 2011, 80.6% of men had tried alcohol some time in their life while only 62.6% of woman did. Finally, 10.8% of men qualified for dependency on alcohol, and only 1.8% of women did (Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz [INPRFM]; Instituto Nacional de Salud Pública [INSP]; Secretaría de Salud [SS], 2012a, 2012b). Men also suffer more health consequences of drug and alcohol use in comparison to women; heart and pulmonary diseases are more common amongst men than women, as well as a higher frequency of car accidents related to driving under the influence (INMUJERES, 2010).

The use of alcohol and drugs as well as the problems associated with it exceed the resources assigned by the state to attend them in Mexico (Borges et al., 2009; Medina-Mora, 1994). This situation has motivated the organizations of civil society with actions that pursue to attend the deficiencies left by the state (Fiorentine, 1999; Humphreys, 1999). With this precedent, one form of organization that has acquired great popularity is the formation of self-help groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Recovered alcoholics or ex-addicts that believe in AA philosophy initiate these groups (Comisión Nacional Contra las Adicciones [CONADIC], Centro Nacional para la Prevención y el Control de las Adicciones [CENADIC], & Comisión Interamericana para el Control del Abuso de Drogas [CICAD-OEA], 2011). They open a group where the typical 90-minute meeting may take place and anyone is welcome. Twelve-step groups and philosophy had a cultural evolution in Mexico and presented important fragmentations (Rosovsky, 2009). This fragmentation resulted in “dissident” groups that affirm to follow AA programs; according to Rosovksy (2009), this fragmentation and the subsequent “dissident” groups are results of the sociocultural adaptation of the AA model to Mexican culture. Because of these fragmentations, 12-step philosophy evolved into other ways of working, such as the groups that are known as 24-hour groups, which are open 24 hours a day, 7 days a week. These 24-hour groups later evolved into what have been named Mutual-Aid Residential Centers for Addiction Treatment (CRAMAA are its initials in Spanish) in Mexico. This evolution was motivated by problems associated with drugs and alcohol, the economic incapacity to access private treatment, and the lack of community residential centers for addiction in Mexico (Rosovsky, 2009). These centers are popularly known as anexos (Marín-Navarrete et al., 2013) and do not follow the principles and policies of traditional AA groups, but do rely on AA philosophy in their recovery approach. Thus, CRAMAAs are not recognized by National and International AA trademarks.

Mutual-Aid Residential Centers for Addiction Treatment and 12-Step Philosophy

CRAMAAs have become a firsthand option for patients and family members with problems related to drugs and alcohol. Of those who seek and enter this type of treatment, 91% are male (CONADIC, 2011). CRAMAAs are characterized by their heterogeneity (Pulido, Moyers & Martínez, 2009), a lot of them offer a diverse array of residential services that can last from 3 weeks to 12 months. Their space is limited, so overcrowding is common. They also operate under the leadership of the person with the longest period of abstinence, who in 58% of the cases, is not trained in addiction treatment (CONADIC, CENADIC, & CICAD-OEA, 2011). Thus, the workers at these centers usually do not have any type of certification that qualifies them as abled to treat addictions and problems associated with them. As such, these centers break the Official Mexican Norm on the Prevention, Treatment, and Control of Addictions (NOM-028-SSA2-2009) by operating without the necessary and professional equipment, staff, and infrastructure. Pulido, Moyers, and Martínez (2009) also state that more than 30% of the patients in these centers suffer some sort of violence during their residency.

Although CRAMAAs are strictly not AA groups, they use the 12-step program and philosophy (Marín-Navarrete et al, 2013); in fact, 83% of the CRAMAAs use 12-step programs as their main treatment (CONADIC, CENADIC, & CICAD-OEA, 2011). Research on the topic of AA has identified that comfortableness and eagerness to participate in 12-step programs are significant for abstinence and sobriety. Time of abstinence is also related to the length of AA membership, the more time of abstinence, longer the membership to AA (Gabhainn, 2003). In general, affiliation to 12-step philosophy and its work program have been reported to enhance treatment outcomes, increasing time of abstinence and reducing alcohol-related problems (Tonigan, 2001).

Witbrodt and Delucchi (2011) report that spirituality and religiousness are important components for recovery in abusive drinkers, and these elements facilitate women’s recovery rather than men’s. Important changes in spirituality and religiousness have been reported in longitudinal studies with AA attendees, where people identify an increase in their beliefs and attitudes; these changes are also associated with greater odds of no heavy drinking after 6 months of attending AA meetings (Robinson, Cranford, Webb, & Brower, 2007). Gutiérrez, Andrade-Palos, Jiménez, and Juárez (2007) reported that the more patients attended AA meetings, the more spiritual they felt, and the more steps they accomplished in the 12-step program. According to these authors, AA groups in Mexico expect that patient’s experiences in the program be of spiritual conversion in order to maintain sobriety, thus making spirituality into a vital element of recovery and abstinence.

Masculinities and Health

Studies on masculinity have reported that men do not talk about their health issues because this can be interpreted as a sign of weakness and femininity (Fleiz, Ito, Medina-Mora, & Ramos, 2008; Kimmel, 2008; Sabo, 2005). de Keijzer (2001) affirms that this practice is a form of masculine violence, a concept that he takes from Kaufman (1989) in order to understand that deterioration in men’s health is a form of violence of men against themselves. Gender studies have linked the construction of masculinity—as identity, traits, and roles—to an articulating axis of power (Ramírez, 2005). Thus, alcohol and drug use can be seen as an activity to demonstrate power over others. In fact, Brandes (2002, 2004) finds that Mexican men’s drinking habits are strongly linked to their sense of masculine identity, and thus, when they stop drinking, they face a critical question that poses the possibility of losing their manhood. Drinking behaviors are also a result of historic processes that involve religious rites such as marriages and baptism, where men are expected and allowed to drink until the point of intoxication (Brandes, 2002; Rosovksy, 2009).

Humility is also an important component of AA philosophy and the 12-step program. According to Hanninen and Koski-Jannes (1999), narratives of men in recovery from addictive processes attend AA only after they have “reached the bottom,” feel completely isolated, and practically have no other option. This helps them realize the severity of their addictive behaviors and pushes them to seek help in AA. According to these authors’ analysis, men’s participation and feeling of being helped in AA grows stronger as the men develop humility. Humility is a feeling that enables these men to become part of the AA community and identify with other alcoholics in order to recover. According to Wilson (1955), one of the founders of AA, humility serves as a guide for men to free themselves of their obsession over alcohol and recover their better judgment as well as to accept their weaknesses. Humility is then a transversal aspect of the AA model that becomes more relevant in certain steps. From a masculinities perspective, the development of humility means to understand manhood (and particularly their substance use) as subordinated to hegemony, because it is a feeling commonly associated with femininity.

Power is a tricky concept that has been adopted by masculinity studies in Latin America (Amuchástegui, 2006; Burin & Meler, 2000; Corsi, 1995; Ramírez, 2005; Ramírez Hernandez, 2000; Tena Guerrero, 2010), and other parts of the world (Bourdieu, 2005 ; Connell, 1987, 1995; Kaufman, 1989, 1999) to understand men’s violence. Power not only refers to ways in which others may be repressed but as a “productive network that runs through the whole social body” (Foucault, 1984, p. 61). Foucault understands power both as a way to repress and a way to produce; repression is dependent on the state, while power in general extends well beyond that. Thus, social organization of sickness and disease is a form of exercising power over individuals that do not “fit in” into modern society. The use of psychiatric hospitals is a way of confining those people (Foucault, 1984). The experience of people in CRAMAAs identifies the power that these centers use to confine and control emotions, behaviors, and individuals (Marín-Navarrete et al., 2013; Pulido et al., 2009). This power may be achieved through discipline and a constant vigilance on those bodies outside of the social order (Rangel, 2009).

According to Amorós (1992), men are those who, because of the body they are born in, and the discursive power provided to certain biological characteristics, inherit power, but who also build, produce, and reproduce it actively in their daily lives (Butler, 1993; Kimmel, 2008). Masculinity is a constant involuntary exercise that goes beyond the notion of individuality and that contributes to the production of normative systems that constrain men and oblige them to undertake certain behaviors (Amorós, 1992; Butler, 2001; Castañeda, 2007; Rubin, 1986). Behaviors that put men’s life at risk are welcomed by masculinity, because they are understood as practices that denote strength and courage. The abuse of alcohol and other drugs speak of a neglect to take care of one’s own body and allow men to move closer to danger because they become ways to reproduce and maintain power (Wilsnack, Wilsnack, & Obot, 2005). For Mexican men, power is commonly expressed as violence over others, because it allows them to maintain a hierarchic position over them (Castañeda, 2007; Díaz-Loving, Rocha, & Rivera, 2007; Ramírez, 2005). For example, Brandes (2002), when working with AA traditional groups, finds that being sober in Mexico City may be hard for men because it implies losing their masculine image. However, the author also finds that men in these groups redefine their masculinity in order to understand themselves as men. Their attendance to these groups allows them to resignify and reconstruct their relationships and understand the damage they have caused to family members because of their drinking, and thus, interact with others from a more egalitarian standpoint.

Little research has been undertaken in Mexico regarding masculine identity and alcohol use (Brandes, 2002, 2004; de Keijzer & Rodríguez, 2007); however, this article is centered on how masculinity as part of gender systems affects treatment in CRAMAAs. In other words, interest lies on analyzing hegemonic masculinity as a social structure and how this structure affects men’s experiences of power and violence within CRAMAAs.

A primary qualitative analysis was developed to explore men’s experience in these centers (Marín-Navarrete et al., 2013). From this analysis, it was evident that men were subject to constant exercise of power and violence; thus, these two topics acquired particular interest. This article displays the results of a secondary analysis to the qualitative data initially collected by Marín-Navarrete et al. (2013), an analysis centered on the way power in masculinity is expressed and maintained in CRAMAAs and how these elements contribute or hinder recovery to sobriety. The use of the category “experience” is extremely useful for this analysis, because this category is an attempt to recover the voices of the people that are potentially subordinated and pathologized. de Lauretis (2008) understands experience as an element that allows the construction of subjectivity, a symbolic space where people hold dialogues with their social realities; it is also a category that allows the comprehension of meanings and how they change and reconstruct constantly. The subjective experience of men is a firsthand resource to understand their contradictory experiences with power (Kaufman, 1999), and how these intertwine with cultural meanings (Bach, 2010; Castro, 2010; Magnusson & Marecek, 2012). This approach suggests parting from a phenomenological standpoint, but that includes an interpretative analysis (Smith & Osborne, 2007). This perspective gives a voice to a clandestine group of men that through other methodologies might be misinterpreted and decontextualized.

Method

Participants and Procedure

The research team has worked extensively at a clinical level with CRAMAAs in Mexico. The centers were contacted to inform them of the objectives and methodology of the initial study. CRAMAAs showed interest in participating. Two members of the team attended four CRAMAAs to meet the residents and sponsors. Residents were informed of the project and were asked to participate. Three of the centers were located in Mexico City and one in the state of Hidalgo, where men from different cities of the region and from different socioeconomic backgrounds attended.

Participation was voluntary, confidential, and anonymous and did not interfere with participants’ relationship to the center. Because most of the participants were residents of the centers where communication with the outside world is very limited, and some interviews took place within the CRAMAA, voluntary participation was brought into question. Two witnesses also signed the informed consent signed by the participants. These witnesses validated that the men’s participation was not coerced, but voluntary. Participants chose their own pseudonyms, with which the interviewers referred to them throughout the conversations and were used in the transcriptions and data analysis. All participants had attended at least two CRAMAAs in order to provide a richer narration of their experience with these centers.

Those who presented psychotic symptoms or cognitive deterioration were not candidates for the study, because of the interference these symptoms may cause in face-to-face interviews. Interviews took place after explaining and signing the informed consent and took place in a private office in each of the centers. The sample was a convenient sample and participants were purposively selected in order to achieve maximum variability (Flick, 2004) with regard to age, education level, and time of residency in the CRAMAA.

Fifteen participants sufficed to reach data saturation; their mean age was 40 years, with men as young as 24 years and as old as 58 years. The participant’s education level varied from middle school to undergraduate degrees. Ten participants had a bachelor’s degree or higher and five only middle school or high school. More than half were divorced or separated, and three lived in a form of civil union with their partner, and the rest were single. All the men who were partnered at some point had at least one child. Even though their monthly income varied, it is safe to state that all but one of the participants were part of the working class; some of them had stopped working altogether because of biosocial deterioration due to their alcohol and drug use and were dependent on their family. All the participants had been residents of at least two CRAMAAs, and their time in the current CRAMAA varied from 1 to 6 months. Even though some participants had attended other forms of treatment at private and public health facilities, the present analysis is focused solely on men’s experiences of power and violence within CRAMAAs, and how these become an institutionalized form of interaction between men.

Instrument

Interviews were semistructured and focalized (Flick, 2004; Kvale, 2007), using a guide that covered the following topics: general data, history of use and abuse, treatment history, previous treatment, experiences in CRAMAAs, and use of services provided by CRAMAAs. Interviews lasted from 45 to 75 minutes each. All interviews were carried out in Spanish. As was stated above, the present interpretations are a result of a complementary analysis of the interview data. The data in this article do not derive from a particular topic covered in the interview guide, but rather, the initial analysis allowed the authors to identify violence and power as transversal elements in these men’s experiences of drug use and rehabilitation.

Data Analysis

The interviews were audio recorded and transcribed verbatim and later translated into English in order to conduct the first reading of the transcriptions, from which a codebook was developed. This codebook was used to assign categories to the narrative using the software Atlas.ti 6.0. Second, a line-by-line analysis (Strauss & Corbin, 1994) was carried out, which allowed for common patterns and singular events to emerge. Once the data were codified, the research team discussed categories extensively in order to interpret them through a masculinities perspective and to understand how power and violence become institutionalized in CRAMAAs and how it affects men’s recovery.

Results and Discussion

Because this analysis was centered on power and violence, it excludes other experiences and events that may take place in CRAMAAs. These results must be understood as a descriptive–interpretative analysis of some men’s experience. Because the sample is a small one, it is by no means the authors’ intentions to generalize the findings to all CRAMAAs in Mexico. However, it does bring light on cultural practices regarding masculinities and addictions and how they affect subjectivity; particularly, it is helpful in understanding power as a masculine attribute and how it affects mutual-aid treatment centers.

Contradictory Experiences of Power and Substance Use Initiation

Men’s experiences show a constant exercise of power through physical and psychological violence throughout their residency in CRAMAAs. In some cases, violence extends to men’s substance use history, and family history. In both cases, men are subject or spectators of violence from family members. For them, this violence has important significance in initiating their substance use.

My dad would come out of his room, of his study, and—fuck! He would get all intense, my dad . . . He would go upstairs and scream at my mom . . . My dad would get all fucked up when he drank, he was violent with my uncles, he would pull out his gun on them . . . It really got to me. (Juan, 23 years)

. . . In a home where you have an alcoholic father, well, I developed a lot of resentment towards him. Why? Because I saw how we lacked a lot of basic needs, and he preferred his friends, his alcohol . . . (Gaby, 31 years)

These experiences of violence are lived more intensely during childhood and early youth; they are understood as a lack of family support and affection, making the men feel isolated and unwanted. However, hegemonic masculinity (Castañeda, 2007; Connell, 1995) did not allow them to express these emotions and interpretations because they would be seen as weak and feminine. For some of the men, this violence and the impossibility of expressing it is extremely significant; they understand it as one of the causes that led them to their substance use. The violence they witnessed was also a form of pedagogy on how to be violent: The men’s families serve as models that teach them that men are violent and that it is expected that they act this way.

Men understand that it is this power and violence that they must reproduce, but at the same time, they are subjected to it. They both are perpetrators and victims of masculine violence; an experience Kaufman (1999) names contradictory experiences of power. According to the author, being subjected to this power brings pain, pain that these men felt since early stages of their life and that lead them to feelings of anger that were only solved through substance use. In many cases, substance use was a way of “getting back” at their families and demonstrating the anger they had carried since their childhood. Kaufman (1999) understands masculine power as a means to acquire and keep resources; one of the resources men find for controlling both themselves and their family dynamic is through substance use:

. . . Fucking bitch, doesn’t let me drink in peace . . . and we fought a lot, it was a battlefield, I never hit her, but we had really strong discussions . . . (Alfonso, 37 years)

The money I made each week, I didn’t care, what I earned each day was enough, it was a nice amount, and I used it all on drugs, day and night . . . (Gaby, 31 years)

Through substance use, they are able to spend the money they earn and their time on themselves and not on providing for their family and investing quality time with them. Substance use is a resource used by these men to accommodate themselves in a position of power, particularly over their families. This is part of what Connell (1995) names patriarchal dividend, which refers to the access and use of resources by men, given to them by gender culture. The access men have to work, and economic resources, and thus to the use and abuse of substances is an exercise of patriarchal resources, mainly when it is women who suffer the consequences of this abuse.

Light and Out of Bounds Groups

The data identified that men had experiences of two types of CRAMAA: what they named Out of Bounds and Light. According to the men’s descriptions, the former type of CRAMAA are usually located in residential houses that are adapted into what the leaders consider to be a treatment facility and are lead by a recovering alcoholic or drug user, the one with the most time of abstinence. Out of Bounds CRAMAAs are characterized by overcrowding, with anything between 80 and 200 men living in the facility; they lack minimum hygienic conditions, such as toilets, sinks, and showers; men are forced to shower with two small buckets of cold water, one bar of soap, and one razor for everyone. In some cases, men reported been given a small dish where they would urinate, defecate, and eat out of. The food usually consisted of what was named “bear soup,” which consisted of boiled water with onions and garlic. These types of CRAMAAs were spaces where a great amount of violence took place, such as severe beatings, public humiliation, rape, being locked up, and in some cases, death. AA meetings were held that lasted up to 20 hours; men were forced to stay awake and participate throughout the whole time and were finally allowed to sleep sitting on the floor or on a chair.

We would shower in the pigpen, it’s really cold, and they would throw cold water on us, we would get sick all the time. (Roberto, 53 years)

One or two pieces of vegetable floating around, right? But it was mostly onions, right? Maybe a small piece of carrot and zucchini on the plate, which isn’t a plate, it’s a piece of plastic where you drink from, where you eat from, that you use to go to the bathroom, right? (El tío, 45 years)

Out of Bounds CRAMAA also lack basic medical attention services, such as a medic, therapist, counselor, and/or psychologist, thus breaking the NOM-028-SSA2-2009 that stipulates that all centers that treat addictions must base their treatments on scientific principles and research, have trained staff on duty 24 hours a day, and provide with hygienic conditions as well as provide a balanced diet for their residents. In some cases, these types of CRAMAA do not charge for their services, but depend on private and family donations.

The Light CRAMAA, according to men’s descriptions, is usually a residential house, with smaller populations of residents. There are beds, sheets, and covers available for all the residents; there are clean toilets, sinks, and showers, and a different menu is cooked everyday. Men in these CRAMAAs participate in household chores, such as cleaning, making beds, and cooking. According to them, they are not subject of violence. Some of the Light CRAMAAs have established professional relationships with counselors, psychiatrists, and/or therapists who attend the center around once a week to evaluate and work with the residents. As the analysis will identify, experiences differed immensely according to what type of CRAMAA the men had attended. However, in both, there is an exercise and institutionalization of masculine power, which is related to AA philosophy and practice, what differs is how this power is used.

According to Marín-Navarrete et al. (2013), both Out of Bounds and Light CRAMAAs allow for the exercise of violence, but in very different ways. While Out of Bounds use physical, sexual, and verbal abuse to humiliate and “humble” its residents, leaders of Light CRAMAAs rely on ideological confrontation. In both cases, the use of power has the intention of making the men controllable and labile as a mechanism of treatment. Through this power, men are forced to a position of subordination; one they are not accustomed to because of their socialization as men with patriarchal privileges (Amorós, 1992). Locating men in a position of subordination facilitates the reproduction of 12-step philosophy as a way to recovery, and in some cases, this philosophy is interiorized in the men’s sense of self and consciousness. In other words, violence in CRAMAAs acquires such a status that residents are able to produce it on their own.

But now I don’t fight anymore, and I do things the right way . . . what I’m supposed to do . . . normal. (Carrasco, 28 years)

But, however, uhm, well, I got over it and then it was just normal. I started to adapt, I can adapt easily . . . (Efrain, 50 years).

. . . one of the leaders came over to us screaming “get out of the way you mother fuckers! Be humble!” . . . (Juan, 24 years)

There, I was nobody, and if you come in kind of crazy, they beat you up good when you arrive, they say that it’s for you to stop feeling so cocky, so stuck up . . . yeah, they beat you up when you arrive . . . (Tío, 45 years)

In this way, the data identify that humbleness in these centers is achieved through power relations, power over the men who attend CRAMAAs, and a process of infliction of violence. This process allows men to become subordinated to those men in control and in a place of hegemony. Even though humility is stated as a guide to recovery within 12-step philosophy, men’s experiences showed that humility was used to make the men who reside in CRAMAAs vulnerable to the leader’s violence. In other words, sponsors and leaders justified their use of power and violence as a way to teach the residents humility and thus help them on their way to sobriety. This use of violence is exercised with the intention of achieving sobriety. Dynamics in CRAMAAs justify the use of violence in order to lead residents into abstinence and sobriety. This form of violence also helps the sponsors guarantee their hegemonic status over the residents.

Involuntary Residency and Subordination

Substance abuse represents contradictory experiences with power for men, because on the one hand, they are using their patriarchal dividend and their resources for their own pleasure and against the well-being of their families. However, men reported feelings of loss of control due to their abuse; even though some desired to stop their abusive drinking and drug use, they were not able to do it:

. . . you don’t want to drink anymore, and everybody tells you the same thing, “stop drinking, you need to stop drinking, control yourself” . . . And you try to stop . . . You try to control it and you can’t . . . (Alfonso, 45 years)

Usually, the man’s family—particularly the mother or wife—seeks ways of controlling their substance use, intents that do not lead to the man’s treatment or recovery. Mothers and wives suffer the consequences of men’s substance abuse; they endure verbal, physical, economic, and sexual violence and the indirect consequences of the man’s biosociopsychological deterioration, which leads them to confront their sons and husbands about their abuse. However, men rely on their masculine privileges and power to ignore or respond with violence. As a result, family turns to CRAMAAs when they feel completely helpless. Some family members learn of CRAMAAs through friends and acquaintances, and others through public programs such as, Locatel and Vive sin Drogas. ¹ The fact that mothers and wives are the ones that seek help for their sons and husbands is significant because it speaks of the role of care and nursing they are socially assigned. Some men only took their substance use seriously when another figure of authority and of masculinity, such as a medic, recommended treatment.

I was lying down in my living room and I hear that someone rings the doorbell, I just raised my head and I looked out to the garage and I saw my wife talking to a man, I laid back down and next thing I know is I have three people, three guys next to me “you know what? We come from a AA group” and I didn’t want to, and I didn’t let them and they carried me out by force . . . (Jerónimo, 39 years)

I mean, they tie you up, they tie your hands and feet and that’s it, but they do it when you’re sleeping . . . (Carrasco, 28 years)

These experiences speak of a reluctance to be admitted into a treatment center and of the serious consequences the men’s drug abuse has brought to them and their families. In many cases, residency to a CRAMAA is not voluntary, but is forced on by family members and members of the CRAMAA. There is a change in who expresses power and who is subordinated. Through violence, family achieves a position of power over the substance user; subordination is apparently the only way in which these men may be taken into treatment. Subordination for men means taking the place of femininity and of weakness. It is through power expressed in violence that they are stripped of their patriarchal privileges that enable them to go into treatment.

The role that members of the CRAMAA play is important, the men who go to residential homes and take drug users are named twelvers (doceaveros in Spanish), which stand for the 12th step in AA philosophy. Twelvers are men that have gone through a 12-step treatment and must now “share the message.” These men believe that through acts of violence, they are sharing the message of AA and helping another alcoholic. AA philosophy is thus interpreted through a particular lens that enables these men to commit acts of violence for what they believe to be the good of the drug user. Men’s experiences with twelvers identify how they are subordinated to other’s will in order to begin treatment in CRAMAA. According to Zemore, Kaskutas, and Ammon (2004), in the 12-step program, “helping helps the helper” (p. 1015). In this case, twelvers may believe they are helping another man with drug problems, even if it is through violence. This involuntary and violent form of going into treatment is also a way of taking away the men’s autonomy and way of intruding into a personal space; according to Ramírez Hernandez (2000), this invasion is a form of masculine violence, one that facilitates the control of the other’s body. However, this helping provides the construction of resistance from the man that is taken into residency, a resistance that produces emotions of anger and frustration that according to the data did little to help in the process of recovery.

Violence and Power in CRAMAAs Treatment

The use of violence by men who work in the CRAMAAs is a permanent activity for their residents. Men become objects of violence throughout their whole residency; they are read as objects as opposed to subjects and thus stripped of their autonomy and decision capacity. This means that they are subordinated to the will of another. This form of power enables the leaders of the centers to control the residents. The interviews were filled with events and episodes of extreme violence that attested against men’s integrity and dignity, particularly from those men that had resided in Out of Bounds.

. . . Afterwards they put me in a room where they held all the meetings, and they sat me in a chair and you can’t move and you have to sit there with your hands held out in front of you, and you can’t fall asleep . . . they solve everything with blows, the call them “applications,” and there are so many of them, right? Sometimes they make you do push-ups with a ton of bricks on your back, or usually they’re punches, right? . . . (Cristian, 24 years)

. . . Yeah, a lot of violence, I was raped, they stuck a broomstick up my anus, they did a lot of fucked up shit . . . (Roberto, 53 years)

We signed a document, they said that I was gonna be there for only a certain amount of time, that my family would be able to come and see me, that they could bring me food . . . That if I ever needed anything I should just talk to the sponsors and they would contact my family . . . They lied, it never happened . . . (Israel, 38 years)

From the perspective of the twelvers, and other CRAMAA leaders, this form of bringing the men into the center and of treating them may be seen as a way to achieve affiliation and humbleness in the residents. As the 12-step philosophy and prior research sustains (Hanninen & Koski-Jannes, 1999; Tonigan, 2001), these are necessary elements in achieving sobriety. The use of this violence is justified by the principle of humility that is important in 12-step programs because of the distortion of the 12-step philosophy by CRAMAA leaders. However, many men continued their drug abuse after leaving the CRAMAA. According to them, they did not feel affiliated or a sense of community from their experience, elements that are consequences of humility. On the contrary, feelings of anger and frustration were very common; feelings that allowed them to continue their drug use.

. . . That’s why every time I went in I was more resentful, right? More angry, every time I wanted to recover less and less, right? I was there because I was forced to be there, not because I wanted to . . . (Ricardo, 53 years)

Sponsors’ use of violence also resides in the hegemonic status they have in the CRAMAA. This hegemony is lived as a form of powerful masculinity that enables sponsors to continue their exercise of violence. This violence was in no way useful for the residents in their path to recovery; rather, their position as subordinates created the possibility of feelings of anger, which relate to their use of power over their families through substance abuse. Anger is both a result of the time they spent in CRAMAA and a motivation to keep using. In this way, Out of Bounds CRAMAA do little to help men in their path to recovery.

Confrontation took a different form in Light CRAMAAs. In these types of centers, use of power from the centers’ leaders was common through verbal and ideological confrontation. From the data gathered, it can be interpreted that this form of confrontation had the purpose of developing a sense of spirituality and affiliation in the residents.

. . . from the platform, I would tell him “and above who do you think you are, you son of a bitch? Look at you, look at how you are, you live in a fucking 4 by 4 meter room, but yeah, you thank God for that, fucking mediocre God you got you son of a bitch.” And he just sat there, saying “keep going” and smiling, he wasn’t making fun, it was a smile like saying “bring it on,” and I kept on going. . . And at the end of the meeting he came up to me and hugged me . . .

. . . and they started with the idea of God, and when the meeting ended, a guy came up to me and he said “you know what? Only God can help you get over this obsession.” And I came out really upset, thinking that these sons of bitches left me worse than I was, but you know, I got out of there and I wasn’t thinking about drinking, I came out thinking about God . . . I spent a while trying to find this God business. (Alfonso, 45 years)

The element of spirituality is immersed in verbal confrontation, which is the modus operandi of the meetings held in Light CRAMAAs. This confrontation represents a more subtle way of the use of power, because even though men feel angry or frustrated as a result of their meetings, these are feelings that enable a process of reflection about oneself and their substance use. It is a form of power that produces ways of thinking and orients the resident toward abstinence. However, this form of power does not allow for capacity of autonomous decision making, rather, it is expected that the resident make only one decision: abstinence. Both types of CRAMAA rely on “zero-sum” power (Rowland, 1995) to control residents. “Zero-sum” power refers to the more power one person has, the less the other has. In both situations, sponsors and center leaders hold and exercise the power over others, taking power of decision and of autonomy from the residents. The difference is the way in which each one exercises said power, and to what means. Out of Bounds CRAMAAs use violence as a way to humiliate and strip of autonomy and independence. Light CRAMAAs use verbal confrontation and discipline to install ideas of spirituality and humbleness without harming men’s integrity.

Conclusion

Masculinities and Health Policies

The data collected and its analysis identify how power is embedded throughout different aspects of social, family, and individual life. Of particular concern is how power avowed by masculinity leads men into problematic substance use. In this sense, men use “power over” others (and themselves) to express their anger and frustration as well as to exercise patriarchal privileges (Amorós, 1992) and dividends (Connell, 1995) over their family. “Power over” becomes oppositional to “power for”; the latter is a power that produces processes and new ideas; the former is a power used to control (Rowland, 1995), one that is characteristic of masculinity in Mexico (Tena Guerrero, 2010). Data from men attended in CRAMAAs identify that because sponsor’s hegemonic violence is institutionalized within these centers, residents become more resentful and angry, which leads them to more use and abuse of substances as a way to exercise power over their families. Sobriety is what gives sponsors this new power, one that the residents do not have because they have not been abstinent or sober as long as the sponsors. Results presented here differ from previous findings. In particular, Brandes (2002) reported that attending AA meetings in Mexico City motivated a resignification of masculine identity for men, where they questioned their domination over other women in their lives. The data from this study suggest that CRAMAAs particular form of interpreting 12-step philosophy does little to help men question their sense of masculinity. Rather, participants felt attacked and responded with violent emotions.

Regardless of the Mexican government’s intent to control treatment necessities of its population, the increase of substance abuse has exceeded its capacities. For more than 60 years, Mexican society has organized mechanisms to correct this lack of attention, which from the beginning were created with the good intention of helping those affected by drug abuse. However, many of the centers tend to distort the initial objectives, which have led to harmful practices within them. These centers have both helped and harmed many people that attend them. These forms of organization must also be understood as forms of public policy, because they are attempts to address a problematic that affects a considerable amount of people.

It is also evident that the state is colluded in the exercise of power: There is an absence of reflection and discussion on the topic of public and social policy regarding health, masculinity, and violence; as well as a lack of dignified treatment centers. The fact that the state does not certify CRAMAAs because they infringe the law, but at the same time recommends them through public phone services is ambivalent at best. At the same time, this certification is not enough to guarantee a worthy treatment because of practical difficulties in the process: the high number of CRAMAAs and the limited resources assigned to health care in Mexico make this process even more difficult (Secretaría de Salud de México, Organización Panamericana de la Salud, Organización Mundial de la Salud, 2011). These actions are a way of institutionalizing masculine power that subordinates certain people.

The use of these centers is something immersed in Mexican social life, according to men’s experiences, many of them learned of these centers from their neighbors, friends, medics, and family members. The use of these centers is not only motivated by the state, but cultural life in general. The use of power and violence is thus a structural problem that affects families and individuals; when the state is not capable of attending public health needs of its population, citizens seek ways of organization that may resolve this problematic; in this case, in the form of AA groups and CRAMAAs. Gender culture and economic limitations of the general population are social conditions that allow for CRAMAAs to become a space where violence is institutionalized as a treatment mechanism that is endorsed by the very families that seek their support.

Internal life of CRAMAAs, also responds to structural systems and conditions described above that, is part of a bigger gender culture, which affect famil life, substance use, and contribute to socially assigned roles for men and women. Internal life of CRAMAAs is also maintained thanks to particular behaviors and practices endorsed by the sponsors and leaders of the centers. Hegemonic masculinity enables men to understand subordination and hierarchy and ways of achieving it. Through men’s experience, it is evident that many of the center’s leaders use lies and deceit to keep men inside CRAMAAs. Men’s experiences of being victims of physical, sexual, and verbal abuse show the impulsivity, aggressiveness, and failure to conform to social norms of the leaders, characteristics that become the modus operandi of CRAMAAs. The combination of these traits as well as a gender culture that emphasizes control and violence for men, allow the perennial use of “power over” others that do not conform to abstinence, spirituality, and humbleness. In other words, cultural aspects of hegemonic masculinity sustain elements of power and violence within CRAMAAs.

As of the 12-step program, spirituality and humbleness are central elements in understanding masculine power within CRAMAAs. In some cases, these elements have led men to successful abstinence (Brandes, 2002, 2004). Both concepts are of fundamental interest for the recovery of the person, but seem to be interpreted in particular ways, especially in Out of Bounds CRAMAAs. It is believed that humility is achieved through subordination and violence. This subordination is important because it takes men into a symbolic space of femininity, which in Mexican culture is very oppressed. This means that humility is understood as a form of oppression: According to Out of Bounds CRAMAAs, oppression is then a path to sobriety. Spirituality is used by Light CRAMAAs to confront men and lead them to a reflection of oneself. The idea of a higher power poses the possibility of having lost control over substance use. Being subordinated produces feelings of anger and frustration in these men, feelings that contribute to relapses. Figure 1 summarizes the process in which power and violence are present in the whole process of addiction treatment in CRAMAAs.

Figure 1.

Residential process for men in CRAMAAs (Residential Centers of Mutual-Aid for Addiction Treatment).

The obvious implication of violence in public policy is that these centers break the law. It is a great advance that the country does have a legal norm that can serve as a basis to the certification of addiction treatment centers. According to the NOM-028-SSA2-2009, all centers that treat addictions must operate with qualified and certified staff and equipment. None of the centers the men interviewed resided in had medics, physicians, nurses, counselors, therapists, or psychologists as part of their staff. The first step in certifying these centers has been taken by Interamerican Commission for the Control of Drug Abuse (CONADIC, CENADIC, & CICAD-OEA, 2011), which has produced a census of all the CRAMAAs in the country. However, this is only the first step of a long path to certification that will guarantee the fulfillment of the law, public policy, the populations’ demand for addiction treatment facilities, and basic ethical and scientific elements in the path to recovery and sobriety. Certification implies certain control and vigilance of the state over CRAMAAs and other treatment centers. The state must be cautious in order not to use “power over” and zero-sum power that is characteristic of hegemonic masculinity and patriarchal cultures, but rather a positive-sum power, where the power of the state may be shared to empower residents in CRAMAAs (León, 2001; Rowland, 1995).

Classical proposals of empowerment from gender perspective underline the importance of attending subordinated groups, such as women and point out that the first step to empowerment is gaining consciousness of their gender condition (León, 2001). Participants in this study did not question their manhood or gender conditions despite being objects of violence. Public policy in prevention and treatment of men’s addictions can benefit from initiation of a reflection process where men begin to understand not only their hegemonic gender condition but their contradictory experiences with power as well (Kaufman, 1999). Twelve-step philosophy considers power relations in order to gain abstinence and sobriety. However, the original model suggests that understanding and gaining humility can be achieved through speaking openly, reflection, and collective identity building. This humility leads men to understand that they have lost control over their use and over their lives. In other words, the 12-step philosophy is closer to a positive-sum use of power rather than a zero-sum use of power. Because power is inherent to human relationships and is characteristic of masculinity, clinical interventions must consider transforming zero-sum power into positive-sum power. The use of this latter form of power may guarantee violent-free treatments.

The small number of public policies in education and prevention of the consequences and repercussions of drug use (that have not been proven to be effective), as well as a culture of masculinity based on the exercise of power, facilitate the prolonged use of substances without the user taking any action to sobriety or prevention of subsequent problems such as losing their job, domestic violence, car accidents, and other problems with the law. Further actions at a public level must be taken in order to guarantee the prevention of substance abuse at an educational level through community interventions, schooling and mass media, as well as actions oriented to the treatment of this abuse. The results of the present analysis help comprehend that public policies in health that address masculinity and violence will be useful in the prevention and treatment of drug dependencies, because it would consider different levels of social life and how they are affected by problematic substance use.