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No Place Like Home: Examining a Bilingual-Bicultural, Self-Run Substance Abuse Recovery Home for Latinos

No Place Like Home: Examining a Bilingual-Bicultural, Self-Run Substance Abuse Recovery Home for Latinos by  R. Contreras, J. Alvarez, J. DiGangi, LA Jason, L. Sklansky, I. Mileviciute, E. Navarro, D. Gomez, S. Rodriguez, R. Luna, R. Lopez, S. Rivera, G. Padilla, R. Albert, S. Salamanca, & F. Ponziano

Author: R. Contreras, J. Alvarez, J. DiGangi, LA Jason, L. Sklansky, I. Mileviciute, E. Navarro, D. Gomez, S. Rodriguez, R. Luna, R. Lopez, S. Rivera, G. Padilla, R. Albert, S. Salamanca, & F. Ponziano

Abstract:

No Place Like Home: Examining a Bilingual-Bicultural, Self-Run Substance Abuse Recovery Home for Latinos

R. Contreras, J. Alvarez, J. DiGangi, LA Jason, L. Sklansky, I. Mileviciute, E. Navarro, D. Gomez, S. Rodriguez, R. Luna, R. Lopez, S. Rivera, G. Padilla, R. Albert, S. Salamanca, & F. Ponziano

Latinos often do not seek substance abuse services, and this might be correlated to the lack of culturally-modified substance abuse treatment approaches. Oxford House is the largest self-help residential recovery program in the U.S., yet few Latinos are among their current residents. In an effort to change this, bilingual-bicultural recovery homes were recently developed for Latinos. This article describes the process in opening these bilingual-bicultural houses and how sociocultural factors such as the family, simpatía, and gender roles impacted the living environment of these houses. In addition, language is highlighted as a key factor to the comfort and success of Latinos living in Oxford Houses. Based on these experiences, the article addresses several obstacles/barriers that impacted this process and possible feasible solutions to these challenges. One challenge is the Latino family system. While this may provide a supportive, cost-effective option for some; it can also perpetuate a cycle of codependence and substance abuse.


Article:

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Introduction

According to the U.S. Census (2009), Latinos make up 15.1 % of the population and are the largest ethnic group in the U.S. This growing and diverse group is comprised of Mexicans (9.7%), Puerto Ricans (1.4%), and other Latinos (3.9%). As the population grows, so too does their rates of substance abuse and dependence. For example, rates of illicit drug use among Latinos increased from 6.2% to 7.9% from 2008 to 2009 (SAMHSA, 2010). However, due primarily to language and cultural barriers, Latinos differ from other groups in their rates of seeking treatment, utilization of services, and length of treatment (Alegría et al., 2007; Lundgren, Amodeo, Ferguson, & Davis, 2001; Ojeda & McGuire, 2006). At present, Latinos have been shown to underutilize substance abuse and mental health treatment services when compared to other ethnic groups (Alegría et al., 2007; Schmidt & Weisner, 2005). One of the primary reasons for Latinos’ underutilization of services appears to be the lack of culturally-appropriate programs (Alegría et al., 2007). It is particularly unfortunate that there is a lack of culturally-specific substance abuse options because research indicates that Latinos consistently report positive treatment experiences and  are least likely to relapse when they receive treatment and support from individuals who are aware of their cultural values and beliefs (Flicker, Waldron, Turner, Brody, & Hops, 2008; Field & Caetano, 2010).

As the population of Latinos who need substance abuse recovery options grows, culturally-appropriate treatment options become increasingly important. One such option may be Oxford House, a self-help recovery model, offering a drug-free environment for residents. Research indicates that African-Americans and European-Americans have benefited from living in an Oxford House for more than 30 years (Jason, Davis, Ferrari, & Bishop, 2001; Jason & Ferrari, 2010). Results have shown that living in an Oxford House is associated with positive changes in social networks and higher levels of abstinence over a two year period, compared to usual aftercare (Jason, Olson, Ferrari, & Lo Sasso, 2006; Jason, Davis, Ferrari, & Anderson, 2007). Despite the effectiveness of Oxford Houses as a recovery option, a study that examined 170 Oxford Houses throughout the country found that Latinos represented only 3% of residents (Jason et al., 2007). Findings from qualitative research suggest that the underutilization of Oxford Houses by Latinos may be due to several factors, including lack of knowledge about this program as well as language and cultural barriers (Alvarez, Olson, Jason, Davis, & Ferrari, 2004).

In order to address a lack of culturally appropriate substance abuse recovery options for Latinos, male bilingual-bicultural houses were opened to create a culturally-comfortable environment. While language might be the most observable difference, these bilingual-bicultural Oxford Houses were designed to promote Latino-centric values, like familism, simpatía, and personalismo. These values have been associated with Latino culture and current literature indicates that integrating them in treatment interventions may be associated with greater retention and better outcomes (Alvarez, Jason, Olson, Ferrari, & Davis, 2007).

The purpose of the article is to depict the recent efforts to open male bilingual-bicultural Oxford Houses in the suburbs of Chicago. Furthermore, it addresses how specific cultural values have changed the living environment in these bilingual-bicultural Oxford Houses, while maintaining the integrity of the Oxford House model. It is anticipated that the information provided in this article may assist others who may be considering opening similar bilingual-bicultural recovery homes.

Opening a Male Bilingual-Bicultural Oxford House
Oxford House
Oxford House is a self-help, sober living environment that operates on a democratic basis. The main goal of Oxford House is recovery from substance abuse. These houses are also financially self-supported. Residents pay their equal share of the rent and other expenses (e.g., electric bill, cable bill). Weekly business meetings are held in an Oxford House in order to follow-up with the financial situation of the house. Oxford House has no prescribed length of stay for residents. Professionals are not directly involved with the houses, and residents must follow three simple rules: pay rent and contribute to the maintenance of the home, abstain from using alcohol and other drugs, and avoid disruptive behavior. Violation of the above rules results in eviction from the house (Oxford House, Inc., 2008). There is a distinction between an Oxford House and halfway houses. Halfway houses have an active rehabilitation treatment program where the residents receive intensive individual and group counseling (Hohman & Gait, 2001). No such in-house services are available for individuals living in an Oxford House. 

Rational for a Male Bilingual-Bicultural Oxford House
Male bilingual-bicultural Oxford Houses were created based on a National Institute of Health (NIH) funded research project titled Evaluating a Bilingual Voluntary Community-Based Healthcare Organization. The goal of this NIH-funded project is to evaluate the effectiveness of the Oxford House model with Latino/a residents whose values, beliefs and behaviors differ depending on their level of acculturation. Bilingual-bicultural Oxford Houses are promoted as Latino recovery homes in which residents are 100% Latino and can communicate in either English or Spanish. Residents have a choice to live in either a bilingual-bicultural or a traditional Oxford House (i.e., non-bilingual-bicultural houses with people of varied racial backgrounds). Latino/a residents, who agree to participate in the study, are interviewed before they enter either Oxford House. Residents are re-interviewed six months later to capture their experiences in the Oxford House.  In conjunction with DePaul University’s research team, Oxford House, Inc. opened its first male bilingual-bicultural Oxford House in October, 2009 in the suburbs of Chicago, and a second house was opened in May, 2010.

Selecting the Location
The process begins by selecting a location to open the Oxford House. Detailed instructions on how to open a house are in the Oxford House Manual (Oxford House, Inc., 2008). Randy Ramirez, a recruiter and the Illinois representative for the Oxford House, was the person responsible for opening the new bilingual-bicultural Oxford House under the guidance of Leon Venable. According to Mr. Ramirez, the first step was to find a house that provided an adequate living environment for six individuals to live together. Other considerations included access to public transportation and jobs. In particular, this recruiter stated, “For (the Latino house), you want to find houses that are in communities that are culturally-sensitive or culturally-friendly. You want to make sure you set up in cities where they do not have any anti-immigration ordinances” (R. Ramirez, personal communication, February 12, 2010). Thus, locating houses in communities that would be more welcoming of Latinos was an important consideration. Efforts were made to open the bilingual-bicultural Oxford House in or near a Latino community. The goal was to allow residents access to bilingual social services, medical clinics, churches/religious organizations, and Latino businesses.  

Outreach
The word outreach refers to the method of locating, contacting, and recruiting groups that are invisible, hidden, or otherwise difficult to engage (Elwood, Dayton, & Richard, 1996). There are two common approaches used to recruit potential residents: passive and active outreach. Passive outreach involves giving out information to the target population through various methods (e.g., flyers, advertisements) whereas active outreach involves direct contact with probable residents (e.g., presentations, telephone calls, interviews) (Elwood et al., 1996).

Successful Outreach Strategies
In order to access the target population, outreach was done collaboratively with a well-known Latino substance abuse residential treatment agency. The relationship between Oxford House and the Latino substance abuse treatment agency represented a strong continuum of care in that individuals were able to graduate from residential care to a more independent living model (i.e., Oxford House). The Latino Oxford House recruiter frequently gave presentations about the Oxford House model to individuals who were in residential treatment, thus providing them with an aftercare housing option. One of the most effective outreach strategies applied in the context of this effort was regular visits to the treatment programs and other community based organizations to build rapport with the staff and program participants. For instance, our recruiter invited current Latino Oxford House residents to participate in our recruitment efforts. These current residents who accompanied the recruiter to various presentations were able to provide a contemporaneous perspective on what it was like to currently live in an Oxford House. 

Recruiting Latinos
Treating potential residents in a culturally-sensitive manner can help break down barriers and increase the possibility of recruiting Latinos (Yancey, Ortega, & Kumanyika, 2005). Recruiters need to be familiar with the traditions, customs, and rituals of those Latinos they are attempting to recruit to an Oxford House. The recruiter is the most important person in the outreach process. Our Latino Oxford House recruiter is bilingual and bicultural who is culturally-sensitive and able to establish a strong rapport with potential Latino Oxford House residents.

In addition to identifying and maintaining contact with recruitment sites, the Latino Oxford House recruiter plays a key role in outreach as they develop and maintain a strong bond with Oxford House residents. For example, our recruiter has been asked to transport residents to employment agencies, help residents obtain food stamps, or advocate to help a resident locate affordable outpatient substance abuse treatment. Personal contact may be particularly effective for recruiting Latinos as it provides the opportunity to build rapport and establish trust. Personal contact and showing respect are consistent with traditional Latino values that emphasize the importance of personal relationships and respect toward those in authority (Skaff, Chesla, Mycue, & Fisher, 2002). The Oxford House model allows for close relationships to develop between recruiters and residents because recruiters are usually Oxford House alumni who continue to stay in touch with the organization. According to a Latino Oxford House recruiter, the primary goal when interacting with potential Latino residents is to decrease the level of mistrust. A key goal is to address any uncertainties about the Oxford House model and how it works. It is crucial that the Oxford House model and the recovery process be understood. An Oxford House is a place where they will acquire their independence by getting a job and being able to sustain themselves in this home. Furthermore, they must understand that an Oxford House is an environment that promotes recovery and social support (G. Padilla, personal communication, February 12, 2010).

The Interview and Orientation Process
After a house is selected, the next step is to recruit potential Latino residents who are in recovery. The selection process is done through interviewing. The language of the interviews is an important factor that has been shown to influence the effectiveness of interventions for Latinos (Griner & Smith, 2006). Prior to the opening of the bilingual-bicultural Oxford Houses, all Oxford House interviews were conducted in English. Thus, when there were Spanish-speaking applicants, an interpreter needed to be present during the interview process. With the opening of the Latino Oxford Houses, Spanish-speaking Latino applicants are now able to receive information about the Oxford House expectations, rules, regulations, and guidelines in Spanish. Moreover, during the interviews, applicants are able to provide information that may be personal and sensitive—such as their history of substance abuse, reasons for applying to Oxford House, and their goal and desire to recover—without an interpreter. An additional component of the bilingual-bicultural Oxford Houses is that potential residents are interviewed by Latino Oxford House residents who understand their language/culture.

Latino Residents and the Job-Seeking Process
Oxford House residents are required to find and maintain a job and pay rent. Residents who are unemployed are required to record their employment efforts in a job log which is reviewed at weekly business meetings. According to a Latino Oxford House recruiter, Latino residents may have difficulty finding jobs due to lack of English skills, immigrant status, lower levels of education, and discrimination (G. Padilla, personal communication, February 12, 2010). Yet, several Latino residents have found jobs within the first month of living in an Oxford House. Most residents that live in the bilingual-bicultural houses have found jobs according to their current skills. For example, they have obtained jobs in construction, banquet hall services, shoe sales, and hair salons. They found these jobs by referrals from other residents, visiting a former employer, receiving a tip at an A.A. meeting, searching online, and getting help from temporary employment agencies.

Cultural Values and Changes to the Oxford House Environment
Culture represents the language, religious ideals, habits of thinking, patterns of social and interpersonal relationships, suggested ways of behaving, and norms of conduct that are passed on from generation to generation (Lu, Lum, & Chen, 2001). Latino cultural values and beliefs will be present in a living environment where Latinos/as reside such as in an Oxford House. Cultural values presented in the article are chosen because they were prevalent among the Latino Oxford House residents. Furthermore, these are cultural values that were observed by the Latino Oxford House recruiter/representatives, research staff, and by means of informal discussions with Latino Oxford House residents.

Latino Oxford House Residents
It is important to note that Latinos are not a homogeneous group. In the United States, the Latino population is comprised of individuals from 22 different countries, each embracing unique traditions, customs, music, dialects, and food.  Other important factors to consider are ethnic identity, cultural norms, levels of acculturation, gender, education, socioeconomic status, and immigration patterns, all of which are related to their belief systems and behaviors (Wells, Klap, Koike, & Sherbourne, 2001). Although we use the term Latino throughout the article, the majority of the Oxford House residents are from Mexico and Puerto Rico.

Language
The most visible change seen in a male bilingual-bicultural Oxford House is the use of both Spanish and English by its residents. According to Oxford House representatives, the ability to communicate in English or Spanish has helped individuals in the bilingual-bicultural homes adjust better to their new living environment. Prior to the opening of the male bilingual-bicultural houses, it was reported by Oxford House representatives that when Latinos with poor English skills would come into the house, they were more likely to feel isolated and more frequently left the Oxford House after short residencies. As research findings have demonstrated, Latinos with substance abuse have better outcomes in culturally-modified residential programs than in traditional treatment programs (Kail & Elberth, 2003; O’Connell et al., 2005; Waters et al., 2002)

Personalismo and Simpatía
The value placed on personalismo and simpatía in interpersonal relationships is consistent with the collectivistic orientation espoused by many Latinos (Schwartz et al., 2010). Trust is established based on the person’s behavior in a relationship and not on formal titles or background. For this reason, it is important for Latinos to establish close and personal relationships with those who will assist them in their recovery process. Simpatía refers to the value placed in Latino culture on smooth and pleasant social relationships. It is the tendency to avoid conflict and promote harmonious interpersonal relationships by being agreeable and pleasant in character (Santiago-Rivera, Arredondo, & Gallardo-Cooper, 2002). Since Latino residents tend to hold a group-oriented mindset, they usually attempt to foster a stable environment and reach agreements on most things. In some cases, residents avoid expressing disapproval about something agreed upon by the majority of residents, and may be careful not to display any demeanor that could be perceived by others as a conflict.

Based on conversation with several of the Latino residents, residents who live in the male bilingual-bicultural Oxford Houses described their living environment as amiable and supportive. While these cultural values are perceived as positive attributes, they may interfere with the guidelines established by the Oxford House Organization. For example, there have been several situations where Latino residents did not confront someone who may have been using illicit substances to avoid a conflict. According to the Oxford House guidelines, it is required that residents who are using a controlled substance be asked to leave the house immediately.

Familism
Familism refers to the tendency among Latinos to value family relationships. Latinos have been shown to maintain contact with family and rely on family as a source of support (Lugo Steidel & Contreras, 2003). The definition of family in the Latino culture includes extended family, such as grandparents, cousins, uncles, and aunts (Raffaelli, & Ontai, 2004). Individuals in a family are held together by common loyalty to each other, to their family name, and to the relationships they enjoy, as distinct from relationships with those outside the family. The Oxford House model itself uses a support system that is very similar to the support seen in a family. According to the Latino Oxford House recruiter, he observed Latino residents in the male bilingual-bicultural Oxford Houses spend a considerable amount of time with one another. At the same time, residents have invited their own families to visit their house in order to meet and interact with other residents. Based on this observation, the integration of two families--the residents’ biological and their newly formed Oxford House family—is common among Latino residents. 

The experience described by a current Latino Oxford House resident highlights the presence of familism in the men’s bilingual-bicultural house. Latino Oxford House residents tend to make it a priority to be together physically and emotionally; they “check up” on each others’ job situations, and share food with each other instead of keeping their own individual supplies. It appears that family values, which clearly manifest themselves in a bilingual-bicultural Oxford House, may play a crucial role in the recovery process.

Gender Roles
Traditionally, a man must show that he is strong, and physically powerful. Cultural lore would suggest that a true man should not be afraid of anything, and he should be capable of drinking great quantities of liquor without necessarily getting drunk (Gonzalez-Guarda, Ortega, Vasquez, & De Santis, 2010). In actuality, machismo is a complex construct that also refers to having pride in personal conduct, respect for others, love for family, and affection for children (Galanti, 2003; Gonzalez-Guarda, Ortega, Vasquez, & De Santis, 2010).  The Oxford House model embraces certain values of machismo, in that residents are generally employed and pay their fair share of the rent. Learning to be responsible, maintaining a job, contributing to the maintenance of the house, and having healthy relationships with others are components of machismo that are supported in Oxford House. According to several Latino Oxford House residents, many feel a sense of pride when they are able to gain employment and begin the slow process of financially supporting their families again.  

Food
Overall, food serves to reinforce ties among residents while allowing them to express their traditions. As mentioned earlier, residents tend to share food and prepare meals for everyone. It appears that residents prefer sharing food and having meals together to strengthen relationships and promote cohesiveness. According to a Latino resident at a male bilingual-bicultural Oxford House, the residents agreed to have breakfast together on Sunday mornings, feeling that they needed more activities as a group. At another male bilingual-bicultural house, residents planned picnics together and held several cookouts during the summer. These cookouts also allowed them to invite their neighbors to the barbeques. Sharing of food is a caring gesture and is used to strengthen relationships.

Lessons Learned
Beginning in July 2009, outreach efforts began in an attempt to specifically recruit potential Latino residents for Oxford Houses. As we witnessed the opening of these male bilingual-bicultural Oxford Houses, many important lessons have been learned about Latinos. Specifically, there appears to be three central issues that one should be prepared to address when engaging in outreach efforts with Latinos who may be appropriate for Oxford Houses:

  • Accessibility: As a minority group, Latinos may have less familiarity with accessing services than other groups. When outreaching to Latinos/as, it is important to engage in a candid discussion of issues related to their concerns and help Latinos develop feasible solutions to address these challenges. Likewise, it is important that they realize Oxford House, regardless of their immigration or criminal background, is a real, fair and safe option for them. 
  • Familism: This may be both a protective and a risk factor for Latinos in recovery. Because the Latino family system can be extensive and insular, Latinos/as in recovery may seek support from their family. While this may provide a supportive, cost-effective option for some, it can also perpetuate a cycle of codependence and substance abuse.
  • Linguistic and cultural accommodations:  By virtue of living with a group of people, communication is essential to the success (or failure) of an Oxford House. Recent experiences integrating Latinos into Oxford Houses have highlighted how important language is in the comfort and success of individuals living in Oxford Houses. While monolingual Spanish speakers certainly indicate a preference for living with other Spanish speakers, many bilingual Latinos/as have indicated that they feel most comfortable in an environment which facilitates use of both languages. The elimination of language barriers make residents feel more empowered to share their experiences and support their fellow residents without the hesitancy of being misunderstood due to cultural differences. Similarly, attention to cultural values in the day-to-day running of the house may facilitate retention of Latinos, particularly for those individuals who identify more strongly with their cultures of origin.

Next Step-Female Bilingual-Bicultural Oxford House
Thus far, the focus of this article has been on the opening of the two male bilingual-bicultural Oxford Houses. Efforts are presently underway to open a female bilingual-bicultural house. Although research indicates that Latinas are less likely to use substances than Latinos and other women in the U.S., the women who do use substances may experience similar problems to Latinos and, in some cases, their need for treatment may be more severe (Alvarez et al., 2004). As attempts are being made to recruit Latinas for a potential bilingual-bicultural Oxford House, it is likely that there may be many of the similar barriers that have prevented Latinos from becoming Oxford House residents. Language, cultural, and gender specific barriers compound treatment disparities for Latinas (Alvarez et al., 2004). Another factor related to cultural values is the difficulty of ending relationships that might perpetuate an unhealthy lifestyle and low self-esteem (Wong & Longshore, 2008).

It is hypothesized that a female bilingual-bicultural Oxford House can meet the needs of Latinas seeking recovery. The Latina’s identity is closely related to her relationships with immediate and extended family members and recovery takes place within this extended network (Black & Hardesty, 2000). Fortunately, an Oxford House fosters the types of relationships that many Latinas feel are necessary for recovery. Support that resembles assistance from extended family members helps many Latinas participate and follow through with treatment (Black & Hardesty, 2000). Jason, Olson, and Foli (2008) reported that women living in Oxford Houses overcome obstacles to recovery by helping each other. Fellow female residents provide “a type of unofficial and informal job assistance program,” connecting new residents with possible employment opportunities that they have personally encountered (Jason et al., 2008). Latinas may associate effective treatment outcomes to their relationship with a fellow recovering addict who becomes their close friend and someone they can trust (Black & Hardesty, 2000). Furthermore, Oxford Houses are stable, safe environments in which women can live with their children. Many women want their children to participate actively in their recovery process and report that their children serve as a motivation for participating in treatment. For example, some Latinas rely on their children to notice their improvements and to encourage them to sustain their rehabilitation efforts (Black & Hardesty, 2000). Thus, efforts to recruit Latinas will emphasize the communal, family-like atmosphere of an Oxford House.

Summary
Oxford Houses offer a specific type of substance abuse recovery that is presently underutilized by Latinos (Jason et al., 2007). As a growing body of research highlights the need for culturally appropriate treatment options for substance abuse recovery, DePaul University, in conjunction with Oxford House, began to investigate Oxford Houses as a recovery option for Latino men and women in need of sustainable, drug-free housing options (Alvarez et al., 2009). Recognizing that cultural issues were a central challenge to recruitment and maintenance of Latinos in Oxford Houses, various steps were taken to ensure the cultural sensitivity of the model. As delineated by this article, recruitment of Latinos into Oxford House has rested on: 1) recruiters who can increase trust and build a good relationship with potential residents; 2) relationships with widely recognized and trusted individuals or Latino agencies/organizations.

Through dedication, communication and culturally sensitive outreach efforts, male bilingual-bicultural Oxford Houses were established in Illinois. These houses may be an effective option for Latinos who are Spanish-dominant and/or identify more strongly with their ethnic culture. Bilingual-bicultural Oxford Houses may provide a living experience that is more culturally-congruent with the needs of Latinos. For example, these bilingual-bicultural houses are more likely to use culturally-congruent communication styles, characterized by an emphasis on relationships, downplaying direct conflict in relationships in order to preserve harmony, and respect. While the road to recovery is littered with challenges, a bilingual-bicultural Oxford House may help Latinos, who identify primarily to their culture, to remain abstinent.

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R. Contreras, J. Alvarez, J. DiGangi, LA Jason, L. Sklansky, I. Mileviciute, E. Navarro, D. Gomez, S. Rodriguez, R. Luna, R. Lopez, S. Rivera, G. Padilla, R. Albert, S. Salamanca, & F. Ponziano R. Contreras, J. Alvarez, J. DiGangi, LA Jason, L. Sklansky, I. Mileviciute, E. Navarro, D. Gomez, S. Rodriguez, R. Luna, R. Lopez, S. Rivera, G. Padilla, R. Albert, S. Salamanca, & F. Ponziano

Richard Contreras, Ph.D. - rcrc3114@gmail.com - is Project Director at the Center for Community Research at DePaul University in Chicago, IL 60604 

Josefina Alvarez, Ph.D.- jalvarez@adler.edu - is on the Core Faculty at the Adler School of Professional Psychology in Chicago , IL USA

Julia DiGangi, MA - jdigangi@depaul.edu - is a clinical-community doctoral student at DePaul University in Chicago, IL USA.

Leonard A. Jason, Ph.D. - ljason@depaul.edu - is a professor of Psychology at DePaul University and the Director of the Center for Community Research in Chicago, IL USA 

Laura Sklansky, Inga Mileviciute, Elbia Navarro, Daisy Gomez, Sandra Rodriguez, Roberto Luna, Roberto Lopez, Sharitza Rivera, Gilberto Padilla, Richard Albert, Stephanie Salamanca, Frank Ponziano are research assistants and recruiters at the Center for Community Research at DePaul University in Chicago, IL USA


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Keywords: Latinos, substance abuse, recovery, residential, culturally-modified