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Substance Use Disorder Treatment and Family Therapy: Updated 2020 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2020. (Treatment Improvement Protocol (TIP) Series, No. 39.)
Family cultures often have specific practices, structures, values, and belief systems that can affect substance use and substance-related outcomes (e.g., achieving recovery).
Understanding the ways in which diverse family cultures function is critical to identifying and addressing family-related factors—like communication patterns, parenting practices, and level of acculturation—that increase the risk for substance misuse.
Family separation (e.g., because of immigration or military deployment) and lack of communication about substance misuse may be present across many family cultures. Similarly, racial discrimination, stigma, shame, and prejudice may exert influence across multiple generations, influencing families’ substance use and help-seeking behaviors. Family characteristics and feelings related to these factors should be addressed as a part of family counseling for substance use disorders (SUDs).
Much of the empirical literature is silent on how best to adapt family-based counseling interventions for SUDs to the specific needs of the diverse family cultures discussed here. However, to the extent possible, you should still try to use family-based treatment/services that meet families where they are—that is, services matched to the family's level of motivation to change and responsive to their unique change goals.
Chapter 5 of this Treatment Improvement Protocol (TIP) will guide providers in delivering family-based SUD treatment that is culturally responsive and evidence based. It addresses:
General information about diverse family cultures and why you, as a provider, need to be aware of their specific treatment/service needs and challenges.
Culturally responsive family counseling.
Background issues and aspects of family structure and functioning in specific populations, which will help guide your approach to meeting the needs of families from a cultural perspective.
Specific family cultures (e.g., families of diverse racial and ethnic backgrounds; families with lesbian, gay, bisexual, or transgender [LGBT] members; military families), with summaries of recent scientific evidence on the use of family-based interventions for SUDs with each population as well as suggestions for how to culturally tailor interventions to get the best outcomes.
This chapter is not a comprehensive summary of all family cultures. The literature on the effectiveness of family counseling for SUDs in specific cultures is often limited but is discussed when available. Populations this chapter discusses are among those commonly seen in SUD treatment settings, and they often have specific cultural practices.
Family-based interventions for SUDs are evidence-based, effective approaches to achieving and sustaining long-term recovery, particularly for adolescents (Hartnett, Carr, Hamilton, & O'Reilly, 2017; Horigian, Anderson, & Szapocznik, 2016; Ventura & Bagley, 2017). But the diverse makeup and culture of a family can affect the degree to which individuals and families facing substance misuse can successfully access, engage in, and benefit from SUD treatment. That partly may be because of culture-related barriers that can make achieving recovery difficult for some families (e.g., language barriers, stigma, or negative attitudes about help seeking).
To successfully use family-based interventions, you must be aware of and pay attention to the unique features of certain family cultures. These features include, for example, the family's structure, communication style, immigration history, experience of individual and historical trauma, and interrelationships with one another.
The topic of culture and cultural competency in SUD treatment (and in behavioral health services in general) is beyond the scope of this chapter. The focus of this chapter is on families and the ways in which family-based interventions can be adapted to, and thus more effective for, specific family cultures discussed here (i.e., those of diverse racial/ethnic backgrounds, LGBT families, military families).
COUNSELOR NOTE: AFFILIATION WITH MULTIPLE CULTURES AND CULTURES WITHIN A CULTURE.
To learn more about culture and diversity issues in behavioral health services, SUD treatment, and ongoing recovery support, review these publications from the Substance Abuse and Mental Health Services Administration (SAMHSA):
Advancing Best Practices in Behavioral Health for Asian American, Native Hawaiian, and Pacific Islander Boys and Men: This report offers tools and best practice guidance for working with Asian American, Native Hawaiian, and Pacific Islander boys and young men (https://store
A Provider's Introduction to Substance Abuse Treatment for LGBT Individuals: This manual informs clinicians and administrators about SUD treatment approaches that are culturally responsive to LGBT individuals. It covers cultural, clinical, health, administrative, and legal issues as well as alliance building (https://store
Continuity of Offender Treatment for Substance Use Disorders from Institution to Community— Quick Guide for Clinicians Based on TIP 30: This publication guides SUD treatment providers in helping offenders transition from the criminal justice system to life after release, including adaptation to community and work cultures and the culture of recovery. It discusses assessment, transition plans, special populations, family involvement in treatment and transition where appropriate, and confidentiality (https://store
TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women: This guide assists providers in offering treatment to women living with SUDs. It reviews gender-specific research and best practices, such as common patterns of initial use and specific treatment issues and strategies (https://store
TIP 55, Behavioral Health Services for People Who Are Homeless: This manual emphasizes that SUD treatment and mental health service providers can improve their service delivery by understanding the cultural context of clients and having the skills to adapt to a variety of cultures of people who are homeless. It also describes intervention methods to address SUDs during a variety of stages of homelessness rehabilitation and discusses methods providers can use to support recovery from mental illness and substance misuse among people and families who are homeless (https://store
TIP 56, Addressing the Specific Behavioral Health Needs of Men: This guide addresses specific treatment needs of adult men living with SUDs. It reviews gender-specific research and best practices, such as common patterns of substance use among men and specific treatment issues and strategies (https://store
TIP 57, Trauma-Informed Care in Behavioral Health Services: Trauma can affect individuals, families, groups, communities, specific cultures, and generations. This manual helps behavioral health professionals understand the impact of trauma on those who experience
it. The manual discusses trauma-informed, culturally responsive assessment and treatment planning strategies, and it highlights the importance of context and culture in people's response to trauma and SUD recovery (https://store
TIP 59, Improving Cultural Competence: This manual provides more information on working with people from various cultures and providing culturally competent treatment (https://store
TIP 61, Behavioral Health Services for American Indians and Alaska Natives: This publication offers practical guidance for addressing the social challenges and behavioral health needs of Native American populations in culturally responsive ways (https://store
Terminology is important. The term specific populations refers to the features of families based on specific, common groupings that influence the process of therapy. The term culture often brings to mind concepts related to race and ethnicity but is used more broadly here. In this chapter, culture refers to the thoughts, interactions, beliefs, and values of a family that shape the way that family feels, thinks, and talks about and reacts to substance use issues. Indeed, the family cultures described here are known to have their own attitudes, ideas, customs and, in some cases, language that shapes the family and the ways in which its members relate to one another.
Why should SUD counselors learn about diversity among families? Family-based interventions for substance use are not “one-size-fits-all” approaches. Different families will have different needs, and in many cases, those needs are affected by the culture of that family. You cannot offer truly comprehensive, evidence-based SUD treatment if you ignore the culture of the family with whom you are working. Think about the following when working with diverse family cultures:
A supportive family is a key protective factor in relapse prevention and recovery promotion, and family support can be heavily influenced by culture. Cultural differences exist in the way families understand, feel about, and respond to mental illness or SUDs (particularly, perceived shame about these conditions). Cultural shame about SUDs and mental disorders can be a relapse risk factor or barrier to treatment engagement. Thus, family ties may affect treatment engagement, adherence, and completion. Psychoeducation about the nature of SUDs and mental disorders as medical issues that can be treated, like many other chronic conditions, may help reduce shame and increase family support and acceptance.
Diversity may be a factor in family-based SUD treatment outcomes. For instance, in some research, ethnicity has been shown to be an influential factor in outcomes from multidimensional family therapy (MDFT) for SUDs. One study that looked at findings from five MDFT clinical trials for adolescent substance use found that MDFT was effective only for men, African Americans, and European Americans, whereas women and Latino individuals did not benefit significantly (Greenbaum et al., 2015).
Cultural background can shape attitudes about factors like “proper” family behavior, family hierarchy, acceptable levels of substance use, and methods of dealing with shame and guilt. Forcing families or individuals to follow the customs of the dominant culture can create mistrust and lower the effectiveness of counseling. A competent treatment provider, however, can work with a culture's customs and beliefs to improve treatment rather than cause resistance to treatment.
Some families may prefer alternative interventions in place of or along with family counseling. In cultures that place a high value on indigenous healing practices and spirituality, such as in some Latino, Asian American, African American, and American Indian/Alaska Native (AI/AN) communities, you can actively support clients with SUDs or mental disorders in using traditional healing approaches, faith-based community resources, and spirituality as supports in their efforts to lower the likelihood of relapse. The key is for you to keep your clients in the center of the conversation about what will be the most effective relapse prevention and recovery strategies for them based on cultural considerations and to adapt approaches to ft the needs of each individual and family.
Behavioral health disparities are real and, if unaddressed, can keep people from achieving and maintaining recovery. Some racial and ethnic groups have higher rates of poverty (which can be intergenerational), domestic violence, childhood and historical trauma, and involvement in the criminal justice system than the general population. These risk factors can increase the chances of relapse or recurrence of SUDs and mental disorders. Levels of education and of health literacy can also influence awareness of and access to treatment and recovery supports. These and other gaps in treatment access and retention exist for a number of populations, including the groups described in this chapter. Your organization can help reduce disparities in SUD treatment and recovery support by improving outreach and sharing of information, promoting active linkages to culturally diverse community resources, and implementing relapse prevention treatment and recovery promotion initiatives that specifically serve these populations.
Cultural competence is an important feature in family counseling because family counselors must work with families from many cultures. Integrated family counseling for SUD treatment works for people from many races, ethnicities, faiths, and educational backgrounds. In many cultures, it is important to include families in treatment. However, a culture's high regard for families does not always equate to healthy family functioning. People may hide substance misuse in the family because revealing it would lead to prejudice and shame.
RESOURCE ALERT: SOCIAL DETERMINANTS OF HEALTH.
Furthermore, using culturally competent, family-based services may help clients reach better SUD outcomes. A meta-analysis of seven studies looking at culturally responsive SUD interventions for racial and ethnic minority youth (including studies that used family-based approaches like MDFT, brief strategic family therapy [BSFT], and the Culturally Informed and Flexible Family-Based Treatment for Adolescents [CIFFTA] Program) showed, on average, that these treatments resulted in greater reductions in substance use than nonculturally adapted treatments (Steinka-Fry, Tanner-Smith, Dakof, & Henderson, 2017).
COUNSELOR NOTE: CULTURAL HUMILITY AND WILLINGNESS TO BE THE STUDENT—NOT THE TEACHER.
To add culture into your SUD treatment approaches:
Engage aspects of the family's culture or religion that promote healing.
Consider the role that drugs and alcohol play in the culture.
Be flexible and meet families where they are.
Be continuously aware of and sensitive to the differences between yourself and the members of the group you are counseling. Is the family a homogeneous group or one that represents different backgrounds? What is the significance that family members assign to their own identities and to the identity of the counselor? Does the family live in one community or several different communities? Are those communities the same as or different from the one in which you live? These considerations and responsiveness to the specific cultural norms of the family in treatment must be respected from the start of counseling. Differences within the family also should be explored. If these factors are not apparent or explicit, ask.
Be aware of and sensitive to your own family culture. Counselors bring their own cultural issues to treatment. Your age, gender, ethnicity, local community, and levels of health literacy and education, as well as other traits, may affect therapeutic processes.
You can be culturally competent even if you don't belong to the same cultural groups as the families you serve. You can develop the cultural competence to work with families who affiliate with cultures other than your own. Cultural competence means you pay attention to cultural nuances, learning from diverse clients. Even if you identify with the same culture as a family you treat, don't assume you understand all their cultural views and beliefs. The ways and extent to which culture influences them may differ from your experience.
Families and family cultures will differ in their structures, values, and beliefs; they also will differ in their SUD treatment needs. However, certain common family features may be present across many family cultures, such as their immigration status and history, level of acculturation (that is, the degree to which individuals or groups adopt the practices of the dominant culture), communication style, and hierarchical structure. Be aware of these general features, but also remember that each family is different and will operate in its own unique way (Exhibit 5.1).
Exhibit 5.1. Eight Questions To Consider When Offering SUD Treatment for Families of Diverse Racial/Ethnic Backgrounds.
For more specific information on common characteristics of families, see Chapter 1 of this TIP.
The ways families are organized can affect the relationships family members have with each other. These, in turn, can directly affect their communication style, expectations for behavior, and more.
For instance, White, Latino, Hmong, and Somali students living with nuclear families (i.e., families made up of only the parents and their children) have a significantly lower rate of exposure to substance-related risk behaviors and substance use than students living in single-parent or cohabitating households (Areba, Eisenberg, & McMorris, 2018).
Hierarchical family structures (i.e., the order/rank of power and authority within the family, such as patriarchal versus matriarchal) are prevalent in some cultures, including Latino populations (Santisteban, Mena, & Abalo, 2013) and Asian populations (Chuang, Glozman, Green, & Rasmi, 2018). For example, military families often adopt the same core values and principles that define military culture in general, like respect for authority and adherence to chains of command. The focus on hierarchies and parents as authority figures can affect parent-child conflict and resolution, especially as children age into adolescence and potentially begin to challenge parental authority.
A related aspect of a family's hierarchy and power structure is the way in which the family views and uses child discipline. For instance, many African American households value child discipline as a critical part of childrearing that can effectively shape children's behavior and help them make good life choices (Adkison-Johnson, 2015). Understanding the intent and use of specific disciplinary strategies, as well as whether discipline is carried out primarily by male or female adult relatives, can help you better work with families to improve parenting practices and reduce negative child behavior (like substance use) in a way that matches their cultural values.
Extended family members within the household are typical in many cultures, especially those of diverse racial and ethnic backgrounds. For example, some families consist of grandparents raising their grandchildren; other families have multiple family groups dwelling together (e.g., two sisters and their spouses and children share a single-family home). Still others may include multiple generations—perhaps a single parent, grandparent, and adult sibling—all sharing the responsibility of raising a child. But how does extended family relate to substance misuse?
In a nationally representative survey (Cross, 2018), 35 percent of children reported ever living in an extended family unit. Responses differed significantly by race and ethnicity, with only 20 percent of White children reporting having lived with an extended family versus 57 percent of African American children, 35 percent of Latino children, and 34 percent of “other race” children (“other race” was not defined by the study authors).
When it comes to substance misuse, extended families can be both positive and negative.
Findings from the Los Angeles Family and Neighborhood Study and the decennial census (Kang, 2019) suggest that children living with extended family members are at an 18-percent increased risk of internalizing disorders and a 22-percent increased risk of externalizing disorders compared with children living in nuclear families. Extended families may exacerbate child misbehavior by increasing strain on family resources (e.g., leaving less time and money for the child), interfamily conflicts, and ineffective collective monitoring of children by multiple family members (Kang, 2019). In some research, extended family members introduced youth to substance use (Gilliard-Matthews, Stevens, Nilsen, & Dunaev, 2015).
Other studies suggest extended families can be protective against child/adolescent misbehavior and maladjustment (Bai, Leon, Garbarino, & Fuller, 2016), including substance use (Areba et al., 2018) and can be an effective part of family counseling for SUDs (Zweben et al., 2015). For example, in a qualitative study of Mexican youth (Strunin et al., 2015), extended family members acted as mentors who provided guidance about safe and acceptable alcohol consumption and modeled negative effects of alcohol misuse, positively shaping youth behavior.
Many diverse family cultures find strength and support from their spiritual or religious beliefs and activities, including prayer and attending services at faith-based institutions.
Religious or spiritual beliefs or activities may influence the family's engagement and participation in counseling. For instance, African American individuals may seek help for SUDs from spiritual or religious leaders (Wong, Derose, Litt, & Miles, 2018) or may view mental illness through a spiritual or religious lens. In Latino communities, church leaders, such as priests, may be sources of help seeking or referrals for formal SUD treatment (Cuadrado, 2018). SUD treatment providers should understand that cultural beliefs and practices may influence help-seeking behaviors. Thus, some families may be reluctant to accept services or may decline them altogether.
Family encouragement of faith-based activities can help people seeking recovery. In the National Longitudinal Study of Adolescent Health, Latino emerging adults engaged in public religious activities (e.g., attending church services, participating in church-related social activities) were less likely to binge drink or use cannabis than youth who were not “publicly religious” (Escobar & Vaughan, 2014).
To understand family cultures and their subgroups, you must learn about their immigration history, because this may be connected to their substance misuse (Marsiglia, Nagoshi, Parsai, & Castro, 2014). Family-based SUD interventions, including prevention programming, also may have different effects depending on nativity (Cordova, Huang, Pantin, & Prado, 2012).
Some people leave their home country voluntarily to pursue opportunities or escape poverty. Refugees, on the other hand, may flee persecution, fear for their safety, and have much more pain and anger associated with their migration. Those who come from war-torn countries may show symptoms of posttraumatic stress disorder (PTSD) and other associated trauma; symptoms might include substance misuse.
Immigration status can affect parent-child relationships when one or both parents immigrate before the child. Parent-child separation can cause major stress and dysfunction in family relationships (e.g., poor attachments, feelings of abandonment). When people immigrate to the United States, it is not uncommon for them to feel family-, work-, and money-related stressors, which can increase the chances of substance misuse.
Degree of acculturation is linked to substance use behaviors and SUD treatment outcomes.
Among Latinos and Asians, greater acculturation may increase the risk of alcohol use, whereas lower acculturation and more recent immigration status may lower the risk of substance misuse because of the presence of protective factors like stronger family cohesion (Vaeth, Wang-Schweig, & Caetano, 2017). Differences in acculturation may be particularly relevant in cases where a person is using substances to cope with stress related to parent-child differences in acculturation.
A study of SUD treatment outcomes from motivational enhancement provided to Latino individuals found differences among subgroups (e.g., Cuban Americans, Mexican Americans, Puerto Ricans, and other Latino Americans) and among levels of acculturation, including differences in treatment retention and percentage of days abstinent (Chartier et al., 2015).
In the National Latino and Asian American Study (Savage & Mezuk, 2014), higher acculturation increased the risk of lifetime alcohol use disorder (AUD) and drug use disorder by 1.67 to 1.8 times.
Strong and stable cultural values may be protective against substance misuse in racially and ethnically diverse families, such as Latino families (Cruz, King, Cauce, Conger, & Robins, 2017):
Familism or familismo may be present in Latino families (Santisteban et al., 2013). These terms refer to the primary values, structures, and expectations of the family, which shape each family member's behavior. Familism may lead family members to make decisions that are best for the family as a whole as opposed to the individual. It has three components: (1) perceived duties related to helping family members; (2) dependence on family members’ support; and (3) use of family members as behavioral and attitudinal referents. Familism emphasizes enmeshment within the family, high family loyalty, and pride in the family as a cohesive unit.
High familism may be beneficial in shaping healthy behaviors (like not misusing substances) if that is what is valued by the family. Yet if substance misuse happens within the family, especially across generations, familism may reinforce these negative behaviors by normalizing them. In one study of Latino adolescents, 3-month substance misuse was significantly correlated with lower levels of familism (Ma et al., 2017).
Understanding the culture-specific ways in which family members talk with one another will help you better understand the context for how the family functions, the dynamics between family members, and what contributes to the family's dysfunction. This in turn can inform the person's chances of achieving and sustaining recovery from substance misuse.
For instance, in a study of Asian and Pacific Islander individuals, family openness about communicating about substance use was a positive factor in SUD treatment seeking, whereas family noncommunication about substance use was seen as discriminating and a barrier to treatment success (Chang et al., 2017).
Communication style also can shape the way families resolve conflicts.
The concept of respeto refers to Latino values of respect in the family, which can influence communication and dealing with conflict between parents and children. Openly disagreeing with parents or voicing one's opinion goes against the concept of respeto and is considered negative behavior (Santisteban et al., 2013). Thus, counseling techniques that fail to account for respeto and that urge adolescents to “speak out” against their parents may be counterproductive.
Simpatía, a focus on interpersonal relationship harmony, is another aspect of traditional communication styles in many Latino families. Greater respeto and simpatía have been linked to lower levels of Latino youth drug and alcohol use over 3 months and to abstinence from substances (Ma et al., 2017).
Feelings of racism and discrimination can increase the risk for substance misuse among people of diverse races and ethnicities.
In the National Latino and Asian American Study (Savage & Mezuk, 2014), discrimination increased the risk of lifetime AUD and drug use disorder by 1.4 to 1.54 times.
Structural racism has led to multiple systemic effects on African American families in many forms, such as socioeconomic disparities, voter suppression, educational disadvantages, and racial discrimination (Kelly, Maynigo, Wesley, & Durham, 2013). These challenges are significant stressors and may increase the changes seen in individuals misusing substances as a coping mechanism.
Also be sure to acknowledge the significance of historical trauma, and consider whether it is playing a role in the family's substance use problems. Certain cultures, like African American and AI/AN populations, have suffered for decades from social injustices, extreme physical and emotional trauma, and ongoing discrimination and prejudice. These experiences have had lasting effects on individuals and families. For instance, there is a widely held belief in AI/AN cultures that loss of culture because of historical trauma and ongoing mistreatment is a primary cause of mental disorders and SUDs in this population today (SAMHSA, 2018). It may be important to address such issues with families before families with substance misuse can fully recover.
In certain family cultures, parent-child separations may happen, sometimes repeatedly. Notable examples include families in which parents and children have immigrated separately and military families in which a parent has been deployed. In some of these cases, one parent may take over parenting responsibilities alone, grandparents may take over the duties of raising children, or children may stay with other members of their extended family or with family friends.
Parental separation from children is a strong independent risk factor for early substance use in children. In a sample of more than 3,000 adolescent and adult children (about 26 percent of whom were African American and 8 percent of whom were of unspecified race or ethnicity), parental separation happening between ages 12 and 17 was as strong a predictor of initiating alcohol use before age 13 and of initiating cigarette and cannabis use before age 16 as living in a household with two parents with AUD (McCutcheon et al., 2018).
Youth in military families are at an increased risk of substance misuse compared with adolescents from civilian families. In one study, military family youth were 50 percent more likely than civilian youth to report both current and lifetime substance use (Sullivan et al., 2015). Long deployments are particularly stressful to children and parents and increase the odds of psychological maladjustment (Nicosia, Wong, Shier, Massachi, & Datar, 2017).
COUNSELOR NOTE: ARE PARENTING INTERVENTIONS FOR SUDs AMONG RACIALLY/ETHNICALLY DIVERSE ADOLESCENTS EFFECTIVE?
This section presents brief summaries of the empirical evidence (Exhibit 5.2) on family-based SUD interventions for family cultures likely to be seen in your service setting, including families of diverse racial and ethnic backgrounds, LGBT families, and military families. This information is not meant to cover everything you need to know about offering SUD treatment to these family cultures; instead, it is designed to give you a broad overview of what evidence-based treatments exist and how you can tailor existing treatments and services to a family's unique needs.
Exhibit 5.2. Family-Based SUD Services for Youth of Diverse Races/Ethnicities.
Family-based interventions for SUDs that have support for use with African American families include MST, MDFT, and BSFT (Huey & Polo, 2017; Pina, Polo, & Huey, 2019; Rowe, 2012). BSFT has been accepted by SAMHSA as a model program for reducing or eliminating adolescent substance use behaviors and is effective for minority youth (particularly African American and Latino youth) (U.S. Department of Health and Human Services, Office of Minority Health, 2018).
In a sample of runaway youth in which 66 percent of participants were African American, ecologically based family therapy led to a decrease in percentage of days with substance use. Non-White adolescents showed significantly greater reductions than White youth (Slesnick, Erdem, Bartle-Haring, & Brigham, 2013). Treatment nonattendance was lower in the family therapy condition (12 percent) than in a motivational interviewing treatment group (34 percent) and a community reinforcement approach intervention group (26 percent); however, proportionally, there were no differences in the number of sessions attended across the three groups.
Over the past decade, increasing evidence has emerged in support of a family-based intervention designed for rural African American families—the Strong African American Families (SAAF) Program. Developed at the University of Georgia, SAAF focuses on the primary prevention or elimination of conduct problems and negative health behaviors (including substance use) in rural African American early adolescents. SAAF has been shown to be effective in improving targeted parenting practices, adolescent self-regulation, and youth vulnerability to problem behaviors (Kogan et al., 2016). Brody, Chen, Kogan, Yu, and colleagues (2012) examined SAAF for reduction of substance use, conduct problems, and depressive symptoms. Techniques included teen and caregiver skill building, prevention programming, health promotion education and skills, and adaptive racial socialization (i.e., helping youth develop racial pride and teaching them how to deal with racism and discrimination). Over 22 months, the intervention was associated with a 32-percent decrease in substance use and a 47-percent decrease in related problems.
An offshoot of the original SAAF Program, called Protecting Strong African American Families (PSAAF), is similarly focused on reducing problem behaviors and health risks in rural African American adolescents but is specifically for two-parent African American households (Barton et al., 2018; Beach et al., 2016). Components of the intervention include (Beach et al., 2016):
Delivery of services in the home to foster greater participation by fathers.
A heavy focus on effective coparenting, including monitoring children's behavior, enforcing family rules, and instilling in children a sense of racial pride (racial socialization).
Techniques to improve communication and problem-solving between couples.
An emphasis on addressing specific domains of stress for African American families, including work, racism, finances, and extended family issues.
Compared with control families, families in PSAAF showed better improvements in parental monitoring; racial socialization (improved but nonsignificant versus controls); and adolescent conduct problems, self-concept, and substance use initiation at follow-up (Beach et al., 2016).
When working with African American families, it may be helpful to tailor treatments and services by:
Including racial socialization promotion strategies. Helping African American adolescents develop a sense of pride about their race and ethnicity and effectively manage discrimination are considered protective practices that can improve self-regulation and promote healthy behaviors, like choosing not to misuse substances (Beach et al., 2016). SUD counselors should incorporate techniques that address racial pride and discrimination into family-based SUD interventions.
Helping parents strengthen their bonds with one another. In African American families with two parents, interventions focused on coparenting and reducing couple strain may be critical to preventing and improving children's health-risk behavior, including substance use (Beach et al., 2016). Family counseling that includes techniques specifically for parents may help enhance family communication and instill in children strength and resiliency.
Using culturally relevant storytelling. Cunningham, Foster, and Warner (2010) note how counselor use of personal narratives during MST for adolescent substance use was particularly effective for African American parents by helping support and reinforce decision making. Other counselor behaviors and core skills they report as beneficial for engaging African American families in MST for substance use and other externalizing disorders include:
Offering instrumental support (i.e., support for practical, everyday needs such as transportation and finances).
Being willing to accept gifts from families and invitations to attend special family events.
Using a strengths-based approach and positive reinforcement.
Validating and empathizing with the family member's point of view.
Helping families build skills by directly educating them (versus using indirect instruction).
Being open and honest in admitting to families when you make a mistake or do not have information or knowledge about a particular topic, question, or problem.
COUNSELOR NOTE: BOOSTING AFRICAN AMERICANS’ ATTENDANCE AT FAMILY COUNSELING.
Substantial research documents underuse of services by Latino families, but family counseling can effectively reduce substance misuse in Latino individuals, especially adolescents (Henderson, Hogue, & Dauber, 2019; Hogue et al., 2015; Pina et al., 2019). For example:
A meta-analysis examined the effectiveness of seven culturally responsive SUD studies for diverse racial and ethnic adolescents—six of which targeted Latino populations in part or entirely (Steinka-Fry et al., 2017). Across all studies, there were significant reductions in youth substance use via interventions like Conjoint Family Therapy, BSFT, MDFT, and the CIFFTA Program.
Another meta-analysis focused solely on culturally responsive interventions for Latino youth with SUDs (Hernandez Robles, Maynard, Salas-Wright, & Todic, 2018) reported small but positive effects of culturally responsive interventions on improving substance use outcomes.
Of the 10 studies examined, 2 used BSFT or structured family therapy, and 4 included parents as part of the intervention.
The authors note than 90 percent of the studies integrated cultural values into services, with familism and respeto being among the most common. (See “General Considerations When Working With Diverse Family Cultures” for a brief explanation of these concepts.)
An analysis of the Bridges to High School Program—a culturally adapted, family-based intervention to prevent future SUDs and mental disorders in middle-school youth—found the program was associated with lowered substance use at 5-year follow-up (Jensen et al., 2014). Analyses indicate the intervention's effects on reducing substance use stemmed in part from improvements in mother-adolescent conflict. Additionally, higher levels of acculturation were associated with greater number of substances used.
Culturally adapted cognitive-behavioral therapy (CBT) for Latino adolescents and their parents (Burrow-Sánchez, Minami, & Hops, 2015) is associated with improvements in the number of days of youth substance use, with ethnic identity and parental levels of familism moderating this effect. Specifically:
Adolescents receiving adapted CBT who displayed greater exploration of and commitment to their ethnic identity showed a lower mean number of days of substance use at posttreatment and 3-month follow-up than did adolescents in the adapted-CBT group with low exploration of and commitment to ethnic identity.
Higher parent familism in the adapted-CBT group was associated with lower mean number of days of substance use at 3-month follow-up than lower familism in the adapted-CBT group.
Two prospective studies of family-based interventions for SUDs among Latino individuals (Sparks, Tisch, & Gardner, 2013) reported significant improvements in substance use after the intervention compared with baseline measurements. Enhancements in Latino families were often on par with, and in some cases better than, improvements among non-Latino families, including improvements in:
Parenting skills.
Drug and alcohol use.
Family strengths/resilience.
Parent observations of children's activities.
Parents’ social/cognitive skills.
In a randomized clinical trial of MDFT in juvenile drug court, Dakof et al. (2015) found treatment resulted in significant reductions in substance use, although reductions were no different from those in a control condition of adolescent group therapy. The study sample was 59 percent Latino and 35 percent African American.
Collaborating with community faith leaders may help behavioral health service providers target Latino families in need of mental disorder and substance use-related treatment (Villatoro, Morales, & Mays, 2014).
In Steinka-Fry et al.'s (2017) meta-analysis of culturally responsive SUD interventions for adolescents, culturally responsive treatment components among Latino families included:
The provision of racially and ethnically diverse clinicians (though not necessarily matched to the race or ethnicity of clients/families).
Use of written materials for parents that were delivered in their native language.
Spanish-speaking counselors.
Easily accessible treatment locations.
Convenient scheduling.
Culture-informed assessments and treatment planning.
Treatment planning and delivery tailored to families who have trouble engaging in services.
COUNSELOR NOTE: FAITH, LATINO FAMILY CULTURE, AND SEEKING HELP FOR MENTAL ILLNESS AND SUBSTANCE MISUSE.
Other suggested approaches when working with Latino families include the following:
Have a working knowledge of how substance use is defined in the family's country of origin. Many countries of origin, such as Mexico, have a culture that is more permissive toward substance use. Immigration and acculturation into the United States may alter family members’ attitudes toward substance use. Such changes must be addressed, given their immediate effect on family relations.
Be aware of regional and national differences (e.g., North, Central, and South American cultural diversity in the Hispanic diaspora; Spanish as spoken in Mexico versus as spoken in Argentina or Spain or the Dominican Republic).
Explore family members’ experiences of migration, cultural transition, and ethnic-minority status. Hold an open discussion about these experiences, which will help you analyze family stories and lead directly to issues affecting substance misuse. For instance, a discussion concerning how family members reconcile their culture of origin and American culture will reveal differing acculturation levels within the family. Also explore the issue through the simple exercise of having family members rate how close they feel to their culture of origin on a scale from 1 to 10. Counselors must make arrangements so that language does not impede a family member's participation.
If you plan to work with Latino families with origins in Mexico, be familiar with spiritual healers, the curandero or curandera (i.e., folk healer). These healers can help resolve intrapsychic and interpersonal problems. Curanderismo, or the art of folk healing, is a particular treatment modality used primarily in Latino/Southwestern rural communities, although it is also prevalent in metropolitan areas with a large Latino population. Curanderos earn their trust from the community; the community validates their “practice.” This modality contains a mix of psychological, spiritual, and personal belief factors. Because the curanderos are considered to be holy, they invoke God's and the saints’ blessings on people seeking their help.
Rather than using a businesslike approach to treatment, which will not appeal to many Latino families, take a personable tack, which will yield much more effective results.
Be attentive to family conflict, which could affect substance use. One study of SUD treatment among Latino adults found that people who had a decrease in family conflict from pretreatment to posttreatment showed less alcohol and drug use at posttreatment than individuals who had an increase in family conflict from pretreatment to posttreatment (Fish, Maier, & Priest, 2015).
For more guidance about family counseling with Latino families, see “Resource Alert: Recovery and Mental Health Services for Latino Families.”
RESOURCE ALERT: RECOVERY AND MENTAL HEALTH SERVICES FOR LATINO FAMILIES.
Family-based drug and alcohol use interventions for Asian American families have not been rigorously studied, but the small amount of evidence seems positive. Culturally appropriate treatment models include CBT, strategic and structural family therapy, and solution-focused brief therapy (Cheung, 2014). Specific study findings include the following:
Family counseling for Asian individuals with SUDs has been linked to decreased substance use as well as improved family relationships (Fang & Schinke, 2014).
In a meta-analysis of parenting interventions for adolescent substance use, one study was focused on Asian American youth; it found the parenting intervention was associated with significant reductions in teen alcohol and illicit substance use (Garcia-Huidobro et al., 2018).
In a small investigation of Asian American mother-daughter dyads (Fang & Schinke, 2013), a family-based, Internet-delivered intervention for SUDs that focused on mother-daughter relationships, conflict resolution, substance use risk, body image, mood and stress management, problem-solving, social relationships, and self-efficacy resulted in many positive outcomes versus a control condition. These included:
Higher levels of mother-daughter closeness.
Improved mother-daughter communication.
Increased maternal monitoring.
Enhanced parental rules against substance use.
Higher self-efficacy.
Greater youth substance refusal skills.
Less intention to use substances in the future.
Reduced 30-day alcohol, cannabis, and nonmedical prescription drug use by daughters.
To help address cultural barriers and ensure treatment/service delivery meets the unique needs of this population, consider the following guidance:
To ensure you are offering appropriate and effective family-based interventions for Asian families, consider taking the following steps (Cheung, 2014):
Strive toward multicultural competency.
Acknowledge and respect Asian collectivist worldviews, values, and customs, and understand how collectivism affects family functioning.
Learn the family's immigration history and any resulting disruptions in the family structure.
Understand that Asian American families are often complex in structure and can differ in how traditional versus modern they are, their biculturalism, and their degree of “Americanization.”
Use strategies that Asian American families are comfortable with, like hypothesizing, perspective taking, gift giving, and balancing “problem talk” with “solution talk.”
Share personal anecdotes or personal information with families, as appropriate.
Conceptualize your role from multiple views rather than just seeing yourself as the family's counselor—for instance, view yourself as a teacher and community liaison for the family.
Avoid thinking of all Asian American families as belonging to one single ethnic group. Rather, clinical programming, approaches, and treatment/service materials should be congruent with and adapted to the unique languages, values, family structure, and life circumstances (e.g., immigration status, history of discrimination) of the many heterogenous subgroups that Asian American families comprise (Chang et al., 2017; Cheung, 2014), such as Chinese, Korean, Japanese, Vietnamese, and Thai populations. This is particularly important because adolescent substance use and risk factors for misuse can vary across Asian subgroups, which are discussed further below (Shih et al., 2015).
Include family members in treatment, with an emphasis on educating them about the recovery process and why recovery is important. Research on Asian American and Pacific Islander individuals suggests these groups have problems with or have been reluctant to enter SUD treatment in part because of certain family factors. Family misunderstandings or misperceptions about SUDs and the need for treatment can cause recoverees shame and embarrassment about seeking help.
Explore families’ level of acculturation and acculturation stress (Cheung, 2014), which have been linked to substance use and misuse across subgroups of Asians immigrating to the United States (Park, Anastas, Shibusawa, & Nguyen, 2014). (Subgroups—or cultures within a culture, as discussed previously—are secondary cultures within the Asian culture at large, such as Chinese people, Japanese people, Korean people, Vietnamese people, and so forth. Subgroups often have separate languages, customs, beliefs, and value systems.)
Asian subgroups are deeply heterogenous in the social, cultural, historical, and contextual factors surrounding their immigration and acculturation experiences. Take time to educate yourself about a family's specific background.
Also be mindful that acculturation and immigration among Asian immigrants can vary by generation. The life experiences of newly immigrated individuals and those not yet proficient in English can affect risk of alcohol use differently than immigrants with a longer residency and greater acculturation into U.S. society (Park et al., 2014).
When possible, match counselors of similar race, ethnicity, or cultural background, similar language, or both to Asian American families (Chang et al., 2017).
Know and incorporate into treatment the unique help-seeking and coping behaviors often present in Asian Americans, including use of religion, meditation, and family support (Lei & Pellitteri, 2017).
Although family-based SUD programs for AI/AN populations are understudied, they appear to be effective, particularly for youth (Pina et al., 2019). Liddell and Burnette's (2017) review of culturally informed SUD interventions for indigenous youth found that all included studies reported some degree of improvement in alcohol or drug use and that community or family involvement was a key component in many studies. There were also improvements in family support and relationships, and the inclusion of family or community into service/interventions was well accepted.
In another review, Rowan et al. (2014) examined interventions offered to indigenous clients (and often their families), which included some aspect of Western-based SUD services (e.g., assessment, education, counseling, treatment, continuing care services) as well as traditional cultural services. The following positive outcomes were reported among the studies that included families in their interventions:
Abstinence was maintained for 1 year in one-third to one-half of participants.
Perceived level of family support was high among intervention recipients (94 percent).
Percentage of days abstinent across 12 months ranged from 80 percent to 100 percent (but was not statistically different from a treatment-as-usual group).
30-day alcohol or drug use declined from 24 percent to 5 percent.
Past-month substance-related stress/emotions/activities decreased from 47 percent to 23 percent.
Part- or full-time employment increased from 11 percent to 20 percent.
Enrollment in school or occupational training programs increased from 7 percent to 17 percent.
Arrests and acts of criminal behavior decreased from 31 percent to 5 percent.
Significant improvements were seen in self-reported depression, anxiety, problems concentrating, hallucinations, problems controlling violent behavior, and suicide attempt.
Other family-based substance use reduction or prevention programs have been adapted to the needs of AI/AN families (Belone et al., 2017; Ivanich, Mousseau, Walls, Whitbeck, & Whitesell, 2020), but findings on substance use outcomes specifically are either currently unavailable (e.g., programs still being pilot tested) or have yet to show significant improvement. Further research will be needed to identify any potential substance-related benefits of such family-based programs.
SUD treatment for AI/AN families has been successfully provided via home visiting programs (Barlow et al., 2015). For instance, tribal home visiting programs funded through the federal Tribal Maternal, Infant, and Early Childhood Home Visiting Program have shown success in identifying and providing referrals for treatment of family-based substance use problems in AI/AN families (Novins, Ferron, Abramson, & Barlow, 2018). Programs offered include the:
Parents as Teachers Program (https:
Family Spirit Home Visiting Program (http://caih
Nurse-Family Partnership Program (www
Parent-Child Assistance Program (http://depts
SafeCare Program (http://safecare
Of nine programs surveyed (Novins et al., 2018), all implemented SUD screening and monitoring at intake and during in-home visits. All screened pregnant women and mothers; five also screened fathers. Eight offered referral for community-based SUD treatment, and six offered home-based SUD services. Eight made referrals to treatment programs with cultural elements or access to traditional providers.
Family counseling techniques for AI/AN populations should take a systems approach that incorporates not just the family but the community, tribe, or clan. The following strategies can help you maintain such an approach and maximize positive substance-related outcomes for AI/AN families (SAMHSA, 2018):
Understand and acknowledge the interconnectedness of AI/AN families. Family counseling with this population requires an approach wherein each member of the family is understood to be interconnected with one another as well as with the surrounding community, tribe, or clan. Thus, when change happens in an individual, it has ripple effects on the group or population at large. Nothing happens in isolation.
Help families build strong relationships between parents and children. A review of protective factors against negative health outcomes in AI/AN youth found positive family bonds, including those between parent and child, were correlated with low substance use (Henson, Sabo, Trujillo, & Teufel-Shone, 2017).
Learn how the family deines itself: Who is considered “family,” and what is each person's role?
Discuss with family members their thoughts and feelings about participating in family counseling.
Discuss with family members their thoughts and feelings about substance use. Parent and grandparent norms have been shown to influence AI youth substance use. The presence of family members who discourage substance use is linked to lower intent to use (particularly alcohol, nicotine, and cannabis) in this population (Martinez, Ayers, Kulis, & Brown, 2015). Thus, open expression of antisubstance use messaging from parents and grandparents may be useful during family counseling in shaping adolescent behavior.
Where appropriate, include valued others (e.g., community elders, spiritual healers) into service/treatments.
Use family genograms to understand the family's history, structure, values, and strengths.
Consider including family sculpting—a family counseling technique that involves role-playing and acting out dramatic representations of past family events.
Seek out information about and be willing to include traditional healing practices.
Build relationships and connections with spiritual advisors, traditional healers, elders, and others in the AI/AN community.
Another key aspect of culturally informed SUD treatment and services for AI/AN families is using trauma-informed care (Lucero & Bussey, 2015). This requires acknowledging and addressing trauma in three areas:
The historical trauma inflicted on AI/AN cultures as a whole (e.g., discrimination, forced relocation).
Intergenerational trauma passed down among family members (e.g., impact of suicides, adverse childhood experiences, and violence within the family and community).
Trauma felt by the individual misusing substances.
A trauma-informed approach means using (Lucero & Bussey, 2015):
Trauma-informed screening and assessment tools.
Treatment/service delivery that fosters feelings of safety.
Staff training in recognizing and responding to trauma symptoms.
Referrals to trauma-informed behavioral health services with providers who have worked with AI/AN clients.
An interaction style that establishes trust and fosters mutually respectful relationships with families.
Myhra, Wieling, and Grant (2015) describe specific family dynamics of AI/AN families affected by SUDs. These dynamics may serve as important targets of clinical intervention or otherwise help inform effective service delivery. They include:
The presence of grandparents as a source of stability, safety, and security for grandchildren, particularly when parents with SUDs are unable to care for their children.
The need for open communication about substance misuse among family members, especially among parents/grandparents and children.
The importance of forgiveness as a part of recovery and of healing broken family relationships.
The use of cultural and spiritual practices in promoting recovery (e.g., sweat lodge practices, cultural ceremonies, passing down cultural and ancestral knowledge to children/grandchildren).
RESOURCE ALERT: TIP 61, BEHAVIORAL HEALTH SERVICES FOR AMERICAN INDIANS AND ALASKA NATIVES.
Research is insufficient to suggest the efficacy of any one type of family counseling over another for use with LGBT families. In fact, little or no empirical research has been published investigating the use of family counseling in SUD treatment for these families. However, a review of SUD treatments for LGBT youth (Aromin, 2016) notes that family therapy is often an effective and critical addition to individual treatment. Specific benefits cited in the review include:
Addressing substance use from a systems approach rather than solely as an individual problem.
Identifying and repairing dysfunctional family dynamics, especially those influencing substance use.
Teaching assertiveness training.
Improving overall family functioning.
Notably, for youth who are nondisclosed and feel that discussions about their sexual orientation cannot be separated from discussions about their substance use, you should weigh the pros and cons of including family in treatment/services (Aromin, 2016). If family members are included, issues about confidentiality and treatment alliance may need to be addressed.
Strong, positive family relationships may buffer against substance misuse among LGBT individuals, as is the case among heterosexual individuals.
For instance, findings from Waves I and III of the National Longitudinal Study of Adolescent to Adult Health (Magette, Durtschi, & Love, 2018) showed that emerging adults who reported close relationships with their mothers in adolescence were less likely to use cannabis, and a strong relationship with fathers during adolescence predicted significantly lower past-year illicit drug use.
In a national survey of 12- to 17-year-olds (Padilla, Crisp, & Rew, 2010), parental acceptance of sexual orientation among LGBT youth (and particularly acceptance by mothers) was protective against future substance use. Specifically, parents’ acceptance lowered the risk of substance use by 35 percent to 39 percent compared with adolescents who were not out to their parents or whose parents were nonaccepting of their sexual orientation.
These findings underscore the influence of parent-child relationships as possible risk factors for substance use later in life. They also suggest the critical role of family counseling in supporting and strengthening bonds among LGBT families, particularly during adolescence.
There is a significant lack of empirically validated research about family-based SUD counseling for LGBT families. Thus, identifying effective changes for this population is difficult. However, it can be useful to consider research on family and couples therapy with LGBT populations in general to learn which adaptations may be useful when applied in the context of SUD treatment.
For instance, guidance on how to adapt attachment-based family therapy to gay and lesbian adults with nonaccepting family members includes the following (Diamond & Shpigel, 2014):
Focus on alliance building, including getting to know clients and their perceptions of the problem. Many LGBT individuals have had problems with developing and sustaining healthy attachments with their family. Thus, rapport building is an important goal of counseling and helps build trust, empathy, and confidence.
Help clients prepare to invite family into treatment. Work with them on the possibility that family will reject their invitation. Use individual sessions to discuss and role-play conversations with family members, or have clients express their thoughts and feelings to family by writing a letter.
As needed, have a separate session with nonaccepting family members, such as parents, alone. If family members are not accepting of your client's sexual orientation, they may feel avoidant or resentful of engaging in family counseling. You may need to gently challenge their false beliefs about their family member's sexuality while remaining compassionate and empathetic.
Other general guiding principles include:
Address your own potential biases about LGBT couples and families. Most communities have some sort of visible LGBT organizations, and countless Internet resources are readily available.
Family can be a very sensitive issue for LGBT clients. Use the client's definition of family rather than relying on a heterosexual-based model. For example, an LGBT client may define family as same-sex parents and their children, rather than a mother and father with children.
Likewise, be accepting of whatever identification an individual chooses for himself or herself and be responsive to the need to be inclusive and nonjudgmental in word choice. For example, gender-neutral words and phrases may be preferred, such as partner rather than husband or wife. Such an approach will ensure a greater likelihood that people will continue with therapy.
Do not overpathologize issues of boundaries and fusion. Many LGBT couples appear to have more permeable boundaries than are commonly seen among heterosexual couples. For example, a lesbian may seek support from an expartner to help with troubles with a current partner more often than would typically be seen in a heterosexual woman. When violence between partners is a treatment issue, safety must be the counselor's main concern.
Many LGBT clients may be reluctant to include other members of their families of origin in therapy because they fear rejection and further distancing. Be open to including nontraditional family members or using nontraditional family models, such as one-person family counseling, which incorporates a family focus without treating the whole family of origin. Be alert to possible substance misuse or mental illness among LGBT clients’ nontraditional family members as well.
LGBT individuals should not be urged to come out when they are not ready.
Active duty and veteran military personnel are at an increased risk for substance misuse, including AUD, drug use disorders, past-month heavy episodic drinking, daily cigarette use, and prescription drug misuse (Hoggatt, Lehavot, Krenek, Schweizer, & Simpson, 2017; Teeters, Lancaster, Brown, & Back, 2017). Additionally, spouses and children of military members are vulnerable to substance misuse (Sullivan et al., 2015; Trone et al., 2018). Thus, family-based approaches in SUD treatment for military personnel can be key.
Nearly all of the empirical research on SUD treatment in military populations has been focused on individual treatment effects rather than the effects of family-based interventions. Furthermore, an abundance of family-based research in military populations concerns topics like deployment, suicide/violence, or PTSD, not SUDs. Thus, it is difficult to know the degree to which family counseling for substance misuse has been successfully used with military families. Examples of available evidence-based findings include the following:
In a very small study of male military veterans and female spouses, behavioral couples therapy for AUD combined with cognitive-behavioral conjoint therapy was associated with a reduction in percentage of days of heavy alcohol use and PTSD symptoms (Schumm, Monson, O'Farrell, Gustin, & Chard, 2015).
A web-based adaptation of Community Reinforcement and Family Training was efficacious in improving social support, relationship quality, family conflict, and spouse perceptions of partner drinking rates (Osilla et al., 2018).
The Department of Defense has made concerted efforts to better address family-wide problems felt by military personnel, including marital issues, child behavioral problems, and adjustment problems, through programs such as Military and Family Life Counseling (MFLC) and Military OneSource. These programs provide services like couples counseling, psychotherapy, suicide prevention, screening, pharmacotherapy, telehealth, inpatient psychiatric care, residential treatment, and SUD treatment (Trail et al., 2017). Unfortunately, little peer-reviewed research has been conducted to assess the efficacy and cost-effectiveness of these programs (Trail et al., 2017), especially regarding SUD services and outcomes. However, recent analyses from the RAND Corporation suggest these programs can be effective at (Trail et al., 2017):
Reducing short- and long-term problem severity.
Reducing interference with work and daily functioning.
Providing needed referrals for outside services (including mental health services).
Improving stress (work-related and life stress) and anxiety.
Meeting clients’ treatment expectations. Specifically, over 90 percent of participants reported feeling satisfied with the speed with which care was accessed, the confidentiality of the care, and continuity of services.
Responding to military-specific needs. Specifically, 25 percent of MFLC participants agreed, and 69 percent strongly agreed, that the counselor understood military culture. For Military OneSource participants, 34 percent agreed and 44 percent strongly agreed that the counselor understood military culture.
Because of the lack of empirical data on family-based SUD treatment for military populations, our understanding of how to adapt traditional family-based SUD interventions for the needs of military families is limited. However, you can draw guidance from research on family counseling for military families in general. Consider the following when working with these families:
For adolescents with or at risk for SUDs, ensure parent involvement in services/treatment.
A study of data from the 2004 to 2013 National Surveys on Drug Use and Health revealed that adolescent children of veteran fathers were more likely than children of nonveteran fathers to report lifetime, past-year, and past-month use of tobacco and nonmedical use of psychotropic medication as well as lifetime cannabis use (Lipari et al., 2017). Lower father involvement predicted greater chances of youth substance use in this study.
The authors suggest that parent involvement and communication with children about substance use can be valuable, especially for prevention efforts. They note that “formal support from programs serving veterans’ families may be necessary to address prevention or intervention for adolescents’ substance use. In addition, effectively supporting families requires the active participation of a network of stakeholders, including extended family members, schools, health and mental health care providers, community leaders and groups, private associations, and faith-based and civic organizations” (p. 705).
Educate yourself about military culture, including what life is like for military families. The RAND assessment of MFLC and Military OneSource (Trail et al., 2017) indicates that, although most participants felt counselors understood military culture, many did not, and that was considered a barrier to successful treatment.
Consider stressors related to military life that may exacerbate or increase the risk for substance misuse. Military family life can be very difficult for families, and children especially, in large part because of parent/spouse deployment and repeated household relocations. These events can be a strain on children (Lester et al., 2016) because of:
Having to take over household responsibilities while a parent is deployed.
Fears about parent safety while deployed.
Reunification and readjusting to life with the returning parent back in the home.
Helping care for a parent who returns with combat-related injuries or trauma.
Adjustment problems with fitting into new schools and communities.
Having to form new bonds with teachers.
Having to build new friendships and integrate into new peer groups.
When working with military families on substance use-related issues, it may be helpful to consider the overall context of military family life and related burdens placed on service members, spouses, and children because of deployment, relocation, or other military-related events and factors. It is possible that recovery will not be successfully achieved and maintained without also addressing such stressors if present, as they could make return to substance use more likely.
Accept that being in the military is extremely demanding and all encompassing; it is not “just a job.” Military life is “24/7.” Working effectively with military families means understanding that the person serving in the military (and his or her family) has made an extraordinary sacrifice and commitment. In a way, the military as an institution almost operates as a third person in the marriage, creating a relational triangle (as refected in the common remark from spouses, “My husband is married to the military”) that may need to be addressed (Moon, 2016, p. 130).
Because military service is often transgenerational, explore whether substance use patterns in military personnel were present in other generations of the family who served (Moon, 2016). For instance, a father in the Army who drinks heavily may have grown up with a father who, like him, served in the Army and drank heavily, perhaps to cope with stress or trauma. This normalizes the substance misuse and, if unaddressed, can become a barrier to recovery.
Explore your own thoughts, beliefs, and biases about the military and military culture. Do this preparation before interacting with military families. The goal is to avoid any reactions you might have that could negatively influence your work with these families (Moon, 2016).
RESOURCE ALERT: PROVIDING SUD SERVICES FOR MILITARY FAMILIES.
You will encounter many diverse types of families in your clinical setting, but no two families are the same. Understanding why you may need to make adaptations to treatment for certain family cultures and how to make those adaptations will increase your chances of success in helping them achieve good outcomes. But it is not enough for just counselors to develop this knowledge. Service delivery that is responsive to families and their cultural needs requires the integration of appropriate staff training, competency, and supervision throughout the entire program. In the next chapter, readers will learn how administrators and supervisors can collaborate with providers to accomplish comprehensive, integrated family counseling for SUD treatment. The goal is to develop SUD programs that successfully provide high-quality, evidence-based care, including referrals, outreach, community linkage, SUD services, and SUD treatments for all families with substance misuse.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
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