"For Prof. Goodman only"

Essentially two types of AOD exposure occur for children: prenatal and interpersonal. Both types of exposure can have dramatic effects on children. Since the 1970s, concern has increased regarding the passage of drugs through the human placenta and through the mother’s breast milk. The resulting research indicates that the use of tobacco, alcohol, and other drugs during pregnancy affects the fetus. Some of these problems may remain even if the mother discontinues her use or if the child is raised in a nonusing environment (Jones, 2007). Jones asserts that the issue of drug use during pregnancy is now considered a critical health concern.

Interpersonal exposure from parental AOD use can affect a child’s social and psychological development through adulthood. However, the effects on children will vary. This is due to individual and environmental differences including age of exposure, progression of use, characteristics of the child and of the AOD abuser, family dynamics, and external events. Copello et al. (2005) assert that a growing body of evidence says that not all children will suffer adversely either in childhood or adulthood. Some children will develop resilience and do not develop significant problems. Therefore, it would be unwise to assume that all children who experience AOD abuse in their families of origin will exhibit similar behaviors.

Perhaps you are wondering why we include a section discussing the possible impairment resulting from prenatal substance use and abuse in a textbook providing comprehensive substance abuse information for school counselors, social workers, therapists, and counselors. The answer will probably become apparent to you as you read through the information. In the meantime, in order to provide a foundation for your understanding of the relationship between what is presented here and your profession(s), let’s look at the many facets of prenatal exposure to alcohol and other drugs.

A few of the variables, or “layers,” relative to prenatal substance use and abuse are the national attachment to partying; the desire to change how one feels, especially if those feelings are uncomfortable; easy access to and availability of legal and illegal substances regardless of age; the stigma of asking for help with AOD use/abuse, especially for pregnant women; limited long-term residential AOD treatment facilities; few treatment facilities for women; even fewer treatment facilities for women and their children; ignorance regarding this issue and ethnic/cultural considerations; the possible loss of custody of the unborn child at birth as permitted by state law; the possibility of maternal prison time; the possible loss of home and family when in treatment and/or prison; and on and on .... When seeking to adequately address the complexities of impairment resulting from prenatal AOD exposure, all of these variables need to be taken into consideration and addressed.

Similar to many issues in the AOD field, prenatal exposure to alcohol and other drugs can generate a great deal of public and media attention. As a result, the topic of the pregnant women’s use of AOD has become emotionally charged and widely publicized, enhancing the shame already experienced. As suggested previously, what woman wants to admit that her AOD use has impacted her helpless, unborn child? What woman wants to risk the possibility of having her child removed from her, being forced to go to residential treatment to address her AOD issues, or possibly going to prison? The stigma relating to this issue is another detriment to accessing much-needed help. For all of these reasons, estimated prevalence rates vary.

For example, Jones (2007) and data from the Substance Abuse and Mental Health Services Administration (2005) both reflect that among pregnant women, almost 10% report using alcohol, 4% report using at least one illicit drug, and 18% report smoking tobacco. Other data from the National Institute on Drug Abuse (2006) estimate that nearly 20% of infants are exposed to alcohol in utero, 17% to marijuana, 5% to cocaine or heroin, and 40% to tobacco. Further, the NIDA data show that about one-half of the pregnancies are unplanned and that the population of pregnant women report binge drinking as well as chronic drinking, both of which may result in the most severe prenatal impairment. Half of the pregnant women surveyed reported drinking in the three months prior to recognizing the pregnancy. These data indicate that the unborn children could have been exposed to alcohol for at least six weeks.

The diagnosis of fetal alcohol syndrome (FAS) was first discovered in 1973 when David Smith and Ken Lyons Jones studied 11 newborns exposed to substantial amounts of alcohol in utero.

Scientific reports confirm that alcohol is a teratogenic drug capable of producing lifelong disabilities after intrauterine exposure. Alcohol is a solvent (i.e., capable of dissolving something, causing a solution [Brown, 1993]) that influences the cells of the developing brain, thus resulting in a spectrum of cognitive deficits. Efforts to provide parameters for understanding this broad range of possible outcomes produced the term fetal alcohol spectrum disorders (FASD). FASD is not a diagnosis; rather it is an umbrella term under which diagnoses fall. FASD diagnoses include fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related birth defects (ARBD), and/or alcohol-related neurodevelopmental disorder (ARND). You also might hear the term prenatal alcohol exposure (PAE), although it is not considered an FASD diagnosis; rather, it simply acknowledges in utero alcohol exposure.

May and Gossage (2001, p. 166) estimate a prevalence rate for fetal alcohol syndrome (FAS) between 0.05% and 2.0% per 1,000 births. When combining FAS, partial FAS (pFAS), alcohol-related neurodevelopmental disorder (ARND), and alcohol-related birth defects (ARBD), the estimate is likely to be at least 10 per 1,000. This ratio translates to 1% of all births.

According to Streissguth et al. (1996), FAS is recognized as the leading known cause of mental retardation in the United States, surpassing Down’s syndrome and spina bifida. Streissguth (1996) also reports that only 16% of 415 individuals diagnosed with an FASD legally qualify as having mental retardation. In other words, 86% of the 415 have an IQ in the “normal” range and subsequently do not qualify for services for developmental disabilities. Streissguth reports that the average IQ of an individual with FAS is 79 and the average IQ of an individual with pFAS or ARND is 90.

Therefore, no time, no type, and no amount of alcohol is safe to drink when pregnant. Fetal alcohol syndrome does not include all individuals affected by alcohol in utero; rather it represents the severe end of the spectrum of disabilities caused by maternal alcohol abuse during pregnancy (Brown, 1993, p. 1961).

We do not want to minimize the problems that can result from prenatal exposure to AOD. We also do not want you to conclude that all children prenatally exposed will have serious and permanent learning, behavioral, social, and emotional problems.

The cognitive impairment, a diagnostic criterion for the FAS, pFAS, and ARND diagnoses results in the behavioral and learning problems that remain throughout the lifetime of an individual with an FASD. Impairment varies from individual to individual and is potentially influenced by many variables. Risk factors such as polysubstance abuse, socioeconomic status, poor nutrition, lack of prenatal care, homelessness, domestic violence, maternal age and health, fetal health, even placental health may also impact the developing fetus. Sadly, this is far from a complete list.

In 1996, a significant study was conducted at the University of Washington by one of the pioneers in the FASD field, Dr. Ann Streissguth (1996). From a descriptive study of a sample population of 415 subjects with an FASD diagnosis, she sought to provide information regarding the occurrence of disabilities/issues that are secondary to the FASDs. The results are as follows:

· 94% had mental health problems (age 6to51)

· 43% had disrupted school experience (age 12 and up)

· 60% had legal problems (age 12-51)

· 50% experienced confinement in jail or treatment facilities (age 12-51)

· 45% engaged in inappropriate sexual behavior (age 12-51)

· 30%of adolescents, 47% of adults had AOD problems

· 83%of the adults were living dependently

· 79%of the adults had problems maintaining employment

Although the sample was based on a limited number, the results were significant.

Compared to how much is known about the possible impairments of in utero exposure to alcohol, very little is known about the possible impairments of in utero exposure to other drugs. The following information discusses the outcomes of various longitudinal studies focusing on prenatal use of tobacco, marijuana, cocaine, and heroin.

Lester, Andreozzi, and Appiah (2004) maintain that the effects of prenatal tobacco use/abuse can include low birth weight, intrauterine growth restriction, and sudden infant death syndrome (SIDS). Pickett and Wakschlag (2011) report as “established consequences of maternal smoking during pregnancy” health problems at two developmental stages (i.e., infancy and childhood and beyond).

In addition to the three effects reported by Lester et al., (2004), infant health problems reported in the Pickett and Wakschlag study include congenital malformations such as cleft palate and cleft lip, limb reductions, and genitourinary malformations. Their 2011 study reports “infants exposed to tobacco in utero are 40% more likely to die in the first four weeks after birth than those born to non-smokers ....” The risk of infant death is notably increased if tobacco exposure continues after birth. Similarly, most SIDS deaths occur between 2 and 4 months of age, with maternal smoking when pregnant being an established cause. The risk of SIDS doubles when the fetus is exposed to tobacco in utero. The risk continues to increase if the infant is exposed to secondhand smoke after birth.

Health problems primarily include reduced lung function due to impaired development of airways, and respiratory illnesses such as asthma, lower respiratory tract infections (e.g., pneumonia, bronchitis, bronchiolitis, and croup). As with infant mortality and SIDS, the risk of each illness mentioned is compounded by exposure to environmental secondhand smoke.

Singer and Minnes (2011) report the following information regarding in utero exposure to cocaine beginning at pregnancy/birth and progressing to conditions remaining throughout a lifetime. Fortunately the current research pertaining to the possible effects of prenatal cocaine exposure has increased substantially since the initial media frenzy regarding so-called “cocaine babies.”

Singer and Minnes (2011) provide helpful information regarding the possible effects of prenatal opiate exposure in the table below once again beginning at pregnancy/birth and progressing to conditions remaining throughout a lifetime.

The drug that is readily available and much sought after on our streets today is meth (i.e., methamphetamine). Service providers and caregivers working with children who may be impaired by prenatal meth exposure are clamoring for research results that determine possible effects of the exposure as well as intervention strategies specific to the learning and behavioral special needs presented. However, the idiosyncratic nature of the drug’s manufacturing process (i.e., the “ingredients” of the “recipe” most often vary from batch to batch and “manufacturer” to “manufacturer” with ephedrine as the only constant) obstructs researchers’ efforts to determine the long-term impact of prenatal meth exposure. Longitudinal research available thus far consists of sample populations studying the impact of prenatal meth exposure on mice that carefully control for variables that may lead to inaccurate conclusions. If the same controls could be applied to human studies about the effects of prenatal exposure to methamphetamines, we are sure that volumes could be written.

Neonatal abstinence syndrome (NAS) (National Institutes of Health and Prevention, 2011) potentially occurs when a pregnant woman ingests addictive substances, including prescription, drugs during the pregnancy. Drugs pass through the placenta and reach the developing fetus. If the mother becomes chemically dependent on the substance, the fetus does as well. If that mother continues substance use throughout the pregnancy, mother and baby are still chemically dependent on the drug at birth. If the drug dependence is unknown to those caring for mother/baby at delivery, symptoms of withdrawal may be unrecognized and medical treatment delayed.

NAS symptoms depend on the drug used; the quantity of the drug used; the period of time over which the drug was used; whether other substances were used during the pregnancy as well; and the length of time in utero (i.e., premature to full-term birth). NAS symptoms can present within 1 to 3 days after birth, or 5 to 10 days following birth. NAS symptoms are consistent with the symptoms presented by the child’s mother. Treatment for the symptoms varies and is determined by medical professionals.

The first recommendation relates to individual interventions, which are “simple but not easy.” The truth is that any old intervention won’t do the job of assisting the person with cognitive impairment resulting from in utero exposure to alcohol. Perhaps the most difficult step is the acceptance that the area(s) of deficit result in an inability to carry out certain life functions (i.e., it’s not about won’t, it’s about can’t).”

Individual interventions build on the person’s strengths and include simple strategies such as consistently providing routine, repetition, ritual, predictability, and structure; minimizing transitions and keeping environmental stimuli at a minimum; teaching by role play and multiple sensory modalities, and so on. This is far from a complete list, but it provides an idea of how extensive and pervasive the interventions need to be.

Another concept that is very important for caregivers and service providers to understand is that once supportive interventions result in positive learning and behavioral outcomes, those interventions must not be eliminated. In addition, if the intervention(s) does not result in the hoped-for outcome, changes must be made by the caregivers and service providers.

Doctor’s second intervention recommendation for the person with an FASD is that dynamic case management (DCM) be used. Briefly stated, DCM expands intra-agency case management to interagency case management. This model pulls together representatives of each agency providing services to the individual with an FASD so that they collectively collaborate to develop asingle case management plan accommodating the life circumstances of that individual. If the individual is receiving services from alcohol/drug treatment, probation, drug court, Child Protective Services, and so on, each agency generates a plan that addresses their process with that person. Someone with an FASD usually finds it difficult to be in compliance with one case management plan, let alone three or four. DSM addresses this dilemma and leads to positive outcomes for the one served.

It is imperative to assess the protocols and policies that enhance or obstruct the provision of services for the person with an FASD. This is far easier to say than to do, since in many cases it is the agency’s policies/protocols that stand in the way of adequate provision of services and that complicate the life of the individual with an FASD. Rather than being thwarted by a policy issue, the support team is encouraged to consider “plan B,” a method of getting the desired results despite interference from a damaging policy. Conversely, it is imperative to evaluate the agency’s policies that are an asset to the provision of services for a person with an FASD.

Fraser, McAbee, and the Committee on Medical Liability (2004) maintain that between 11 and 17.5 million children in the United States younger than 18 currently live with a parent with alcoholism. The number of children living in homes where other drugs are abused is relatively unknown. However, multiple studies confirm that many children do experience negative effects as a result of being exposed to the interpersonal and environmental influences of AOD abuse in their homes (Eiden, Molnar, Colder, Edwards, & Leonard, 2009; Coppello et al., 2005; Hussong et al., 2010). Studies demonstrate that children who grow up in homes where AOD are abused may view themselves as worthless, may feel unimportant as a result of being consistently rejected, and may feel responsible for their parents’ substance abuse (Towers, 1989). Around the holidays, especially, elementary-school-aged children of alcoholics may become moody and “withdrawn, irritable, and certainly not ready or able to participate with the rest of the class and the teacher in holiday-related lessons and activities” (Towers, 1989, p. 20). Another result may be seen in the young child’s expressed defiance toward activities of these kinds. It is thought that reasons for this behavior center on the child’s anxiety regarding a family get-together or celebration in which drugs will likely be abused.

In a review of the literature, Kroll (2004) used content analysis to investigate the impact of AOD misuse on children. Findings revealed that children’s lives were affected in six overarching areas: denial, distortion and secrecy; attachment—separation and loss; family functioning—conflict and breakdown, violence, abuse, and living with fear; role reversal, role confusion and child as caretaker; and what children would say that they needed. A study by Ohannessian and Kesselbrock (2009) found that children have feelings of hostility and guilt as well.

Apart from the idiosyncratic behaviors demonstrated during or around holidays, general feelings of alienation can lead children into social isolation and reinforce the child’s beliefs that they are socially incompetent. A child who comes to school having slept little the night before because of anxiety or because of parental fighting or abuse cannot really be expected to perform well. As a result, the child’s self-concept can be diminished by repeated failures at learning. A vicious cycle can be born. The result can be that the child feels hopeless, fearful, and lonely. In some cases, the effects can be fateful. Although the impact on children is not always severe, the possibility exists that parental drug abuse may be a significant factor in adolescent suicide attempts.

More often than not and depending on the child’s age when first encountering parental alcohol or other drug abuse, the impact of interpersonal and environmental exposure will be reflected in the school classroom and can affect students’ hygiene, cognitive issues such as concentration, achievement, attitudes toward learning, attitudes toward teachers and others in authority, attitudes toward classmates, attendance, completion of homework assignments, and participation in extracurricular activities and sports (Lawson & Lawson, 1998; Towers, 1989; Woolfall & Sumnall, 2010).

The Centers for Disease Control and Prevention (CDC) (2010e) suggest that school connectedness is a significant protective factor that can help insulate children from substance abuse and a range of other maladaptive behaviors. These factors include having adult support, belonging to a positive peer group, having a commitment to education, and having positive perceptions of the school environment. Counselors and social workers who work in the schools will be faced not only with student-clients who are children of alcoholics but will, as well, be consulting with teachers who attempt to teach these children. Helping teachers become familiar with the symptoms is important. Teachers need to know basic facts about AOD abuse. With some empathic guidance from school counselors and social workers, teachers can emphasize the need to make their classrooms safe havens where students can learn to overcome their difficulties and experience success. As in dealing with children affected by in utero exposure to AOD, school counselors can help teachers emphasize the need for structure in their classrooms where children can learn or reinforce appropriate social skills. Helping teachers see the need for students’ healthy expression of feelings, including anger and frustration, and helping teachers see the need for activities that aim at bonding, autonomy, and problem solving can aid in helping students develop protective factors against drug abuse and can help with students’ self-esteem and successes at learning in school.

So far, we have discussed the effects of AOD misuse only on children. Substance misuse can also negatively impact other family members and disrupt a range of family dynamics and processes including family rules and rituals, routines, communication structures, social life, finances, homeostasis, and family roles (Arcidiancono et al, 2010; Copello et al., 2005). Rhodes, Bernays, and Houmoller (2010) reviewed the literature of the impact of drug use on parenting and of the impact of parental drug use on the family functioning. These researchers concluded that drug use is “overwhelmingly damaging.” No consistent or accurate figures that estimate the number of family members who are affected by substance misuse are available. However, in taking a global perspective, Copello, Templeton, and Powell (2010) estimate that a minimum of 91 million family members are affected across the world.

Regardless of ethnicity, families are dynamic systems and are influenced by changes that occur both within and outside of the family context. The larger social, political, and economic forces exert their influence in the family from the outside, while internal changes such as illness, aging, entering and leaving the family, changes occurring in the workplace, changing geographical locations, and changes in stress levels affect families from within.

Jackson (1957) first used the term family homeostasis to describe the natural tendency of families to behave in such a manner as to maintain a sense of balance, structure, and stability in the face of change. Significant to the concept of homeostasis is the notion that, as one family member experiences change in his or her life, the entire family will be affected and will adjust in some fashion. Family members can adjust overtly and covertly in an effort to maintain this balance and will exert much effort during times when the balance is threatened. This natural resistance can be both a blessing and a bane: by facing some changes with resistance, families can avoid losing their structures and becoming chaotic systems. However, there will inevitably be times when change requires the family to adjust (Gladding, 2011).

During these times, the family, to varying degrees, will need to reorganize its roles, rules, boundaries, and values to create a new balance that fits. If families are too resistant to change, they can become rigid and unable to adjust adequately, and family dysfunction can follow. For example, Ewing and Fox (1968) describe the alcoholic marriage as a homeostatic mechanism that is “established to resist change over long periods of time. The behavior of each spouse is rigidly controlled by the other. As a result, an effort by one person to alter typical role behavior threatens the family equilibrium and provokes new efforts by the spouse to maintain status quo” (p. 87). Alcohol is seen as playing a key role in attempting to maintain the status quo in alcoholic families.

Wegscheider (1981) believes that, in an alcoholic family, members attempt to maintain balance by compulsively repressing their feelings while developing survival behaviors, as well as emotional walls, to ward off the pain associated with the family member’s drinking. If drinking is removed from the family system, the family can be thrown into chaos. For example, an alcoholic father who becomes sober may attempt to reexert his influence as head of the household, thus throwing the marriage out of the balance to which it had become accustomed. The mother is no longer needed as a buffer between the children and their father, so she fades into the background as the children begin to address their father directly. The oldest son is no longer the surrogate father and begins acting out his frustration. The relationship between the mother, who has relied upon this son for support, and her son becomes strained as the father cannot hide his jealousy over this relationship. Unless the family can adjust adequately, drinking may be initiated again to reestablish balance.

We pointed out in Chapter 4 the variety of roles assumed by culturally and ethnically diverse families. Roles are an important part of Euro-American families as well. Role is often defined by the individual’s behaviors in performing the rights and obligations associated with a certain position, and usually involves a set of complementary expectations concerning one’s own actions as well as the actions of others with whom one is involved (Gladding, 2011). Irrespective of the presence of alcohol, one of the basic principles of family homeostasis is predictable family roles. Through these roles, family members can act out the overt and covert family rules in an effort to maintain homeostasis within the family system. According to Satir (1964), because the marital relationship is the “axis around which all other family relationships are formed” (p. 1), it is the interaction of roles in the marital relationship that influences the character of the family homeostasis.

Roles can also be further divided into affective and instrumental areas. Instrumental roles are those aimed at addressing the day-to-day human needs. The latter, affective roles, have particular significance in alcoholic or other drug-abusing families. Often in these families, certain individuals will experience and express particular emotions for the family. For example, the alcoholic who becomes angry and sullen when drunk may be carrying the anger for other family members who have difficulty in expressing this emotion. So, when the alcoholic gets angry, things may finally be said (inappropriately or not) to other family members that might not be discussed otherwise because the sober family members do not overtly express their own hostility. In this example, the anger role is carried by the alcoholic, and the emotions of sadness and helplessness may be carried and expressed by other nonalcoholic family members.

Children in families carry two essential roles. One role is that of child. The other is the role of family member. Roles exist within roles, and the child may assume any of them. For example, many believe that birth order in the Euro-American family affects the child’s role in the family and see the oldest child as taking on a dominant role with the second child taking on a more rebellious role. Youngest children are often used to having things done for them and take on a more passive role. While birth order alone does not determine an individual’s perception of relationships, it does have an influence.

These two role structures remain fairly constant across families of varying ethnic and racial origins. However, the manner in which these roles are played out in the family as well as in the larger social contexts is different. For instance, many Latino families who immigrate to the United States may leave some of their children behind temporarily for practical and financial reasons. In these situations, the mother may tend naturally to overcompensate by showering abundant affection upon those with whom she does have contact. As a result, Latino children may appear infantilized or overprotected to Euro-American teachers and counselors when, in fact, the family’s transitions and subsequent reorganization may greatly intensify these behaviors (Garcia-Preto, 2005). In more traditional families, children may also have bonded with their mothers, and the centrality of their position allows them to wield great power when it is used against a disengaged, authoritarian father (Giordano & McGoldrick, 2005). For African American youth, significant family difficulties may be brought on by the compounding effects of poverty, racism, and the general vulnerabilities of adolescence. Families in poverty will vary in structure, coping styles, and levels of resilience (Hines & Boyd-Franklin, 2005). Some families may support themselves by exchanging resources within their family support systems. Ho (1992) and other researchers maintain that in many Asian American families, the roles of family members are highly interdependent. The family structure is arranged so that conflicts in the family are minimized in order not to disrupt family peace and harmony. Even when adult children marry, allegiance to their parents—especially among the adult sons—is to remain paramount. Male offspring have especially revered roles in traditional Asian American families. Native American perceptions of family are universal in that the entire universe is thought of as a family in which every member serves a useful and necessary function. The Native American child may live in several different households at various times (Iron Eye Dudley, 1992). In these traditional Native families, grandparents, aunts, uncles, and community members are all responsible for the raising of the children. One can readily see how the roles of the child in Native American families are both stable and quite varied (Sutton & Broken Nose, 2005).

Little data exist on childhood roles among culturally and ethnically diverse populations in alcoholic or other drug abusing families. Most, although not all, of what we know about childhood roles in AOD-abusing families is the result of early clinical impressions of the Euro-American population and the research that has been reported in the popular literature (Vernig, 2011). It is clear that the roles are very difficult to operationalize, and the researchers’ attempts to operationalize roles has not produced consistent results.

Nonetheless, while their clinical utility may not be as significant as previously thought, some understanding of the potential roles and dynamics that can occur in families is important. Black (1981) described the roles adopted by children of alcoholic homes as based upon their perceptions of what they need to do to survive and bring stability to their lives. It was Wegscheider (1981) who first described the dysfunctional family roles of “hero,” “scapegoat,” “lost child,” “mascot,” and “enabler.” Other researchers have written about these roles since Wegscheider’s initial identification.

According to Howard et al. (2010), the hero or heroine child is often a compulsive high achiever who, through accomplishments, defocuses attention from the alcoholism in the family system. Music, sports, and academics are frequent arenas in which the heroes or heroines act out their roles, often at the expense of their own needs. Because they can often excel in one or more undertakings, they create the impression that their family must be quite well adjusted. In our own practice, we have seen many adolescents who are valedictorians, captains of sports teams, cheerleaders, and/or student government officers who come from homes where alcohol is abused.

The scapegoat child is seen as acting out the family problem by demonstrating defiance and irresponsibility. The unconscious or conscious agenda for these children is to create a need for overt parental attention as they attempt to defocus from the problem of alcohol.

Lost children are believed to be shy, withdrawn, and require very little attention so that the family does not have to worry about them These children often cope through avoidance that, unfortunately, leaves them isolated from the joys and richness of life, feeling unloved and unworthy of love.

The family mascot is the funny and often mischievous child who defuses the tension inherent in alcoholic families. In the classroom, this child may act out as the class clown.

The enabler is the person who attempts to protect the alcoholic or drug addict from experiencing the natural and logical consequences of his or her behavior. These roles are seen as survival roles in alcoholic families and are deemed as dysfunctional or maladaptive in that they do not allow children to experience the normal, full range of emotions and behaviors.

All culturally and ethnically diverse families as well as Euro-American families have overt and covert contracts between their members that operate as rules governing family interactions (Gladding, 2011). In general, these rules govern (1) what, when, and how family members can communicate their experiences about what they see, hear, feel, and think; (2) who has permission to speak to whom about what; (3) the extent and manner in which a family member can be different; (4) the manner in which sexuality can be expressed; (5) what it means to be a male or female; and (6) how family members acquire self-worth and how much self-worth a member can experience. In all likelihood, culturally and ethnically diverse families are governed by these same rules. The only differences between these families revolves around what happens if the rules are broken. For example, a Euro-American family may punish the child who has talked back to his or her parents. An Asian American family might use shame to correct aberrant behavior.

Case Example

Tony and His Family

In 1981, Black stated three imperatives or rules that govern alcoholic families: Don’t talk; Don’t trust; Don’t feel. In families where alcohol and other drugs are abused, these rules form the basis for family interactions and for the alliances between individual family members and society at large.

Tony, a very successful businessman, was married to Mary, and they had three children: Loretta, Mark, and Donnie, ages 16, 15, and 9. Tony was an alcoholic, but nobody in the family believed his drinking to be problematic. That was rule 1: Do not believe that your father has a drinking problem.

Every night when he arrived home after 12 hours on the job, the children would come downstairs and greet their father, then allow him to change clothes while their mother would mix their father’s usual drink: his favorite Scotch with crushed ice. She would have a glass of red wine. The children would leave their mother and father alone to discuss the day. That was rule 2: Do not disturb your father’s ritual.

Even when the children had something exciting to talk about that had occurred during the day, they were not to disrupt the ritual until it was time for dinner. Gathered around the table, with Tony nursing his second or third drink or even a beer, the children would then “report” the day to their father. The children were not allowed to leave the table until everyone, including their Dad, was finished. Sometimes, if Tony was drinking a lot, the dinner could last an entire evening. Frustrations about wasting time at dinner were not to be discussed; however, when they were eventually aired, out of exasperation, Tony would most often respond by becoming argumentative, oppressive, threatening, and upon occasion physically abusive. This was rule 3: Your father is the head of the household and you must do exactly as he wants.

When Tony lost his temper at the table, Mary would jump in to mediate between Tony and the children. Usually, the fighting occurred between Tony and Mark, the oldest son, so Mary usually wound up arbitrating between these two. While they did not like the situation, Loretta and Donnie did appreciate Mark’s intervening on their behalf because it allowed dinner to be over. The shouting and threatening behavior created so much chaos that Loretta and Donnie could slip away while Mary, Tony, and Mark were fighting it out. This was rule 4: Mark is the scapegoat.

Two or three times during the week, dinners would proceed in a fashion similar to that just described. Hence, rule 5: Even when things are unpleasant and could be changed, do not change the family.

The weekends were just an extension of the weekdays, except that on the weekends Tony would play tennis in the mornings rather than spend time with the family and would begin drinking at lunchtime. Often, he would come home drunk or noticeably high from alcohol. If he had had a good game of tennis, his mood would be pleasant; if he played poorly, he was easily agitated. The children knew enough to be gone all day Saturday to avoid whatever might occur, while Mary would do household chores until Tony came home. Because Tony and Mary would usually go out on Saturday night, the children would most often find something to do until they were sure that their dad and mom were out of the house before coming home to eat the meal their mother had prepared for them. On Saturday nights, whoever was home would sit watching television with the lights out, prepared to run to their rooms and feigning sleep at the first sign of their parents’ arrival home.

It was Loretta who first asked her mother about her dad’s drinking. This occurred after the school counselor had done a guidance unit on alcohol and other drugs during Loretta’s fifth-period social studies class. Her mother readily confessed to having similar concerns but told Loretta that her dad worked very hard and everyone should be understanding because he was under a great deal of stress. She told Loretta not to worry and to keep this information between the two of them. Rule 6: Do not talk about your feelings about your dad’s drinking problem to anyone.

As Tony’s drinking progressed over the next two years, Mark became the focus of his dad’s displaced hostility. Mark felt as if he could do nothing right in his father’s eyes, and, during his later teen years, began to express his own hostility toward his dad. However, when Mark confronted his dad about how unreasonable he was when he drank, his father would respond by yelling, pointing his finger in his son’s face, and would eventually become more angry than his son. Mark learned to back down, swallowing his pride, his feelings, and his lowered sense of self-respect. Gradually, his grades began to drop. In spite of his being a very talented golfer, Mark lost his eligibility to participate in athletics due to his grades. Having lost his friends who were busy participating in after-school sports, Mark fell into a crowd who used alcohol and other drugs, and he began drinking alcohol on the weekends and eventually began using marijuana and cocaine. Loretta continued her attempts to soothe her father’s nerves by doing whatever he asked but emotionally removed herself from the family and focused her attentions on her boyfriend and her grades. She confided in Mark that she couldn’t wait to get out of the house. Donnie was his mother’s favorite, and Mary did everything she could to protect Donnie from her husband. Donnie was able to escape the direct wrath of his father by keeping quiet, getting straight A’s, and devoting himself to helping his mother.

What was most confusing to Loretta, Mark, and to some extent to Donnie was how their father could be seen as so successful at work, yet be so different at home. When their father was away on business trips and the discussion about his drinking would come up during dinner, Mary would consistently respond by saying that the children’s father loved them very much so they need not worry. When pressed by Loretta and Mark, their mother would usually start crying, saying that she did not know what to do, yet she would balk at suggestions to see a counselor and/or confront their dad. Loretta and Mark would comfort their mother by telling her that she was a good mother and that she did not need to cry because her children loved her. Rule 7: Believe that your mother is helpless and that you need to take care of her.

This example shows how rules are developed and maintained by family members. Nobody was supposed to confront the alcohol problem because “there was no alcohol problem.” That their father loved the children was supposed to be enough. There was to be no anger. If that rule were broken, Tony would become angrier than anyone, thereby overpowering the family’s anger and sending it back into a repressed state. Eventually the children, especially Loretta and Mark, learned to control their emotions—especially anger, hurt, and fear. The rigidity of the rule “don’t talk, don’t trust, don’t feel” led to Loretta’s desire to leave the family and to never confront her father, so that her father never knew how she really felt. Mark responded to his feelings of helplessness and frustration by internalizing his shame and coming to believe that he was to blame for his father’s drinking since he was usually the one who fought with his dad. As a result of his internalized shame, he began using drugs and acted out his helplessness by becoming irresponsible, thus neglecting his own desires and hopes in life. Donnie eventually became the family “hero” by getting exceptional grades and becoming involved in student government. He posed “no threat and no problem” to the family. Mary worked herself to the bone as a mediator between her children and their father, all the while attempting to become the apple of her husband’s eye. Her whole life was her family, and the centrality of her position provided her with a sense of meaning in an otherwise unhappy marital situation. Because these family rules were rigid, the family system functioned to maintain itself as best it could, but there were grave consequences. In spite of the severity of the consequences, the family was unable to adjust until Tony’s alcohol problem was addressed and the rules changed.

Reilly (1992) identifies two underlying themes that serve to fuel the interactive patterns of families experiencing drug abuse: impaired mourning and homeostasis collusion. Impaired mourning refers to the family’s preoccupation with “issues of attachment and separation, loss and restoration, and death and rebirth” (p. 109). Because of the strong sense of loss, either through abandonment, death, divorce, rejection, or neglect, concomitant with an inability to transform the experience, children never fully grieve the loss, and the family can become stuck. In the example, Tony’s drinking problem precluded his ability to develop a strong attachment to his family. The ensuing abandonment left his children and his wife grieving for a relationship with him. The rules were such that any attempt to work through the grieving process would have been met with severe opposition from Tony. So the children and their mother were left to deal with the problem either indirectly or surreptitiously. As a result, the family was not able to fully grieve the loss of a functional and healthy relationship with their father.

Remember how, in Chapter 4, we discussed the issue of Native American mourning and its impact on the risk factors for AOD abuse among this population? Knowing that impaired mourning seems to be characteristic of alcoholic families in general, you can readily see how the issue of impaired mourning may have an additive effect with regard to the Native American family. That is, mourning for their lost culture has been cited as increasing the risk among Native Americans for substance abuse (Young, 1992), and impaired mourning is seen as fueling the dysfunctional interactive patterns among families once AOD are abused in the family. It would seem that mourning, in some form, can be seen as both partly causing alcoholism and helping to maintain the resulting dysfunctional family patterns in the Native American population.

When the whole family becomes stuck or unable to transform itself due to its following the “don’t talk, don’t trust, don’t feel” rule, as it did in this case example, family collusion can occur (Haley, 1973; Noone & Reddig, 1976). Paul (1967) points out that families who have not grieved the losses in the early cycles of their system develop a family style that reflects a lack of empathy, a lack of respect for individuality, and a tenacious and unconscious attempt to hold back the passage of time, with the concomitant need to keep individual family members in a dependent position.

Paul’s (1967) study demonstrates how family collusion results from a break in the grieving process and how it reinforces the interactive patterns characteristic of families with AOD abuse. In the example, Mark turned to using AOD as a means to identify with his father. Eventually, Mark’s problem became the focus of attention for the family, thereby diminishing the centrality of Tony’s drinking. Mark gained much power in the family because he became a rallying point around which the family could address issues of his drug abuse. Without that rallying point, Mary might have chosen to leave the marriage. She stayed in order to help the family deal with Mark’s problems. Also, the family colluded and remained stuck because they covertly reinforced Mark’s drug problems. Loretta would occasionally buy marijuana for her brother and often bought him beer until he became of legal age. When she periodically found drug paraphernalia in her son’s room, Mary chose to not confront Mark. And Donnie remained distant from his older brother, although he loved him deeply. While these were all conscious decisions, the family members unconsciously knew that, if Mark’s problems were addressed and corrected, Tony’s alcohol problems would once again become the focal point of concern as well as reminding each of their shame, grief, and helplessness. To avoid the pain, the family unconsciously colluded to keep Mark the scapegoat and the family member with the problem.

Clearly, the character and extent of family collusion in culturally and ethnically diverse families will be influenced by family values, by values regarding AOD, and by the degree of acculturation among family members. The collusion transpiring in Latino/Hispanic, African American, and Asian American families could include extended family members who likely live nearby and who probably share in child rearing, discipline, and problem solving. Gallardo and Curry (2009) found that “escapist drinking” of alcohol is an accepted way of dealing with the stresses of acculturation for Latino/Hispanic males, and that the value of machismo tends to strengthen that notion. In this example, should the alcoholic family member be a less acculturated male, then family collusion might include the male members of the immediate and extended family who share a common value of machismo. The resulting collusion might serve to sharpen the differences between male and female family members as well as exacerbate the generic difficulties found in the process of acculturation.

All families, regardless of cultural or ethnicity diversity, are made up of subsystems and boundaries. The Euro-American family essentially consists of three family subsystems: marital, parental, and sibling. In Native American, Asian American, African American, and Latino/Hispanic families, the family subsystems would include, to varying degrees, extended family members or other significant individuals. For example, the participation of godparents in the child-rearing practices of many Latino/Hispanic families and its parallel value, known as “child-keeping,” seen in many African American families, might reflect an extended parental subsystem.

The primary subsystem is the marital or couple subsystem made up of the wife and husband. This subsystem is closed in that certain duties and primary functions are performed only by the married partners (e.g., earning money, managing the home). With the birth of a child, the marital subsystem extends to that of a parental subsystem. Interactions continue between the marital partners, which are aimed at the marriage itself (e.g., having a romantic dinner after the child is asleep) or are carried out between the spouses with an aim toward their parenting (e.g., juggling schedules to cover child care). A third main subsystem is the sibling subsystem. The number of children, along with their ages, sexes, and interests, will suggest the number of potential sibling subsystems. In addition, African American and Latino/Hispanic families may have sibling subsystems that include cousins.

Rules or boundaries help define these subsystems. Boundaries are like fences surrounding one’s home: They define one’s property and regulate the nature and type of interactions between neighbors. In essence, boundaries result from cultural and family values and define who can talk to whom, when one can talk, and what one can talk about. Regardless of cultural or ethnic background, both subsystems and boundaries need to be flexible enough to allow for adjustments to changes brought on either within the family or as a result of outside influences. However, in families where AOD are abused, boundaries are often violated (Kelley et al., 2007).

Our example of Tony and Mary reflected a disengaged family in which Tony was rather removed from his spouse and his children. The children were not allowed to talk with their father about his drinking problem and so began to disengage and live their lives emotionally distant from other family members. With the onset of Mark’s drug use, the disengaged nature of the family made it very difficult to regroup in order to address the underlying issue that was Tony’s alcohol abuse. Nor was the family able to find ways to deal effectively with Mark’s drug use. To avoid interacting with her father, Loretta spent all of her available time with her boyfriend. Donnie, despite his strong feelings for his older brother, remained rather aloof from him because he didn’t understand or like what his brother was doing. Mary, the mother, was emotionally removed from her husband after years of emotional neglect by him. She tolerated her husband’s drinking patterns so that she could avoid conflict and more hurt and pain in their relationship.

The issue of disengagement is clearly culturally biased. In traditional Asian American families, the father is expected to be disengaged. Therefore, the construct of disengagement would not always be an appropriate measure of family unity. An African American male who works two jobs and is not home much in order to help get his family out of poverty may be labeled as disengaged when, in fact, his disengagement is a healthy adaptation to poverty. Likewise, “el amor de madre” (motherly love), a value highly regarded in Latino/Hispanic families, could be described as enmeshment, but this enmeshment is central to Latino/Hispanic culture and is not seen as dysfunctional behavior.

Where AOD abuse exists, all families, regardless of cultural or ethnic background, act as “the fulcrum, the pivot point, the mediator, and the interpreter between its members and their culture” (Reilly, 1992, p. 105). The family thus is seen as having a significant influence upon the socialization of its members. As a social lens, the family screens, filters out, or magnifies social influences from the outside. These influences may be antisocial. Reilly maintains that the disturbed Euro-American family system needs a symptom bearer, and this would be the member who is susceptible to drug abuse. In our example, the symptom bearer was Mark, the eldest son. Reilly also believes that the family will consciously or unconsciously push this individual into antisocial, drug-abusing values as was reflected in our case example.

Living with an addicted partner is demanding and difficult. Research suggests that partners affect the long-term drinking patterns of their partners most strongly in the initial phase of their relationship (Otten, van der Zwaluw, van der Vorst, & Engels, 2008). Additionally, some research suggests that heavy drinking does have deleterious effects on the drinkers’ health.

McKinney, Caetano, Rodriguez, and Okoro (2010) found that the marital relationship where alcoholism exists reflects communication that is hostile, critical, and disapproving. As alcoholism progresses, the communication between spouses tends to increase in hostility, thereby suggesting a growing cycle of hostility and resentment. The cycle of hostility produces couples who are at greater risk for relationship dissolution, unless couples have similar drinking patterns. This means that couples where one drinks and the other spouse does not are more likely to dissolve the relationship than in those relationships where both drink (Ostermann, Sloan, & Taylor, 2005). Dethier, Counerotte, and Blairy (2011) found that the alcoholic’s wife experiences quite a bit of stress, including verbal and physical abuse, and this eventually leads to a lowering of her self-esteem. If the relationship lasts into older adulthood, and the drinker stops drinking, research suggests that the nondrinking spouse can regain a sense of efficacy (Moos, Brennan, Schutte, & Moos, 2010).

In a seminal study, Kaufman and Kaufman (1992) identified structural patterns in families affected by AOD abuse, based on the works of Minuchin (1974). Most of their sample was observed for more than six months, and the research design included postgroup discussions of patterns. In addition, verbatim transcripts of all sessions were made and were analyzed to confirm initial clinical impressions. Videotapes were produced and were given to a group of experienced clinicians who rated the structural patterns they observed. The sample consisted of 75 families representing eight different ethnic groups (Latino/Hispanic, 23%; Italian, 19%; Euro-American, 18%; Jewish, 13%; African American, 10%; Irish, 9%; Greek, 1%; and Mixtures, 6%). Kaufman and Kaufman found that of the 75 families, 88% had enmeshed (undifferentiated boundaries) mother-child relationships and 40% had enmeshed father child relationships. Forty-two percent of the fathers were considered disengaged while only two mothers were seen as such. The mothers of addicts were seen as enmeshed across all ethnic groups. Seven of 13 Italian fathers were described as enmeshed as were six of 13 Jewish fathers. Puerto Rican, African American, and Euro-American fathers tended to be disengaged. The authors found that, while the sample of African Americans was too small to generalize, “most of the Black families had strong, involved mothers” (p. 39). Categorically, no relationship between the addicted family member and other family members was seen as having clear boundaries. A more recent study of Japanese drinking in relationships found that women’s care of their alcoholic husbands was institutionalized and normalized by Japanese views of human relationships that values female dependency (Borovboy, 2009). Hence, a traditional Japanese female spouse would likely be hesitant to confront her drinking husband.

In a study on family dysfunction and alcoholism, Dube, Anda, Felitti, Edwards, and Croft (2002) found interesting results. These researchers agree with the professional literature indicating the relationship between adult alcohol abuse and childhood abuse and family dysfunction. However, Dube et al. were interested in the impact of multiple adverse childhood experiences (ACEs) with parental alcohol abuse and later alcohol abuse by the child. From their data, they categorized eight adverse childhood experiences associated with parental alcohol abuse. The results indicated a strong association between each of the eight adverse childhood experiences and risk for later alcohol abuse. When multiple ACEs were involved, it did not seem to matter whether parental alcohol abuse was involved or not. Compared to persons with no ACEs, those experiencing multiple ACEs were two to four times more likely to self-report adult alcoholism, marry an alcoholic, and be at risk for heavy drinking.

While many studies show that dysfunctional family structure imposes a significant influence on the risk for AOD use patterns among family members (e.g., Barrett & Turner, 2006; Dunn et al., 2002; Ledoux, Miller, Choquet, & Plant, 2002; Meness, 2000), other studies offer hope for families. Results of a systematic review of longitudinal studies on parenting factors associated with adolescent alcohol indicates that families provide strong protective factors against AOD abuse (Ryan, Jorm, & Lubman, 2010). Specifically, these authors identified protective factors that include parental modeling, limiting availability of alcohol to the child, parental monitoring, high quality parent-child relationship, parental communication, and general parental involvement with their children.

Siblings do appear to have an influence on adolescent drug use in terms of providing the drug and/or modeling drug behaviors (e.g.Friese, Grube, Seninger, Paschall, & Moore, 2011; Slomkowski et al., 2009). In a seminal study, Kaufman & Kaufman (1992) studied the impact of siblings upon sibling drug use. In their study, the researchers identified an environmental reactive mechanism, which refers to the ways in which brothers are linked through their environment. That is, when the relationship between brothers is characterized by tension, there appears to be an increase in the intrapsychic distress in the younger brother. As a result of that distress, the younger brother may disengage from the relationship and withdraw from responsibility. In the case study example, Donnie’s distancing from his brother exemplified the environmental reactive mechanism.

Not much research on the unique experiences of being a sibling of a “user” has been conducted. However, some general themes emerge: efforts aimed at trying to stand out, trying to step back, feelings of anger, hurt, resentment, guilt, compassion, love, frustration, hope, loss, and numerous others (Howard et al., 2010). Sibling violence is often underreported. However, an important finding is that sibling relationships characterized by violence are associated with substance abuse, delinquency, and aggression (Button & Gealt, 2010).

When examining the intergenerational processes involved in the transmission of alcoholism, the terms adult child of alcoholic andcodependency immediately rise to the surface. These terms are easily recognized in the AOD field. Yet one aspect often overlooked is the effect that family systems have on the transmission process. Thus, while these terms and concepts are discussed elsewhere in the text, this section focuses on the family system and structures related to the transmission process of alcoholism.

Family therapists will recognize Bowen’s (1978) notions of the intergenerational emotional transmission process. This is the mechanism by which family rituals and rules are passed down from one generation to another. In the AOD field, the issue of intergenerational transmission of alcoholism is of keen interest as well, and studies consistently demonstrate that a family history of alcoholism is one of the strongest risk factors (Campbell & Oei, 2010). These same researchers agree with the works of Steinglass, Bennett, Wolin, and Reiss (1987) and Lawson, Lawson, and Rivers (2001), who maintain that the transmission of alcoholism across generations tends to involve the whole family system over time. In other words, the transmission process is both subtle and overt, and it includes the entire system of family interactions, rituals, attitudes, and beliefs that define the family. To refer to the origin of the process is something of a misnomer, as no particular starting pointing, specific ending point, or specific nodal event exists—it is an ongoing process. In general, genetics clearly play a major role in the father-son transmission of alcoholism, while family environment may be a significant factor in the transmission of alcoholism among females (Lawson et al., 2001).

Lawson et al. (2001) describe several other studies aimed at understanding the intergenerational transmission process. For instance, they cite the Bennett, Wolin, and Reiss (1988a) study that identified several behaviors tending to decrease the likelihood that alcoholism would be transmitted downward to other generations. The researchers found that spouse selection and the establishment of new family rituals in which families participate in the community are helpful to reduce risk. Moreover, these researchers found that families who utilized a selective disengagement strategy to distance themselves from the dysfunctional aspects in their families of origin reduced the transmission of alcoholism across generations. Jennison and Johnson (2001) found children modeling their parent’s use of alcohol as a means to cope. In addition, these same researchers see alcoholism transmitted through a variety of disturbed family interactions that result from marital distress, health problems, legal problems, vocational/financial instability, and disrupted family rituals such as holidays, birthdays, or other special family occasions.

Back, Contini, and Brady (2007) report that there has been a growing awareness of the importance of gender differences in medical treatment and research. Attention to gender differences is very important in light of Cyr and McGarry’s (2002) review of the National Household Survey on Drug Abuse (Substance Abuse and Mental Health Services Administration, 2001) which found that women account for one-third of those abusing alcohol or having alcohol dependence. In addition to environmental and biological factors, women’s substance use and addictions are mitigated by cultural norms and practices of the ethnic group to which they belong. For instance, Conner, LeFauve, and Wallace (2009) reviewed the literature on addictions among diverse women. They found that African American substance abuse was a way to numb painful feelings of loss, racism, prejudice, rejection, physical abuse, incest, and feelings of shame. Another finding was that educated, employed, and/or acculturated Hispanic women faced higher risks for addiction. These authors go on to say that, in general, the psychological fallout from historical trauma, powerlessness, marginalization, gender socialization, violence, and victimizations contribute significantly to addictions in women.

Tuchman (2010) and others (e. g. Hood, 2003; van der Walde, Urgensen, Weltz, & Hanna, 2002) have noted differences between males and females. These differences include variations in etiology, social factors, biological responses, progressions to dependence, medical consequences, co-occurring psychiatric disorders, and barriers to treatment entry, retention, completion and recovery. Specifically, women are at higher risk for breast cancer (Aronson, 2003), cardiovascular disease, osteoporosis, and hip fractures (Cyr & McGarry, 2002). Women drink most heavily during their midlife, and these women are more likely to be involved with a partner suffering from addiction. They are also more likely than men to present themselves in a more severe state of psychological or physical impairment, such as cardiovascular disease or cancer (Chang, 2002).

Some global initiatives are aimed at improving the primary care of the 2.5 million women meeting the criteria for alcohol use disorder. Nevertheless, many women with serious problems are not seen, are misunderstood, misdiagnosed, or ignored (Vandermause & Wood, 2009). The complicated presentation of symptoms is only one factor that influences the lower rate of diagnosing alcoholism in women. Women need to seek help before a diagnosis can be rendered, and research suggests that women with alcohol problems have a difficult time coming in for help. This difficulty may be due to the stigma of alcoholism and/or the associate feelings of shame. For example, Corrigan, Miller, and Watson (2006) found that the stigma of “drug dependence” was viewed as more negative than the stigma for “other mental disorders.” Beckman (1994) found shame associated with drinking and not fulfilling traditional roles to be a factor in women not seeking help.

Even when women present for help at a physician’s office, research indicates many more women than men deny that they have a drinking problem or that they identify problems other than drinking (Chang, 2002). The fact that their situations may be more medically complicated when they do seek help increases the likelihood that other conditions will be identified by the patient as problematic. In many cases, a diagnosis of depression will precede substance abuse (Ambrogne, 2007). This makes a diagnosis of alcoholism more difficult. A confounding result can be a diagnosis for one disorder and a misdiagnosis for another. Hence, physicians cans be prescribing medications for one disorder that obscures the symptoms of the other (van der Walde et al., 2002).

However, a more insidious factor may be the stereotyping of the disease of alcoholism itself. Conner et al. (2009) and Cyr and McGarry (2002) maintain that a major reason for not diagnosing women with alcohol problems is that alcoholism is seen as a male disease based on male characteristics. In essence, the cultural discourse has not overtly posited a connection between alcoholism and being female, and the myths that have resulted are hard to dispel. Cho and Crittenden (2006) have identified three major streams of research in the professional literature. Some research suggests that women drink more alcohol because of the multiple roles and conflicting expectations they experience when they enter the workforce. In opposition to this perspective is a second line of research holding that performing multiple roles is gratifying to women, which would preclude an increased need for drinking. A third line of inquiry is that working women simply drink more because they have more opportunity. Cho and Crittendon (2006) attempted to research women and drinking and found that drinking for women is a multidimensional construct in which adult roles “differentially influence a woman’s likelihood of being a drinker, if she drinks, how much alcohol she consumes, and how likely she is to become a ‘problem’ drinker” (p. 27). While Cho and Crittenden’s research is revealing as well as promising to spawn further research, their present results further complicate the issue. More studies and more time will be needed to re-narrate the cultural discourse to reflect the relationship between women and alcoholism.

The preceding discussion clearly points to the need for early screening of alcohol problems in women. Conner et al. (2009) believe that it is a categorical imperative that counselors understand the values and cultural expectations of diverse women when assessing for addictions. Counselors must ask themselves such questions as 1) What are the historical contributions to the shaming and destructive behaviors of diverse women? 2) Does the exploration of family histories (ethnic, cultural, familial) help build resilience or heighten risk among these women? and, 3) What are the culturally appropriate guidelines for prevention and treatment of diverse women?

As discussed in Chapter 6, the CAGE is an effective screening instrument that is easy to administer and score. Dhalla and Kopec (2007) maintain that the CAGE is less reliable for white women, prenatal women, and college students. What is important to note is that when used to screen women, the scoring on the CAGE can be adjusted. The CAGE has a cutoff score of 2. This indicates a positive for alcohol disorders in both men and women. In applying this for women, Bradley, Boyd-Wickizer, Powell, and Burman (1998) believe that a cutoff score of 1 point may be indicative of a problem. In addition, Bradley et al. found in their study of brief alcohol screening instruments that the CAGE was relatively insensitive for racial/ethnic minorities. The National Institute on Alcohol Abuse and Alcoholism (2007) recommends that the threshold for a positive AUDIT-C for women be lowered to 4 (from the standard point of 8). In all cases, these various screening instruments should be used along with other measures because their performance as stand-alone assessments is unclear (Burns, Gray, & Smith, 2010).

Clearly, the best treatment for AOD problems is primary prevention. Dethier et al. (2011), Cadiz et al. (2004), and Schuck and Spatz (2003) suggest that efforts to increase women’s sense of self-efficacy are also an important protective factor in reducing the risk for alcohol use problems. They assert that this is especially true for women who have been abused or neglected. These same researchers found that high self-efficacy was significantly associated with lower levels of alcohol symptoms among women who were abused or neglected. They suggest that interventions can be aimed at showing the importance of improving educational achievement and increased feelings of self-efficacy. Schuck and Spatz believe that this can potentially be very powerful in enhancing protective factors for these women.

Women are still underrepresented in most substance abuse treatment programs. Multiple research studies have focused on the barriers that women, especially rural women, face (e.g. Greenfield & Grella, 2009; Greenfield, Trucco, McHugh, Lincoln, & Gallop, 2007; Kim, Xiang, Yang, & Lewis, 2010; Small, Curran, & Booth, 2010; Taylor, 2010). Among the barriers are social stigma, denial, fear of losing children, and a reluctance of primary care physicians to refer. Although researchers maintain that once in treatment, males and females receive similar benefits, many women who abuse alcohol have a history of sexual and physical abuse and are hesitant to come in to work through issues for fear that the environment will not be safe and gender sensitive. In addition, women are often very concerned about their children and will not present themselves for treatment because of a lack of child care. Once there, these women may drop out of treatment when a problem arises with their children. In addition, Blume (1997) found that some state laws view alcohol abuse by women as child neglect or endangerment. So, some women have a real fear that they will be considered unfit as a parent and risk losing their children. Pregnancy is also a potential barrier to treatment. Kinney (2012) says that if a woman is pregnant, many treatment programs will not admit out of fear of being liable if something goes awry. Pregnancy and drinking should be addressed early on in the process, and efforts should be focused on helping the pregnant women stop drinking or, at least, curtailing it as much as is possible. In those cases where the prospective father is also alcohol-dependent, it is critical to provide additional support and help for the mother.

In addition, economic concerns are seen as potentially significant barriers to treatment (van der Walde et al., 2002). Men will often divorce their alcoholic wives. This can leave a woman with few financial resources. Women who experience divorce are often left with inadequate insurance coverage, and if the alcoholic and divorced woman is unemployed, she is more likely to be uninsured (Blume, 1997). Even though studies show that insurance status is not a consistent predictor for who seeks treatment (Kim et al., 2010; Mojtabai, 2005), the fear of being left alone and destitute through divorce or legal separation while in treatment can preclude women from wanting to get treatment. Finally, cultural and linguistic gaps in communication, lack of familiarity with the treatment community, and concerns about discrimination and/or stigma can be a significant deterrent for diverse women seeking treatment (Taylor, 2010)

Nonetheless, a growing body of research supports gender-specific treatment for women abusing alcohol in a variety of settings (Greenfield & Grella, 2009; Sideman & Kirschbaum, 2002). In general, helpers who understand, utilize empathy, invoke good communication skills, and are gender sensitive and initially less problem-focused are seen as more helpful. Regarding gender-specific treatment, van der Walde et al. (2002) believe that to understand and appreciate the issues, counselors need to remember several other things in treating women of any racial/ethnic background. First, it is important to know that women are especially sensitive to their peers, significant others, and family members. Second, care for alcoholic women must be ongoing and focused on the individual needs of each woman. Successful treatment requires sensitivity to the plight of minority women. Krejci, Marholin, Rowland, and Wetzell (2008) and others note that substance abuse and trauma co-occur at high rates for women. Hence, the integration of relational modeling, motivational interviewing, emotional regulation, and distress tolerance should be included in the treatment of women.

McCrady (2009) believes that alcohol behavioral couple therapy (ABCT) is more effective than individual therapy in treating women alcoholics. Kinney (2012) strongly advocates for children of all ages to be included in treatment. Even though a child may appear too young to comprehend what is going on, it is important to remember that children can sometimes say what the parents are only hinting at. Leaving children out of treatment can increase their feelings of isolation and vulnerability. Kinney goes on to say the children are asking, “What will become of me?” and “Who will be taking care of me?” Because of this, children should be included in the treatment plan and allowed to ask questions in the process (p. 312). Finally, it is worth repeating that the stigma for women who abuse alcohol is a significant and deleterious factor. Clearly, regardless of whether treatment is gender specific, these issues need to be addressed with all women during treatment.

The Centers for Disease Control and Prevention (2009a) reported that the rate of divorces (per 1,000 total U.S. population) has fallen from 8.2 in 2000 to 6.8 in 2009. Nonetheless, this still confirms that since the 1980s, at least 50% of marriages, many with children, end in divorce (Jay, Freisthler, & Svare, 2004).

This means that, statistically speaking, it is almost as normal to come from a traditional two-parent family as it is to come from any number of alternative family structures. Unfortunately, research on the stepfamily system and structure does not usually include alternative forms of family structure. One thing seems to be clear: Children in stepfamilies are at higher risk for AOD abuse (Brown & Rinelli, 2010).

Little research has been conducted on the dynamics of other forms of parenting related to AOD. So, when discussing the research on traditionally defined stepfamilies, it is important to consider those observations in a more general way when applying the findings to racial/ethnic groups and gay and lesbian couples. Some issues may be the same for these groups as for the Euro-Caucasian population, and some issues may be different or more complex. For instance, think of how different and complex it might be for a stepfamily to learn about a previously hidden GLBTQQI lifestyle in one of their new members. This new family would not only be dealing with the adjustments of a new formation, but they would concurrently be dealing with the “coming out” of one (or more) of its members. The stepparent may be drawn into the disciplinarian role if the biological parent has been ineffective in dealing with AOD issues, and this move can result in marital strife if the biological parent steps in to protect the adolescent. Such a situation certainly reinforces the biological parent-child coalition, while continuing to exacerbate the child’s feelings of guilt and stress (Jay et al., 2004). This dynamic can also lead to acting out with substance abuse. Still another variation in stepfamilies concerns adoption. Stewart (2010) maintains that adopted stepchildren have significantly more behavior and emotional issues than children with two biological parents, and this is true regardless of the age of the adoptee. The point here is that when you think of stepfamilies, you need to think of the variations and complexities.

Although many of the same problems in stepfamilies also exist in other families, stepfami-lies are different in terms of the family developmental tasks. In general, stepfamilies are seen as having psychic and physical boundaries that are more permeable than those in a nuclear family (Anderson, 1992). Emotional bonds or psychic boundaries have to be loose enough to allow for affections to be expressed to both the biological parent as well as to the stepparent. The physical boundaries need to be permeable enough to allow for the revolving door of noncustodial visitation and need to be able to allow for visits of a longer duration, such as coming or leaving for an entire school year. Anderson also identifies the complexities involved in decision making in stepfamilies. Often, a coordinated effort of two households in making plans is required. The stepfamily does not have the history that the nuclear family does, and sometimes children (and their parents) can experience a type of culture shock. Anderson says that this culture shock is “an acute feeling of an unfamiliar, sometimes alien, environment that is very disorienting to their basic sense of what ‘my family’ is” (p. 174). Because stepfamilies are born out of previous losses due to divorce or death, children (and parents) need to be able to grieve the loss adequately. However, grieving the loss is often painful, and many may be reluctant to do so when it appears that the grieving process may impinge upon the happier times of the current relationship.

While stepfamilies have a host of issues, many factors can produce resilience in these families. For example, Greeff and Du Toit (2009) identified eight factors that can help insulate stepfamilies from problems, including those concerning AOD use and abuse: 1) supportive family relationships; 2) affirming and supportive communication; 3) a sense of control over outcomes in life; 4) activities and routines that help families spend time together; 5) a strong marital relationship; 6) support from family and friends; 7) reframing stressful events; and, 8) spirituality and religion within the family (p. 114).

Helping families includes both equipping clinicians with appropriate and effective assessment techniques and providing families with the necessary level and structure of care. Assessing for AOD problems was covered in Chapter 6. Here, among other things, we want to draw your attention to issues of spirituality in families as well as to a particular assessment strategy that can help in working with various racial/ethnic families. With this information, treatment concerns for many racial/ethnic families can be better aimed.

Treating families with substance abuse problems is a complicated process, and treatment takes place on many different levels (Kaufman & Kaufman, 1992). Templeton, Belleman, and Russel (2010) conducted a review of the literature on psychological interventions with families of alcohol misusers. These researchers found that interventions involving family members fell into three essential categories: interventions oriented toward the engagement of the alcohol abusing person into treatment; interventions oriented toward working with the abuser and his or her partner; and interventions that work with family members.

Fischer, Pidcock, Munsch, and Forthun (2005) believe that the concepts of “hero” or “lost child” are easily recognized by families and are effective to use with some families in treatment. However, in discussing the process of differentiation in families, they caution against limiting the child’s roles only to those roles. Interventions should expand the choices for children while honoring the role(s) that they have taken on for the family. They go further to state that when enhancing the positive roles, helpers should not do it by exaggerating the differences between siblings on the negative roles. It is critical that as helpers work through roles they do not substitute one sibling for another. In other words, in the process of helping one work through the scapegoat role, helpers should be cautioned against the possibility of another sibling taking on that role. Finally, these researchers say that in identifying positive forms of differentiation, helpers should work through a perspective of difference rather than labeling one role as better or worse than another.

The treatment of families is usually aimed at enhancing the cognitive, physical, emotional, and social development of individual family members. What is often overlooked is the need to help individuals and families develop spiritually. Pargament (2006) maintains that spirituality involves profound changes across development of individuals and families. Spirituality is different from religiosity in that the former emphasizes a relationship between an individual and a higher power or some other transcendent force, while religiosity refers more to religious practices and beliefs. The spiritual development in families reflects individuals attempting to differentiate themselves within families as they attempt to reconcile the dialectical tension of autonomy and connectedness. This means that individual family members are both autonomous individuals and connected members of a family. The process of differentiation increases autonomy and intimacy potential while decreasing emotional reactivity and enmeshment among family members.

Spirituality helps many families cope and be resilient. For instance, the spirituality for African American families is seen as providing buffers against the effects of structural oppression while promoting the values of compassion and service to others (Neff, 2008). InChapter 4, we discussed the value of the collective or communalism among African Americans. This interpersonal orientation is a core spiritual value, and it is also a key component in treatment of this group for substance abuse disorders. This means that treatment should involve family, friends, church, and others because it is through others that individuals make meaning of their own existence.

In general, families who share common beliefs and who are intrinsically motivated by religious/spiritual orientation report more relationship satisfaction than those whose partners are divided on the issue. Spirituality in families can be especially helpful during times of crisis or dramatic change because it allows families to ground their stress.

To help address the spiritual issues in families, treatment often involves spiritual aspects of recovery. This orientation is clearly embedded in the twelve-step programs (see Chapter 10). However, various spiritual interventions for substance abuse treatment are available, and these vary across diverse groups. In reviewing the literature, Stoltzfus (2007) found several spiritual interventions that are used in substance abuse treatment. The Native American sweat lodge ceremonies use steam and high temperatures in a round, womblike structure. This process is a spiritual one in which people rid themselves of infections and contaminants while helping them contact the sacred substances that include stones, water, and the earth. Mindfulness meditation is another spiritual intervention that involves developing an ability to be both focused and detached while being nonjudgmental and self-accepting. Religious treatmentprograms, usually associated with evangelical churches, include such programs as Teen Challenge, Celebrate Recovery, and the Salvation Army Adult Rehabilitation Centers. Prayer, shamanism, and exorcism are other spiritual interventions used by diverse groups to treat substance abuse.

Because of the nature of these various spiritual treatments for AOD abuse, it is difficult to study their effectiveness. They do not easily lend themselves to scientific inquiry. A main reason is that spirituality itself is a concept, an awareness, and way of being. It cannot be separated from the rest of an individual’s life because it is pervasive and incorporates all aspects of one’s being. Nonetheless, its presence and power cannot be disputed, and it is wise for helpers to respect all forms of spiritual perspectives used in treating those with substance abuse issues.

In discussing addiction treatment for Mexican Americans, Barón (2000) builds on the multidimensional perspectives of several researchers and presents a model aimed at helping therapists integrate the complex individual, family, and culturally related variables that underlie and color the various beliefs, cognitions, and adaptive as well as maladaptive behaviors (p. 227). When used in assessment, this model is thought to constitute a comprehensive assessment of the internal and external influences affecting racial/ethnic minorities. The concepts still guide other culturally sensitive models such as multdimensional family therapy (Liddle, 2009).

The integrative cross-cultural model (ICM) draws from the earlier works of Jones (1985), who conducted research on African Americans. Jones’s earlier model identifies four sets of interactive factors that need to be considered with minority clients and their families: (1) personal experiences and endowments, (2) influence of native culture, (3) reactions to racial oppression, and (4) influence of the majority culture (Barón, 2000; Jones, 1985). The more recent ICM enhances the earlier approach by expanding these interactive factors and reorienting them as general domains of inquiry. These domains of inquiry include (1) individual and systemic variables and dynamics, (2) cultural and ethnically related variables, (3) dominant group influences, and (4) minority group experiences.

Individual and systemic variables and dynamics incorporate neurobiological conditions, developmental issues, family-of-origin dynamics, childhood experiences, education, and the like. Specific to AOD issues, clients and/or their families might be queried about use, frequency, presence, tolerance and withdrawal symptoms, alcoholic family dynamics, and the centrality of AOD in the client’s life. Regarding culturally and ethnically related variables, clinicians would likely assess the culturally based beliefs regarding AOD use and the beliefs surrounding being clean and sober. Clinicians would also find it important to assess differences in help-seeking behavior, family organization, family life cycle, hierarchies, gender roles, parenting styles, subsystems, and other related variables. Thedominant group influences describe the extent to which the individual or family incorporates beliefs, values, attitudes, and patterns of behavior reflecting the dominant discourse. According to Barón, an assessment aimed at AOD abuse would focus on differences and similarities between the client’s views of use, misuse, and abuse and those of the dominant culture. Included in this domain of assessment would be the identification and discussion of the client’s perspectives on abstinence, sobriety, help-seeking behavior, and the twelve-step programs. Understanding the degree of congruence or incongruence with the dominant culture’s view is also needed. Finally, the client’s experience with being a member of a minority group (minority group experience) should be examined. This is a type of within-minority group variance in which the assessment would become more specific to the minority person’s experience as a unique minority member. According to Barón, differential treatment by members of society’s dominant group as well as treatment by other minority groups related to personality development, beliefs, attitudes, and origin and maintenance of the current problem profoundly influence a minority person’s experiences. Because of the differential effects on individuals, it is important to examine the prevalence and impact of these particular beliefs on a case-by-case basis.

The four domains are considered effective in the understanding of the significant contextual influences affecting the general experience of racial/ethnic minorities. When working with a racial/ethnic family suspected of having alcohol and other drug problems, a clinician using this ICM approach would first want to construct a profile based on three mediator variables: level of acculturation, stage of ethnic-identity development, and worldview related to locus of control and responsibility. From here, the clinician can advance some hypotheses about the relative contribution of each of the four domains of inquiry (individual and systemic variables, cultural and ethnic variables, dominant group influences, and minority group experiences) that were just described. According to Barón, the ICM can be especially helpful in the early stages of assessment.

Imagine a situation in which the ICM was used with a Mexican American couple. The Mexican American couple was referred to a mental health counselor for help with Mr. Aguilar’s (husband’s) drinking. The individual and systemic variables would reveal valuable information that could help explain why they stated they were experiencing distress over acculturating. It could reflect the fact that the Aguilars are first-generation immigrants without documents. By using the model, the clinician would easily note the Aguilars’ preference to speak Spanish to one another while at home and at most places in public. The individual and systemic domain would reflect the fact that Mrs. Aguilar’s mother spoke almost exclusively Spanish. As is also common, her mother also lived with her daughter and son-in-law.

The assessment would reveal that the Aguilars’ children were bilingual and more acculturated than their parents. The model would allow the interview to guide a discussion of Mr. Aguilar’s beliefs about the dominant culture being misguided and that he preferred to mingle with other Mexican Americans. His beliefs were seen as both helpful and hurtful by his children.

Questions guided by interest in the individual and systemic variables could also reveal that Mr. Aguilar had been exposed to drinking at an early age. This exposure came in a culture where heavy drinking was more tolerated. As a result, Mr. Aguilar was seen as being caught between his culture of origin and the practices of his current cultural environment with regard to AOD use. He maintained that his situation was inevitable and blamed his condition on the system. To his way of thinking, drinking was an appropriate way to cope.

An assessment of the second domain, cultural and ethnic variables, could reveal the family’s proclivity to respond to stress through culturally congruent behaviors, which reflected more tolerance. Moreover, this assessment domain would show that the family would not ordinarily go about solving problems through the help of a therapist. In assessing the impact of the Aguilars’ dominant group and minority group experiences, it was clear that he was resentful and bitter over his adaptation woes. Perhaps the family’s most telling difficulty in seeing the problem from a different perspective was the fact that they had identified their 15 year-old son, Enrico, who was having academic problems, as the issue.

In the treatment phase of the ICM, initial efforts were aimed at establishing credibility and an effective psychological and therapeutic contract. Motivational interviewing techniques were employed to help to create dissonance for Mr. Aguilar between his perception of what his role as a father and provider needed to be and the impact that his behavior was having on his family—and on Enrico in particular. Barón (2000) suggests the use of psychoeducational approaches as well. In this case, the psychoeducational component was actually a professional’s confirmation about the existence of a problem.

It was also pointed out that Enrico was not trying to be disrespectful of his father. Through family therapy, Mr. Aguilar came to see how Enrico’s behaviors were a way to signal to his father that something was wrong. The fact that Mrs. Aguilar often wanted to speak to the clinician in private reflected her own cultural conflicts. She was caught between being seen as disrespectful to her husband and her need to help him to manage his problematic drinking.

In this hypothetical case, the ICM would be able to help the clinician formulate the appropriate cultural context for the Aguilars’ problems. By understanding the interplay of acculturation, ethnic identity development, and worldviews related to responsibility and locus of control, the clinician was able to be more effective in the planning of treatment.

As previously mentioned in working with racial/ethnic families in Chapter 4, several authors underscore the importance of narrative approaches to individual and family treatment. Krestan (2000), Harrison (2004), and others suggest the relevancy of postmodern narrative principles in working with diverse populations. In writing about the relationship between addiction and power and powerlessness among diverse populations, Krestan discusses the influence of the dominant social discourse regarding the conceptions of power and powerlessness for racial/ethnic minorities. Krestan notes the particular challenges facing counselors in discussing the culturally powerless client’s need to accept the concept of powerlessness in recovery (p. 35).

In general, the narrative approaches underscore the importance of the relationship in the helping process. A fundamental principle of the narrative and dialogic approaches is the ability of individuals to create a sense of power through the helping relationship. According to the theory, this power is then re-created over and over in the relationship so that it becomes a dominant reality for helpees (Abney & Harrison, 2003). In relating narrative principles to racial/ethnic families in need of AOD treatment, the approach itself is not so much effective as the adherence to the importance of the helping relationship developed in the process. Because the relationship between the counselor and the person being counseled is emphasized to such a great degree, it is imperative that the counselor maintain professional standards in keeping the roles of counselor and counselee distinct. Application of the narrative approach to counseling can be very effective and can open the doors to a deepened understanding and appreciation of diversity.

Krestan, Abney, and Harrison, and other researchers attempt to describe how the dominant class narrative or discourse related to power, powerlessness, and difference serves to promote the narrative discourse of risk factors for addiction among racial/ethnic families. Researchers such as Coyhis (2000), who writes about Native Americans, and Chang (2000), who writes about Asian/Pacific American addicts, are not asserting that the dominant discourse is causal. They are describing the manner in which this discourse interacts with racial/ethnic populations and the importance of understanding cultural differences in intervening so as to not promote the deleterious components of the dominant discourse.

In other research, Roberts and McCrady (2003) write about working with alcohol problems in intimate relationships. These researchers identify several modalities of change, such as family-involved treatment, change through referral, and change through self-help groups. These same authors claim that cognitive-behavioral therapy (CBT), motivational enhancement therapy (MET), and twelve-step facilitation (TSF) approaches have been empirically proven to be effective. To their credit, Roberts and McCrady also identify and discuss alternative treatment models and programs, even though these are not empirically tested. Approaches that are designed specifically for certain populations, such as gay and lesbian clients, women, racial/ethnic populations, and those programs designed to use alternative spiritual, medical, or nutritional approaches, do not lend themselves to empiricism. As a result, these treatment modalities will likely not be accepted by insurance and managed-care organizations because they are hard to measure. It would be a mistake to assume that the models themselves are ineffective simply because they cannot be measured or because managed-care does not recognize the treatment. In some cases, individuals and families can benefit from these more idiosyncratic approaches. The important thing to remember is that no one approach holds the magic key to recovery for all people. Appreciating diversity means appreciating the potential benefits of diverse approaches (Chan, 2003).

Four types of Euro-American families will likely present themselves for treatment (Kaufman & Kaufman, 1992). In one family type, members might talk openly about drinking or drugging but are more concerned with other important issues. In these families, drinking or drugging may be present but not to the degree that it is a problem, and helping professionals should focus on the presenting problems but should also attempt to emphasize the possible connection between AOD use and other problems in their lives. In the second family type, clues to alcohol and other drug-use problems may be present, but the clues are oblique and difficult to discern. In these families, the symptom bearer will probably be the child who could be involved in drug abuse. Other clues may be found in reports of drinking in the parents’ families of origin, in parental role reversals, in children’s attempts to protect their parents, in children’s fears of talking about the family, or when the parents present themselves as overly concerned about teenage alcohol and drug abuse. The mental health professional should focus on the presenting problem and should attempt to infuse drinking or drugging into the presenting issue. The third family type is the one whose members present themselves for therapy after the alcohol or other drug abuser has completed some type of treatment program and is clean and sober. The issues here will likely be rebalancing the family system to avoid a full-blown relapse. Slips (see Chapter 9) are to be expected, so the work of the mental health professional is to help the family anticipate situations in which a slip might occur and help the family to determine effective ways to keep the slip from becoming a relapse. The fourth family type is the one presenting alcohol or other drug abuse as the major problem. In these families, alcohol or other drug abuse is the focus of the family, and the conflict will be quite open and apparent. Mental health professionals may need to take more control of these sessions if emotional reactivity is running too high.

Regardless of which family type presents itself for counseling, mental health professionals need to attend to the spousal subsystem, the parent-child subsystem, and the sibling subsystem. The reason for this is simple: Families will balance themselves. So, mental health professionals need to take into account how interventions impact these critical subsystems, the individual family members, and the family itself so that the rebalancing that inevitably will take place will be beneficial.

Kaufman and Kaufman (1992) point to situations in which individual counseling may be the preferred mode of treatment for alcoholic families. They see individual work being done in those situations in which family therapy may be misused to deny personal responsibility, psychopathology of one family member can be prevented by individual work, the parents are psychopathological to the point that helping a child cope with the psychopathology is preferred, a family member is deceitful, individual pathology remains after family intervention, and detoxification or getting the client clean and sober is needed prior to family therapy.

Many avenues are open for helping the alcohol or other drug-abusing client or family. The actively drinking or using family member should be directed to a facility where he or she can become clean and sober. Abstinence may be just an ideal for some families. Therefore, if the individual does not want to go into treatment, the family members have a decision to make: They can learn to cope better with the abusing family member, known as maintaining a “wet” system, or they can decide to go further into an intervention (seeChapter 7) and attempt to move their family into a “dry” system. In either case, support groups for family members such as Al-Anon, Alateen, and Codependents Anonymous (see Chapter 10) can be very effective in many, but not all cases.

MyCounselingLab™

· Children can be exposed to AOD use and abuse while in the uterus as well as interper-sonally exposed after birth.

· Prenatal exposure to AOD is a critical health concern, because fetal alcohol syndrome is the leading known cause of mental retardation.

· In general, children interpersonally exposed to AOD abuse can take on survival roles that include hero, mascot, lost child, scapegoat, and/or enabler.

· Research shows that these children experience a host of problems related to loss, denial, distortion, and secrecy as well as attachment and separation, and families suffer also in terms of family functioning, violence, abuse, and living with fear.

· Children from AOD abuse families have difficulty in stating what they need or want in the family.

· Families often invoke rules such as “Don’t talk, don’t trust, and don’t feel.”

· One reason that families with AOD problems maintain dysfunction is due to underlying family themes related to impaired mourning, which revolves around separation and loss as well as family collusion.

· Stepfamilies and adoptees are at higher risk for AOD misuse and abuse due to a myriad of obvious reasons.

· Women present much later in the course of alcoholism, by which time other medical issues may obscure a diagnosis; however, once in treatment they benefit about the same as males.

· Although women account for one-third of those abusing AOD, alcoholism is still considered a “male” disease, and women alcoholics often go undiagnosed.

· The CAGE and AUDIT are assessment instruments that can be used effectively with the general as well as diverse populations; clinicians can also assess for AOD problems by being aware of Kaufman and Kaufman’s four family types.

· Evidence exists that family-based interventions can work.

· Culture plays an important role in determining the type of treatment for alcoholism.

· Spiritual interventions are important for families and individuals.

· Baron’s integrative cross-cultural model (ICM) for treating racial/ethnic minority families attends to four domains of inquiry that include individual and systemic variables and dynamics, cultural and ethnically related variables, dominant group influences, and minority group experiences.

Fetal alcohol syndrome

1. What, if any, drugs did your mother engage in while you were in the womb?

2. Since FAS is the leading cause of mental retardation, how is it that this is still a public health crisis?

3. Why would you think that stepfamilies and adoptees are at greater risk for AOD problems?

4. Many issues are related to women and AOD. What role does gender play in the identification and treatment concerns for women?

5. What are the reasons that diverse populations mistrust the treatment system, and what would you recommend be done to counter the problem?

Substance Abuse. Information for School Counselors, Social Workers, Therapists, and Counselors, Fifth Edition

Chapter 11: Children and Families

ISBN: 9780132613248 Authors: Gary L. Fisher, Thomas C. Harrison

Copyright © Pearson Education (2013)