Jennifer L. Rogers, Jamie E. Crockett, Esther Suess
About one in four women will experience miscarriage of pregnancy, which can be the impetus for significant and persistent psychological distress. Because of cultural norms of silence and minimization around pregnancy loss, as well as a notable lack of scholarship on the topic, counselors may neglect this area in their clinical work. This article describes the relevance of Bronfenbrenner’s ecological systems theory for counselors seeking to account for the numerous variables that may be at play when working with clients who have lost a pregnancy. Using a detailed case example to demonstrate ecologically informed case conceptualization, the authors draw upon practically applicable clinical literature to highlight the possible developmental, relational, cultural, political, and economic impacts of miscarriage.
Keywords: miscarriage, pregnancy loss, Bronfenbrenner, ecological systems, case conceptualization
Miscarriage is defined as the premature loss of pregnancy occurring so early that the embryo or fetus is not viable outside the womb, up to about 23 weeks’ gestation (Mutiso, Murage, & Mukaindo, 2018). Miscarriage is the most common early pregnancy complication, occurring in approximately 15%–20% of known pregnancies, and is usually caused by chromosomal abnormalities in the embryo or fetus (Bardos, Hercz, Friedenthal, Missmer, & Williams, 2015). The estimated rate of loss for both known and unknown pregnancies is 20%–50% (Markin, 2017). Risk of miscarriage declines as a pregnancy progresses, with most occurring in the first 13 weeks of gestation, and 75% occurring in the first 17 weeks (Mutiso et al., 2018). Many women and couples are unaware of the high incidence of miscarriage until, or even after, they experience one (Bardos et al., 2015). In a recent survey assessing public perception of miscarriage in the United States, most participants were mistaken in their beliefs about both the prevalence and causes of miscarriage (Bardos et al., 2015). This widespread misinformation is related, at least in part, to powerful cultural norms of silence around the premature loss of a pregnancy (Markin & Zilcha-Mano, 2018). Despite societal taboo and minimization obscuring both prevalence and impact, approximately one out of every four women will experience a first trimester miscarriage (Wallace, Goodman, Freedman, Dalton, & Harris, 2010). As such, counselors are likely to work with clients who have encountered this specific type of loss.
Women vary in their responses to miscarriage (Trepal, Semivan, & Caley-Bruce, 2005). Some women feel relief upon learning that an unplanned pregnancy will not continue (Wallace et al., 2010), and others consider miscarriage a minimal obstacle to overcome (Engelhard, 2004). Bardos and colleagues (2015) reported that women who had personally experienced miscarriage and men whose partners had one endorsed feelings of guilt (47%), having done something wrong (41%), isolation (41%), and shame (28%), as well as a belief they could have done something to prevent the loss (38%).
Multiple factors influence a woman’s reactions to miscarriage, including how she experienced and ascribed meaning to the loss, her level of psychological distress prior and subsequent to the event, and variables within her environment (deMontigny, Verdon, Meunier, & Dubeau, 2017; Engelhard, 2004; Engelhard, van den Hout, & Arntz, 2001; Shreffler, Greil, & McQuillan, 2011). Many women experience grief after miscarriage (deMontigny et al., 2017; Randolph, Hruby, & Sharif, 2015; Trepal et al., 2005). Half of women grieving after pregnancy loss report clinically significant psychological distress, most commonly manifested as anxiety or depression (Randolph et al., 2015). Of the 30%–50% of women who experience severe symptoms in the 6 months after a pregnancy loss, most can still be described as grieving, and their symptoms often decrease over time (Engelhard, 2004). Identifying those women who are at high risk for intense psychological distress is important in order to facilitate assessment and treatment (Hutti et al., 2018). Predictors of acute and persistent symptoms of depression and anxiety after an early pregnancy loss include pre-existing mental health diagnoses, childlessness, and dissatisfaction with health care received (deMontigny et al., 2017). Given the prevalence of miscarriage and associated risks to psychological well-being, as well as the cultural norms that may influence both clients’ and counselors’ willingness to acknowledge this type of loss as significant enough to warrant assessment and intervention, mental health professionals are advised to seek out knowledge and strategies to inform their work when they encounter clients who are struggling after the loss of a pregnancy (Markin & Zilcha-Mano, 2018).
The aim of this article is to provide a clinically salient and practical overview of the current literature for practitioners, educators, and researchers, as well as to suggest a conceptual lens that may counter counselors’ own assumptions about miscarriage and through which multiple germane variables influencing the client can be seen. In the following sections, we: (1) highlight the dearth of counseling-specific scholarship focused upon early pregnancy loss, (2) briefly review recent practically applicable clinical literature, and (3) describe the relevance of Bronfenbrenner’s ecological model (1979, 1994) as a conceptual tool for counselors seeking to account for multiple systemic factors that may be at play when working with clients who are experiencing psychological distress after miscarriage. We then (4) apply this ecological conceptualization strategy to a case example, demonstrating how one woman’s miscarriage is an important life span event influenced by numerous variables—developmental, relational, cultural, political, and economic.
Miscarriage: Missing in the Counseling Literature
Cultural silence regarding pregnancy loss is noted by multiple authors (e.g., Engelhard, 2004; Markin & Zilcha-Mano, 2018; Randolph et al., 2015; Trepal et al., 2005), and this reticence extends to the counseling literature as well. Our search for the word “miscarriage” in 25 peer-reviewed journals specific to the counseling profession revealed only six articles published in the last 20 years (from January 1, 1998, to August 7, 2018) in which there was more than an incidental mention of the term. A recent qualitative study examined fathers’ lived experiences of miscarriage (Wagner, Vaughn, & Tuazon, 2018). Randolph and colleagues’ (2015) review focused on counseling women who had experienced pregnancy loss; they identified six themes in the literature (silence, grief, psychological distress, the role of social support, satisfaction with health care, and coping strategies) and noted the paucity of counseling scholarship on this topic. Another article discussed grief associated with pregnancy loss, particularly as related to work with infertile couples who had experienced recurrent miscarriages (Stark, Keathley, & Nelson, 2011). Betz and Thorngren (2006) explored family grief around ambiguous losses, with miscarriage mentioned multiple times as an example of such; they described a family counseling model that includes defining the loss, accessing coping resources, and creating a meaningful narrative of the event. Trepal and colleagues (2005) offered an empathy-infused overview of the topic, including conceptual and developmental perspectives and case-specific examples of diverse reactions to this type of loss. Sperry and Sperry (2004) presented a brief review of the literature as related to medical and psychological aspects of miscarriage and ectopic pregnancy, as well as a case example illustrating a therapeutic approach with a married, heterosexual couple who had experienced early pregnancy loss. It is noteworthy that four of the six miscarriage manuscripts that were selected for publication by counseling journals did not focus specifically on women clients, instead examining families (Betz & Thorngren, 2006), heterosexual couples (Sperry & Sperry, 2004; Stark et al., 2011), and male partners’ experiences as part of such a couple (Wagner et al., 2018). Only three of the six focused on miscarriage specifically (Randolph et al., 2015; Trepal et al., 2005; Wagner et al., 2018). The limited literature on this topic can be viewed as a systemic barrier to the development of clinical competence related to pregnancy loss—an isomorphic reflection of the lack of awareness, customs, conversations, and resources related to the experience of miscarriage in our culture. In the next section, we seek to begin to address this gap in the counseling literature by offering a brief review of empirical and conceptual scholarship relevant to counselors working with clients who are struggling after pregnancy loss.
What Counselors Need to Know: Women’s Reponses to Miscarriage
As previously mentioned, women vary in their responses to miscarriage, which may include relief that an unwanted pregnancy is over, resilience in the face of a setback, or deep sadness at the loss of a child (Engelhard, 2004; Trepal et al., 2005; Wallace et al., 2010). Although grief following early pregnancy loss mirrors other grief responses in intensity and duration, it is unique in its focus on the demise of an anticipated future rather than on memories of the past, leaving the griever to create a narrative of this ambiguous loss (Betz & Thorngren, 2006). Feelings of guilt, isolation, and shame are common (Bardos et al., 2015), exacerbated by cultural taboos regarding the expression of perinatal grief and related responses of minimization and dismissal by others (Markin & Zilcha-Mano, 2018). Such taboos and responses are reflected in multiple ecological systems. Historically, the ability to reproduce has been a measure of women’s worth; this, along with the fact that pregnancy loss can be a physically and psychologically disturbing event, may contribute to the long-standing taboo, silence, and a lack of scripts around miscarriage in many cultures and settings (Burnett, 2009; Engelhard, 2004). In light of this, women and couples may struggle to find both outlets to process their stories and resources for coping with the physical, mental, relational, and spiritual dimensions of their loss (Betz & Thorngren, 2006; Randolph et al., 2015; Trepal et al., 2005), highlighting the need for counselor competence in this domain.
Findings from Shreffler and colleagues (2011) support a “social constructionist approach” (p. 353) to understanding the psychological impact of pregnancy loss. Their research showed that women’s beliefs about motherhood, their fertility, and loss; their current desire for a baby; whether or not their lost pregnancy was planned; whether or not they subsequently gave birth to a child; and time since the loss were significant predictors of distress—in other words, a woman’s experience and understanding of her miscarriage within her unique environment is related to her ability to cope with her loss.
Serious and Persistent Responses to Miscarriage
There are subsets of women for whom miscarriage is the catalyst for serious and persistent mental health symptoms (deMontigny et al., 2017; Engelhard et al., 2001; Hutti et al., 2018; Shreffler et al., 2011). Markin (2017) reported that 15%–30% of women have major psychological difficulties after losing a pregnancy and that 10% of these reactions may be classified as diagnosable, including anxiety disorders, depressive disorders, acute stress disorder, substance use disorders, and post-traumatic stress disorder (PTSD). Women already struggling with mental health concerns before their miscarriage, women without living children, women who were dissatisfied with the health care they received related to their pregnancy loss, and women who were traumatized by their miscarriage can be more vulnerable to persistent symptoms (deMontigny et al., 2017; Engelhard, 2004; Engelhard et al., 2001; Shreffler et al., 2011).
The primary foci of most investigations of the psychological impact of miscarriage are depression and anxiety, and studies often do not include trauma-specific assessments (deMontigny et al., 2017; Hutti et al., 2018; Shreffler et al., 2011). Some women, however, are traumatized by the experience of miscarriage: physical pain, distressing amounts of blood and tissue, emergency medical interventions, doubts about future fertility, insufficient support within their microsystem, and the unexpected and unexplained loss of a future child (Engelhard, 2004). The experience of pregnancy loss can represent the devastating demise of a nascent primary relationship with associated destabilizing effects (Markin & Zilcha-Mano, 2018). Some women who have a miscarriage—especially those with higher neuroticism, lower emotional regulation, more negative life events, and who experience dissociative reactions to the event—may meet criteria for PTSD (Engelhard, 2004). In a prospective longitudinal study of PTSD and depression after loss in any stage of pregnancy (including both miscarriages and stillbirths, the latter of which is much rarer and holds a much greater risk for trauma), 25% of participants met criteria for PTSD one month after pregnancy loss, dropping to 7% after four months (Engelhard et al., 2001).
A study by Engelhard and colleagues (2001) is particularly noteworthy for its inclusion of qualitative, first-person participant accounts of both miscarriage and stillbirth. These descriptions offer a window into the potential traumatic nature of such experiences—shedding light on both the stories themselves and the possible origins of cultural taboos around this topic. Such stories underscore the need for timely, sensitive interventions for some women, perhaps similar to work done with individuals who have closely experienced disaster or assault. Meeting diagnostic criteria for PTSD was associated with persistent depressive symptoms after pregnancy loss (Engelhard et al., 2001). This result raises questions as to whether women who were identified as having higher than average levels of depression and anxiety in other studies were experiencing a post-traumatic response. Even when not meeting the diagnostic threshold for PTSD, women may experience trauma-specific symptoms such as re-experiencing, hyperarousal, and intrusive recollections (Engelhard et al., 2001). Diagnosis and treatment planning for women experiencing severe distress can be improved by pushing through cultural norms of silence and minimization and fully assessing clients for trauma responses.
Health Care Experiences During and After Miscarriage
The amorphous psychological vulnerabilities associated with miscarriage exist alongside concrete biological ones; the loss of a pregnancy is, at least in part, a medical event. When appropriately managed, the physical risks of miscarriage are relatively low (Wallace et al., 2010). The first stages occur inside a woman’s body without her immediate knowledge. Quickly, however, there are interpersonal and ecological variables that begin to influence a woman’s experience (Trepal et al., 2005). Bleeding or pain may be the first sign; some women present in the emergency room with these symptoms and find out about both their pregnancy and impending miscarriage at the same time (Wallace et al., 2010). Women may learn that a pregnancy is non-viable at a prenatal medical appointment, based upon routine bloodwork or ultrasound scans. Medical professionals may not receive adequate training about working with patients who are experiencing pregnancy loss. Among a sample of third-year medical students, less than 25% had observed a physician deliver news about a miscarriage during their obstetrics and gynecology rotation (Marko et al., 2015). The high cost of medical care, particularly when not openly discussed with patients, might be another source of marked distress (Ubel, Abernethy, & Zafar, 2013). Culturally condoned minimization of miscarriage can manifest in multiple interpersonal interactions, including those with health care providers, and leave women isolated and disenfranchised in efforts to cope with their loss (Markin & Zilcha-Mano, 2018).
Satisfaction with health care was identified as a theme in the literature on early pregnancy loss (Randolph et al., 2015), and dissatisfaction with the health care received during and immediately after a miscarriage predicted atypically persistent psychological distress more than 2 years after the event (deMontigny et al., 2017). This finding is particularly important for counselors, as the nature of clients’ previous interactions with health care providers may not emerge or be noticed as potentially pertinent in standard biopsychosocial assessments. Dissatisfied patients cite providers’ attitudes and failure to convey awareness, empathy, compassion, information, and suggestions for follow-up related to the emotional impact of the loss (Geller, Psaros, & Kornfield, 2010).
Despite the large number of women impacted by miscarriage and its effects, a shortage of published clinical research in this domain across disciplines has been noted (e.g., Markin, 2017; Randolph et al., 2015). Many existing studies lack empirical or theoretical rigor (e.g., exclusive focus on only certain symptoms, use of very brief interventions that may or may not be performed by trained mental health clinicians, lack of longitudinal follow-up). Our societal classification of miscarriage as primarily a medical matter contributes to a scarcity of psychologically focused scholarship regarding how to fully support women during and after the multi-faceted experience of losing a pregnancy (Markin, 2017).
Understanding Miscarriage: Clinical Application of the Ecological Model
Counselors without specific training focused on awareness of miscarriage and ways to intervene with clients experiencing distress related to it can inadvertently neglect this area in their psychotherapeutic work (Markin, 2017). Engaging in a systemically informed approach to learning about and conceptualizing this highly prevalent life span event is one way to combat cultural silence regarding pregnancy loss. Bronfenbrenner’s (1979, 1994) ecological systems model is firmly situated within the psychological and developmental canon and is a powerful foundation from which to explore and develop systemic thinking skills in students, professionals, and clients. In it, a series of ever-broadening environmental systems influence the development and functioning of individuals (see Figure 1). Some factors related to resilience and distress originate in or are exacerbated by variables in distal systems (meso-, exo-, macro-, and chronosystems); counselors who share these complexities with their clients may help lessen self-directed attribution leading to blame, shame, and guilt (Rogers, Gilbride, & Dew, 2018). Counselors who utilize an ecological approach to understanding clients are less likely to ignore or minimize the many complex and nuanced variables that may influence clients’ experiences related to miscarriage.
During a time in which she may have just begun to grapple with the physical, emotional, and existential ramifications of her pregnancy (e.g., wanting or not wanting the pregnancy, nausea, soreness, fear, joy, what it means to become a mother, plans for the future), a woman who is miscarrying is suddenly beset with biopsychosocial ramifications of loss (Engelhard et al., 2001; Trepal et al., 2005). Awareness, understanding, and exploration of the multiple systemic influences in women’s stories of miscarriage are inherent in an ecological conceptualization of this topic. Williams, McMahon, and Goodman (2015) used ecological systems (Bronfenbrenner, 1979) as the foundation for a pedagogical intervention called eco-webbing, which is intended to develop counseling students’ critical consciousness through the creation of a visual representation of systemic influences in their clients’ lives. Resilience researchers Ungar, Ghazinour, and Richter (2013) expanded upon the traditional nested ecological model through the introduction of the idea of differential impact. This concept suggests that the importance of a given variable is not predicted by its closeness to the individual at the center of Bronfenbrenner’s model; rather, variables existing in the outer levels of the ecosystem may be extremely significant to a specific person in a specific context. Drawing upon this, Rogers and colleagues (2018) proposed the use of an eco-map, a visual representation of environmental variables organized both by systemic level and current salience to the client. Clinical relevance is noted by distance to the client at the center of the map and by the size and ordering of variables within each level. The eco-map for a particular client will change over time, with different variables gaining salience while others recede. This strategy for organizing client information may be of particular use to counselors, educators, and supervisors in search of clinical and teaching tools that counter biased assumptions and capture the complexities of current environments (Rogers et al., 2018).
Figure 1. Bronfenbrenner’s Ecological Model.
Ecologically Informed Clinical Encounters
During clinical encounters with women who have experienced miscarriage, the importance of acknowledgment and validation is emphasized by authors working from a variety of disparate theoretical vantages (Diamond & Diamond, 2017; Markin & Zilcha-Mano, 2018; Wenzel, 2017). Narrative therapy is one recommended approach (Betz & Thorngren, 2006; Stark et al., 2011), with particular focus on clients’ reproductive story (Diamond & Diamond, 2017; Jaffe, 2017). This conceptual construct integrates exploration of the past, present, and future into work with clients who have experienced a reproductive loss, normalizing and validating both acknowledged and unacknowledged reactions to the loss, as well as making space for the client to create a hopeful narrative about the future. Therapeutic exploration of the meaning of the loss, both to the individual client and within broader relational and cultural contexts, is encouraged in order to facilitate client understanding and growth (Diamond & Diamond, 2017; Markin & Zilcha-Mano, 2018; Wenzel, 2017), supporting the utility of the ecological model as a conceptual frame. Ecological conceptualization pairs easily with a wide variety of theoretical approaches to clinical work. It can be used to facilitate a more deeply person-centered encounter, to provide context for adaptive and maladaptive relational strategies at play both in and out of the therapy room, to facilitate existential exploration, and to co-create goals and strategies tied to specific variables. Counselors can infuse ecological conceptualizations and observations into the therapeutic encounter, providing rich opportunities for reflections of meaning, re-framing, and narrative restructuring.
Following a detailed case example describing a client who has recently experienced a miscarriage, the next sections progress through each level of the ecological model (Bronfenbrenner, 1994). After explicating the level, we identify clinically relevant variables from both the literature and the case example and offer clinical implications for counselors working within an ecological framework. An eco-map summarizing ecological variables from the case example can be found in Figure 2.
Figure 2. Eco-map of Michelle.
Case Study: Michelle
Michelle is a 27-year-old woman who lives in a mid-sized East Coast city. She resides with her boyfriend of 3 years, Jon, and is employed as a server at a high-end restaurant. She is currently applying to graduate school to be an occupational therapist. She presents for counseling at a large clinic, asks about sliding scale fees for uninsured clients, and states on her paperwork that she would prefer to see a female clinician, “middle aged or older if possible.” Intake assessments suggest mild to moderate symptoms of depression and anxiety.
During the first session, Michelle discloses that she experienced a miscarriage 4 weeks ago. She learned she was pregnant from a home pregnancy test at approximately five weeks gestation, after her menstrual period did not arrive on time. She began experiencing pregnancy symptoms (sore breasts, sensitivity to smells) the next week. When she visited a medical clinic at 9 weeks gestation, pregnancy hormone levels in her blood did not align with the dates of her last period. A transvaginal ultrasound was ordered, and results showed that the embryo had stopped developing at approximately seven weeks, with no visible heartbeat. She was told that the pregnancy was not viable, that she should prepare for “nature to take its course,” and that she should expect to begin bleeding in the coming days. She was told that if she did not spontaneously miscarry in the next week, she would need to undergo a procedure called a dilation and curettage (D&C), during which her cervix would be partially dilated and the pregnancy-related tissue would be surgically removed from her uterus in order to avoid infection and other complications.
Michelle described a growing sense of anxiety and sadness upon hearing the news that her pregnancy was not viable. Though she was initially shocked and upset about her unplanned pregnancy, she and Jon had begun to plan for their new identity as a family of three. In the days after her doctor’s appointment, Michelle had two panic attacks—something that had not happened to her since high school. Michelle experienced some painful cramping and spotting one week after her appointment. She called and reported her symptoms, and the nurse scheduled her for a D&C at an outpatient surgery center. She asked what would happen if she did not get the D&C, what to expect from the procedure, and if the D&C posed any risks for future fertility. Her male doctor offered minimal information, stating that the D&C was necessary, that she should not worry, and that the procedure would be “quick, with only mild cramping, if anything.” Jon accompanied her to the surgery center, though per facility’s policies he was not allowed to be in the room during the procedure. She experienced panic symptoms prior to and during the D&C as well as moderately severe pain, and she was reminded of the time in college when she accompanied a friend who got an abortion.
In the month since the procedure, Michelle reports a variety of distressing symptoms and situations. Though they were planning a long-term future just weeks ago, she describes a growing distance between her and Jon. He is spending more time going out with friends and does not want to talk about the pregnancy or their relationship. Michelle was unable to work for a week after the surgery, and the missed income is creating short-term financial strain. She reports this would be manageable if not for the multiple medical bills for appointments, labs, scans, and the D&C that are starting to arrive in the mail. Michelle does not currently have health insurance: She was removed from her parents’ plan on her birthday, her employer does not offer benefits, and she has been trying to save money for a few months before starting graduate school and getting a new plan through the university. So far, the bills from the surgery center alone total over $5,000. When the largest of these bills arrived in the mail, Michelle had a panic attack that included chest pain and shortness of breath. During this episode, she convinced Jon not to call an ambulance because of the cost, even though he feared she was having a heart attack. She has also been experiencing inability to sleep, loss of appetite, nightmares, and ruminations focused upon the state of her relationship with Jon, whether she still wants to go to graduate school, whether she could have done anything to prevent the miscarriage, and whether she will be able to have children in the future. She has told a few close friends about her situation, but they are confused about why she is not simply relieved to have the unplanned pregnancy no longer be a hindrance to her educational and professional aspirations. She reports that she is close with her parents but has not told them anything. They already disapprove of Michelle and Jon living together because of their religious beliefs, and she does not want to further complicate her relationship with them.
Ecological Conceptualization of Michelle
Individual. At the center of Bronfenbrenner’s model is the individual (see Figure 1). There is a great amount of variability among individual women’s experiences of miscarriage. Baseline physical and mental health, presence or absence of physical and psychological symptoms, the length of the pregnancy, whether or not the pregnancy was wanted, number of prior pregnancies, plans for the future, and the physical experience of the miscarriage are just some of the many variables that counselors should be aware of when working with clients (deMontigny et al., 2017; Shreffler et al., 2011).
Though Michelle’s pregnancy was unplanned, she demonstrated resilience and flexibility regarding the news and had begun planning for her future as a mother. She may be mourning the loss of this new life and identity (Betz & Thorngren, 2006). Her pregnancy symptoms were caused by shifting hormones; her current physical and psychological symptoms may be influenced by her hormonal levels returning to a non-pregnant state. She has a history of panic attacks from 10 years prior, and this pattern reemerged upon learning that her pregnancy was non-viable. She has undergone a series of invasive medical procedures, including transvaginal ultrasound, dilation of her cervix, and surgical removal of tissue from her uterus, as well as unexpected pain. Michelle’s surprise over her pregnancy, her adaptive response to it, the unanticipated miscarriage, and her resultant novel physiological and medical experiences have coalesced into an overwhelming intrapersonal incident. Conveyance of a caring and nonjudgmental stance around these variables, as well as normalizing her reaction to a series of physically and existentially significant life span events, is essential to creating a clinical space where she can freely explore her unique experience (Trepal et al., 2005). Knowledge on the part of the counselor around what many find to be a taboo topic may serve to both normalize the experience and highlight its uniqueness to this client at this moment in her life.
Microsystem. Per Bronfenbrenner (1979, 1994), the microsystem is made up of the person-to-person engagement that an individual experiences in their immediate environment. These interactions, and the relationships associated with them, hold tremendous sway through encouraging or discouraging an individual’s behaviors. There is a deep body of research examining the influence of relational patterns on human development and psychological functioning (Bronfenbrenner, 1994). It is within our relationships that we learn whether it is safe or unsafe to be unguarded and authentic in our environment (Ainsworth, Bell, & Stayton, 1972; Miller, 1986). As such, variables in the micro-level are of utmost importance when assessing, conceptualizing, and working with clients who have lost a pregnancy. Counselors should be aware that some clients do not tell anyone about the pregnancy, tell only a select few people in their microsystem, or share the news more broadly. Although women experience more support when loss is public (Betz & Thorngren, 2006), many are dissatisfied and distressed by others’ response to their loss (Geller et al., 2010; Randolph et al., 2015). Medical professionals may inadvertently minimize the experience (deMontigny et al., 2017; Geller et al., 2010). They and others in the client’s microsystem may project their own emotional reactions (e.g., grief, relief) or processes (e.g., minimization, spiritual bypass) onto the client.
Over the last 2 months, there has been much clinically noteworthy activity within Michelle’s microsystem. There were marked shifts in her relationship with her romantic partner: a growing intimacy with energy focused on a long-term future together, followed by a distancing that includes new behavior patterns that did not exist before her pregnancy. Though she reports closeness with her parents, she has chosen not to disclose news of her pregnancy or miscarriage to them because of her predictions regarding their reaction, suggesting a current lack of transparency in relationships that had previously been a source of support. Michelle reports a perceived lack of empathy from her close friends, who do not understand her response to the miscarriage. Similarly, her experience of pain during her surgery was not the response predicted by her physician.
Michelle’s sense of disconnection in her microsystem may be related to feelings of shame. Shame is a documented reaction to losing a pregnancy (Bardos et al., 2015). Women may feel ashamed that their body did not carry the pregnancy to term or that they are responding differently than they imagine others have responded to such a loss. Shame has been described as a sense of unworthiness to be in authentic connection with others, based upon previous experiences of disconnection or hurt in relationships (Miller, 1986), such as those that Michelle has recently experienced. Her growing sense of isolation within her microsystem is of utmost clinical importance. Her request for an older woman therapist can be understood as evidence of her resilience and ability to care for herself—she is seeking to enrich her microsystem via connection with a new person who is more likely to be empathic and validating than those currently within this sphere.
Mesosystem. The mesosystem is the system of microsystems in an individual’s life, describing interactions between environments (Bronfenbrenner 1979, 1994). Michelle describes her relationship with her parents as close, but the interactions between the system she currently lives in (Michelle and her boyfriend) and her family of origin are not without tension. She reports that her parents disapprove of her living with Jon. Based upon this, she has not told them about her pregnancy or miscarriage. Is this an example of healthy boundaries between the couple and Michelle’s parents, or are there other aspects of this system-to-system relationship in which Michelle feels torn between the norms of one system versus the other?
Questions also arise regarding the communication with and between her medical providers. Her physician minimized her concerns, and his prediction about the amount of pain she would experience during the procedure proved inaccurate. Assuming the surgical center has greater knowledge about the variability of patient responses to such procedures, could better channels of communication between the center and offices of referring physicians promote increased patient understanding regarding what they might expect? Was Michelle’s doctor aware of her history of anxiety, and was this communicated to the surgical center? If so, in what way? An ecologically informed counselor might request permission to facilitate communication between Michelle’s health care providers, so as to best serve the client and to model how advocating for such interactions might be helpful to her in the future.
Exosystem. Bronfenbrenner’s exosystem (1979, 1994) is similar to the mesosystem in that it describes interactions between two or more environments, except that the individual of interest is not present in at least one of them. This construct captures how a setting or system can have observable influence over an individual’s experience, even though a person may not ever have direct contact with it. There are multiple exosystem variables evident in Michelle’s story at intake, and more would likely emerge during the course of clinical work. For example, her current economic challenges are having a profound effect on her well-being. Michelle’s removal from her parents’ health insurance plan, her medical providers’ fees for services, and her employer’s guidelines (backed by federal and state law) regarding lack of health insurance and medical leave options for hourly employees are all examples of how the policies and actions of a seemingly distant entity can have profound consequences for an individual.
It is possible that Michelle’s physician did not receive specific training regarding communication with patients about miscarriage (Marko et al., 2015). In the absence of training and protocols that acknowledge the great variability in women’s responses to pregnancy loss, including the individual variables that influence reactions and preferences for the type of care received, medical providers may make incorrect assumptions regarding their patients’ needs and experiences. Furthermore, given the current economics of the U.S. health care system, even those providers who might like to offer a more patient-centered approach to care are pressed for both time and resources. In Michelle’s case, the information she received from her physician was likely informed by his training and the norms of the clinic where he is employed, but she experienced more physical pain during her procedure than she had been told to anticipate, exacerbating her feelings of fear and powerlessness.
Michelle is an uninsured patient who has experienced both an unplanned pregnancy and an unexpected loss; the medical organizations that have been involved in her care have not expressed awareness or concern regarding the health ramifications of their fiscal policies and procedures, a common practice in the U.S. health care system (Ubel et al., 2013). Michelle’s current distress is largely focused on her fears around her growing medical debt, which she conceptualizes as a problem that is hers alone. Sharing an ecologically informed conceptualization of this issue during the course of counseling, including the complex influence of systems on her current situation, may help broaden her view regarding both her level of personal responsibility and possible avenues for solving the problem. For instance, she may recognize that the billing department’s processes are likely automatic and choose to contact them (thus bringing them into her microsystem) in order to explain her situation and inquire about manageable payment plans and possible bill adjustments for uninsured patients.
Macrosystem. The macrosystem encompasses the societal context in which an individual exists, including elements such as laws, economics, and social norms (Bronfenbrenner 1979, 1994). The cultural environment is rich with variables that affect intra- and interpersonal experiences, and the macrosystem can hold much influence over how situations in a person’s life are understood and acted upon—even though individuals may not be aware of its effect. There are multiple influential macrosystem-level factors at play in Michelle’s situation. The cultural taboo around miscarriage—including the lack of general knowledge around causes and prevalence (Bardos et al., 2015) and the lack of traditional behaviors for both women experiencing miscarriage and those whom they tell about the loss (Trepal et al., 2005)—are woven throughout her story. Jon’s need for distance in their relationship may be a manifestation of a number of macro-level factors, including the taboo around the topic and the more general cultural expectations regarding masculine avoidance of painful emotions and the imperative for men to disguise a lack of knowing what to do in a given situation. Religion, another pervasive cultural force, influences Michelle’s parents’ conceptualization of her decision to live with her romantic partner, thus affecting microsystem relationships and the mesosystem interactions between those systems. Religious and other deeply held personal beliefs (e.g., how miscarriage should be addressed—or not addressed—per the norms of a specific culture) were likely at play in many of the interactions Michelle has experienced since the loss of her pregnancy.
Michelle’s removal from her parents’ health insurance plan upon turning 27 is deeply influential; this occurrence is one based upon laws that were enacted amidst a complex economic and political environment. Through a systemic lens, the quality and cost of her health care without insurance, as well as the cost of her upcoming graduate education, can be conceptualized not merely as facts, but rather as products of a dynamic and complex ecology. In this way, Michelle’s difficulties are not hers alone, but those of a much larger system. When ecologically framed, questions arise regarding the expectation that an individual should or even could be able to grapple with such situations in a vacuum. Through this lens, her economic anxiety may be seen as a normative and appropriate response, rather than as a symptom to overcome.
Research indicating the importance of patients’ perceptions of their health care and its relationship to ongoing distress after miscarriage (deMontigny et al., 2017) supports the notion that Michelle’s dissatisfaction with some elements of her medical care and her current mental health symptoms are not unrelated. These micro- and macrosystem interactions also occurred within a broader cultural context. In a recent exploration of the status of women physicians within the field of obstetrics and gynecology, Hughes and Bernstein (2018) noted:
Physicians are social creatures raised within a society with historical roots founded on patriarchy and a system in which men, particularly white men, have disproportionate power. People living today did not create this system, but all of us perpetuate it to some degree, usually without realizing it. (p. 365)
In Michelle’s case, the minimization of her miscarriage—including her doctor’s incorrect predictions about her pain level and a lack of assessment related to her emotional response to her pregnancy loss and related procedures—seems to have exacerbated her distress. Michelle may have benefited from expressed empathy and discussion both normalizing and educating her about the wide variety of biopsychosocial reactions to miscarriage (e.g., pain, relief, grief, guilt, anxiety, depression, trauma), as well as a collaborative conversation about her choices and the risks and benefits of her options, including costs. The lack of such discussions stems at least in part from macrosystem-level sexism that silently minimizes women’s experiences, thus placing the responsibility for the distress on the individual rather than spreading it throughout the system.
Chronosystem. The chronosystem in Bronfenbrenner’s (1994) ecological systems theory captures the role of time within environments. Specific events and developmental transitions that occur over the course of an individual’s life span and the parallel unfolding of sociocultural history are included in this level. Women’s personal histories of trauma, previous pregnancy losses, and concerns about future fertility (Engelhard, 2004; Shreffler et al., 2011) are significant variables identified in the miscarriage literature that may be understood more deeply when placed within the time-dependent chronosphere. For Michelle, her pregnancy and subsequent miscarriage occurred at a time in her life when her focus was on plans for furthering her education, not on having children. However, she quickly found herself developing a new facet of her identity—that of a future mother. This unexpected life span event may have triggered changes in her concept of self, including her assumptions about how, when, and if she might become a parent. This transition, followed by the existentially activating event of the miscarriage, has caused Michelle to question many other of her previous assumptions; she feels unable to simply return to her original plans.
Michelle’s personal experience is unfolding during a time of burgeoning national awareness regarding multiple areas of instability and injustice in our culture. Specific to Michelle at this point in both her individual life and in history are concerns about the present and future as related to economics (medical bills, upcoming costs of graduate school), health care (availability, quality, cost; her chosen future career in the health care field), and gender (her experiences of becoming pregnant, miscarrying, and exploring what it might mean to become a mother; awareness of how sexism and gender stereotypes may have influenced these experiences). An ecologically attuned counselor can utilize the construct of the chronosystem to highlight Michelle’s development as a person within the context of historic developments. Framing of her self-concerns (e.g., debt, lack of empathic responses) alongside societal-level concerns (e.g., economic instability, hostile and benevolent sexism) suggests a universality in her individual experiences and offers an explanation for the depth of her responses—her problems are not just significant within the arc of her own life, but are examples of significant events within the arc of history as well.
Miscarriage is a highly common life span event that is shrouded by misinformation and silence regarding its prevalence, causes, and associated outcomes (Bardos et al., 2015; Wallace et al., 2010). This opacity also is evidenced in the paucity of counseling scholarship that includes mention of miscarriage, much of which focuses on the early loss of a pregnancy as a challenge experienced by heterosexual couples en route to parenthood (Sperry & Sperry, 2004; Stark et al., 2011; Wagner et al., 2018). Women’s reactions to miscarriage are varied and unique, influenced by a multitude of variables (deMontigny et al., 2017; Engelhard, 2004; Engelhard et al., 2001; Shreffler et al., 2011). Some women experience clinically significant and persistent psychological distress subsequent to miscarriage (deMontigny et al., 2017; Hutti et al., 2018). Dissatisfaction with health care among women is widely reported, and research indicates a need for improved biopsychosocial care for women after miscarriage, which would fulfill women’s stated needs regarding acknowledgment, validation, education, and resources (Geller et al., 2010). The necessity of system-to-system communication between medical and mental health services, as well as for emotional support provided by clinicians who have knowledge of the complex potential ramifications of miscarriage, is evident. Such care could improve outcomes for many women, particularly those who are vulnerable to clinically severe and persistent distress.
Counselors’ education, theoretical leanings, cultural beliefs, and personal experiences influence their understanding of clients. A lack of both societal norms and clinical training regarding helpful ways to intervene with women who have experienced miscarriage may lead to challenges for clinicians. Clients with a history of miscarriage may or may not view the experience as important in their own story, but—particularly given the documented prevalence of silence, distress, and dissatisfaction around responses to this common life span event (Randolph et al., 2015; Trepal, 2005)—its possible clinical salience for individual clients warrants both inclusion in standard counseling assessments and therapeutic attention, according to the goals and needs of the client. It is important for counselors to: (a) be aware of the possibility of serious and persistent distress related to miscarriage; (b) thoroughly assess clients around this topic, despite cultural norms of not mentioning or minimizing pregnancy loss; and (c) have knowledge of the myriad of risk and protective factors around this issue, as well as recommended strategies for working with such clients.
The counseling profession has recognized that advocacy to diminish systemic impediments to our clients’ growth is an ethical and clinical imperative (Ratts, Toporek, & Lewis, 2010). When viewed through an ecological lens, the current literature on pregnancy loss describes the influence not just of individual- and microsystem-level variables (e.g., premorbid anxiety disorder, unsatisfying interactions with medical professionals), but also the influence of distal system interactions (e.g., health care policy, cultural norms). Politics and economics are inherent in health care, both of which are deeply influenced by cultural beliefs and historical context. Awareness of ecological variables when understanding a woman’s reaction to her miscarriage—the attitudes conveyed by the individuals in her immediate sphere, as well as the practices and policies enacted by those outside it—may provide the foundation for a more complex and deeply person-centered approach to counseling.
Although the complex definitions of Bronfenbrenner’s levels (1994) may not be of use or interest to many clients, learning to think about oneself and one’s experiences as occurring within a nuanced ecology is a valuable skill. The ability to self-conceptualize ecologically can transfer to multiple domains beyond the counseling office. Counselors may choose to share elements from their ecological conceptualizations with clients directly, both to check in regarding possible salience to the client and to demonstrate systemic thinking as useful cognitive strategy.
As people become more aware of the complexity of the systems in which all experiences are embedded, issues related to social justice and advocacy will naturally emerge (Rogers et al., 2018). Ecologically attuned counselors may feel called upon to seize opportunities for systemic-level interventions, using their awareness of complex systems and relational expertise as a foundation for actions that extend beyond their work with individual clients. In turn, as clients experience authentic connection based upon being deeply understood by their counselors, they may reap therapeutic benefits by using their growing awareness of the interplay between experience, relationships, and systems to take action outside the therapy room (Miller, 1986).
Miscarriage is a common life span event that can be the impetus for persistent mental health concerns. Distress may be exacerbated by non-supportive cultural norms that are both internalized by the client and systemically manifested. By utilizing established models that account for the influence of variables throughout the environment in which a person exists, counselors are more likely to consider the wide variety of factors that may be affecting an individual client. Bronfenbrenner’s bioecological model (1979, 1994) places individuals within complex ecosystems and posits that even interactions between system-level variables not directly connected to a person still influence their experience and development. We propose that an ecological assessment of the variables impacting the client as related to her miscarriage can counter culturally learned avoidance and facilitate complex, nuanced conceptualizations and interventions around the unique biopsychosocial issues that may emerge related to pregnancy loss. Research is needed to further examine women’s experiences of miscarriage and the processes and outcomes of miscarriage-specific counseling interventions. An investigation of the validity and the utility of the proposed conceptual model is just one example of the many areas rich with potential for further inquiry. Future scholarly endeavors on this important topic may ultimately improve awareness, visibility, knowledge, resources, and care for the many women who endure miscarriages during their lifetimes.
Conflict of Interest and Funding Disclosure The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
Ainsworth, M. D. S., Bell, S. M., & Stayton, D. J. (1972). Individual differences in the development of some attachment behaviors. Merrill-Palmer Quarterly of Behavior and Development, 18(2), 123–143.
Bardos, J., Hercz, D., Friedenthal, J., Missmer, S. A., & Williams, Z. (2015). A national survey on public
perceptions of miscarriage. Obstetrics and Gynecology, 125, 1313–1320. doi:10.1097/OG.0000000000000859
Betz, G., & Thorngren, J. M. (2006). Ambiguous loss and the family grieving process. The Family Journal, 14, 359–365. doi:10.1177/1066480706290052
Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.
Bronfenbrenner, U. (1994). Ecological models of human development. In M. Gauvain & M. Cole (Eds.), Readings on the development of children (2nd ed., pp. 37–43). New York, NY: Freeman.
Burnett, J. A. (2009). Cultural considerations in counseling couples who experience infertility. Journal of Multicultural Counseling and Development, 37(3), 166–177. doi:10.1002/j.2161-1912.2009.tb00100.x
deMontigny, F., Verdon, C., Meunier, S., & Dubeau, D. (2017). Women’s persistent depressive and perinatal grief symptoms following a miscarriage: The role of childlessness and satisfaction with healthcare services. Archives of Women’s Mental Health, 20, 655–662. doi:10.1007/s00737-017-0742-9
Diamond, D. J., & Diamond, M. O. (2017). Parenthood after reproductive loss: How psychotherapy can help with postpartum adjustment and parent–infant attachment. Psychotherapy, 54, 373–379. doi:10.1037/pst0000127
Engelhard, I. M. (2004). Miscarriage as a traumatic event. Clinical Obstetrics and Gynecology, 47, 547–551. doi:10.1097/01.grf.0000129920.38874.0d
Engelhard, I. M., van den Hout, M. A., & Arntz, A. (2001). Posttraumatic stress disorder after pregnancy loss. General Hospital Psychiatry, 23(2), 62–66. doi:10.1016/S0163-8343(01)00124-4
Geller, P. A., Psaros, C., & Kornfield, S. L. (2010). Satisfaction with pregnancy loss aftercare: Are women getting what they want? Archives of Women’s Mental Health, 13(2), 111–124. doi:10.1007/s00737-010-0147-5
Hughes, F., & Bernstein, P. S. (2018). Sexism in obstetrics & gynecology: Not just a “women’s issue.” American Journal of Obstetrics & Gynecology, 219, 364–366. doi:10.1016/j.ajog.2018.07.006
Hutti, M. H., Myers, J. A., Hall, L. A., Polivka, B. J., White, S., Hill, J., . . . Kloenne, E. (2018). Predicting need for follow-up due to severe anxiety and depression symptoms after perinatal loss. Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(2), 125–136. doi:10.1016/j.jogn.2018.01.003
Jaffe, J. (2017). Reproductive trauma: Psychotherapy for pregnancy loss and infertility clients from a reproductive story perspective. Psychotherapy, 54, 380–385. doi:10.1037/pst0000125
Markin, R. D. (2017). An introduction to the special section on psychotherapy for pregnancy loss: Review of issues, clinical applications, and future research direction. Psychotherapy, 54, 367–372. doi:10.1037/pst0000134
Markin, R. D., & Zilcha-Mano, S. (2018). Cultural processes in psychotherapy for perinatal loss: Breaking the cultural taboo against perinatal grief. Psychotherapy, 55, 20–26. doi:10.1037/pst0000122
Marko, E. K., Buery-Joyner, S. D., Sheridan, M. J., Nieves, K., Khoury, A. N., & Dalrymple, J. L. (2015). Structured teaching of early pregnancy loss counseling. Obstetrics & Gynecology, 126, 1S-6S. doi:10.1097/AOG.0000000000001015
Miller, J. B. (1986). Toward a new psychology of women (2nd ed). Boston, MA: Beacon Press.
Mutiso, S. K., Murage, A., & Mukaindo, A. M. (2018). Prevalence of positive depression screen among post miscarriage women—A cross sectional study. BMC Psychiatry, 18, 32. doi:10.1186/s12888-018-1619-9
Randolph, A. L., Hruby, B. T., & Sharif, S. (2015). Counseling women who have experienced pregnancy loss: A review of the literature. Adultspan Journal, 14, 2–10. doi:10.1002/j.2161-0029.2015.00032.x
Ratts, M. J., Toporek, R. L., & Lewis, J. A. (2010). ACA advocacy competencies: A social justice framework for counselors. Alexandria, VA: American Counseling Association.
Rogers, J. L., Gilbride, D. D., & Dew, B. J. (2018). Utilizing an ecological framework to enhance counselors’ understanding of the U.S. opioid epidemic. The Professional Counselor, 8, 226–239. doi:10.15241/jlr.8.3.226
Shreffler, K. M., Greil, A. L., & McQuillan, J. (2011). Pregnancy loss and distress among U.S. women. Family Relations, 60, 342–355. doi:10.1111/j.17413729.2011.00647.x
Sperry, P., & Sperry, L. (2004). The family experience of loss associated with miscarriage and ectopic pregnancy. The Family Journal, 12, 401–404. doi:10.1177/1066480704267547
Stark, M. D., Keathley, R. S., & Nelson, J. A. (2011). A developmental model for counseling infertile couples. The Family Journal, 19, 225–230. doi:10.1177/1066480711400171
Trepal, H. C., Semivan, S. G., & Caley-Bruce, M. (2005). Miscarriage: A dream interrupted. Journal of Creativity in Mental Health, 1(3–4), 155–171.
Ubel, P. A., Abernethy, A. P., & Zafar, S. Y. (2013). Full disclosure—out-of-pocket costs as side effects. New England Journal of Medicine, 369, 1484–1486. doi:10.1056/NEJMp1306826
Ungar, M., Ghazinour, M., & Richter, J. (2013). Annual research review: What is resilience within the social ecology of human development? Journal of Child Psychology and Psychiatry, 54, 348–366. doi:10.1111/jcpp.12025
Wagner, N. J., Vaughn, C. T., & Tuazon, V. E. (2018). Fathers’ lived experiences of miscarriage. The Family Journal, 26(2), 193–199. doi:10.1177/1066480718770154
Wallace, R. R., Goodman, S., Freedman, L. R., Dalton, V. K., & Harris, L. H. (2010). Counseling women with early pregnancy failure: Utilizing evidence, preserving preference. Patient Education and Counseling, 81, 454–461. doi:10.1016/j.pec.2010.10.031
Williams, J. M., McMahon, H. G., & Goodman, R. D. (2015). Eco-webbing: A teaching strategy to facilitate critical consciousness and agency. Counselor Education and Supervision, 54(2), 82–97. doi:10.1002/ceas.12006
Wenzel, A. (2017). Cognitive behavioral therapy for pregnancy loss. Psychotherapy, 54, 400–405.
Jennifer L. Rogers, NCC, is an assistant professor at Wake Forest University. Jamie E. Crockett, NCC, is an assistant professor at Wake Forest University. Esther Suess, NCC, is a counselor at the Mood Treatment Center in Winston-Salem, NC. Correspondence can be addressed to Jennifer Rogers, P.O. Box 7406, Winston-Salem, NC 27109, email@example.com.
Jennifer L. Rogers, Dennis D. Gilbride, Brian J. Dew
This conceptual article provides a counselor-oriented overview of the origins and consequences of the current opioid epidemic in the United States. After a thorough review of Bronfenbrenner’s ecological perspective on human development, this article presents a case conceptualization model aimed at providing counselors with a tool and strategy to better understand how systemic complexities impact opioid-dependent clients and their communities. A detailed composite case study is used to demonstrate the influence of multiple ecological variables on a specific client. Individual, micro-, meso-, exo-, macro-, and chronosystem stimuli are explored, and the role of advocacy as inherent in systemic conceptualization and treatment planning is discussed.
Keywords: opioid epidemic, ecological, Bronfenbrenner, opioid-dependent, case conceptualization
Alarming national headlines related to opioid addiction highlight a public and mental health emergency across America. Overdoses and opioid-related deaths are skyrocketing (Rudd, Seth, David, & Scholl, 2016; Skolnick, 2018; Suzuki & El-Haddad, 2017), and the lifespan of many Americans, especially in rural areas, is declining for the first time in generations due in part to maladaptive use of narcotics (Katz, 2017a). Opioid painkillers are the most frequently prescribed class of drugs in the United States (Skolnick, 2018). Misuse of these drugs often leads to the use of heroin, a cheaper and more potent alternative to prescription painkillers (Skolnick, 2018). Heroin is increasingly cut with the synthetic opioid fentanyl (50–100 times stronger than morphine) and its various analogs, such as carfentanil (a veterinary drug used to rapidly immobilize wild animals; Suzuki & El-Haddad, 2017), contributing to the recent dramatic rise in overdose deaths (Katz, 2017b; Suzuki & El-Haddad, 2017). The opioid epidemic also is associated with increases in a host of other negative outcomes, including rates of HIV and hepatitis C, arrests and incarcerations, and neonatal abstinence syndrome (Skolnick, 2018).
Addictions, mental health, rehabilitation, and school counselors are challenged to find better ways to understand and assist users, families, and communities being ravaged by this public health crisis. Clinicians and researchers have developed multiple individual and community-based strategies to assist clients with substance abuse, but current circumstances have underscored the need for members of the counseling profession to take a more comprehensive and ecological approach to both understanding and addressing the needs of people struggling with opioid addiction (Dasgupta, Beletsky, & Ciccarone, 2018; Hewell, Vasquez, & Rivkin, 2017; Keyes, Cerdá, Brady, Havens, & Galea, 2014; Kolodny et al., 2015). In subsequent sections, details of this public and mental health crisis are described, and an ecological case conceptualization model that utilizes eco-mapping to assist counselors in better understanding and developing systemic treatment plans is presented. A case study allowing for the application of the model is provided, and implications for counselors are explored.
An Opioid Overview
Mental and public health officials have long recognized the popularity and uniquely addictive potential of substances classified as opioids. Use of opium and morphine first became a problem in America during the late 1800s (Kolodny et al., 2015). Morphine was used to treat a variety of chronic and acute ailments, including diarrhea and injuries sustained in battle. Smoking opium recreationally became popular in some circles, and physicians also inadvertently addicted their patients by prescribing opioid treatments. As medicine and public health advanced, more diseases could be avoided, cured, or treated without the use of highly addictive opioids, and their use fell out of favor by 1919 (Kolodny et al., 2015). In the second half of the 20th century, heroin addiction intermittently rose to epidemic levels among disadvantaged urban populations, especially in the large cities of the northeast and west coast of the United States (Kolodny et al., 2015; McCoy, McGuire, Curtis, & Spunt, 2005). More recently, the introduction of synthetic prescription opiates (e.g., Vicodin, Percocet) in the 1980s and the approval of sustained-release oxycodone (brand name OxyContin) in 1996 brought pain relief to millions of users, but has contributed to high levels of abuse and dependence nationwide (Van Zee, 2009).
To understand the addictive nature of opioids, counselors must account for the acute effects of their use (e.g., relief from physical and psychological pain), unique side effects (e.g., opioid-induced pain sensitivity, painful withdrawal symptoms), ease and speed with which tolerance is established, and potential resulting impairments in daily functioning (Kosten & George, 2002). When opiates bind with neural opioid receptors in the brain, spinal cord, gastrointestinal tract, and other organs, they inhibit the release of pain signals, blocking the user from experiencing both physical and emotional suffering. Some people are naturally more vulnerable to developing opioid tolerance (taking more drug for the same effect) and dependence (drug required to avoid withdrawal; Kosten & George, 2002). Susceptibility is influenced by a variety of biopsychosocial factors (e.g., brain structures, cellular differences, context of use, stress). In a study examining opioid prescribing patterns, 25% of patients who had a new opioid prescription progressed to receiving additional prescriptions episodically or chronically (Hooten, St. Sauver, McGree, Jacobson, & Warner, 2015). Nicotine addiction, overall poor health, psychiatric diagnosis, and history of substance abuse were found to increase the likelihood of ongoing opioid use. Withdrawal symptoms lasting three to five days—including nausea, muscle cramping, body aches, anxiety, and inability to sleep—can compel users to obtain immediate symptom relief via the use of additional opioids (Kosten & George, 2002). In an attempt to avoid debilitating withdrawal symptoms, users become reliant on the drug to function at a normative, baseline state.
Current Opioid Epidemic
Although the pathway to opioid abuse and addiction is not new, a culmination of ecological factors over the last 20 years has led to what is now commonly referred to as a national epidemic (Kolodny et al., 2015; Skolnick, 2018). These factors include changes in prescribing patterns, increased supply, rampant growth of illicit use, the progression to intravenous heroin use among chronic users, and the lethal contamination of heroin and fake prescription pills with highly potent synthetic opioids like fentanyl, as well as broader systemic variables such as poverty and access to health care (Dasgupta et al., 2018).
The dramatic increase in the availability of prescription opioids in the early 21st century stemmed, in part, from changes in medical attitudes and policies (Kolodny et al., 2015; Skolnick, 2018). Spearheaded by the American Pain Society’s advocacy efforts to have pain recognized as a fifth vital sign (along with temperature, pulse, respiration rate, and blood pressure) in the mid-1990s, the Joint Commission and the Veterans Health Administration formally endorsed patients’ rights to pain assessment management in 2000 (Kolodny et al., 2015; Skolnick, 2018). Helping patients avoid physical pain thus became a primary focus of medical care. During the same time period, Purdue Pharma provided financial contributions to multiple medical and patient organizations (e.g., the American Pain Society, the Joint Commission, the Federation of State Medical Boards) and lobbied to allay concerns regarding long-term use of prescription opioids in the treatment of chronic non-cancer pain (Kolodny et al., 2015). Methodologically questionable research studies were widely cited to minimize the perceived risks associated with long-term use and addiction. Sales of Purdue Pharma’s doggedly promoted, non-generic OxyContin grew from $48 million in sales in 1996 (316,000 prescriptions) to almost $3 billion (more than 14 million prescriptions) in 2001–2002 (Van Zee, 2009). Though the time-release formula was touted as a deterrent for misuse, users discovered the pills could be crushed and then snorted or injected. In 2000, Purdue released a 160 milligram tablet (up from the previous high dose of 80 milligrams) approved for use by patients who had developed opioid tolerance, further increasing OxyContin’s draw as a drug of abuse (Van Zee, 2009).
An increase in opioid supply via both unwitting and unscrupulous prescribers was quickly followed by the rapid acceleration of opiate abuse across the country (Van Zee, 2009). Unlike other illicit substances (e.g., cocaine, methamphetamine, ecstasy), these pain-killing medications were prescribed by medical professionals and therefore assumed to be safe. Prescription opiates were accessible through doctors, family, friends, the internet, and on the black market. Long-term use of prescription opiates can lead to tolerance and eventual physical dependence, requiring a continuous supply of drugs and financial resources to purchase them. Users of prescription opiates have increasingly turned to heroin (Skolnick, 2018) as a cheaper, more readily available option to keep painful withdrawal symptoms at bay. With increased availability and visibility, many people now report that their opioid use started with heroin rather than prescription drugs (Dasgupta et al., 2018).
The rise of the presence of illegally manufactured fentanyl in opioids available on the illicit market has had increasingly deadly consequences, with fentanyl-related deaths in the United States up 540% between 2013 and 2016 (Katz, 2017b). Average life expectancy is now declining among some segments of the population—unusual except in times of war (Dasgupta et al., 2018). Unlike other U.S. drug use crises that have disproportionately affected minority populations (e.g., crack cocaine), there has been a focus in this crisis on over-prescribing as the root cause, rather than the moral failings of individual users. This broader view may help destigmatize the current situation, but it is imperative to recognize that complex factors lead to susceptibility to all such crises. For instance, in areas particularly affected by the opioid crisis, mortality associated with alcoholism, drug overdoses, and suicide (known as “diseases of despair”) has increased as local economies have declined (Dasgupta et al., 2018).
The devastation of individual lives, families, and communities resulting from this epidemic is clear, and the complexity of the issues it has engendered requires counselors to expand treatment strategies and interventions. In the next section, we review Bronfenbrenner’s (1979, 1994) ecological systems theory and present a strategy designed to help counselors both understand and intervene with clients and communities battling this challenge.
Bronfenbrenner’s foundational work, The Ecology of Human Development (1979), described how a child develops within a series of interrelated systems. He posited that human development processes are influenced by individual characteristics, as well as features in one’s immediate and more distant environments. Over the course of a lifetime, development progresses through a series of increasingly complex and reciprocal interactions between an individual and the people, things, and symbols in their environment. Research designed to investigate this developmental progression is described as aligning with a process-person-context model (Bronfenbrenner, 1994) and is endemic in our current understanding of psychological health and illness.
Drawing upon Lewin’s (1935) theory of psychological fields (as cited in Bronfenbrenner, 1979), the ecology of a developing person is described as a set of nested structures, one inside the other (see Figure 1). The innermost system, called the microsystem, was defined by Bronfenbrenner as the pattern of personal interactions and activities that occur face-to-face with a person in their immediate environment (Bronfenbrenner, 1979, 1994). These interactions include an individual’s family, friends, schoolmates, teachers, neighbors, and colleagues. The proximal processes occurring between family members in the microsystem are among the most frequently studied in the psychological literature (Bronfenbrenner, 1994). These close relationships have extraordinary power to normalize or stigmatize behaviors and to support or hinder optimal individual development. Examples of behaviors that may be supported or discouraged within a microsystem include child-rearing practices, therapeutic or recreational use of prescription medication, pursuit of educational or occupational goals, religious practices, and encouragement of relationships with persons or groups outside the immediate microsystem.
Figure 1. Bronfenbrenner’s Ecological Model
The mesosystem includes the processes and connections occurring between two or more environments in which an individual exists, or the system of microsystems in a person’s life (Bronfenbrenner, 1979, 1994). Interactions between a person’s home, school, workplace, neighborhood, place of worship, or medical providers are described as occurring within the mesosystem. Examples of mesosystem processes include how the closing of a manufacturing plant where an individual was employed could lead to a decline in the condition of his or her neighborhood, or how patients of a local physician who frequently prescribes pain medication may experience an increase in the off-market availability of such medication within his or her neighborhood, family, or peer group.
The exosystem is comprised of processes occurring between two or more environments, at least one of which does not include the individual of interest (Bronfenbrenner, 1979, 1994). Even though a person may not exist within a certain setting, outside events can indirectly influence that person’s immediate environment. Examples of exosystem processes include how a new local company’s practice of only hiring college-educated workers influences less educated workers in a nearby neighborhood, or how decisions by legislators regarding health care policy influence local hospitals and family decisions about medical care.
The macrosystem represents the patterns, policies, laws, values, and trends that comprise the broad cultural, political, economic, and societal/environmental backdrop of an individual’s life (Bronfenbrenner, 1979, 1994). Macrosystems include mega factors such as advances in technology and the rapid transition into the information age, the precipitous move away from manufacturing in the United States, the increasing need for a college education to obtain a salary that can sustain a middle-class lifestyle, changes in how health care is funded and delivered, the decline in membership in organized religious institutions, and a growing cultural emphasis on individualism. Other trends include changes in how information is delivered and consumed, and the increasing gulf between rural and urban communities.
The chronosystem describes changes in an environment over time related to each of the other systems (Bronfenbrenner, 1994)—the normal growth and development of a person or family, the effect of a move or migrations of families or groups, and the effects of large historic events such as wars, natural disasters, and recessions. The chronosystem highlights that along with living within nested or interacting systems, a person also lives within the history of their own life—as well as within the history of their family, community, state, nation, and world (Bronfenbrenner, 1994).
Ungar, Ghazinour, and Richter (2013) expanded Bronfenbrenner’s model in their studies of resilience to include a focus on the success of individuals and groups to secure resources leading to healthy development, even in adverse circumstances. Ungar and colleagues’ model describes systems as reciprocal rather than hierarchical. The effect of a systemic variable is not just related to its proximity to an individual (per Bronfenbrenner’s nested model as described above and in Figure 1), but rather on its importance to a particular person at a specific point in time. For example, a war and its related geo-politics (a macrosystem issue) may be much more salient than school (a mesosystem issue) for a particular child living under siege in Syria.
An Ecological Conceptualization of Opioid Addiction
A social-ecological perspective is tacit in many popular journalistic efforts focused upon the opioid use epidemic, including books (e.g., Hillbilly Elegy; Vance, 2016), documentaries (e.g., Warning: This Drug May Kill You; Peltz, 2017), and investigative news reports (e.g., Talbot, 2017). In these long-form examinations, a multitude of distal and proximal variables influencing opioid use patterns among individuals are described. Recent scholarly publications outside of the counseling literature have utilized implied (Dasgupta et al., 2018; Kolodny et al., 2015) and overt ecological (Hewell et al., 2017; Keyes et al., 2014) lenses to examine this problem. Keyes and colleagues (2014) undertook a large ecological synthesis of the extant empirical literature related to the opioid crisis in rural America. They identified the following risks in their analyses: (1) increased availability and access; (2) lower perceptions of harm; (3) self-medicating for pain; (4) more increased availability in rural rather than urban areas; (5) out-migration of young people (rural economic declines, and via selection effect, young adults remaining in economically depressed areas may have a greater number of risk factors); (6) differences between urban and rural social and kinship networks (importance of community investment, family ties, work over education, and local social capital in rural areas); and (7) structural stressors of modern rural living (unemployment and economic deprivation).
In their qualitative inquiry about systemic and individual factors in medication-assisted treatment for opioid abuse, Hewell and colleagues (2017) reported findings supporting the construct of recovery capital (including personal recovery capital, family and social recovery capital, and community recovery capital), as well as suggesting the interactional relationship of such resources. They advised practitioners to be educated about multiple ecological influences and to be flexible in their approaches so as to utilize ever-changing sources of recovery capital available to their clients.
Ecological Conceptualization and Treatment Planning
The proposed counseling, teaching, and intervention strategies are an extension and elaboration of the eco-webbing model proposed by Williams, McMahon, and Goodman (2015). The authors described a strategy designed to facilitate more critical consciousness thinking in their students by creating visual representations of the factors and forces that may be affecting a client’s life and situation. Concept mapping strategies have been found to be powerful tools in creating visual representations of key factors affecting a client’s health and treatment needs (Gul & Boman, 2006) and in enhancing critical thinking.
In Phase 1 of Williams and colleagues’ (2015) model, they ask counseling students to brainstorm all the variables related to a client’s problem. In the present model, we expand and structure this phase to include a systematic analysis of each of the system levels identified by Bronfenbrenner (1979, 1994) in order to create an eco-map. Phase 2 of the Williams’ et al. model (2015) involves the distillation of information and themes. We address this phase by utilizing Ungar et al.’s (2013) concept of differential impact. Ungar and colleagues assert that although Bronfenbrenner’s systemic levels are often visually represented as nested and hierarchal (i.e., levels closer to the center where the individual is more important), this structuring is merely a heuristic device, and that it is more useful to understand various systems and subsystems as reciprocal, having differential impacts at various moments and in various contexts. In the present model, we address Phase 2 by visually prioritizing different systemic issues and factors. As indicated in Figure 2, key factors from each of Bronfenbrenner’s systemic levels are illustrated by circles in the eco-map rather than in the traditionally nested manner. Based upon the client and counselor’s joint evaluation, many variables are included in the eco-map, with their current importance to the client represented by both relative size and distance from the center of the map.
The final phase of the eco-webbing process, as described by Williams and colleagues (2015), calls for reflection upon the central issue and the multiple eco-systemic factors, and how these may inform the counseling process. Reflection upon the eco-webbing process itself is also encouraged. Our model expands upon these steps by using the information visually represented in the eco-map to structure and develop a formal treatment plan including both individual and systemic variables in the order and priority of their current effect on the client. Over the course of counseling, the eco-map can be revisited and restructured to represent the shifting centrality of various factors. For example, in an initial eco-map, access to a detox treatment center may be largest and at the center, while 6 months later, labor market or family relationship issues may enlarge and move toward the center.
Figure 2. Eco-map for Jason
In the following sections, we present a client case study, suggest an ecological approach to understanding our client, and offer treatment strategies based upon our ecological conceptualization.
Case Study: Jason
Jason is a 37-year-old White male who lives in a southwest West Virginia town with a population of 30,000. Jason’s father and grandfather were both coal miners who worked hard, made a good living, and were active in the local community as church members and volunteer firemen. Jason had a happy childhood with no remarkable adverse events. He was a star of the high school football team. Having seen his grandfather die from black lung disease and his father suffer from emphysema, Jason vowed to never work in the mines. By the time he graduated high school, there were few mining jobs available. Jason began work for a concrete company, pouring concrete for residential and commercial projects. He was popular among his coworkers and relished working outdoors. At age 21 he married a young woman he had known since childhood and within 3 years they had two sons.
After 10 years on the job, Jason was laid off because of the lack of new development in his town. Jason moved his young family to a larger town in Ohio to do concrete work for a commercial construction company. The working environment was very different, and Jason was required to take orders from contractors, rather than being in charge of each job as he had become accustomed to back home. Jason’s wife was very unhappy living away from their friends and family. After a few months, she and the children moved back to live with her parents. Jason visited on the weekends, but the arrangement strained their marriage, and within 2 years his wife filed for divorce. Around the same time, his father died from lung cancer.
Jason had a number of back injuries over the years while working, but when he fell at home while moving a piece of heavy furniture, he herniated three discs and was restricted from many physical activities because of continuous pain. Because this debilitating injury occurred at home, Jason did not qualify for worker’s compensation benefits. He had surgery on his back and returned home with a prescription for narcotic pain medication. He did not comply with his doctor’s orders regarding physical therapy because as an hourly laborer, he could not afford any more time off work. Though the surgery did alleviate some of his pain initially, after a year it was clear that the operation did not fully repair his spine, and his pain again became unbearable. His doctor prescribed Percocet for him to take in the evenings when his pain was the worst, but over time, the medication became less effective. He visited a pain clinic near his apartment and received a prescription for OxyContin, which was stronger and long-acting. Jason noticed he felt less lonely and discouraged after taking the pills, which he began to do more often. Soon, Jason was not himself at work—making mistakes, forgetting things, and having conflicts with his supervisors. He was fired from his job.
With no savings, outstanding medical bills, and being unable to work in his field, Jason returned home to live in a small house on his mother’s property. He applied for disability benefits and began receiving prescription opioids through a pain clinic in town. As his tolerance for opioids increased, he tried various strategies to avoid the horrific withdrawal symptoms he experienced when his supply of opiates ran out: crushing and snorting pills for a stronger effect, “borrowing” medication from family and friends, and buying additional pills from dealers. Nine months ago, the high street cost of pills led Jason to begin snorting heroin, which was cheaper, but more potent. Within 2 months, he began using heroin intravenously on a daily basis. Acquiring and using heroin became his primary endeavor, increasingly isolating him from his family and his group of lifelong friends. After showing up to church several times late and disheveled, Jason’s mother told him he was no longer welcome to join her in the family’s regular pew on Sundays. Last Friday, he met his ex-wife and younger son to attend his elder son’s first varsity football game as a family. In an effort to avoid becoming ill during the long game, Jason shot heroin in the parking lot and was visibly high when he entered the stadium. The evening ended with his ex-wife enraged, his younger son in tears, and his elder son saying he could not wait to go far away to college and never see Jason again. Two days ago, Jason’s mother found him unresponsive in his truck and called 911. EMTs administered naloxone (branded as Narcan), which restored his breathing after an accidental heroin/fentanyl overdose. He was taken to the hospital and referred to an outpatient community addiction and mental health clinic upon release. With no one in his family willing to pick him up from the hospital, and his mother saying she is unsure if she wants him to continue living on her property, Jason used a hospital bus pass to travel directly to a local substance abuse treatment facility.
Treatment Planning Implications by Ecological Level: The Case of Jason
Individual: Traditional treatment focus. Assuming a disease model of addiction, a counselor would view Jason’s opioid dependence as primary, chronic, progressive, and potentially fatal (Angres & Bettinardi-Angres, 2008). As such, many substance abuse professionals would advocate that Jason’s addiction is the primary presenting problem and must be addressed first, before tackling other concerns and challenges. A treatment plan including goals and objectives focused upon enhancing his ability to remain abstinent from opioids and all other mood-altering substances should be developed, implemented, and monitored from the outset of treatment.
It is essential for Jason to reduce his isolation by developing a social network supportive of his recovery efforts. Specific objectives to meet this goal might include attending daily 12-step meetings for a minimum of 90 days, obtaining a sponsor who has a minimum of 5 years in recovery, and reestablishing relationships with non-using childhood friends.
An additional individual-level concern that must be addressed is Jason’s chronic pain from multiple herniated disks. During the first week of substance abuse treatment, Jason’s plan should include a complete physical examination with an emphasis on assessing pain level and spinal functioning, as well as HIV and hepatitis screening. Throughout his substance abuse treatment, Jason should receive psychoeducation via group work, lectures, reading materials, and videos or other media in order to enhance his understanding of the cyclic nature of pain disorders and opioid addiction. Jason also should make an appointment and establish a relationship with a medical specialist who is knowledgeable in both pain management and addictive disorders. Jason and this medical professional can develop an action plan to address his chronic back pain while minimizing his risk of opiate relapse.
Acute fiscal concerns and the accompanying stress associated with lack of financial resources were identified as primary risk factors for relapse. Individual-level interventions should include connecting Jason with vocational rehabilitation counselors who will assist him in identifying personal and employment strengths, acknowledging limitations in the current job market, and assisting him in finding employment. Finally, in order to enhance the likelihood of success in his recovery, Jason should address issues of shame resulting from his drug use and loss of family, employment, health, and identity. While in treatment, he should receive extensive psychoeducation as to the meaning and significance of shame in the recovery process. Jason should be encouraged to discuss, in individual and group counseling, the complex nature of his drug use and related intra- and interpersonal consequences.
Microsystem: Face-to-face interactions between individual and environment.Primary face- to-face interactions impacted by Jason’s addiction to opiates include communications with his ex-wife, sons, and mother. Although Jason’s marriage was negatively impacted by the family’s moving to Ohio, his use of prescription opioids following the move hurt his ability to communicate, restricted his interactions with his wife and children through gradual withdrawal from family events, and transferred parenting responsibilities to his wife. These changes in functioning within his nuclear family caused further alienation from others, including but not limited to his mother, friends, neighbors, fellow church members, and extended family. As a result of his opiate use, he no longer attended parent–teacher conferences at school and only sporadically appeared at his children’s baseball and football games.
Having grown up in a small town, Jason was well known and well liked by many in his community. While working at the local concrete company in his home town, he had developed a tight-knit group of close friends, many of whom he knew from childhood. Upon his return to West Virginia following his loss of employment and injury while in Ohio, Jason no longer reached out to this group of friends. Instead, his primary focus became finding, paying for, and using opioids in order to avoid painful withdrawal symptoms. His social circle was nearly replaced by his drug dealer and occasional fellow heroin users with whom he would shoot up and share needles.
It should be noted that all of the individual-level treatment concerns involve microsystem-level interactions between Jason and his environment. Jason’s counselor should be aware that achieving these goals will depend upon Jason’s pursuit or avoidance of interactions with various individuals, groups, and settings (i.e., the microsystem). This ecological awareness will increase the counselor’s understanding of the magnitude of Jason’s task, allowing for both deeper empathy and better planning. By highlighting the microsystem interactions required to pursue treatment goals, the counselor can help Jason become aware of the many variables in the environment he may not be able to control, thus emphasizing the importance of remaining steadfast regarding those elements of his treatment and life in which he does have power and choice.
Mesosystem: Interactions between two or more environments where an individual exists. In Jason’s West Virginia and Ohio communities, there were several changes in economic and medical systems that impacted his use of opiates. The shutting down of coal mines and businesses associated with the coal industry (housing, rail transportation, and facility maintenance provision) made a significant economic impact on communities and extended to multiple industries outside of mining. New houses were not being constructed, and local small businesses began to struggle and disappear. As a result, the need for concrete diminished and Jason’s boss was forced to lay off workers. Families like Jason’s were faced with a difficult choice: remain in a community in which they and multiple generations before them had lived and hope jobs would one day return or uproot their families in search of employment opportunities elsewhere. Many families chose the latter—which left the small town void of human resources and an adequate tax base from which to provide municipal and human services.
Jason’s long-term treatment provider should take into account employment opportunities within the community and assess if Jason has adequate training for today’s workforce. Vocational rehabilitation counseling is recommended to assess his skills and to determine if further education is needed. All of the local helping service providers (e.g., medical, addictions, mental health, vocational, and school professionals) in Jason’s town are overwhelmed because of high needs and dwindling financial resources. As such, Jason’s counselor must be aware of mesosystem-level obstacles; these interactions between microsystems may be fraught because of the challenges being experienced in each system. For example, the process of one facility making a referral to another can be difficult because of high demand and a lack of resources in either system. For clients like Jason, already struggling with shame and disenfranchisement, a mesosystem-level challenge might be taken personally and be potentially triggering. A counselor working with Jason through an ecological lens could engage with him regarding such an obstacle, and draw parallels to other system-to-system interactions that have affected him (e.g., how decline of coal is impacting other economic opportunities in his town; how the influx of cheap heroin is impacting hospitals, treatment centers, and neighborhoods). As mentioned above, increasing a client’s awareness as aperson in a system may help create more accurate assessments of the forces at play within the respective environments.
Exosystem: Interactions between two or more environments, at least one of which does not include the individual.In addition to the economic shifts noted in the previous section, important changes in the way pharmaceutical companies marketed prescription opioids to both consumers and medical providers impacted the availability of these narcotics in the communities where Jason lived. Jason was told by physicians that the drugs he was prescribed carried a very low risk of addiction and was given documentation supporting the effective and safe use of Oxycontin as a treatment for pain (Van Zee, 2009). Jason was not aware that his physician had attended an all-expenses-paid pain management conference at a Florida resort, hosted by Purdue Pharma, or that his doctor had been invited to become a speaker for the company. He also was not aware that his physician was being tracked by Purdue as a frequent prescriber of OxyContin and thus receiving increased attention and gifts from their regional sales representative, who was eagerly pursuing an annual sales bonus that could more than double her salary.
These distal variables had a profound effect on Jason as an individual, along with many other examples in the mesosystem: his Ohio boss’s enforcement of company policies regarding drug use and addiction; health care policies about prescription opiates, addictions treatment (including medication-assisted therapies), and insurance for people with pre-existing conditions; drug traffickers contaminating heroin with fentanyl and pushing an influx of heroin into Jason’s vulnerable community; and state and local policy regarding the availability and administration of naloxone—which likely saved Jason’s life. If Jason’s counselor views Jason and the helping process through an ecological lens including such variables, both counselor and client will be better prepared to co-construct a treatment narrative around the past, present, and future that draws upon Jason’s strengths and recognizes his limitations within the realities of a complex system.
Macrosystem: Cultural, political, economic, societal backdrop.Jason’s current circumstances have unfolded against a multifaceted socio-political backdrop, influencing many clinically salient factors in his treatment. The economic decline of his hometown is not isolated, but rather part of global trends related to the urbanization of wealth and resources. There has been a marked decline in well-paying blue-collar jobs with benefits, overall economic dislocation due to automation, and an increasing need for advanced education in order to be competitive for open positions. Technology has increased the breadth and depth of information available to the average American, and those who cannot afford access to technology fall further and further behind. With access to information about opportunities available elsewhere, young adults from small rural communities increasingly leave areas their families may have resided in for multiple generations. Religious authority and institutions have declined, and the purpose and services churches traditionally provided in rural areas have also eroded. State- and federal-level health care policy, pharmaceutical industry regulations, scientific progress in the fields of pain management and addiction, and changing norms in our cultural understanding of addiction, treatment, and outcomes are all at play in the macrosystem.
As part of Jason’s long-term treatment, psychoeducation and client-centered processing regarding these and other macrosystem variables can support multiple treatment goals, particularly those related to issues of shame. Placed within a broad ecological context, Jason’s feelings of anger and shame can be normalized while facilitating a shift from a personalized focus (e.g., “I am bad,”) to a broader perspective (e.g., “These are difficult times, and new skills I never had the chance to learn before are needed for survival”).
Chronosystem: Historical context and changes in environments over time. In developing a comprehensive treatment plan, along with the systems already outlined, the ecologically sensitive counselor should help Jason plan for challenges that are likely to occur over time as a result of his developmental process, along with the historical moment in which Jason lives. He is 37 years old and still in the first half of his working life. He has adolescent children who will be growing into young adulthood; they may look toward him for guidance or choose to challenge and reject him. This moment in time is a developmentally critical one for Jason’s family.
At the time of writing this article, the United States is in the midst of a number of policy debates that will have an enormous effect on Jason’s life and health (Kessler, 2018). Long-term funding and access to health care is a contentious and unsettled issue. Ecologically aware counselors should both monitor and engage in the unfolding policy debates related to the funding of substance abuse treatment and other ongoing services Jason and clients like him need now and in the future. Furthermore, economic trends toward clean energy, globalization, technology, urbanization, and higher education continue to accelerate; the world is already a different place than when Jason first started working, or when he first started using drugs as a means to cope with pain. Jason and those seeking to help him must have accurate, up-to-date knowledge of how industry trends are impacting local and regional sectors, and devise strategies to engage and compete in the current economic environment.
Although vital, it is not enough for Jason’s counselor to help him survive only in the present moment. The counselor should anticipate future challenges Jason will confront and assist him in mapping out a sustainable, long-term plan. Such a plan will normalize the influence of both individual- and systems-level variables, emphasizing the importance of multiple sources of support, maintenance of his sobriety, and the inevitability of confronting both developmental and historical challenges. Just as a person with progressive multiple sclerosis needs to anticipate their future medical and assistive technology needs, so does Jason need to identify and plan for his future health, wellness, and economic needs within our rapidly changing society. An ecologically sensitive counselor understands both Jason’s personal development and larger historical trends, and is thus able to advocate for Jason’s preparation to survive and thrive over time.
Advocacy as an Inherent Element of Ecologically Informed Treatment
Over the past few decades, the counseling profession has increasingly recognized that advocacy is a vital component of the counselor’s role (Chang, Barrio Minton, Dixon, Myers, & Sweeney, 2012; Ratts, Toporek, & Lewis, 2010). Counselors are ethically required to understand their clients in a deeply contextualized manner and have a responsibility to try and reduce social and ecological barriers that may be blocking their clients’ growth, development, and flourishing, and exacerbating their clients’ mental and physical health challenges. Understanding the pivotal role ecological factors play in clients’ health, relationships, and careers has long been central to the field of rehabilitation counseling (Parker & Patterson, 2012). Issues such as accessibility and universal design were recognized as central to the success of people with disabilities, just like evidence-based treatments. For example, if a client who uses a wheelchair is seeking to participate in a program or obtain a job requiring access to a particular building, and that building lacks accessible parking or public transportation, curb cuts, and an accessible entrance and bathroom, the client is likely going to be blocked from reaching goals. Such systemic, advocacy-oriented thinking can be applied to the current opioid crisis.
As described in the previous sections, using Bronfenbrenner’s ecological model and creating an eco-map as a tool in the client conceptualization process led to the identification of a wide range of variables related to Jason’s treatment and recovery. Counselors need both awareness of and knowledge about factors affecting their clients at multiple systemic levels. Advocacy as understood within this model includes understanding labor market trends and participating in public policy discussions concerning support for workers displaced by globalization and automation. It means working to obtain more medical resources and treatment centers for clients struggling with addiction, striving to change laws to emphasize treatment over incarceration, and providing more access to life-saving medications such as naloxone. In short, the pursuit of social justice and counselors’ roles as advocates are intrinsic in this model of conceptualization and intervention, highlighting the clinical and societal relevance of a broad range of systemic variables and public policy debates.
One area in which counselors can advocate for the improved access to services for those struggling with opioid use is through supporting programs, such as the Mental Health Facilitator program (Hinkle, 2014), aimed at training laypersons with the basic skills to identify, briefly intervene with, and refer people in their communities who are experiencing a mental health crisis. The increased presence of persons with such skills in the microsystem—in schools, hospitals, faith communities, businesses, and neighborhoods—creates opportunities for detection, referrals to treatment, and life-saving emergency interventions, particularly among underserved populations. Mental Health First Aid is an international, evidence-based, 8-hour training course that teaches community members steps they can take if they encounter a person who is having an emergency, such as having suicidal ideation, a panic attack, or an overdose. Mental Health First Aid has recently added opioid-specific overdose training and naloxone administration to their curriculum (Pellitt, 2018).
Ecological thinking is a powerful skill, and one we argue is necessary for clinically competent counseling. The ecological conceptualization and treatment planning process outlined in this article is designed to provide a structured and systematic template for helping counselors identify clients’ complex needs, as well as the many influential variables at play in the past, present, and future. Engaging from an ecological perspective requires counselors to understand their clients as embedded in multiple systems. Further, it calls upon counselors to develop a deep understanding of the social, economic, and political contexts in which their clients live, and to develop systemic intervention skills. Utilizing this model in clinical settings could enrich the lives of clients, who may come to embrace a more nuanced and inclusive way of conceptualizing themselves and their environment.
Counselors-as-advocates are inherent in this model, and those professionals who espouse ecological thinking cannot ignore the multitude of powerful forces that either enhance or impede our clients’ well-being. Clinicians who understand and engage with their clients through this lens may find that ecological psychoeducation can lead to clients-as-advocates as well. Clients who come to understand themselves and others as people in environments may find their individual-level goals are supported and enhanced by goals associated with learning about and eventually acting upon systems-level variables in their lives, thus increasing the recovery capital (Hewell et al., 2017) available to them within their own environments. Attention to the American opioid epidemic is increasing based on advocacy by citizens, journalists, public servants, and health professionals. As focus and resources are directed to this complex problem, ecologically informed interventions by stakeholders in all of the interconnected systems are advised to both save and improve lives now and in the future.
Conflict of Interest and Funding Disclosure The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
Angres, D. H., & Bettinardi-Angres, K. (2008). The disease of addiction: Origins, treatment, and
Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.
Bronfenbrenner, U. (1994). Ecological models of human development. In M. Gauvain & M. Cole (Eds.), Readings on the development of children (2nd ed., pp. 37–43). New York: Freeman.
Chang, C. Y., Barrio Minton, C. A., Dixon, A. L., Myers, J. E., & Sweeney, T. J. (Eds.). (2012).
Professional counseling excellence through leadership and advocacy. New York, NY: Routledge.
Dasgupta, N., Beletsky, L., & Ciccarone, D. (2018). Opioid crisis: No easy fix to its social and economic determinants. American Journal of Public Health, 108, 182–186. doi:10.2105/AJPH.2017.304187
Gul, R. B., & Boman, J. A. (2006). Concept mapping: A strategy for teaching and evaluation in nursing education. Nurse Education in Practice, 6, 199–206. doi:10.1016/j.nepr.2006.01.001
Hewell, V. M., Vasquez, A. R., & Rivkin, I. D. (2017). Systemic and individual factors in the
buprenorphine treatment-seeking process: A qualitative study. Substance Abuse Treatment, Prevention, and Policy, 12(3), 1–10. doi:10.1186/s13011-016-0085-y
Hinkle, J. S. (2014). Population-based mental health facilitation (MHF): A grassroots strategy that works. The Professional Counselor, 4, 1–18. doi:10.15241/jsh.4.1.1
Hooten, W. M., St. Sauver, J. L., McGree, M. E., Jacobson, D. J., & Warner, D. O. (2015). Incidence and risk factors for progression from short-term to episodic or long-term opioid prescribing: A population-based study. Mayo Clinic Proceedings, 90, 850–856. doi:10.1016/j.mayocp.2015.04.012
Katz, J. (2017a, June 5). Drug deaths in America are rising faster than ever. The New York Times. Retrieved from https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html
Katz, J. (2017b, September 2). The first count of fentanyl deaths in 2016: Up 540% in three years. The New York Times. Retrieved from https://www.nytimes.com/interactive/2017/
Kessler, D. A. (2018, January 10). How to fight the opioid crisis. The New York Times. Retrieved from https://www.nytimes.com/2018/01/10/opinion/fight-opioid-crisis.html
Keyes, K. M., Cerdá, M., Brady, J. E., Havens, J. R., & Galea, S. (2014). Understanding the rural–urban differences in nonmedical prescription opioid use and abuse in the United States. American Journal of Public Health, 104(2), e52–e59. doi:10.2105/AJPH.2013.301709
Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W., & Alexander, G. C. (2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 36, 559–574.
Kosten, T. R., & George, T. P. (2002). The neurobiology of opioid dependence: Implications for treatment. Science & Practice Perspectives, 1, 13–20.
McCoy, K., McGuire, J., Curtis, R., & Spunt, B. (2005). White chicks on dope: Heroin and identity dynamics in New York in the 1990s. Journal of Drug Issues, 35, 817–841. doi:10.1177/002204260503500408
Parker, R. M., & Patterson, J. B. (Eds.). (2012). Rehabilitation counseling: Basics and beyond (5th ed.). Austin, TX: Pro Ed.
Pellitt, S. (2018, May 10). Briefing showcases Mental Health First Aid and opioid epidemic [Web log post]. Retrieved from https://www.thenationalcouncil.org/capitol-connector/2018/05/briefing-showcases-mental-health-first-aid-and-opioid-epidemic/
Peltz, P. (Director). (2017). Warning: This drug may kill you. [Motion picture]. United States: HBO Documentary Films.
Ratts, M. J., Toporek, R. L., & Lewis, J. A. (2010). ACA advocacy competencies: A social justice
framework for counselors. Alexandria, VA: American Counseling Association.
Rudd, R. A., Seth, P., David, F., & Scholl, L. (2016). Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. Morbidity and Mortality Weekly Report, 65, 1445–1452.
Skolnick, P. (2018). The opioid epidemic: Crisis and solutions. Annual Review of Pharmacology and Toxicology, 58, 143–159. doi:10.1146/annurev-pharmtox-010617-052534
Suzuki, J., & El-Haddad, S. (2017). A review: Fentanyl and non-pharmaceutical fentanyls. Drug & Alcohol Dependence, 171, 107–116. doi:10.1016/j.drugalcdep.2016.11.033
Talbot, M. (2017, June 5). The addicts next door. The New Yorker. Retrieved from https://www.newyorker.com/magazine/2017/06/05/the-addicts-next-door
Ungar, M., Ghazinour, M., & Richter, J. (2013). Annual research review: What is resilience within the social ecology of human development? Journal of Child Psychology and Psychiatry, 54, 348–366. doi:10.1111/jcpp.12025
Vance, J. D. (2016). Hillbilly elegy: A memoir of a family and culture in crisis. New York, NY:
Van Zee, A. (2009). The promotion and marketing of OxyContin: Commercial triumph, public health tragedy. American Journal of Public Health, 99, 221–227. doi:10.2105/AJPH.2007.131714
Williams, J. M., McMahon, H. G., & Goodman, R. D. (2015). Eco-webbing: A teaching strategy to facilitate critical consciousness and agency. Counselor Education and Supervision, 54(2), 82–97. doi:10.1002/ceas.12006
Jennifer L. Rogers, NCC, is an assistant professor at Wake Forest University. Dennis D. Gilbride is a professor at Georgia State University. Brian J. Dew, NCC, is an associate professor at Georgia State University. Correspondence can be addressed to Jennifer Rogers, P.O. Box 7406, Winston-Salem, NC 27109, firstname.lastname@example.org.
Many theories are used to conceptualize adolescent substance use, yet none adequately assist mental health professionals in assessing adolescents’ strengths and risk factors while incorporating cultural factors. The authors reviewed common adolescent substance abuse theories and their strengths and limitations, and offer a new model to conceptualize adolescent substance use: The Adolescent Substance Use Risk Continuum. We posit that this strengths-based continuum enables clinicians to decrease stigma and offer hope to adolescents and their caregivers, as it integrates relevant factors to strengthen families and minimize risk. This model is a tool for counselors to use as they conceptualize client cases, plan treatment and focus counseling interventions. A case study illustrates the model and future research is suggested.
Keywords: adolescents, substance use, case conceptualization, cultural factors, strengths-based
For decades, theorists have worked to understand adolescent behaviors and conceptualize adolescent substance use. These theories have provided a strong base to conceptualize adolescent substance use, yet none integrate important counseling-focused concepts such as strengths and cultural factors. The Adolescent Substance Use Risk Continuum (ASURC) expands upon previous theoretical models and is designed to enhance counselors’ ability to conceptualize adolescent substance use from a strengths-based, stigma-reducing, and culturally sensitive perspective. The ASURC adds to counselors’ abilities to conceptualize adolescent substance use and enhances their abilities to create comprehensive treatment plans and interventions.
The theory of planned behavior (TPB; Ajzen, 1985), social learning theory (SLT; Akers, 1973), social control theory (SCT; Elliott, Huizinga, & Ageton, 1985), and social development theory (SDT; Hawkins & Weis, 1985) are four theories that have been applied to adolescent substance use. The TPB was developed to describe an individual’s behavior in a general sense, while the other three theories were developed to explain deviant and delinquent behavior. Even though these four theories were developed in the 1970s and 1980s and were not developed specifically for adolescent substance use, researchers have applied these theories to predict substance use within this population (Corrigan, Loneck, Videka, & Brown, 2007; Malmberg et al., 2012; Schroeder & Ford, 2012).
The TPB was developed as an expansion of the theory of reasoned action, which describes behavior as contingent upon an individual’s beliefs about a certain behavior and the perceived social pressure on the individual to perform that behavior (Ajzen, 1985). In addition to individual beliefs and perceived social pressure, the TPB adds an additional element to describe behavioral intention: self-efficacy. Self-efficacy refers to one’s perception of control to complete certain behaviors (Ajzen, 1985). Petraitis, Flay, and Miller (1995) introduced two types of self-efficacy related to adolescent substance use: use self-efficacy and refusal self-efficacy. Use self-efficacy consists of adolescents’ beliefs about their ability to obtain alcohol or other drugs, whereas refusal self-efficacy is indicative of adolescents’ beliefs about their abilities to refuse social pressure to use substances (Petraitis et al., 1995).
SLT was developed to explain so-called deviant behavior, and it is heavily influenced by behavioral theories, particularly operant conditioning and reinforcement. Therefore, behavior is learned when it is reinforced (Akers, 1973). The anticipation of either reinforcement or punishment can lead to behavioral increase or decrease, depending on who has the most influence on the adolescent, and who controls the reinforcement or punishment. Delinquent behavior can be influenced and maintained by a variety of sources, including parents, family, peers and school (Petraitis et al., 1995).
Similar to SLT, SCT emphasizes the importance of rewards and punishments in terms of deviant or delinquent behavior (Elliott et al., 1985). The result of either punishment or reinforcement is influenced mainly by an individual’s socialization into what the authors described as conventional society (Elliott et al., 1985). Conventional society points to general societal norms, largely congruent with dominant cultural norms. Therefore, according to SCT, an adolescent with a strong attachment to conventional society would have stronger internal and external controls and would be less motivated to choose delinquent behaviors. Inversely, an adolescent with a weak attachment to conventional society would have weaker internal and external controls and be more likely to engage in deviant behaviors (Elliot et al., 1985).
Hawkins and Weis (1985) integrated SLT and SCT to develop the SDT. The SDT is a developmental model of delinquent behavior that focuses on how adolescents are socialized through family, peers and school. Delinquent behaviors develop when adolescents are not socialized into conventional society appropriately. Opportunities for involvement with conventional individuals are seen as necessary but not sufficient for an individual to develop positive social bonds (Hawkins & Weis, 1985). There are two mediating factors associated with this socialization process toward positive social bonds: skills possessed by an adolescent and reinforcement of the opportunities for involvement (Hawkins & Weis, 1985). Skills that enhance an adolescent’s ability toward social bonds include adolescents’ social skills, or skills needed to interact and form social bonds with others (Hawkins & Weis, 1985). Similar to SLT and SCT, the SDT stresses the need for reinforcement, where behavior must be reinforced to continue (Hawkins & Weis, 1985).
Strengths and Limitations of Theoretical Underpinnings
The aforementioned models have made significant contributions to how counselors conceptualize adolescent substance use. Particularly, these models highlight the role social influences play in adolescent substance use and, accordingly, how social influences impact behavioral factors like reinforcement, punishment and reward (Akers, 1973; Elliot et al., 1985; Hawkins & Weis, 1985; Petraitis et al., 1995). Additionally, all models have been validated empirically to be predictive of adolescent substance use (Corrigan et al., 2007; Malmberg et al., 2012; Schroeder & Ford, 2012). Although these studies provide empirical support for predicting adolescent substance use and highlight social influences and behavioral factors, limitations exist, namely a lack of specificity related to social influences, the use of problematic language, and failure to incorporate cultural factors and contexts. Below, we detail the strengths and limitations of the aforementioned models to provide a rationale for a more encompassing, strengths-based approach to conceptualizing adolescent substance use.
Research has shown that social factors, such as family and peer group, play a mediating role in adolescent substance use in both positive and negative ways (Piko & Kovács, 2010; Van Ryzin, Fosco, & Dishion, 2012). Also, research highlights how important social influences are on adolescents’ substance use. The TPB suggests that substance use is dependent upon the adolescent’s individual attitudes of substance use and perceived social pressure to use substances (Petraitis et al., 1995). SLT and SCT emphasize how behavior, including substance use, is learned through reinforcement or punishment (Akers, 1973 Elliott et al., 1985). Someone in the adolescent’s life has to reward or punish the adolescent’s substance use for it to continue or cease.
Further, the SDT emphasizes the socialization process in regards to deviant behavior in adolescents. According to the SDT, socialization begins within the family unit, where a child has variable opportunities to develop social, cognitive and behavioral skills (Hawkins & Weis, 1985). As a child grows older, ostensibly these skills are reinforced positively within the school setting and peer group (Hawkins & Weis, 1985). However, if children are not socialized appropriately in the family system, children may not develop socially, cognitively and behaviorally as expected. In turn, they may turn to substance use to cope with stressful life events. Further, if adolescents were not socialized appropriately in early childhood, they may be at greater risk to become involved with adolescents who use substances.
While the four theories emphasize social influences as a factor in adolescent substance use, the TPB, SLT and SCT used the term social influences in a general sense only, and do not differentiate between the different types of social influences. There are a variety of social influences, including family, peers, school, sports teams, clubs and religious organizations, and each can have a varied impact on adolescents’ substance use. For example, involvement in religious organizations can protect some adolescents from substance use (Steinman & Zimmerman, 2004), while engagement with sports teams may increase adolescent substance use for others (Farb & Matjasko, 2012). The SDT was the only model discussed that divides socialization into three units: family, peer and school; however, the SDT suggests that family, peer, and school units all go through the same development process, seemingly at the same rate. Presumably, an adolescent is given the same opportunity for involvement with all three units toward the goal of creating healthy social bonds, and these opportunities are influenced by an adolescent’s current social skills and reinforcement from others (Hawkins & Weis, 1985). This adolescent substance use conceptualization can be problematic because it suggests the family, peer group and school all go through the same developmental process simultaneously and fails to recognize that different units can have different influences (some positive, some negative) on an adolescent, and these influences may develop asymmetrically. Further, the SDT proposes that a “social bond” (Hawkins & Weis, 1985, p. 80) to conventional society is a common goal and that adolescents have the social skills in place to create these bonds. Although it is hoped that adolescents will have strong social skills and that their support systems will endeavor to create healthy social bonds, this may not be the case for all adolescents. Further, some adolescents who have strong social skills may use them to procure substances and influence others to use.
The developers of SLT, SCT, and SDT used the terms deviant behavior, delinquent behavior, and conventional society to describe aspects contained in their theories. In juvenile justice literature, the terms deviant and delinquent point to adolescent behaviors considered to be age-inappropriate and destructive to self and family, as well as illegal (Pope, 1999). However, these terms are not used to simply describe behaviors as they were intended—they have become labels used to classify and marginalize adolescents who have made poor choices and acted in ways incongruent with conventional society (Constantine, 1999). Often, these terms are applied to adolescents who encompass non-dominant cultural identities (e.g., race, social class), which can serve to further oppress and marginalize adolescents who may experience societal and structural inequality. At the very least, these terms define adolescents by choices they have made and may lead to assumptions about who they are, adding additional stigma and shame to worthy individuals who can learn to make different choices, which is incongruent with a strengths-based perspective.
Conventional society is a term used to describe societal norms, determined most often by dominant U.S. cultural groups (Duncan, 1999). Similar to the issues with the terms deviant and delinquent, the term conventional society may not account accurately for cultural nuances and differences that vary from dominant culture expectations, furthering societal and structural oppression, discrimination and inequality clients experience (Constantine, 1999). For example, according to SCT, weak attachment to conventional society contributes to weaker internal and external controls, and an adolescent can develop a weak attachment to conventional society when she experiences a strain between her aspirations and her perceptions of the opportunity to actualize such aspirations. Therefore, through an SCT lens, if this adolescent lives in a low-income neighborhood where crime and unemployment are prevalent, she may be perceived to have a weak attachment to conventional society (Petraitis et al., 1995), without taking into account that her environment is out of sync with conventional society and cultural norms as defined by the dominant culture.
The final common limitation of the aforementioned models is the lack of inclusion of cultural influences on adolescents’ substance use. As mentioned previously, these four models highlight the importance of social influences on adolescents’ substance use yet do not specifically take cultural factors into consideration. The TPB discusses social influences in regard to an adolescent’s beliefs and perceived social pressure (Ajzen, 1985); however, there is no mention that these beliefs might be influenced by cultural values and experiences. Similarly, SLT suggests that an adolescent’s deviant behavior is influenced by positive or negative reinforcement received within the social context (Akers, 1973), yet fails to acknowledge that these positive or negative reinforcements are most likely influenced by cultural factors. The SDT outlines the socialization process through three different units (Hawkins & Weis, 1985), all of which exist within cultural contexts that influence adolescents’ substance use, yet the authors do not cite this as a possibility. Similarly, SCT discusses social influences on a systemic level, focusing on adolescent academic and occupational goals (Elliott et al., 1985). Adolescents’ cultural factors can influence their academic and occupational goals, as well as their perception of the likelihood of obtaining these goals. The theme among these four models is that they include factors influenced by culture without specifically mentioning or addressing culture or cultural variations.
We suggest a conceptual model for adolescent substance use that addresses specific social influences, uses inclusive and strengths-based language, and integrates cultural factors. We propose the ASURC as a model to meet this need. The ASURC asserts that while different social contexts are intertwined with one another, they all influence adolescent substance use in distinct ways. Further, the ASURC model uses strengths-based terms to reduce stigma and shame, and empowers clients and their caregivers to make person-affirmative choices. Finally, the ASURC integrates cultural components into all aspects of the model in order to provide appropriate context, acknowledging that adolescent substance use develops in a cultural context.
The Adolescent Substance Use Risk Continuum
The aforementioned theoretical models contain strengths and limitations and influenced the development of the ASURC model. Prior models emphasized social influence on adolescent substance use, and we emphasize social influences in our model as well. However, we believe that different social systems will have different influences on each adolescent, and each social system develops at its own rate. Further, the included areas are not meant to be predictive of substance use, and can serve both as strengths and risk factors, depending on the individual’s circumstances. The areas featured in our model include: parental and caregiver engagement, relationship between parents and caregivers and adolescent, family history of substance use, biological factors, level of susceptibility to peer pressure, childhood adversity, and academic engagement. While we believe the areas in our model have distinct impacts on adolescents, all areas interact and influence one another, and all areas are influenced by singular and intersecting cultural identities.
The ASURC emphasizes the importance of cultural considerations when conceptualizing adolescent substance use. We used Hays’ (1996) “ADDRESSING” model as a foundation. The included cultural factors are by no means exhaustive; counselors are encouraged to expand this list to work with their clients appropriately. Cultural factors should be considered in terms of the individual, family, community and societal contexts when applied to the ASURC areas. Further, it is important to consider ways in which cultural identities can serve as protective or risk factors, depending on the individual’s dominant and non-dominant cultural identities, and the identities most salient to the client. Client cultural influences are subjective experiences, and counselors should take great care and time to determine their relevance for each client.
Further, the ASURC is a strengths-based approach to conceptualizing adolescent substance use. Previous theories contain the use of problematic language, such as conventional society, deviant behavior, and delinquent behavior, when describing adolescent substance use. We feel the use of this language can lead to stigma and instill a sense of shame for this population. Focusing on strengths while using the ASURC will aid clinicians in fostering a sense of hope while working with this population. Strengths are not a separate component of the model, but rather are incorporated in each aspect of the model.
As the name suggests, the ASURC (Adolescent Substance Use Risk Continuum) is a continuum, ranging from minimal risk to high risk. The continuum starts at minimal risk instead of no risk because substance use and addiction can occur in anyone. Further, a continuum suggests that an adolescent can move bi-directionally along the continuum depending on changes. This potential for movement can instill hope and serve to reduce shame associated with adolescent substance use. To use the ASURC model (see Figure 1), one starts at the bottom of the model and considers how the areas listed serve as adolescent protective or risk factors. When working through these areas, cultural identities are incorporated. These identities are represented above the entire model to indicate how they influence everything underneath them. Cultural factors should be considered from the perspective of the individual, family, community and society as a whole, because their influence could be different in each area. Finally, the counselor determines where the adolescent falls on the risk continuum. Because multiple aspects influence an individual’s location on the continuum, it is important to note the protective and risk factors associated with each of the model’s areas for any specific client. This assessment can assist counselors in developing holistic treatment plans that address not only adolescents’ substance use, but also their strengths and areas that could be enhanced as they strive to eliminate substance use.
There are many cultural factors to consider when conceptualizing adolescent substance use. The ASURC is based on Hays’ (1996) ADDRESSING model. There are nine overlapping cultural influences included in the ADDRESSING model: age, disability status, religion, ethnicity, socioeconomic status, sexual orientation, indigenous heritage, national origin and gender (Hays, 1996). To these we added race and language. This list is not exhaustive but rather a starting point to consider how culture can be a protective or risk factor for adolescents.
When clinicians consider adolescents’ cultural identities, it is important to do so within individual, family, community and societal contexts. To consider only one context diminishes the multiplicity of adolescents’ experiences, and it can negate the impact these contexts have on them. For example, it is common for societal context to be overlooked in favor of individual experiences due to the importance placed on individualism by the dominant culture (Johnson, 2006). When societal context is neglected, structural inequality may be ignored. Structural inequality denotes the oppression or restrictions non-dominant groups experience when they attempt to access resources, including mental health treatment, which are available without hindrance to dominant culture groups. Structural inequality can impact adolescents’ beliefs about their ability to choose not to use substances and their ability to achieve success and access resources, and can reduce hope about their life circumstances (Hancock, Waites, & Kledaras, 2012).
Religion and spirituality. Religion and spirituality can be a protective factor for adolescents. Higher levels of religious involvement tend to correlate with lower levels of substance use (Mason, Schmidt, & Mennis, 2012). Mason et al. (2012) identified two specific aspects of religiosity associated with lower levels of alcohol and drug use: social religiosity and perceived religious support. Social religiosity refers to public displays of religious behavior, such as church attendance and participation in religious activities; perceived religious support encompasses emotional support one receives from a religious institution as well as tangible support like materials or money donated by a religious organization (Mason et al., 2012). Private religiosity, such as personal importance of religion and individual prayer, was not found to be a protective factor (Mason et al., 2012), suggesting the more social aspects of religion are more beneficial for preventing adolescent substance use. Similarly, religion may be a risk factor when adolescents, such as lesbian, gay, or bisexual (LGB) youth, feel judged, shamed, or shunned by their religious community, which may increase the likelihood of substance use (Barnes & Meyer, 2012).
Ethnicity. Ethnicity is significant because reported substance abuse and dependence rates are higher for people of color than for White people in the population (Substance Abuse and Mental Health Services Administration, 2012). Of the total population of people of color, who represent only 38.5% of the U.S. population, 9,319,277 people reported substance abuse and dependence. This number is particularly staggering when compared to White people, who represent 61.5% of the population, 15,713,373 of whom reported substance abuse and dependence (Substance Abuse and Mental Health Services Administration, 2012). These statistics demonstrate that adolescents of color are more likely to develop substance abuse issues than their White counterparts. However, these statistics do not incorporate issues related to structural inequality, nor do they speak to restricted treatment access or racial groups’ protective factors that could be bolstered. For example, Native Americans, who have the highest statistical rate of substance use, also emphasize spirituality and the importance of the extended family (Sue & Sue, 2013). These factors can serve as protective factors for Native American adolescents. Similarly, researchers have found religious engagement among African American adolescents to be a protective factor (Steinman & Zimmerman, 2004). African American adolescents who attended religious services regularly had lower substance use rates than their peers who did not.
Socioeconomic status. Socioeconomic status (SES), particularly education level, influences substance use in adolescents, and subsequently intersects with race and ethnicity. Adolescents who drop out of high school are more likely to engage in substance use, and lower levels of education are associated with higher prevalence of substance-related diagnoses (Henry, Knight, & Thornberry, 2012). American Indian, Latino, and African American adolescents’ math and reading proficiency rates are less than half of White adolescents, most likely due to structural inequality in low-income schools. Students in these groups are less likely to graduate from high school than their White peers (Henry et al., 2012). Furthermore, living in poverty or low SES are associated with higher risks of substance use, and adolescents from racial minority groups are at a higher risk for living in poverty and low-SES families (Van Wormer & Davis, 2013).
Sexual orientation. Sexual orientation is another cultural factor to consider. The LGB community is at greater risk for substance use compared to heterosexual individuals (Brooks & McHenry, 2009). One explanation for the increased risk in the LGB community may be due to homophobia and heterosexual superiority and internalized homophobia, which can lead individuals in the LGB community to turn to substances as a way to cope (Brooks & McHenry, 2009). Further, gay bars are a mainstay of the LGB community, and even though adolescents may not be allowed to drink legally, bar environments may be integral during adolescents’ coming out process (Brooks & McHenry, 2009). Socialization in a bar environment can lead to adolescent substance use as a way to fit in and cope.
Caregiver Engagement and Adolescent–Caregiver Relationship
Family environment can serve as a protective or risk factor for adolescent substance use. A key factor associated with family environment is parental or caregiver supervision. Strong caregiver supervision has been shown to minimize an adolescent’s risk-taking behavior, such as substance use (Van Ryzin et al., 2012). While caregiver supervision is an important protective factor for adolescents, it also is important for adolescents to be able to experience a sense of autonomy within their family of origin. Allen, Chango, Szwedo, Schad, & Marston (2012) defined autonomy within the family of origin as adolescents’ ability to have opinions and beliefs that differ from their caregiver(s) and can be fostered through a supportive adolescent–caregiver relationship. Positive relationships between caregivers and adolescents can increase self-esteem and healthy coping skills, leading to a decrease in risk-taking behaviors (Piko & Kovács, 2010). According to Piko and Kovács (2010), high levels of both satisfaction and caregiver support perceived by the adolescent define this positive relationship. Further, positive relations within the family can lead to higher levels of family obligation perceived by the adolescent. Family obligation is the perceived importance of spending time together, family unity and family social support; higher levels have been found to deter adolescents from unhealthy risk taking, including the use of alcohol and drugs (Telzer, Fuligni, Lieberman, & Galván, 2013).
Conversely, low caregiver involvement can be a risk factor for adolescent substance use. Adolescents who have low caregiver supervision are more likely to engage with peers who use substances and, subsequently, use substances as a way to find social support (Van Ryzin et al., 2012). Additionally, adolescents who do not have positive relationships with their caregivers have a more difficult time self-regulating their behaviors and increased risk for using substances as a way to cope with stress (Hummel, Shelton, Heron, Moore, & van den Bree, 2013).
Family Substance Abuse History and Biological Risks
Family history of substance use is an additional risk factor for adolescents. Children of parents and caregivers who abuse alcohol are four times more likely to develop an addiction (Van Wormer & Davis, 2013). This risk may be partly due to biological predisposition, and part may be environmental. Scientists have begun to better understand how genes affect substance use disorder development and posit that 40–60% of alcohol use disorders can be explained by genes (Van Wormer & Davis, 2013). It can be difficult to determine whether an individual’s addiction is inherited through genetic composition or is learned via the family environment, or a combination of both. Genetics can include predisposition to impulsivity, and some scientists believe individuals at risk for substance use disorders may be biologically predisposed to overreact to stressful situations and life events. Individuals predisposed genetically to engage in sensation-seeking and impulsive behaviors are more likely to experiment with alcohol and other substances (Van Wormer & Davis, 2013). While biological risk can increase adolescents’ predisposition to develop addiction, it does not necessarily lead to addiction (Van Wormer & Davis, 2013). This message can instill hope and infuse self-efficacy in families who may have a history of substance abuse.
Adolescence is marked by an increase in risk-taking behaviors, which may be associated with developmental biology (Telzer et al., 2013). Adolescents show a heightened response in the ventral striatal, which is part of the brain’s reward system. This heightened response in the ventral striatal can cause adolescents to engage in more reward-seeking behaviors compared to children and adults. Further, adolescents show less activation in pre-frontal regions of the brain, the part of the brain in charge of executive functioning, which can lead to increased risk-taking behaviors (Telzer et al., 2013). Research has shown that an increase in family obligation can lead to decreased sensitivity in the ventral striatal and increased activity in the pre-frontal region of the brain (Telzer et al., 2013). These findings suggest that improved quality in the adolescent–caregiver relationship can jettison substance abuse. Specifically, increased family obligation can help buffer some adolescent biological risks for substance use.
Susceptibility to Peer Influences
Peer relationships can play a role in the development of adolescent substance use. During adolescence, individuals start to spend more time with peer groups than with their families (Piko & Kovács, 2010). Additionally, adolescence is marked by a heightened sense of reward. This focus on reward can lead to an increased desire for adolescents to please their peers, making it more difficult for them to resist peer pressure (Van Ryzin et al., 2012). If adolescents associate with peers who use alcohol and drugs, they are more likely to begin using substances as a way to be accepted by their peer group (Van Ryzin et al., 2012).
Inversely, if adolescents are associated with peers who are not involved in substance use, they are less likely to use substances (Van Ryzin et al., 2012). Moreover, there is a negative correlation between adolescents who are involved in supervised extracurricular activities and substance use (Farb & Matjasko, 2012). Specifically, involvement in school-based activities such as performing arts, leadership groups and clubs is associated with lower rates of substance use (Darling, Caldwell, & Smith, 2005). However, there is a positive correlation between athletics and substance abuse, meaning adolescents involved in athletics are more likely to engage in substance use (Farb & Matjasko, 2012). Researchers believe this positive correlation is due to the subculture of high school athletics that promotes alcohol and drug use (Denault, Poulin, & Pedersen, 2009).
Adolescents who experienced childhood adversity are at greater risk for developing substance use disorders (Benjet, Borges, Medina-Mora, & Méndez, 2013). Childhood adversity refers to family instability such as parental and caregiver mental illness, substance use, and criminal behavior, witnessing domestic violence, and experiencing abuse, neglect, interpersonal loss, and socioeconomic disadvantage. Researchers have suggested that this relationship is due to the self-medication hypothesis, in that adolescents who experience childhood adversity may turn to alcohol and drugs in order to alleviate the pain they encounter as a result of such experiences (Benjet et al., 2013).
Not only are adverse childhood experiences a risk factor for developing substance use disorders, but also for substance use opportunities (Benjet et al., 2013). One possible explanation for such opportunities is the presence of substances in the family environment. For adolescents who experienced child abuse or neglect or who witnessed domestic violence, there is an increased chance that substances were present in their household, making it easier for them to gain access to substances (Benjet et al., 2013).
The absence of childhood adversity can be a protective factor against adolescent substance use (Benjet et al., 2013). Another protective factor in terms of childhood adversity is early intervention (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011). Early intervention can help children develop healthy coping skills to manage stress. Healthy coping strategies can be implemented to replace more negative coping strategies like substance use (Durlak et al., 2011).
Academic engagement can have positive and negative effects on adolescents’ potential substance use. Adolescents who drop out of high school are more likely than their counterparts to engage in substance use (Henry, Knight, & Thornberry, 2012). Further, early school disengagement can be a warning sign to predict high school dropout (Henry et al., 2012). For some adolescents, school engagement can be a protective factor. Particularly, adolescents who experience a positive school climate and have strong school engagement are less likely to use substances (Piko & Kovács, 2010). A positive relationship between adolescents and their teachers can be another protective factor. Previous studies have shown that adolescents who have a positive relationship with their teachers and have a high level of perceived support from teachers are less likely to engage in substance use (Demanet & Van Houtte, 2012).
The case study below provides an example of how clinicians can use the ASURC to conceptualize and plan interventions when working with this population.
John is a 14-year-old, biracial male and high school freshman. He lives with his mother and grandmother, both of whom are African American, and they reside in a low socioeconomic neighborhood. Both John’s mother and grandmother work full-time, and his mother works a second job, leaving John unsupervised after school and on the weekends. John’s father, a 38-year-old Puerto Rican male, left the home when John was 4 years old. Prior to his father’s departure, John witnessed domestic violence between his parents. During a fight, John intervened on his mother’s behalf and his father hit him. After this event, John’s mother forbade her husband from living in their home and sought counseling services for her son. After his father left, John had only sporadic visits with him, mainly due to his father’s alcohol use. In addition to John’s father’s alcohol use, there is family history of substance use on his mother’s side. His maternal great-aunts use alcohol, and his maternal uncle uses marijuana daily.
This year, John made the varsity football team and has been spending time with the senior football players after practice during the week and on weekends. In addition to being involved with the football team, John is involved with his church community. At school, John is an average student, earning mostly Bs and Cs, and he reports that he enjoys learning.
John started drinking and smoking cigarettes shortly after joining the football team in order to impress the junior and senior football players. Initially, John was hesitant to drink or smoke; however, after using more frequently, he started to enjoy it and reported feeling more relaxed. Currently, John drinks with his friends on the football team two to three times a week and smokes with them daily. John drinks only when he is with this group of peers, yet he has started to smoke when he is alone.
Over the past two months, John’s grandmother has caught him sneaking back into the house at night smelling like alcohol and cigarettes. The first two times this occurred, John’s grandmother decided not to tell his mother because she believed John when he said it would not happen again. When John’s grandmother caught him a third time, she told his mother. John’s mother was surprised when she heard this news because she believed she and John had a close and honest relationship. Distraught, John’s mother brought him to counseling.
Case Analysis Using the ASURC Model
Conceptualizing this case using the ASURC model reveals that John has both protective and risk factors related to his substance use. In terms of his family environment, John’s mother reports that she and John have a close and honest relationship. This close relationship serves as a protective factor for John because a positive relationship between adolescents and their parents is associated with a decreased risk of adolescent substance use (Piko & Kovács, 2010). Yet, John has minimal supervision at night and on the weekends due to his mother and grandmother’s work schedules. Low caregiver supervision is a risk factor for John because research shows that it is associated with an increased risk of adolescent substance use (Van Ryzin et al., 2012). The family’s low SES impacts John’s low caregiver supervision, and low SES can be associated with a higher risk of substance use (Von Wormer & Davis, 2013).
This year, John joined the football team, and previous research has shown that involvement in athletics in high school can be a risk factor for substance use (Farb & Matjasko, 2012), and adolescents who become associated with peers who use are at an increased likelihood to use (Van Ryzin et al., 2012). Furthermore, adolescence is a period characterized by a heightened sense of reward (Van Ryzin et al., 2012), suggesting that John may have an increased desire to please his peers and difficulty resisting peer pressure. At this point in time, John is drinking only when he is with his friends on the football team, suggesting this peer group is influencing John, yet he has begun smoking alone. Additionally, John is involved in his church community, which serves as a protective factor because being involved in a faith community lowers the risk for substance use in adolescents (Mason et al., 2012). Religious engagement, particularly among African American adolescents, can be a protective factor (Steinman & Zimmerman, 2004), which may be true for John if he identifies with this part of his racial identity as a biracial youth.
The next area of risk and protective factors in the ASURC model is childhood adversity. John witnessed domestic violence between his parents when he was younger, and as a result of attempting to intervene on behalf of his mother, John was hit by his father, a risk factor for adolescent substance use (Benjet et al., 2013). Fortunately, John’s mother sought counseling services for her son after the incident occurred. Early intervention can help offset the negative effects of these experiences (Durlak et al., 2011), and it is possible counseling provided John with healthy coping strategies.
According to the ASURC model, biological factors can impact adolescent substance use. John has a family history of substance use on both his maternal and paternal sides, and genes can play a role in the development of substance use disorders (Van Wormer & Davis, 2013). Further, adolescents experience an increase in risk-taking behaviors due to biological changes associated with adolescence (Telzer et al, 2013), and these changes may cause John to engage in increased risk-taking and pleasure-seeking behaviors.
Higher levels of academic engagement correlate with lower levels of substance use (Henry et al., 2012). John reported that he enjoys learning, suggesting he could have a high level of academic engagement. Nonetheless, John is currently earning Bs and Cs at school, pointing to a disconnection between his motivation to learn and his current grades. This disconnect could be due to associated cultural factors. John is biracial and living in a low socioeconomic neighborhood, and adolescents who live in such neighborhoods and are racial minorities can be at a disadvantage due to structural inequality (Henry et al., 2012).
When taking all of the risk and protective factors into account, we placed John on the low end of moderate risk using the ASURC model. While John does have various risk factors contributing to his substance use, he also has protective factors that can help to buffer these factors. Further, John’s cultural identities impact him in various areas of the model. In particular, John’s biracial identity and living in a low socioeconomic neighborhood could be risk factors for substance use, while being involved in his church community is a protective factor. It would be important to explore with John how he views his race, SES, and religion, and if he sees them as protective or not. Further, it would be helpful to understand how John views his gender and sexual orientation, and how these identities affect his worldview.
Using the ASURC model to conceptualize John’s case can assist counselors with their interventions with John and his family. While using the model, a counselor is able to assist John and his family to identify current strengths such as positive family relationships, involvement in his church community, and potential for high academic engagement. Identifying these strengths allows John and his caregivers to concretize what is helpful in their situation and allows the counselor to encourage more of these behaviors as tools to strengthen weaker areas. For example, because there are strong family relationships, John’s mother and grandmother can increase their engagement with John when they are away from home via texts or phone calls. Increasing parental engagement will be beneficial for the family, particularly John’s mother and grandmother knowing who John is spending time with because his substance use is heavily influenced by his friendships on the football team. Similarly, because John likes to learn yet is not achieving high grades in school, tutoring programs can be sought to bolster his academic performance and solidify his academic engagement, as well as fill his time with positive activities that may decrease his desire to use. Additionally, it may be helpful to educate John and his caregivers about biological predispositions and risk factors in adolescence. This information can empower John to make positive choices when he understands both that he is not destined to develop an addiction and that he is experiencing normal physical changes. Additionally, it could prove helpful to talk with John and his family about how they might be experiencing structural inequality due to their race and SES. Engaging them in this conversation can normalize their experiences and serve to determine points where advocacy with and on behalf of the family may alleviate some of the strain they experience. Finally, because John’s risk level is on the low end of moderate, structured substance abuse treatment may not be warranted at this time. Interventions could include assessing John’s readiness to stop using and working through a change commitment while strengthening John’s protective factors in an effort to decrease his risk factors.
Currently, the ASURC is a conceptual framework yet to be evaluated for efficacy with adolescent populations. Empirical research is needed to determine the model’s viability, validity and efficacy. Further, qualitative research would inform clinicians about the ways in which adolescents and their families felt stronger and more empowered by engaging in counseling practices that use this model’s approach.
Further research can be conducted to evaluate the degree of influence different components of the model have on adolescents with substance use concerns. Also, future research could investigate the relationship the model components have with one another, particularly the interplay of different cultural identities. Research is warranted to determine additional ways in which cultural factors can be used to strengthen clients and their families to mitigate deficit-based research and the pervasive negative cultural messages about non-dominant cultural groups and their struggles with substance use.
The ASURC is a strengths-based approach focused on identifying protective and risk factors as counselors conceptualize adolescent substance use. While previous theories conceptualized adolescent substance use using strengths, they had limitations, including only discussing social influences in a general sense, use of problematic language, and lack of cultural influences. The ASURC builds upon the strengths of previous models while addressing their limitations. The ASURC model emphasizes the need for a strengths-based approach while working with adolescent populations and focuses on the importance of the consideration of cultural influences during the conceptualization process.
Finally, this model serves as a tool to help guide interventions that best serve adolescents and their families. Using the ASURC model for case conceptualization can help counselors determine the most salient factors of the model to the particular case, which will in turn assist in the treatment planning process. Future research is warranted to determine the viability of the ASURC model as an evidence-based practice.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. In J. Kuhl & J. Beckmann (Eds.), Action-control: From cognition to behavior (pp. 11−39). New York, NY: Springer.
Akers, R. L. (1973). Deviant behavior: A social learning approach (2nd ed.). Belmont, CA: Wadsworth.
Allen, J. P., Chango, J., Szwedo, D., Schad, M., & Marston, E. (2012). Predictors of susceptibility to peer influence regarding substance use in adolescence. Child Development, 83, 337−350.
Barnes, D. M., & Meyer, I. H. (2012). Religious affiliation, internalized homophobia, and mental health in lesbians, gay men, and bisexuals. American Journal of Orthopsychiatry, 82, 505−515.
Benjet, C., Borges, G., Medina-Mora, M. E., & Méndez, E. (2013). Chronic childhood adversity and stages of substance use involvement in adolescents. Drug and Alcohol Dependence, 131, 85−91.
Brooks, F., & McHenry, B. (2009). A contemporary approach to substance abuse and addiction counseling: A counselor’s guide to application and understanding. Alexandria, VA: American Counseling Association.
Constantine, M. G. (1999). Labeling theory. In J. S. Mio, J. E. Trimble, P. Arredondo, H. E. Cheatham, & D. Sue (Eds.), Key words in multicultural interventions: A dictionary (pp. 169−170). Westport, CT: Greenwood Press.
Corrigan, M. J., Loneck, B., Videka, L., & Brown, M. C. (2007). Moving the risk and protective factor framework toward individualized assessment in adolescent substance abuse prevention. Journal of Child & Adolescent Substance Abuse, 16(3), 17−34. doi:10.1300/J029v16n03_02
Darling, N., Caldwell, L. L., & Smith, R. (2005). Participation in school-based extracurricular activities and adolescent adjustment. Journal of Leisure Research, 37, 51−76.
Demanet, J., & Van Houtte, M. (2012). School belonging and school misconduct: The differing role of teacher and peer attachment. Journal of Youth and Adolescence, 41, 499−514. doi:10.1007/s10964-011-9674-2
Denault, A.-S., Poulin, F., & Pedersen, S. (2009). Intensity of participation in organized youth activities during the high school years: Longitudinal associations with adjustment. Applied Developmental Science, 13(2), 74−87. doi:10.1080/10888690902801459
Duncan, L. (1999). Social norms. In J. S. Mio, J. E. Trimble, P. Arredondo, H. E. Cheatham, & D. Sue (Eds.), Key words in multicultural interventions: A dictionary (pp. 239−240). Westport, CT: Greenwood Press.
Durlak, J. A., Weissberg, R. P., Dymnicki, A. B., Taylor, R. D., & Schellinger, K. B. (2011). The impact of enhancing students’ social and emotional learning: A meta-analysis of school-based universal interventions. Child Development, 82, 405−432. doi:10.1111/j.1467-8624.2010.01564.x
Elliott, D. S., Huizinga, D., & Ageton, S. S. (1985). Explaining delinquency and drug use. Beverly Hills, CA: Sage.
Farb, A. F., & Matjasko, J. L. (2012). Recent advances in research on school-based extracurricular activities and adolescent development. Developmental Review, 32, 1−48. doi:10.1016/j.dr.2011.10.001
Hancock, T. U., Waites, C., & Kledaras, C. G. (2012). Facing structure inequality: Students’ orientation to oppression and practice with oppressed groups. Journal of Social Work Education, 48, 5−25.
Hawkins, J. D., & Weis, J. G. (1985). The social development model: An integrated approach to delinquency prevention. Journal of Primary Prevention, 6, 73−97. doi:10.1007/BF01325432
Hays, P. A. (1996). Addressing the complexities of culture and gender in counseling. Journal of Counseling & Development, 74, 332−338. doi:10.1002/j.1556-6676.1996.tb01876.x
Henry, K. L., Knight, K. E., & Thornberry, T. P. (2012). School disengagement as a predictor of dropout, delin-quency, and problem substance use during adolescence and early adulthood. Journal of Youth and Adolescence, 41(2), 156−166. doi:10.1007/s10964-011-9665-3
Hummel, A., Shelton, K. H., Heron, J., Moore, L., & van den Bree, M. (2013). A systematic review of the relation-ships between family functioning, pubertal timing and adolescent substance use. Addiction, 108, 487−496. doi:10.1111/add.12055
Johnson, A. G. (2006). Privilege, power, and difference (2nd ed.). New York, NY: McGraw-Hill.
Malmberg, M., Overbeek, G., Vermulst, A. A., Monshouwer, K., Vollebergh, W. A., & Engels, R. C. (2012). The
theory of planned behavior: Precursors of marijuana use in early adolescence? Drug and Alcohol Dependence, 123, 22−28. doi:10.1016/j.drugalcdep.2011.10.011
Mason, M. J., Schmidt, C., & Mennis, J. (2012). Dimensions of religiosity and access to religious social capital: Correlates with substance use among urban adolescents. The Journal of Primary Prevention, 33, 229−237. doi:10.1007/s10935-012-0283-y
Petraitis, J., Flay, B. R., & Miller, T. Q. (1995). Reviewing theories of adolescent substance use: Organizing pieces in the puzzle. Psychological Bulletin, 117, 67–86. doi:10.1037/0033-2909.117.1.67
Piko, B. F., & Kovács, E. (2010). Do parents and school matter? Protective factors for adolescent substance use. Addictive Behaviors, 35, 53−56. doi:10.1016/j.addbeh.2009.08.004
Pope, R. L. (1999). Deviance. In J. S. Mio, J. E. Trimble, P. Arredondo, H. E. Cheatham, & D. Sue (Eds.), Key words in multicultural interventions: A dictionary (pp. 92−93). Westport, CT: Greenwood Press.
Schroeder, R. D., & Ford, J. A. (2012). Prescription drug misuse: A test of three competing criminological theories. Journal of Drug Issues, 42, 4−27. doi:10.1177/0022042612436654
Substance Abuse and Mental Health Services Administration. (2012). Results from the 2011 national survey on drug use and health: Summary of national findings. NSDUH, H-44(12−4713). Rockville, MD: Author.
Steinman, K. J., & Zimmerman, M. A. (2004). Religious activity and risk behavior among African American adolescents: Concurrent and developmental effects. American Journal of Community Psychology, 33(3), 151−161. doi:10.1023/B:AJCP.0000027002.93526.bb
Sue, D. W., & Sue, D. (2013). Counseling the culturally diverse: Theory and practice (6th ed.). New York, NY: John Wiley & Sons, Inc.
Telzer, E. H., Fuligni, A. J., Lieberman, M. D., & Galván, A. (2013). Meaningful family relationships: Neuro-cognitive buffers of adolescent risk taking. Journal of Cognitive Neuroscience, 25, 374−387.
Van Ryzin, M. J., Fosco, G. M., & Dishion, T. J. (2012). Family and peer predictors of substance use from early adolescence to early adulthood: An 11-year prospective analysis. Addictive Behaviors, 37, 1314−1324. doi:10.1016/j.addbeh.2012.06.020
Van Wormer, K., & Davis, D. R. (2013). Addiction treatment: A strengths perspective (3rd ed.). Belmont, CA:
Alexis Miller, NCC, is a professional counselor for the Dual Diagnosis Partial Hospitalization Program at Rogers Memorial Hospital in Madison, WI. Jennifer M. Cook, NCC, is an Assistant Professor at Marquette University. Correspondence can be addressed to Rogers Memorial Hospital, Attn: Alexis Miller, 406 Science Dr., Suite 110, Madison, WI 53711, email@example.com.