Jun 3, 2026 | Volume 16 - Issue 2
Dana Ripley, Justin R. Jordan, Jyotsana Sharma, Taylor Allesch
Research has consistently shown a link between substance use disorders and trauma; however, there is a need to explore the experience of dual recovery from these struggles. The purpose of this qualitative research study was to examine the lived experiences of individuals in recovery from both trauma and problematic substance use. This study involved semi-structured interviews with 10 individuals who identified as being in recovery from both trauma and substance use. A hermeneutic phenomenological approach was used to gain an in-depth understanding of the recovery experience. Emergent themes included the importance of social support, self-discovery, and that recovery is an ongoing process rather than a time-limited goal. Implications for understanding dual recovery and for counseling clients with dual trauma and substance use recovery experiences are explored.
Keywords: substance use, trauma, dual recovery, lived experiences, counseling
Research has established a link between addiction and trauma (Gidzgier et al., 2023; Jacobsen et al., 2001; Kilpatrick et al., 2013). Approximately 97.4% of individuals diagnosed with a substance use disorder (SUD) have been found to have experienced a traumatic event (Gielen et al., 2012). Farrugia et al. (2011) also found the prevalence of childhood trauma to be significantly higher among individuals with an SUD diagnosis compared to the general population. Problems with substance use are categorized as an SUD based on impairment of functioning and significant distress (American Psychiatric Association [APA], 2022), while trauma is defined by an acute event threatening one’s physical safety or complex, chronic experiences threatening one’s mental and emotional well-being over time (May & Wisco, 2016; Wamser-Nanney & Vandenberg, 2013). LeTendre and Reed (2017) found that increased exposure to adverse childhood experiences, such as exposure to domestic violence or having a parent with a serious mental health struggle, accounts for a 34% increase in the likelihood of developing an SUD in adulthood. A recent study focused on comparing indirect and direct exposure to traumatic events found an increased risk for substance use and behavioral addictions with both types of exposure (Levin et al., 2021). Direct exposure in this study included combat and sexual assault trauma. Childhood trauma is linked to substance use, with more extensive trauma histories predicting earlier initiation and greater severity of substance use (Farrugia et al., 2011).
Based on the research demonstrating a correlation between trauma and substance use, dual recovery experiences warrant exploration. In clinical treatment settings, clients will present with a need to address these co-occurring struggles. To date, research has focused primarily on the correlated pathology rather than the co-occurring healing and recovery process. To address this gap, this study aims to explore the lived experiences of individuals who self-report dual recovery experiences.
Understanding the Link Between Trauma and Addiction
Evidence suggests that individuals who have these co-occurring struggles have poorer treatment outcomes than clients with only one of these presenting issues (Brewerton & Brady, 2014). Although several explanations for the relationship between trauma and substance use exist, self-medication theory predominates (Hawn et al., 2020). Self-medication theory posits that substances are used to cope with and mitigate trauma-related symptoms. Despite offering a respite from unwanted hypervigilance, anxiety, or thoughts related to trauma, substances do not eliminate symptoms or resolve the underlying reactions. Self-medication suggests that a cycle of experiencing symptom distress and using substances to cope becomes problematic. Once the substances’ effects subside, the cycle may begin again, often with exacerbated emotional distress and additional concerns about one’s inability to control consumption.
Counter to self-medication, some theorists believe there is a relationship between post-traumatic stress disorder (PTSD) and the predisposition to substance use (Khoury et al., 2010; Van den Brink, 2015). Although not all individuals who identify as in recovery from trauma meet criteria for PTSD, research has often focused on creating sampling parameters to explore epidemiology and treatment protocols (Zrineh et al., 2026). Brewerton and Brady (2014) agreed that epigenetics and genetic predisposition may contribute to substance use vulnerability for people who have experienced significant traumas. Additionally, early trauma caused individuals in the study to feel abnormal and misunderstood, potentially leading them toward social groups involved in substance use (Brewerton & Brady, 2014).
Treatment Considerations
Traditionally, many treatment approaches have sought to disrupt this cycle via a sequential model of treatment, with substance use problems addressed first. This approach assumes that meaningful mental health treatment cannot be effective while a person is still impaired by regular substance use (Schumm & Gore, 2016). Newer evidence suggests that concurrently treating trauma and addiction shows promise in producing successful outcomes like reduced substance use and relapse, and improved quality of life (Flanagan et al., 2016). Concurrent treatment of trauma and substance use has become more widely accepted (Flanagan et al., 2016; Priester et al., 2016; Schumm & Gore, 2016). It remains unclear if this research has influenced treatment practices, especially in addiction programs not affiliated with research institutions (e.g., hospitals and universities). Scholars have recommended universal trauma screening for clients entering care for substance use (Van den Brink, 2015), and concurrent treatment is now seen as efficacious and safe (Flanagan et al., 2016). The National Institute on Drug Abuse (2014) recommends simultaneous treatment for these issues, acknowledging a correlation between substance use and underlying mental health struggles, including trauma.
Evidence that this concurrent approach leads to successful treatment for those who have experienced co-occurring substance use and trauma is accumulating. Studies have found that participants prefer an integrated approach to treatment, such as receiving treatment for both SUD and PTSD in the same treatment program (Brown et al., 1998; Gielen et al., 2016; Roberts et al., 2023). This, however, is not a common experience for individuals with co-occurring diagnoses (Gielen et al., 2016), as most substance use treatment programs do not include trauma-focused interventions (Giordano et al., 2016). The European Society for Traumatic Stress Studies utilized a systematic review of research and expert opinions to develop a list of nine assessment strategies and 21 treatment recommendations for co-occurring trauma and substance use (Roberts et al., 2023). These recommendations include: concurrent treatment, helping clients navigate logistical barriers to treatment (e.g., transportation), case management services, building a strong therapeutic relationship, and psychoeducation about the relationship between trauma and substance use. The current study aims to examine the lived experiences of people identifying as in recovery from both trauma and substance use, with the intent to clarify the phenomena of dual recovery.
Purpose of the Study
Understanding the process of dual recovery for individuals who experience traumatic events and have struggled with substance use is vital for providing appropriate care. The current study aimed to examine the lived experiences of people identifying as in recovery from both trauma and substance use issues, with a focus on their recovery journey over time. The purpose was to build on prior research that focused on trauma and substance use by exploring intersecting recovery processes, rather than etiology, and investigating the phenomenon of recovery by exploring lived experiences. A qualitative study design and methodology was utilized and guided by the overarching research question: What is the experience of recovery for someone who struggles with trauma and substance use?
It is important to acknowledge that a variety of recovery definitions exist. There is disagreement among experts regarding the precise language to describe recovery, and individuals choose to identify for themselves when they are in recovery without precise criteria (Piat et al., 2009). According to Neale and colleagues (2015), individuals in active recovery find previously established definitions to be limiting and focused on a deficit-based mindset and framework. Conceptualizations that are strength-based consider social and context influences and acknowledge that individual differences are preferred. Recent studies have moved away from offering their participants a definition of recovery; instead lived experiences and individual definitions of recovery conceived by the participants themselves are now common in addiction research (Zemore et al., 2023). The current study did not provide a definition of recovery to participants but focused on eliciting participants’ conceptualizations of what defines recovery to the individual.
Methods
In looking at the experience of recovery for someone who struggles with trauma and substance use, we intentionally sought a research methodology that would account for the depth and complexity of these life experiences. Given this focus, hermeneutic phenomenology was chosen as our research approach. Phenomenology aims to understand a phenomenon through the lens of those with direct experience (van Manen, 2016). Phenomenology prioritizes meaning making and attempts to get at the depth of experiences, as opposed to examining generalizable patterns across a broad range of perspectives (Hays & Singh, 2012). Through first-person accounts, phenomenology pulls together key descriptions to form a picture of an experience or phenomenon. Hermeneutic phenomenology was specifically chosen because it places participants as co-researchers (Hays & Singh, 2012). This means that participants are viewed as experts in the field of study, thus lessening the power differential between researcher and participant (Hays & Singh, 2012). Given the marginalization and stigma of those who experience substance use issues and trauma, it was important to utilize a method that recognizes power dynamics and attempts to diminish those between the researcher and the participants. This included asking participants to self-define their recovery status and what qualifies as being in recovery.
Reflexivity
Transparency regarding researcher perspective and positionality is essential in qualitative inquiry (Levitt et al., 2018). We are invested in advancing the understanding of recovery processes, especially among counselors who work with individuals with co-occurring trauma and substance use histories. Through this research, we hope to help counselors use this information to better support those they serve, as well as enhance the awareness of educators and supervisors. Dana Ripley, Justin R. Jordan, and Jyotsana Sharma have been colleagues through their doctoral program, are licensed counselors, and hold doctoral degrees in counselor education and supervision. Ripley, Jordan, and Sharma are currently tenure-track professors in counselor education programs, with Ripley and Jordan consistently teaching addiction counseling courses to master’s-level students. Taylor Allesch is pursuing licensure as a professional counselor and is a former student of Ripley. Ripley has a background in substance use and addictions counseling, which is also her primary teaching and research interest. She teaches at a public university in the Midwest United States. Jordan is a professor at a mid-sized public university in the southern United States. He has more than a decade of experience counseling individuals with trauma and substance use struggles in a public mental health agency and in private practice. Sharma is a professor at a large, research-focused university in the southern United States and has experience working with clients with trauma and other stress-related disorders. Allesch was a master’s student in clinical mental health counseling who completed her degree during the data collection and analysis phases of our study. She has experience addressing trauma in private practice settings, predominantly with couples and individuals.
Beginning with the initial planning for this study, we discussed how academic, research, personal, and treatment-providing experiences with addiction and trauma would affect development of the research protocol. None of the team members identify as being in recovery from substance use, although multiple members have experienced traumas of varying severity and chronicity. We collectively lean toward wellness-based interventions and respecting personal autonomy in navigating healing from substance use or trauma. Throughout the study, we held reflective discussions about how our experiences influenced the development of interview questions and interpretations of the coding process and distillation of themes, and we kept reflexive journals, which were audited by Sharma, and conveyed results in writing. This included exploring: the influence of client issues and treatment systems we had worked in; personal experiences with substances, trauma, and the impacts on those we care about; and research and literature that had impacted our perspectives on recovery journeys. We were deliberate and consistent in acknowledging personal perspectives and biases while attempting to allow the voices of study participants to be captured accurately and fully.
Participants
After securing IRB approval from our three affiliated institutions, participants were recruited through contacting peer recovery specialist organizations via email. Peer recovery specialists are trained as helping professionals who identify as being in recovery from substance use/addiction, or having mental health struggles, including trauma, or both, which is why we targeted this population for recruitment. Purposeful sampling was used to identify appropriate candidates who were recruited directly through organizational websites and through connections to local communities in Kentucky, Ohio, and Virginia. Snowball sampling was also used, as participants recommended other peers who might be interested in the study. Participants were not required to be trained as peer recovery specialists, but all participants were recruited through these networks. Emails to peer recovery specialists and associated organizations were sent with a link to an online screening survey utilizing Qualtrics software, which clarified which prospective participants met inclusion criteria.
The three inclusion criteria for this study were that participants must: be 18 or older, self-identify as being in recovery from substance use issues, and self-identify as being in trauma recovery. Because definitions of recovery vary, participants were not asked about the length of time since their last use of specific substances or the timeline of their trauma symptoms. Participants were asked to describe their recovery process from each struggle as part of the interview protocol; they were also asked how they define recovery. Although personal definitions vary, participants referenced government definitions, freedom from use or symptoms, normalcy in their lives, sustaining quality relationships, and having balance in their lives. Some participants referenced sustained abstinence from substances and reduction in trauma symptoms, while others spoke to the absence of chaotic behavior patterns and a sense of mental peace and calm. Potential participants who met eligibility criteria were contacted via email to schedule an interview. Each participant was sent a copy of informed consent documentation and gave verbal agreement to participate at the start of the interview.
Our final sample included 10 participants. Bartholomew et al. (2021) suggested that there is no specific range for sample sizes in phenomenological research, but 10 participants is within a normative range; larger samples often lose some of the essential qualities of this methodology. Other researchers have suggested three to 10 participants for phenomenological studies (Dukes, 1984).
In our study, participants’ ages ranged from 23 to 61, with a mean age of 42.2. Participants were asked open-ended questions regarding how they identified their gender, race/ethnicity, and sexual orientation. Two participants identified as male, with the rest identifying as female. Three participants identified as Black or African American, one as Hispanic, two as mixed race, and four as White. One participant identified as bisexual, one as lesbian, and the rest identified as heterosexual or straight. Table 1 summarizes pseudonyms and pertinent demographic information.
Table 1
Participant Demographics and Pseudonyms
| Participant |
Age |
Gender |
Race or Ethnicity |
Sexual Orientation |
Pseudonym |
| Participant 1 |
61 |
M |
White |
Heterosexual |
Jackson |
| Participant 2 |
46 |
F |
Hispanic |
Bisexual |
Dedra |
| Participant 3 |
49 |
F |
Black |
Heterosexual |
Erica |
| Participant 4 |
40 |
M |
African American |
Heterosexual |
Levon |
| Participant 5 |
31 |
F |
White |
Heterosexual |
Olivia |
| Participant 6 |
37 |
F |
White/Colombian |
Heterosexual |
Kara |
| Participant 7 |
41 |
F |
White/Puerto Rican |
Heterosexual |
Alecia |
| Participant 8 |
41 |
F |
White |
Heterosexual |
Rhonda |
| Participant 9 |
53 |
F |
Black |
Heterosexual |
Corva |
| Participant 10 |
23 |
F |
White |
Lesbian |
Rosemary |
Participant Background
The participants were thoughtful in sharing their unique experiences in recovery. Jackson is a 61-year-old heterosexual White man who spoke about an abusive father and his drug use causing him to miss time with his kids. He talked about self-forgiveness as a key part of his recovery. Dedra is a 46-year-old bisexual Hispanic woman who discussed being hit by a truck while intoxicated and the complications of receiving inpatient nursing care while being prescribed Suboxone for opioid addiction. Erica, a 49-year-old heterosexual Black woman, currently works in a harm reduction program and talked a lot about people who died in active use and how Narcotics Anonymous (NA) was key in her early recovery. Levon is a 40-year-old heterosexual African American man who spent 18 years in prison on charges related to alcohol and prescription pill use. He described trauma recovery as very difficult, as he did not realize how his lived experiences had led to impaired functioning, even after achieving sobriety. Olivia, a 31-year-old heterosexual White woman, is currently pursuing a degree in social work and is employed as a peer specialist. She feels the cognitive behavioral therapy she received for trauma and 12-step fellowship for addiction were essential for the healthy relationships she has in her life now.
Kara is a 37-year-old heterosexual biracial (Columbian/White) woman who turned to alcohol and other drugs after the death of her brother. She says pregnancy and parenthood helped push her toward recovery and she is an advocate for improving Methadone access. Alecia is a 41-year-old heterosexual biracial (Puerto Rican/White) woman, who credits a supportive probation officer for helping her work toward recovery after 20 years of active addiction. She is a supporter of multiple interventions for recovery, including harm reduction, prevention, and diversion programs. Rhonda, also 41, is a heterosexual White woman. She supports many pathways to recovery, but for her, becoming involved in her church was the key to making progress. Corva is a 53-year-old heterosexual Black woman who talked about how her chaotic childhood led her to cope with alcohol, as well as having an unhealthy relationship with food and sex. Finally, Rosemary is a 23-year-old lesbian White woman. She was a college student who participated in a collegiate recovery program and has found substance recovery through harm reduction rather than abstinence.
Data Collection
Participants gave verbal consent at the beginning of each interview. Data collection included semi-structured interviews (see Appendix for the interview protocol). Interviews were scheduled for 1 hour, and participants were advised that they may receive contact for a brief follow-up if clarification was needed (no participants were contacted for follow-up). Questions focused on the participants’ lived experiences of recovery from trauma and substance use. Zoom videoconferencing software was used to meet with the participants, and all interviews were video-recorded. The recordings were transcribed by Ripley, Jordan, and Allesch.
Data Analysis
Each transcript was read and coded by two members of the research team. Ripley, Jordan, and Allesch completed the coding. In reviewing the transcripts, each member used the selective or highlighting approach (van Manen, 2016). This approach requires several readings of the text, paying attention to statements that “seem particularly essential or revealing about the phenomenon or experience being described” (van Manen, 2016, p. 93). We highlighted these statements in the text, then copied and organized the data in an Excel spreadsheet with repetitive data being identified and deleted. Statements were synthesized into a phrase that encompassed the statement’s meaning. Using cross-case analysis (Patton, 2015), the statements were grouped based on focus and perceived meaning (coding), leading to initial coded themes. In hermeneutic phenomenology, themes are used to describe a common aspect of the experience (van Manen, 2016). Collaborative analysis, or hermeneutic conversations, were then conducted by the three coders (van Manen, 2016). This entailed coding team meetings in which members discussed patterns and content, and preliminary ideas for themes emerging from the transcripts. Each coding review meeting included Ripley, Jordan, and Allesch.
Collaborative analysis assures “themes are examined, articulated, re-interpreted, omitted, added, or reformulated” as needed (van Manen, 2016, p. 100). Ripley, Jordan, and Allesch met several times over 4 months for collaborative analysis to calibrate and reach consensus regarding emergent themes. They examined lines of text that seemed to capture the essence of the recovery phenomenon and experience. We generated ideas for thematic groupings and descriptions; some themes were dropped because of inconsistency or lack of consensus, including a theme focused on “giving back” in recovery, which did not have the same amount of participant endorsement as the other themes. These dialogues included examining potential biases in interpreting transcripts, exploring overlaps and distinctions between themes, and ensuring each theme was evaluated and agreed upon amongst us. Once consensus was reached, themes were audited by Sharma. Sharma checked each coded statement to ensure its match to the assigned theme and then reported potential mismatches or poorly fitting codes to Ripley, Jordan, and Allesch. Further meetings and dialogues were held to work through different interpretations until consensus was met for all themes and coded statements (sometimes, a vote was held, requiring a majority to move forward). Themes were considered sufficiently refined when we all agreed that the essence of the interviews had been captured and no additional themes were needed to understand the participants’ experiences.
Trustworthiness
Our research team engaged in several strategies to enhance the trustworthiness of our findings. Researcher bias was addressed using reflexive journals (Hays & Singh, 2012). Reflexive journals were kept by Ripley, Jordan, and Allesch. After each interview, the interviewer would write a reflexive journal documenting thoughts, assumptions, feelings, and reactions to the interview. The reflexive journals were read and examined for influence on code/theme generation by Sharma while auditing the themes. Sharma spoke about the journals and inquired about biases during meetings. Based on this feedback, the coding team was able to talk through and mitigate biases that affected data analysis, including transference related to personal and professional experiences.
Trustworthiness was also ensured using triangulation with multiple analysts (Patton, 2015). Ripley, Jordan, and Allesch conducted interviews and coded the transcripts, thus helping to “reduce the potential bias that comes from a single person doing all the data collection” and analysis (Patton, 2015, p. 665). Additionally, Sharma did not participate in conducting interviews or the initial coding process. Sharma audited the coding and themes without prior exposure to the data, with the intent of remaining objective.
Findings
Interviews with 10 participants were analyzed via a hermeneutic phenomenological approach. Six themes emerged from the interviews and subsequent coding process: recovery is hard, recovery includes structured support services, recovery is an ongoing process, recovery is relational, recovery is self-discovery, and substance use and trauma recovery are interconnected. These themes encompass defining characteristics of the dual recovery journey for the 10 participants in our study.
Recovery Is Hard
Participants discussed how working toward and living in recovery comes with many challenges, especially related to stigmas and navigating systemic barriers in receiving help. Looking for support early in their substance use recovery process, Dedra highlighted, “Even if I’m an addict, I still deserve the proper treatment and proper care and proper empathy, and I didn’t get that.” She elaborated that, “I had to fight for myself; nobody else was doing it so I just had to fight hard.” Rhonda talked about multidimensional challenges that led to being overwhelmed in early substance use recovery, stating, “The hardest thing for me to get over in that first year is changing absolutely everything.”
Another common difficulty that participants expressed was finding a place to “fit in.” After experiencing traumas related to homelessness during pregnancy while simultaneously managing a chronic blood illness, Kara described, “I think some of the hardest parts for me were just sort of like learning how to reintegrate in society, and I think that continues to be hard for me, like ‘where do I fit in here?’” Kara felt that finding a sense of belonging was essential for healing, given the disconnection from supports she experienced before pursuing recovery. In pursuing formal treatment for co-occurring struggles, Kara indicated that she encountered “all these wait lists,” and shared, “if you want to go to a program . . . you can’t get in right away.” Olivia also described substance use and trauma having “such a stigma on it already anyway, receiving any kind of mental health service . . . it just seemed so unobtainable.” Dedra discussed judgment within the substance use recovery community because of being prescribed Suboxone, a medication used to treat opioid use disorder: “I experienced a lot of stigma because I was an opiate user and they had to put me on Suboxone. I just had all this weird treatment toward me that was so uncomfortable, so embarrassing, and really degrading.” Participants had a lot to overcome in order to receive support in pursuing recovery and sustaining their efforts amidst treatment barriers and social stigma. Some participants reported that they had to learn how to advocate for themselves because of the lack of support and barriers they encountered trying to seek support.
Recovery Includes Structured Support Services
Most participants emphasized the necessity of structured support such as mental health and substance use treatment programs, mutual self-help groups (AA and NA), and other systems (e.g., church) as essential to their recovery journeys. The theme of recovery includes structured support services encompasses the importance of treatment programs, groups, and organizations that provide help to participants. Participants talked about the importance of these support systems to help people work toward change early on in pursuing recovery. Olivia benefited from both mutual self-help and professional therapy, sharing:
I personally worked a 12-step program [for substance recovery], and so, in that, [my counseling] was really based more on my trauma than it was actual substance use and I, I went to counseling and just a lot of things like that. . . . cognitive behavioral therapy is really what helped me work through those childhood traumas that I had, and the trauma that I added on to it as an adult, and it was difficult.
She elaborated about positive experiences working on trauma in formal treatment: “When I went into that treatment setting, the people there were already so well equipped to handle the kind of things that I needed to talk about, that I wanted to talk about.” Speaking more broadly, Olivia shared the importance of having multiple systems for support in dual recovery, saying, “I also think it’s really important to be able to connect people to a lot of different services, kind of like the wraparound services.” Jackson also benefited from both mutual self-help groups and formal treatment, stating: “When I got out [of incarceration], I did kind of dive into AA, which was integral, in my early recovery, and, you know, continued to see my therapist [for trauma counseling].”
Kara found out that she was pregnant while she was incarcerated and did an intensive 3-year program for women who were prescribed Methadone and pregnant. She reported this as an important step for her recovery. That group meant a lot to her. When asked about her trauma recovery process, Alecia talked about a peer specialist being a role model when she entered treatment, saying, “I can do this. If she can do it, I can do it,” as well as participating in SMART [Self-Management and Recovery Training] Recovery meetings. She expressed that this specialist helped her feel understood as someone who had been incarcerated and using substances to subdue childhood trauma symptoms. Overall, this theme showed that participants felt that they could not achieve sustained recovery on their own and benefited from programs, services, and mutual help spaces in healing from trauma and addiction.
Recovery Is an Ongoing Process
Another theme that emerged from the interviews was that recovery is an ongoing and continuous process. Participants described their recovery from trauma and substance use as continuing to unfold, rather than a destination where they had already arrived. This process was discussed as an individual journey because, as they recovered, each person had to make choices about what resources to utilize and what changes fit their lives. Several participants explicitly identified that their co-occurring recovery is a continuous process. In characterizing her journey in dual recovery as being unique, Rosemary stated: “It took time for me to learn that recovery is a spectrum, and there’s not one right way to do this.” Alecia agreed with this theme and made similar statements, including: “I know this is a process that I’ll go through for the rest of my life.” In speaking primarily to substance recovery, Rhonda had similar sentiments, sharing her belief that “everybody’s not the same, and there’s so many different paths out there now. It’s just finding the right path in the right way for you.” She added, “Yes, I went to treatment, but I don’t use that as my recovery. My recovery was honestly therapy and going to church.”
This theme encompasses descriptions of making broad lifestyle changes and continuing to grow as a human, while still acknowledging the influence of substance use and trauma in one’s life journey.
Recovery Is Relational
All participants spoke to relationships as they related to their recovery journeys. This theme is given more attention here, as it was the most frequently coded and consistent theme. Recovery is relational focuses on the importance of bonding and human connection in the recovery process. This theme is distinct from the theme of recovery includes structured support services, which focuses on therapy/counseling, education, or tangible resources, such as medications or financial assistance, rather than the general importance of interpersonal relationships.
Specifically, participants highlighted how relationships facilitated recovery, which included connections to individuals in the mutual self-help community, professionals, and treatment providers, but also support from their families, friends, and community. These connections helped participants cultivate hope and accountability as they progressed in healing from substance use and trauma. The sense of being understood and accepted through the challenges of recovery was impactful and motivating.
Jackson described the importance of his relationship with his 12-step sponsor, a high school teacher that “really got me.” His sponsor worked the steps with Jackson, trying to understand Jackson’s unique perspectives on the steps and recovery. He described his sponsor as patient and intelligent. The sponsor was able to repackage the AA message in a way that fit for Jackson, who said that “if I hadn’t had somebody like that, I wouldn’t have stopped.” Kara and Erica similarly shared the importance of relationships in the 12-step community, including not feeling alone in pursuing recovery.
Sources of support varied widely in our study. Olivia described the important relationship she had with her children’s foster parent. Not only did the foster parent take care of her children, but she became an integral part of Olivia’s life; she described her as “my absolute biggest supporter.” This foster parent helped her build back community and showed her that it is possible to live the kind of life she had always wanted.
Other participants also emphasized the benefits of community and support broadly. Olivia shared that she had to learn new ways of living and building relationships within her community. Her local community has been essential to her success in recovery. She detailed how this support facilitated recovery from trauma and substance use:
I spent almost an entire year just digging through those things and opening up and sharing about them, and that’s also where I built that first sense of community of speaking on those traumas with like-minded people who had been through similar situations.
Alecia spoke about the significant support she received from her probation officer. She stated that having a probation officer who really understood her and wanted to see her succeed was “a game changer.” The probation officer’s investment in her was a turning point for Alecia. Corva felt that recovering from both issues has given her relationships authentic connection: “Being around people who really know us and know us at our depth and, you know, and that’s what life is truly about. So, for me, that’s what recovery is about. And it’s given me a family.”
Participants were consistent in pointing to relationships boosting their success in recovery, which included building back bonds with people they had lost touch with or been cut off from during active use, as well as building a new network of support. The theme of recovery is relational had the highest number of identified codes from participants supporting the theme.
Recovery Is Self-Discovery
Participants identified the development of self-awareness and connecting with themselves as part of their recovery. This theme of recovery is self-discovery included emphasizing new personal growth since confronting trauma and addressing substance use struggles, including reconnecting with prior values and aspects of their identity. Additionally, participants described self-awareness as a key component of their life in recovery, including being honest with themselves and processing emotions that they may have avoided previously. Epitomizing this theme, Jackson stated:
So much of my recovery is about finding my place in the world—that sense of comfort and connection and stuff. A lot of my trauma that I experienced entails me forgiving other people. This, you know, is forgiving myself for the mistakes I’ve made, which I still struggle with, but also is letting go of resentments.
When asked about critical points in his recovery, Levon also spoke about personal development, saying that he started to see how to present a stronger version of himself, knowing internally that he was courageous and could fight through obstacles. Olivia added that she had created walls that served the purpose of protecting her but had to “chip away” at those protections for her true self to emerge in recovery.
In terms of confronting emotions and suppressed thoughts, Dedra shared that trauma recovery required “this ability, which only came to me late in life, to just be objective with my own self, and to be honest and objective about what [trauma is] doing, and who I am, and what’s happening to me.” In connecting this to substance use recovery, both Dedra and Rosemary agreed that self-awareness and honesty are key to recovery and that secrets can continue the cycle. Multiple participants alluded to increased self-awareness, understanding, and reconnection with their true self as being an important part of the recovery process.
Substance Use and Trauma Recovery Are Interconnected
The theme of substance use and trauma recovery are interconnected was described in multiple ways by participants, often referencing trauma being an underlying aspect of substance use struggles. Participants spoke about realizing the connectedness of trauma, mental health issues, and substance use in recovery. Erica acknowledged the close connection between substance use and trauma recovery, saying that “they just kind of overlap and intersect, and it’s kind of hard to differentiate where one ends and one begins.” Dedra spoke about trauma being the underlying issue, explaining, “Trauma is the root for me, and you know, with other people it might be that, you know, once they quit drinking, things get better, but I’ve always had to struggle with trauma.” Levon also described that he was unaware of how affected by trauma he was, recounting: “Trauma drove the substance use in that sense . . . because the trauma had certain effects on me that I didn’t [recognize].”
Additionally, participants noted that addressing trauma, including associated mental health concerns, along with substance use, was an essential part of recovery. Jackson spoke about the importance of getting help with mental health diagnoses, which he didn’t start until 10 years after engaging in substance use recovery. He had experienced multiple hospitalizations related to suicide attempts, which eventually spurred him to address his mental health:
But it was at that point I kind of really took my mental health issues as seriously as I took my substance use issues because it was easy to see that my substance use issues were killing me, were going to kill me. It’s harder to see that with mental health issues.
Alecia used similar language, describing that “addiction is just one of the symptoms of trauma, and . . . you can’t get to the root with the symptoms still there.” The direct relationship between trauma healing and substance use recovery was consistent in the interviews. Participants were directly asked if these recovery processes were related, and all participants replied affirmatively and elaborated on the reasons for this connection. Although many responses highlighted the trauma as an underlying cause of substance use, the responses showed that in conceptualizing the recovery process, healing from each was interconnected.
Discussion
Six themes emerged from the phenomenological analysis of these 10 interviews focused on the experience of trauma and substance use recovery: recovery is hard, recovery includes structured support services, recovery is an ongoing process, recovery is relational, recovery is self-discovery, and substance use and trauma recovery are interconnected. Taken as a whole, these themes demonstrate that the lived experience of dual recovery from substance use and trauma is an individual, holistic journey supported by personal and formal relationships. There is an inherent connection between trauma and substance use recovery for these participants. This type of dual recovery includes hardships on the path to healing for both trauma and substance use. Among our participants, there were multiple pathways to recovery, and yet there were parallels in how they described essential elements of long-term recovery. Recovery is a forward-focused endeavor rather than a cure for pathology (Witkiewitz et al., 2020), which is a useful perspective for laypersons and professionals who offer guidance to people working to overcome trauma symptoms and substance use addictions.
This study deepens the understanding of dual recovery from these correlated struggles, which counselors commonly address. Acknowledging the ongoing nature of recovery reduces the focus on acute symptom management and shifts the focus toward lifestyle factors such as relationships. These themes support an individualized self-exploration process for discovering a new sense of self within substance use and trauma recovery. All participants indicated that these two recovery processes were correlated. This finding supports a simultaneous approach to healing substance use and trauma, as opposed to a historical emphasis on sequential treatment.
These findings call for a focus on development and wellness congruent with counselor professional identity (Woo et al., 2014), in contrast to a medical model framework. Conceptualizing recovery as an ongoing purpose, rather than a destination, supports the benefits of counselors embracing holistic wellness and developmental perspectives. Participants described a long-term process enabled by relationships and structured support, calling on counselors to be responsive to recovering clients’ ongoing healing journeys. This aligns well with how counselors join clients in pursuing meaningful, multidimensional changes in their lives (Woo et al., 2014) rather than focusing solely on symptom reduction. Trauma and substance use are correlated, but each individual navigates unique challenges in pursuing a better life in recovery. This healing is not just alleviating symptoms but rather finding new identities and maintaining wellness daily. These findings demonstrate that counselors benefit from recognizing that there is no one-size-fits-all approach to dual recovery. Long-term support is needed in recovery and that care should target both trauma and substance use in order to be successful. The participants acknowledged that addressing the trauma at the root of their struggles would benefit both their mental wellness and ability to avoid harmful substance use. Our participants have given us evidence in their own voices to help clarify what the phenomenon of co-occurring recovery looks like.
Refining the understanding of recovery as a process advances the pursuit of better supports for survivors persevering through trauma and substance use that has negatively impacted their lives. Recognizing that trauma and substance use recoveries are intertwined calls for services designed to support the long-term healing process. This recognition also discredits siloed treatments that do not address co-occurring needs. The importance of relationships and support networks was clear, as was the individualized nature of the recovery process over time. Counselors are trained and equipped to meet clients where they are by matching interventions to individual needs. This means cultivating recovery based on clients’ unique strengths rather than using cookie-cutter prescriptive approaches to support sustained recovery.
Implications for Counselors
Counseling, being defined as a relationship that facilitates growth and healing (Kaplan et al., 2014), is a fitting intervention for people pursuing recovery. Emphasizing holistic wellness, supporting development through the lifespan, and honoring the specific needs of the client are all aspects of professional counselors’ duty (American Counseling Association [ACA], 2014). Counselors are uniquely equipped to provide holistic and development-focused support for individuals in dual recovery, given that these approaches are congruent with counselor professional identity (Woo et al., 2014).
Historically, addiction treatment has relied on a prescriptive, sequential approach to substance use recovery, usually involving the pursuit of sobriety before addressing mental health concerns. Recent research supports concurrent treatment as best practice for treating trauma and substance use (Garland et al., 2015; Roberts et al., 2023; Schumm & Gore, 2016). This approach to co-occurring treatment supports the holistic approach emphasized by leaders and researchers in the counseling profession (Dollarhide & Oliver, 2014; Fickling, 2023; Kaplan et al., 2014). Valuing client autonomy and personal preferences in navigating recovery is necessary for counselors, which aligns with the individuality of recovery journeys found in our study. This research demonstrates that for many individuals, trauma struggles were not addressed until after they managed substance use effectively, which likely inhibited progress and overall wellness. Additionally, counselors integrating wellness, prevention, and developmental perspectives can help these individuals thrive long after the pathology of acute addiction or trauma symptomology is relieved.
Motivational interviewing and principles of trauma-informed care embrace this stance, including focusing on empowering the individual on their own terms and assuming a natural tendency toward growth (Miller & Rollnick, 2023). Addiction treatment, specifically, has traditionally been confrontational and behaviorally focused (White & Miller, 2007). This contradicts a trauma-informed approach to recovery and is particularly concerning given the high rates of co-occurrence between these struggles (Dore et al., 2012; Giordano et al., 2016). Harm reduction is another approach that fits for dually recovering individuals based on these findings. One of the main hardships that participants described was the experience of stigma because of their substance use. This approach mitigates stigma by focusing on wellness without judgment (Collins & Clifasefi, 2023). Harm reduction is a humanistic and pragmatic approach that prioritizes autonomy and the holistic well-being of the individual. Harm reduction is uniquely suited to co-occurring trauma and addiction, given its emphasis on collaboration with those being helped, a trauma-informed approach, and avoiding retraumatization through power-over dynamics. This philosophy has been adapted as an approach to psychotherapy by multiple scholars (Collins & Clifasefi, 2023; Tatarsky & Kellogg, 2012). Some participants had awareness, knowledge, and experiences receiving or providing harm reduction care and expressed their support for harm reduction within the continuum of services supporting substance use recovery.
With trauma, counselors may wish to engage with post-traumatic growth phenomena, as well as validating the natural tendency toward self-improvement, wellness, and growth. With substance use, counselors can draw from motivational interviewing, harm reduction, and self-guided changes to empower clients to take responsibility for personal change and respect their autonomy in the process. In supporting the dual recovery process, professional counselors can honor the unique strengths and meaning created through relationships, self-discovery, overcoming barriers, and the unfolding pursuit of growth in their clients.
Limitations
The current study did not differentiate the types of substances participants were recovering from, nor did it focus on specific types of trauma. Our research team intentionally focused on self-defined experiences with these struggles and the phenomena of recovery rather than the etiology of the struggle. It is difficult for these themes to be applied to substance use or trauma separately, as most interview questions focused on the participants’ experiences in co-occurring recovery. Sometimes, there was a clear distinction in which process, or sequential experience with recovery, they were referring to; those are noted in the Findings section. However, by design, most of the time, they were speaking about the dual recovery process. It is likely that complex trauma recovery may have phenomenological differences from acute event traumas. Similarly, recovery from different types of substances includes unique needs and experiences, such as medication treatment for opioid use recovery. During the coding and theme development process, our researchers may have been influenced by prior definitions of recovery in the literature. Despite this influence, our research team was diligent in focusing on giving voice to the participants as they reviewed coded statements from the interviews in clustering emergent themes.
Broadly, our study provides nuance in conceptualizing the phenomenon of dual recovery from trauma and substance use, but it cannot be generalized given that it is a qualitative study. Our study was limited geographically and by purposeful sampling. It is noteworthy that peer recovery specialists may have received education or exposure as helpers that has influenced their conceptualizations of recovery, which may differ from the broader population of individuals recovering from trauma and substance use. Finally, recovery as an experience extends to many other struggles beyond trauma and substance use issues, and it is unclear if the themes found in the current study would apply to other medical or mental health recoveries.
Future Research
These findings build on prior studies examining how substance use and trauma experiences are correlated and provide an in-depth look at the phenomenon of recovery with 10 individuals. Future studies may utilize quantitative methodology to determine if the themes found in this study are generalizable to people in recovery from trauma and substance use. Research is also needed to explore the specific experiences of peer recovery specialists in dual recovery. Additionally, further research may also explore factors that differentiate trauma recovery from substance use recovery experiences, both for individuals with co-occurring recoveries and those who only identify as being in recovery from one or the other. The current study adds to the research in a significant way but also reinforces a need for more studies looking at subtleties of recovery experiences.
Conclusion
Recovery is a multidimensional process that is defined by wellness and improved overall functioning (Witkiewitz et al., 2020). The current study examined the experience of recovery for 10 individuals identifying as in recovery from both substance use and trauma using hermeneutic phenomenology. Six themes emerged that conceptualize recovery from trauma and substance use as an ongoing, interconnected, individualized process that includes hardships and self-discovery and is facilitated by relationships and formal services. These findings support existing research calling for a concurrent and holistic approach for counseling individuals pursuing recovery from substance use and trauma-related symptoms.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Appendix
Interview Protocol
Research Question: What is the experience of recovery for someone who struggles with substance use and trauma?
- When I say the word “recovery,” what comes to mind? How do you define “recovery”?
- Tell me about the process of your recovery from trauma.
- Tell me about the process of your recovery from substance use.
- Do you feel your recovery process from substance use and trauma are related? If so, can you describe how?
- What are some of the critical moments or turning points in your recovery?
- Describe in as much detail as possible what you struggled with the most during recovery and how you managed those struggles.
- How has being in recovery influenced your life and what have you learned from those experiences?
- If you could go back and change anything about the process of your recovery, what would it be?
Dana Ripley, PhD, LPC (KY, VA), is an associate professor at Northern Kentucky University. Justin R. Jordan, PhD, LPC (VA), LSATP (VA), is an assistant professor at Longwood University. Jyotsana Sharma, PhD, LCMHC (NH), ACS, is an associate professor at Oklahoma State University. Taylor Allesch, MS, LPC (OH), LPCA (KY), is a professional counselor at Be Known: Sex and Relationship Counseling. Correspondence may be addressed to Justin R. Jordan, 201 High Street (222 Hull Hall), Farmville, VA 23909, jordanjr2@longwood.edu.
May 22, 2024 | Volume 14 - Issue 1
Darius A. Green, Katharine R. Sperandio
Because of the long history of anti-drug policing in the United States and the criminalization of substance use, clients who use substances are vulnerable to direct and vicarious experiences of police violence. Consequently, those who use substances may face a greater risk of experiencing symptoms of trauma that counselors should address in treatment. We recommend the use of a trauma-informed and abolitionist praxis in clinical and social justice practices as a framework to support clients who use substances and have histories of exposure to police violence.
Keywords: substance use, police violence, trauma, abolitionist, social justice
Policing in the United States has received increased scrutiny in recent years with renewed attention resulting from the Black Lives Matter protests in 2020. Specifically, policing has been critiqued by prison–industrial complex abolitionists—activists who advocate toward an end to systems of policing, prisons, and related carceral systems in favor of systems and practices that promote accountability, justice, healing, and transformation—as being inherently violent, meaning that it relies on the use of behavior that is considered violent in any context (Cullors, 2019; A. Y. Davis et al., 2022; Green, 2022; Kaba, 2021; Klukoff et al., 2021). Violence is defined as “the intentional use of physical force or power, threatened or actual, against oneself, another person or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation” (Krug et al., 2002, p. 5). Thus, we define police violence as the inherently violent uses of force by police officers. According to the World Health Organization, there are four types of violence that can be used to categorize police violence: physical (e.g., arrests and the use of weapons), sexual (e.g., strip searching and sexual assault), psychological (e.g., intimidation and verbal threats), and neglect (e.g., failing to provide support to medical and mental health needs; DeVylder et al., 2017; Krug et al., 2002).
Current data suggests that 58.3 million U.S. residents over the age of 16 experienced contact from police officers in 2020 with roughly 1 million experiencing or being threatened with non-fatal force (Tapp & Davis, 2022). Moreover, of the 82 million arrests reported by the Federal Bureau of Investigation (FBI; 2022) between 2011 and 2021, substance use violations were the second most common arrests, accounting for 14% of arrests. Oftentimes, counselors may work with clients who have been court-ordered to treatment as part of diversion programs that seek to route individuals away from incarceration and toward treatment for criminalized behaviors, such as substance use (Scott, 2020). Given that substance use–related offenses are among the most common offenses leading to violence through an arrest (FBI, 2022), it is essential for substance use counselors to prepare to address experiences of police violence that may result from anti-drug policing—the use of police violence as a response to individuals who use substances. Although anti-drug policing impacts both those who use substances and those who traffic them, our discussion on anti-drug policing will focus on populations who use substances.
Research on counselor preparation suggests that most counselors receive no training regarding clinical practice and advocacy to address matters of police violence despite a recent study that found that 68.2% of counselors reported working with clients who had experienced police violence (Green & Evans, 2021). Moreover, Bride et al. (2009) found that most substance use counselors do not learn about treating psychological trauma in their academic programs and instead predominantly rely on continuing education. Given the vulnerable nature of those who use substances and evidence suggesting that gaps exist in training counselors in treating police violence and trauma, we will explore approaches to clinical practice, social justice, and advocacy to best support substance use clients who experience police violence because of anti-drug policing. Specifically, the purpose of this article is to provide a sociopolitical analysis of anti-drug policing in the United States that informs our proposal for substance use counselors to adopt and integrate an abolitionist praxis into their practice of counseling with clients who use substances.
Sociopolitical Context of Anti-Drug Policing in the United States
Initiated by President Richard Nixon in 1971 and escalated by President Ronald Reagan in 1982, the war on drugs increased and incentivized anti-drug policing and enforcement, intensified legal penalties associated with drug-related crimes, and demonized individuals, particularly those who were part of marginalized communities and struggled with substance use disorders (Benson et al., 1995; Cooper, 2015; Koram, 2022; Park et al., 2019). Cooper (2015) and Saleem (1997) noted that contemporary anti-drug policing practices, such as stop-and-frisk and police drug raids, have been permitted through court cases such as Terry v. Ohio, Whren v. United States, and Illinois v. Wardlow and have eroded the Fourth Amendment and 1878 Posse Comitatus Act protections against unreasonable searches, seizures, and militarization of policing. Specifically, these court cases have permitted frisking for reasonable suspicion, allowed police to conduct stops in which police may stop individuals for suspicion of drugs under the pretext of other minor criminalized violations, and expanded the definition of suspicious behavior that may warrant being stopped by police (Cooper, 2015; Saleem, 1997). Although several anti-drug policing reforms have been made, such as the development of drug courts and the decriminalization of substances in various states (Klukoff et al., 2021; Scott, 2020), anti-drug policing practices have persisted, expanded, and received legislative support. For example, despite stop-and-frisk searches being declared unconstitutional in 2013 with the decision in Ligon v. City of New York, the practice was reduced by 98% by 2017 as opposed to ceasing entirely (New York Civil Liberties Union, n.d., 2019). Despite this decrease, racial disparities were maintained in these stop-and-frisk practices between 2014 and 2017, as 53% of targets were Black and 28% were Latino (New York Civil Liberties Union, 2019). Lastly, President Donald Trump voiced support for greater anti-drug policing efforts, while President Joseph Biden’s Safer America Plan seeks reform that simultaneously increases funding for policing and substance use treatment resources (Kaba & Ritchie, 2022; Koram, 2022; The White House, 2022). Although these systemic supports for reform from the executive branch may be aimed at drug trafficking, individuals who use substances may be at continued risk of being impacted by anti-drug policing with the increased support for and reliance on carceral approaches.
Although reforms related to criminalized behaviors may reduce harm through their trauma-informed focus, abolitionist authors and activists have critiqued such reforms as counter-productive when they expand the power and legitimacy of policing, maintain the criminalization of substance use, and perpetuate harm and violence toward those who use substances (Klukoff et al., 2021; Purnell, 2021a). For example, according to Fazel et al. (2017), 24% of the global imprisoned population meets the criteria for alcohol use disorder, compared to the less than 2% of the general population (Global Burden of Disease Network, 2016). Similarly, 30% of male prisoners and 51% of female prisoners meet the criteria for illicit drug use disorder, while less than 1% of the global population meets the criteria (Global Burden of Disease Network, 2016). Moreover, as stated earlier, substance use violations are the second most common arrest reason in the United States (FBI, 2022). Lastly, some authors have concluded that mixed results exist on the effectiveness of diversion programs for offenses associated with mental illness and substance use regarding recidivism and subsequent arrests (Klukoff et al., 2021; Scott, 2020). These data highlight a prevalent connection between policing, incarceration, and substance use in the United States and around the world despite contemporary reforms to anti-drug policing established through the war on drugs.
Policing functions to maintain social order and provide security by enforcing laws, policies, and social norms (Bureau of Justice Statistics, 2021; Giovengo, 2016). Moreover, police are ordained to investigate, arrest, and enact force upon those deemed as, or suspected to be, threatening to the safety and interests of dominant communities. Thus, the criminalization of substance use has been conceptualized as exerting control over and oppressing minoritized groups (Dollar, 2019; Purnell, 2021b). Marginalized communities have been hit especially hard by these zero tolerance policies, which drastically increased community members’ run-ins with police (Cooper, 2015). For example, the influx of stop-and-frisk procedures, a method that permitted police officers to detain an individual suspected of illegal activity and physically search them, led to minoritized individuals being racially profiled and targeted for searches without specific cause (Cooper, 2015). In fact, anti-drug policing has resulted in a shift from Black people accounting for 22% of those arrested in 1976 to 40% in 1992, despite making up 12% of the U.S. population (Cooper, 2015; Tonry, 1994). Thus, instead of eliminating substance use in communities, these crackdowns have only further increased the prevalence of police brutality, traumatized communities and individuals, and increased violence within communities (Cooper, 2015; Rhodes et al., 2006; Werb et al., 2011).
Structural Violence and Trauma From Anti-Drug Policing
Given the confiscation of an individual’s bodily autonomy, resulting in the infringement of the individual’s basic and constitutional rights and liberties, as well as the possibility for physical harm to take place during searches, anti-drug policing, which can involve violence, harassment, and killings, can place significant psychological stress and turmoil on targeted individuals (Park et al., 2019; Sarang et al., 2010). It is essential to analyze the long-term consequences of police violence perpetuated upon impacted individuals, including the possibility of traumatization and death (Bryant-Davis et al., 2017; Cooper, 2015; Krieger et al., 2015). Emerging research has demonstrated connections between being stopped by police and symptoms of anxiety and post-traumatic stress disorder (PTSD), particularly when the experience is perceived as intrusive and unjustified (Geller et al., 2014); suicide attempts (DeVylder et al., 2017); and symptoms of manic and depressive episodes (Meade et al., 2017). Likewise, vicarious traumatization from watching or learning of another individual experiencing police violence is also a concern given the high proportion of individuals living with substance use disorders who have both experienced trauma and witnessed police violence (El-Bassel et al., 2011; Park et al., 2019; Shaw et al., 2016). Research on those who witness police violence has often emphasized the unique impact on Black people. This research has demonstrated associations with vicarious exposure and poor mental health (Bor et al., 2018), distress from anticipated exposure following media consumption (Green et al., 2024), and psychological distress among Black mothers (Joe et al., 2019). Galovski et al. (2016) demonstrated that community protests following instances of police violence may result in symptoms of depression and PTSD among community members. Additionally, recent research has demonstrated a connection between vicarious exposure and increased cannabis use among Black Americans (Motley et al., 2022). Taken together, these findings suggest that directly and vicariously experiencing police violence may promote greater risk of traumatization.
Literature suggests that these encounters with police may end in violence beyond psychological distress because of the influence of stigmatization and prejudice against people who use substances (Cooper et al., 2005; Hayashi et al., 2013; Lunze et al., 2015; Wood et al., 2017). Officers may also confiscate civilians’ syringes during stop-and-frisk encounters, increasing the prevalence of syringe sharing, a known risk factor for HIV and HCV transmission (Beletsky et al., 2010; Park et al., 2019; Small et al., 2007). Detainment for substance use is also associated with increased risk of death following release because of withdrawal and increased risk of overdose (Chang et al., 2015; Fazel et al., 2017; Kinner et al., 2012; Pratt et al., 2010). Stress and traumatization experienced from anti-drug policing is also associated with high-risk behaviors, including drug injection, among addicted individuals (Maher, 2004; Shannon et al., 2008; Volkmann et al., 2011). Moreover, in one study, individuals needing treatment for substance use disorders were 2.74 times more likely to experience arrest and physical assault from police (Werb et al., 2016). Additionally, Werb et al. (2016) found that 27.5% of police encounters occurred within 500 meters of a substance use treatment facility. Similarly, Park et al. (2019) found in a sample of people who inject drugs in Baltimore that 7% experienced physical police violence and one in four knew someone else who had experienced physical police violence, fueling a deep mistrust of the system. Fear of potential retaliation by the police may also discourage individuals, particularly those with marginalized identities, from going to the police during a crisis or emergency situation, such as in cases of overdose. This mistrust of the system negatively impacts individuals’ willingness to pursue treatment services, especially when they are in fear of being detained or harmed by police officers (Alang et al., 2017; Cooper, 2015; Park et al., 2019). For example, a qualitative study described the impact of increased surveillance from police as both threatening and interfering with harm reduction practices (Cooper et al., 2005). Treatment centers are typically more centralized in areas where there is a higher drug activity which means that, because policing has a significant presence in these parts of communities, individuals may be hesitant to seek out help and support to avoid police encounters, negatively impacting social and health outcomes (Werb et al., 2016). Additionally, these crackdowns are associated with reductions in syringe exchange programs, drug treatment, and HIV testing accessibility (C. S. Davis et al., 2005; Park et al., 2019; Ti et al., 2013). These findings highlight how anti-drug policing actively inhibits access to safe and needed care.
A Case for Abolition in Substance Use Counseling
Because of the increased risk of experiencing police violence and the subsequent risk for traumatization from police violence, it is essential for counselors to address encounters stemming from anti-drug policing in treatment and develop practices that divest from policing practices and systems. Trauma-informed practice is a “fundamental obligation” (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014, p. 5) for counselors who work with clients at the intersections of substance use and police violence to reduce or mitigate the adverse impacts of trauma on individuals’ physical, emotional, psychological, and spiritual well-being and to prevent further systemic (re)traumatization. Trauma-informed practice is that which recognizes and understands the impact and salience of trauma, effectively responding to it in ways that do not retraumatize and further perpetuate traumatic stress while also recognizing that marginalized groups are at greater risk of experiencing trauma and its effects (SAMHSA, 2014; Sweeney & Taggart, 2018). There are four assumptions that ground trauma-informed practices (adapted from SAMHSA, 2014): 1) a realization of the potentially long-lasting effects of trauma on individuals, communities, groups, families, and systems and that trauma can be perpetuated by systems like the criminal legal system, resulting in a significant impact on continued substance use and mental health; 2) the importance of recognizing the signs of trauma and refraining from pathologizing these responses; 3) the crucial need for a system or organization to respond supportively by applying the six principles of a trauma-informed approach; and 4) resisting the potential to retraumatize individuals who are accessing supports and care. Moreover, SAMHSA (2014) identified six principles of trauma-informed practices that are intended to serve as the fundamental spirit of trauma-informed care: 1) safety; 2) trustworthiness and transparency; 3) peer support; 4) collaboration and mutuality; 5) empowerment, voice, and choice; and 6) cultural, historical, and gender issues.
By SAMHSA’s description, current substance use treatment falls short of being trauma-informed when it occurs under systemic conditions in which anti-drug policing and police violence are part of the historical and current response in the treatment and care of individuals who struggle with substance use. As outlined above, anti-drug policing practices can result in police violence that includes stop-and-frisk, arrests, and an intimidating presence that may negatively interfere in treatment accessibility for individuals who are fearful of potential run-ins and harassment (Werb et al., 2016). Anti-drug policing and the broader criminalization of substance use may disrupt safety, retraumatize substance use clients, and diminish trust and transparency in accessing substance use treatment. Moreover, incarceration for using substances may inhibit the potential for peer support and collaborative approaches to treatment. Lastly, the existing racial disparities in anti-drug policing practices demonstrate a history of systemic racism that may disproportionately create a barrier to accessing trauma-informed care for racially marginalized groups, particularly Black Americans. Thus, we contend that an abolitionist praxis that opposes anti-drug policing and divests from carceral approaches to responding to individuals who use substances is needed to fully realize trauma-informed practice with clients who use substances.
Abolitionist Praxis for Substance Use Counseling
Abolition is a social justice praxis that is commonly referenced as a necessary solution to policing and its impact (A. Y. Davis et al., 2022; Kaba, 2021). Abolition refers to the broad movement of divesting from and eliminating carceral systems, such as law enforcement and prison systems, and carceral logics that seek to legitimize the use of punishment, retribution, and vengeance through carceral systems. Rooted in the efforts of Black feminist thought, advocacy, and organizing, abolition calls for a critical analysis of the ways in which policing has functioned to enact the violence of overlapping systems of oppression (Kaba & Ritchie, 2022). Kaba and Ritchie (2022) identified three objectives of abolitionist praxis. First, abolitionist praxis seeks to create collective safety from community violence and the violence of policing and related carceral systems that reinforce systems of oppression, such as White supremacy, patriarchy, and capitalism (Kaba, 2021; Kaba & Ritchie, 2022; Purnell, 2021a). Second, abolitionist praxis seeks to end violence from carceral systems through eliminating those systems as opposed to seeking reforms that preserve the inherent violence of policing and incarceration (Kaba & Ritchie, 2022; Klukoff et al., 2021). This second objective extends beyond institutions of policing and incarceration and extends to the ways in which carceral logic and behaviors of policing are embedded in other systems, institutions, and communities and often internalized by individuals (Kaba & Ritchie, 2022). Lastly, to achieve collective safety, abolitionist praxis necessitates a simultaneous transformation from reliance on the violence of policing and related carceral systems toward cultivating cultures, systems, communities, and ways of being that are centered around care, healing, justice, and accountability (Kaba & Ritchie, 2022).
Abolition exists beyond a theoretical and conceptual framework. It is an iterative process that combines theorizing, action, and reflection upon efforts that divest from and dismantle carceral systems and logics while simultaneously brainstorming solutions to community violence that promote safety, healing, and justice (Cullors, 2019; A. Y. Davis et al., 2022; Kaba & Ritchie, 2022; Klukoff et al., 2021). Abolitionist praxis often utilizes a transformative justice framework to achieve its objective of eliminating carceral systems while creating new systems and ways of being that foster safety, healing, and justice. Transformative justice aligns with abolitionist praxis in that it is a liberatory strategy that seeks to transform systems and structures that create the conditions for violence (Afuape & Kerry Oldham, 2022). While policing and incarceration focus on retributive justice that assigns inherently violent punishment as a mechanism for change regardless of the harm it causes, transformative justice through abolitionist praxis seeks to create processes of accountability for harm caused interpersonally from criminalized behaviors and systemically from policing and related carceral systems. As a result, abolitionist praxis utilizes transformative justice to create new systems, institutions, communities, strategies, and internalized ways of being that value safety, healing, and justice that are needed to cultivate trauma-informed care and practices for substance use clients.
Regarding substance use counseling, an abolitionist praxis seeks to reduce and eliminate violence as a response to substance use, decriminalize all substance use, and eliminate contact between substance use clients, police, and the broader criminal legal system. Similarly, an abolitionist praxis to substance use counseling challenges the logic that criminalization is a needed step in treatment for substance use. For example, in 2001, the Portuguese government enacted nationwide laws to decriminalize all substances, resulting in a decrease in the prevalence of drug use and overdose rates (Castelpietra et al., 2022; James et al., 2020; Pombo & da Costa, 2016; Smiley-McDonald et al., 2023). In 2021, Oregon decriminalized low-level drug possessions and subsequently increased options for substance use disorder treatment and harm reduction programs (Good et al., 2023; Smiley-McDonald et al., 2023). In their study, Smiley-McDonald et al. (2023) found that the Oregon legislation resulted in a decrease in the number of interactions between police officers and individuals who use drugs. Thus, the abolitionist goal of decriminalizing substance use while implementing harm reduction programs may function to both minimize inherently violent contact with police and reduce the prevalence of substance use.
Abolitionist praxis would also call for the development of accountability for interpersonal and community harm caused by client substance use that does not rely on legal punishment, or the threat of it, from the criminal legal system (Cullors, 2021). Accountability for harm caused under abolitionist theory entails a developed recognition of wrongdoing and harm, both interpersonally and as mediated by social, economic, and political context, and sustained effort toward intrapersonal, interpersonal, and institutional change that repairs harm (Cullors, 2021; Kaba, 2021). Counselors must re-envision both their clinical practice and engagement in advocacy toward abolition to holistically care for clients who use substances.
Clinical and Advocacy Recommendations
Given the previously outlined mental health outcomes that are associated with direct and vicarious experiences of police violence that suggest its traumatic impact (DeVylder et al., 2017; Galovski et al., 2016; Geller et al., 2014; Green et al., 2024; Joe et al., 2019; Meade et al., 2017; Motley et al., 2022), a trauma-informed approach is essential to working with those who experience police violence as a consequence of anti-drug policing. Counselors seeking to use a trauma-informed approach to treat substance use disorders must infuse abolition into their delivery of services while also engaging in advocacy beyond direct clinical work to better achieve SAMHSA’s six identified principles of trauma-informed practice. We provide an abolitionist framing of these six principles and offer abolitionist re-envisioning for substance use counseling below. Moreover, we adapted the sixth principle of cultural, historical, and gender issues to cultural competence and advocacy to emphasize the professional role of advocacy in counseling for substance use clients who experience anti-drug policing.
Safety
Ensuring safety in the therapeutic space is essential because anti-drug policing and the threat of police violence pose a safety risk to clients who use substances and are involved in or at risk of being targeted by the legal system. One step toward maximizing safety for clients is to end the use of abstinence-based treatment. Given that counselors may serve as treatment referral sources for court-mandated clients who meet criteria for diversion programs that seek to route individuals toward treatment for substance use and away from incarceration (Scott, 2020), abstinence-based treatment needs critical examination. Although such interventions can reduce engagement in substance use and mental health symptoms (Pinals et al., 2019), they do so with a looming threat of police violence and incarceration as a consequence for failure to complete the requirements of the diversion program (Scott, 2020). This poses a value conflict with counselors who are treating court-mandated clients for substance use. Counselor participation in diversion programs may require disclosures of client participation and progress in counseling that may lead to legal consequences for clients if they do not meet requirements of the diversion program. For example, counselors may be ethically obligated to document client relapses, which are more common in substance use treatment for minoritized groups and those with histories of experiencing multiple traumatic events (Farley et al., 2004; Heffner et al., 2011), which may be requested by probation officers, attorneys, or courts. In such a scenario, disclosure of client progress in treatment could produce a risk of clients experiencing police violence and incarceration. Moreover, this may produce a circumstance in which a client’s dominant motive for engaging in treatment is to avoid the consequences of police violence and incarceration. Consequently, acknowledging the intrapersonal, interpersonal, and community impact of one’s substance use and engaging in accountability are likely to become secondary motives for change and repair of any harm caused. Although the potential for incarceration may serve as motivation for change for substance use clients, substance use counselors can align with an abolitionist praxis by engaging in theorizing to develop methods and systems that motivate client accountability and transformation without the threat of violence induced by carceral systems. Moreover, alignment with an abolitionist praxis may require substance use counselors to proactively use their power to advocate for harm reduction in treatment as alternatives to approaches that risk harm through police violence and incarceration. Harm reduction approaches emphasize safe use over non-use of substances and have demonstrated evidence of both maintained and reduced substance use, reductions in harm related to substance use (e.g., less police contact and fewer arrests and emergency hospital visits), and self-reports of feeling safer (Carrico et al., 2014; Smiley-McDonald et al., 2023; Vallance et al., 2016).
Anti-drug policing views substance use as threatening and seeks to foster security through violent force and criminalization (Kaba, 2021). This security comes at the expense of the safety and well-being of those who use substances. An abolitionist re-envisioning of safety is one that seeks to ensure safety from the harm that both substance use and carceral systems cause to individuals, families, and communities. Regarding safety for substance use clients who experience anti-drug policing, Drustrup et al. (2023) offered an abolitionist approach to safety planning that counselors can adapt to fit the needs of clients mandated to substance use treatment. This approach decenters the default reliance on police in crises and emergencies and emphasizes collaboration with clients to establish methods that can maintain safety. Adapting this to clients, counselors can minimize disclosures of substance use, especially to police, probation officers, and employees of the criminal legal system. Noting the importance of building networks of care in place of carceral systems (Drustrup et al., 2023; Kaba, 2021), counselors should simultaneously collaborate with clients to identify interpersonal and community mechanisms to maintain safety and progress toward substance use–related treatment goals, particularly for when relapses occur. Consequently, this also promotes safety from the impact of substance use and client empowerment, voice, and choice in their treatment and wellness. For example, counselors could simultaneously utilize family therapy as a mechanism to support structural change associated with the development of a client’s substance use and to promote accountability for harm caused by substance use within the family system. Furthermore, when harm from substance use extends to one’s community, in collaboration with clients and those directly impacted, counseling could be used to promote reparation for harm caused (Cullors, 2019). Counselors should be mindful of the possibility that clients may not readily share experiences of police violence and substance use because of distrust fostered by carceral systems and if they have experienced invalidation, blame, or neglect regarding their experiences of police violence. Thus, counselors can enhance safety, trust, and the potential for change with clients through a consistent practice of accurate empathy and attunement to clients’ subjective experience of police violence (Miller & Rollnick, 2013).
Trustworthiness and Transparency
Trustworthiness and transparency are essential given the systemic distrust fostered by histories of collaboration between helping professions and carceral systems (Jacobs et al., 2021; Klukoff et al., 2021). Counselors need to promote an optimal level of safety and trustworthiness with their clients through nonjudgement, empathy, transparency, positive regard, validation, normalization of the client’s responses to adversity, and consistency (SAMHSA, 2014). Counselors pursuing abolition can establish trustworthiness and transparency through using the informed consent process to build rapport and establish parameters of the therapeutic relationship within a societal context that largely criminalizes substance use. While Drustrup et al. (2023) offered inspiration for abolition in the therapeutic relationship, counselors are ethically obligated to make exceptions to confidentiality when imminent risk to self and others is established. Additionally, as mentioned above, substance use counselors may be required to make exceptions to confidentiality to share progress for court-mandated clients. Informing clients of these exceptions to confidentiality is standard in helping professions; however, abolition can maximize trustworthiness and transparency by going beyond merely capturing client signatures on informed consent documents. In addition to establishing the limits of confidentiality, counselors pursuing abolition are recommended to ensure that clients fully understand these limits and the impact of these limits on their participation in the therapeutic context. For example, a substance use counselor could clearly articulate known risks of making exceptions to confidentiality of the therapeutic relationship with police and legal system employees, such as increased risk of experiencing police violence, incarceration, and state-sanctioned surveillance. Counselors pursuing abolition who are directly embedded in carceral systems as a function of their employment, such as prisons, should inform clients of any dual or conflicting interests associated with their counseling in the prison system. Additionally, counselors can use open-ended questioning to provide clients an opportunity to check their understanding of confidentiality, its limits, and the impact of needing to make exceptions to confidentiality. Moreover, counselors pursuing abolition should collaborate with clients to identify external resources to counseling that offer greater trustworthiness that can facilitate transformation and healing from substance use in situations where clients may feel a lack of trust in counseling because of the threat of carceral systems.
Peer Support
Providing opportunities for peer support for clients who have experienced police violence and are living with substance use disorders could also be promotive and helpful for healing because of the access to other individuals who have undergone similar experiences. Group therapy has been associated with positive mental health outcomes, particularly among individuals with PTSD and substance use disorders, due to receiving mutual support from others who have similar experiences and can provide empathy, a sense of belongingness and collectivism, and the opportunity to provide and receive feedback; build safety through interpersonal relationships; and reduce feelings of isolation and loneliness (Barrera et al., 2013; Mott et al., 2013; Schwartze et al., 2019; Sloan et al., 2013). Substance use counselors pursuing abolition can actively incorporate group therapy within the therapeutic context and help clients heal following traumatization from police violence while promoting their long-term recovery. Additionally, counselors employed in treatment centers who are pursuing abolition should be mindful of added benefits toward safety and trustworthiness that embedding peer support can offer, particularly for court-mandated clients. When a client is unable to experience enough safety and trustworthiness because of the threat and impact of carceral systems, embedded peer support that exists outside of the counselor–client relationship can provide alternate spaces for clients to be heard and validated. Abolitionist substance use counselors can advocate for the inclusion of peer mentoring for accountability and transformation akin to that which exists within 12-step groups through sponsor relationships. Although it may be conceptualized as part of a process of accountability to utilize clients who have advanced in their treatment as peer mentors, counselors pursuing abolition should also consider the feasibility of paying peer mentors to avoid replicating the occurrence of unpaid and underpaid labor that may occur in prison systems.
Collaboration and Mutuality
It is essential for counselors pursuing abolition to cultivate environments and therapeutic relationships that promote collaboration and mutuality. It would behoove substance use counselors to utilize frameworks for treatment that are inherently trauma-informed and collaborative, such as motivational interviewing, for assessing client motivation for change and structuring treatment with clients that is centered around partnership, acceptance, compassion, and evocation (Clark et al., 2014; Miller & Rollnick, 2013). These efforts may be particularly beneficial for clients who have experienced police violence as a result of anti-drug policing in that they allow greater client participation and trustworthiness to a client population that may be prone to experiencing coercion and restricted freedom and being acted upon. Abolitionist substance use counselors can foster greater collaboration and mutuality in their practice of counseling by making mutual aid foundational to their practice. Mutual aid is an intentional resistance to reliance on institutions that cause structural violence (S. W. Davis & Fayter, 2021; Jacobs et al., 2021). Instead of relying on such institutions, mutual aid seeks to establish networks of care that use community members and resources to meet the needs of others (S. W. Davis & Fayter, 2021; Jacobs et al., 2021). Establishing mutual aid in substance use counseling for clients who experience anti-drug policing requires counselors to advocate to establish and streamline connections to community resources that address underlying, unmet, or neglected needs of clients that play a role in their use of substances and experience of anti-drug policing. For example, an abolitionist substance use counselor may actively coordinate with community agencies that provide support in securing shelter to mitigate substance use and the risk of subsequent anti-drug policing that may be associated with homelessness. Integrating peer support and mentoring, as mentioned previously, within and outside of treatment facilities could function as mutual aid; however, substance use counselors working in carceral institutions may experience pushback to such efforts given that mutual aid seeks divestment from carceral systems (S. W. Davis & Fayter, 2021). Lastly, in terms of collaborative goal-setting, the counselor can work with the client to identify the client’s objectives for attending therapy. The counselor is recommended to honor the client’s voice and work with the client to establish whether the client would like to refrain from using substances in the future, engage in harm reduction practices, and/or process the trauma that the client may have experienced at the hands of police.
Empowerment, Voice, and Choice
Anti-drug policing, incarceration, drug courts, and related carceral approaches to substance use may use interventions that limit the agency of those subjected to their demands. Counselors can engage in an abolitionist praxis that is rooted in trauma-informed practice by screening and assessing for the prevalence and impact of police violence as a potentially traumatic stressor that relates to the use of substances (Green, 2022; Green & Evans, 2021). Given the importance of divesting from carceral systems and logic in abolitionist praxis, counselors need to engage in an ongoing and iterative process of reflection and change in attitudes and practices that reinforce the criminalization of substance use and practices that treat it as the moral failure of the individual. This can be achieved through screening and assessment for substance use and police violence that counteracts experiences of shame and guilt that may be fostered from interactions with police and the criminal legal system (Clark et al., 2014). Moreover, abolitionist praxis in counseling with clients who experience police violence due to anti-drug policing requires a strength- and healing-oriented approach as an act of radical resistance to the pathologizing and moralizing norm of carceral approaches (Cook et al., 2014; Moh & Sperandio, 2022). In practice, this may entail an intentional focus on a client’s progress in collaboratively defined goals and support in actualizing accountability for harm caused from substance use. Similarly, this would require a commitment to approaching clients who use substances with care and compassion, rather than criminalizing, shaming, or infantilizing the individual’s responses to trauma and violence they have endured prior to, during, or after their substance use. Lastly, abolitionist praxis in the context of substance use treatment may require counselors to provide opportunities for clients to have input regarding their needs in treatment by prioritizing individualized treatment over a standardized “one size fits all” approach to counseling. Thus, rather than prescribing a course of treatment or implementing treatment prescribed by a referring carceral system, abolitionist praxis would leverage collaboration to allow clients to have a voice in determining what they need to cope and heal from their use of substances and any traumatic experiences that precede and result from substance use.
Cultural Competence and Advocacy
Abolitionist praxis requires efforts to repair histories of structural violence (Cullors, 2019); thus, substance use counselors pursuing abolition must develop a critical understanding of the sociopolitical history of anti-drug policing toward those who use substances. This article provided a snapshot of this history as a starting point; however, counselors can delve further into learning about the intersection of anti-drug policing and race, gender, sexuality, disability, and socioeconomic status to develop more robust competence in addressing the scope of anti-drug policing. Counselors should critically reflect upon this historical knowledge to confront and actively dismantle any internalized biases they may have about substance use clients that are perpetuated by carceral systems. Counselors should specifically become aware of how the criminal legal system may perpetuate racial prejudice, particularly anti-Black racism, and how these attitudes affect the counselor’s conceptualization of their clients to avoid pathologizing or blaming the client for the structural violence they endure through anti-drug policing. To that end, counselors should actively incorporate practices that are not only trauma-informed, but also culturally responsive (SAMHSA, 2014).
Abolitionist praxis aimed at repairing historical structural violence through anti-drug policing would broadly include efforts toward the decriminalization of substance use. In addition to decriminalization efforts, counselors engaged in an abolitionist praxis might advocate with legal professionals and lawmakers for the retroactive and automatic expungement of drug-related criminal record charges for substance use clients (Adinoff & Reiman, 2019). These efforts would ensure that those with histories of substance use disorder are able to experience transformation that such records and their associated stigma may hinder. Given that abolition calls for counselors to address and promote healing from issues that underlie substance use, counselors seeking to engage in abolitionist praxis should advocate for funds that are currently and formerly used toward criminalizing substance use to be invested in transformative justice practices and trauma-informed treatment for substance use disorders (Adinoff & Reiman, 2019). For example, abolitionist praxis would call for transformative justice systems and practices to replace drug courts and related diversion programs. Although drug courts may be successful in deterring those who use substances from arrests and incarceration, Klukoff et al. (2021) highlighted the paradoxical nature of relying on carceral punishment as a motive for change because it risks police violence toward those who use substances when drug court requirements are not met. As stated earlier, this creates a value conflict for counselors who may have to disclose information regarding relapse during treatment that can be used in ways that jeopardize and harm the wellness of clients who use substances.
Limitations and Considerations
Adopting and incorporating an abolitionist praxis to counseling with clients impacted by anti-drug policing comes with challenges that counselors must critically reflect on prior to and during the implementation of this practice. First, counselors should prepare themselves to navigate pushback and resistance to social justice practices that would disrupt the status quo (S. W. Davis & Fayter, 2021). For example, it is common for individuals to criticize abolitionist praxis as utopian to inhibit the process of creatively imagining communities and systems that do not rely on carceral logics and systems (Kaba, 2021). Approaches like motivational interviewing are poised to navigate these challenges from colleagues who may be hesitant to embark upon making abolitionist change. In addition to pushback from individuals, it should be noted that, as a praxis seeking the elimination of carceral systems, barriers to the adoption of an abolitionist praxis can be expected from current carceral systems and approaches that may have existing evidence that establish them as efficacious. To counteract this expected barrier, substance use counselors need to engage in research, assessment, and program evaluation of efforts that are developed in alignment with an abolitionist praxis to establish efficacy. This would serve the purpose of ensuring that progress toward safety is achieved, that substance use clients are receiving trauma-informed care, and that other substance use counselors are introduced to new alternatives to existing carceral approaches that may increase the risk of harm to substance use clients. Additionally, counselors should critically reflect on and identify solutions to ethical, legal, and employment-related barriers if implementing an abolitionist praxis on their own. For example, making the choice as an individual counselor in a broader agency to not report substance use to a referring probation officer may be construed as fraudulent and unethical, thus jeopardizing a counselor’s employment and career. When making these decisions about whether or not to report substance use, counselors need to carefully weigh the options and consider consequences that can come from each course of action from a legal and ethical perspective, similar to what is suggested in the Forester-Miller and Davis (2016) Ethical Decision-Making Model. In the meantime, counselors can inform and educate probation officers about the nature of addiction and the potential for relapse to occur. Increasing awareness about these matters could generate a landscape shift for how probation officers and other authorities treat those struggling with addiction. Lastly, counselors should consider advocating for organizational support to adopt and implement trauma-informed and abolitionist changes to prevent such outcomes.
Conclusion
Clients who meet criteria for substance use disorders may have experienced, have witnessed, or be vulnerable to experiencing police violence. As a result, those who use substances are vulnerable to experiencing trauma that stems from exposure to police violence, which counselors must address. Counselors need to utilize abolitionist praxis to achieve a trauma-informed practice that supports healing from experiences of trauma affiliated with substance use and police violence, aim to prevent retraumatization, and create opportunities for both accountability and repair of harm caused by one’s use of substances.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Darius A. Green, PhD, NCC, is an assistant professor at the University of Colorado Colorado Springs. Katharine R. Sperandio, PhD, NCC, ACS, LPC, is an assistant professor and a CACREP-accreditation coordinator at Saint Joseph’s University. Correspondence may be addressed to Darius A. Green, 1420 Austin Bluffs Pkwy, Colorado Springs, CO 80918, dgreen20@uccs.edu.
Feb 28, 2017 | Volume 7 - Issue 1
Alexis Miller, Jennifer M. Cook
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.
Theoretical Underpinnings
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.
Social Influences
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.
Problematic Language
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.
Cultural Factors
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.
Model Components
Cultural Influences
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).
Childhood Adversity
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
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.
Case Study
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).
Case Discussion
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.
Future Research
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.
Conclusion
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.
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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, alexis.miller626@gmail.com.