SWK 3805: Module 6- Social Context Theories

Dr. Audrey Begun

Contents

- Module 6: Preface

- Module 6: Introduction

- Ch. 1: Social Context and Physical Environment

- Ch. 2: Social Contexts

- Ch. 3: Family

- Ch. 4: Applying Content About Family

- Ch. 5: Summary

- Module 6: Key Terms

- Module 6: References and Image Credits

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Module 6: Preface

Welcome to the online coursebook for Module 6 of our Theories and Biological Basis of Addiction course. The material is designed to be read interactively or after downloading; while the embedded interactive exercises require internet connectivity, each can also be downloaded for offline work. These exercises are presented to help you test and apply what you are reading, challenge yourself, prepare for quizzes, and have a little fun along the way. The list of key terms at the end explains text highlighted in bold italics throughout the book—in the interactive mode you can click on a highlighted word to jump to its explanation in the key terms section. Use the back arrow to return to where you were reading.

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Module 6: Introduction

The reading for Module 6 introduces concepts essential for understanding many of the social context/social environment theories of addiction. This online textbook includes content prepared by the book’s author, as well as several readings from the published literature.

Module 6 Reading Objectives

After engaging with these reading materials and learning resources, you should be able to:

- Explain how the social context and physical environment influence substance use, misuse, and addiction patterns

- Identify the components of the social ecological model as they relate to substance use

- Describe how social norms influence substance use and misuse behavior

- Identify social structure theories and how they explain substance use and misuse (culture and subculture, labeling theory, deviance, theory, and the impact of “isms”)

- Explain additional social context factors and theoretical perspectives, including family, peers, workplace, neighborhoods, behavioral economics/behavioral choice theory, and stress and coping theory

- Define key terms related to the social context and physical environment factors related to substance use and substance use disorders.

Ch. 1: Social Context and Physical Environment

The first reading for Module 6 presents a general overview of theories concerning the role of social contexts and physical environments in substance use, substance use disorders, and opportunities for prevention or treatment. These are often referred to as sociocultural theories, but that label does not provide sufficient emphasis about the role of environmental factors. Evidence points to many relevant social and environmental factors that play a role, such as:

- Family and family system dynamics

- Peer groups

- School and workplace

- Neighborhood and community

- Policy and enforcement

- National and global forces

In this first chapter you will read about:

- Social systems, the physical environment, and the social ecological model;

- Social norms theory;

- Social structure influences, culture/subculture and deviance theory, the impact of “isms,” and labeling theory; and,

- key terms used in relation to the social context of substance use and addiction.

Social Systems

Anthropologists argue that the use of substances can only be properly understood when placed within a social context: the family, social, school, work, economic, political and religious systems (Hunt & Barker, 2001). An obvious physical environment aspect of context that is important to consider has to do with a person’s access to alcohol or other drugs. In general, the physical environment produces opportunities and obstacles that shape the behavior of people living or functioning in those spaces and places. For example, a person who grows up in a warm southern climate may not have an opportunity to learn snowboarding. Someone living in a dangerous neighborhood may not build outdoor exercise into his or her regular daily routine. And, the nutritional value of a person’s diet is influenced by living in a “food desert” versus in an area where healthful foods are easily accessed and affordable. Specific to our discussion of substance use, we need to consider how difficult or easy it is to gain access to alcohol, tobacco, or other substances in the family home, school, workplace, peer group, or neighborhood.

One set of questions tracked over time in the U.S. national survey of middle and high school students called Monitoring the Future concerns how easy or difficult the students believe it is to obtain various substances. As you can see from Table 1, the 12th graders believed they had easier access to all of the substances (cigarettes not reported) than did 8th and 10th graders. We have no way of knowing for certain if access actually increased with age, only that belief in access increased; however, the belief may be based on reality.

Table 1. Percent of students responding “fairly” or “very” easy to obtain substances, 2016*

substance

8th graders

10th graders

12th graders

alcohol

52.7

71.1

85.4

cigarettes

45.6

62.9

—

marijuana

34.6

64

81

LSD

6.9

15.2

28

heroin

8.9

10.6

20

other narcotics

8.9

16.8

39.3

cocaine

11.0

14.9

28.6

*Table created from data presented in Monitoring the Future report for 2016.

Social Ecological Model. The social ecological model presents a framework with great applicability for understanding human development and behavior within social systems and contexts. To consider how the social ecological model might apply to the problems of substance use, misuse, and addiction, we can start with the central sphere that represents the individual person. This innermost sphere contains what we have studied so far in relation to a person’s biological and psychological makeup—the biopsycho components from our earlier course modules. This is what the person brings to any interactions with the social or physical environments in which he or she functions. Next, we look at the many spheres of influence that form that individual’s social ecology: the micro, meso, exo, and macro systems with which individuals interact (see Figure 1). These systems influence us, we influence them, and they influence each other, which explains why there are arrows between the system levels in Figure 1.

Figure 1. Diagram representing social ecological model’s multiple system levels

Microsystem components include those social systems with which we directly interact on a regular basis: partners, immediate family members, close friends and others in our most personal, intimate sphere of daily living.

These people have a powerful effect on behavior through a number of mechanisms, including the way that they influence learning through delivering consequences (reinforcing or punishing) behaviors that we exhibit, as well as serving as the models for behavior related to social learning theory. They also shape our immediate environments. For example, they may make it easy to access alcohol, tobacco, or other drugs. While the microsystem influences our experiences, we have an influence on the microsystem, as well. Consider how a person’s substance use affects behavior, which in turn has an influence on his or her parenting, relating to an intimate partner, or interacting with friends.

The microsystem influences and is influenced by the mesosystem, as well. The mesosystem components include those elements in the relatively immediate environment with which we routinely interact in ways that are less intimate than what happens within our microsystem. For some people this includes extended family and peers/friends with whom we are close but not as intimate. It might include the people with whom we work or go to school and it might include neighbors. For some people this might be a religious community. Health care providers might be part of the mesosystem if a person needs health or mental health care related to substance use.

The exosystem is one more step removed in terms of regular interactions and direct impact. This includes social institutions with which we directly engage less frequently. Depending on the nature of our interactions, social institutions designed to provide services might be in the mesosystem or exosystem for a particular person or family. For example, this might distinguish between the office where someone works (mesosystem) and the company for whom the person works (exosystem). Or, it might distinguish between the person providing recovery treatment (mesosystem) and the agency where treatment is being provided (exosystem). The practices and policies of these social institutions (e.g., zero tolerance policies) influence the individual’s experience in the social environment through indirect interactions, often filtered to us through our intervening systems (mesosystem and microsystem). A significant component of the exosystem involves community policing and law enforcement around substance-related activities. For individuals involved with drug court by virtue of their substance-related activities, the team of intervention professionals might be part of the mesosystem. Social service delivery systems are part of the exosystem for many people.

Finally, we have the macrosystem to consider. While few of us directly interact on a routine basis with the elements shaping the cultures and societies in which we live, they do have a powerful (though indirect) influence on our experience. Consider, for example, how change in the legal status of certain substances occurs, and how that change influences behavior at the individual level. Popular media provides an interface between what happens at the macrosystem (and exosystem) level and the more intimate levels of our social environments. It helps shape attitudes, values, beliefs, stereotypes, and stigma about substance use that are expressed by our mesosystem and microsystem members. Social workers and other professionals cannot afford to ignore the impact of policy, laws, and law enforcement patterns at the exosystem and macrosystem levels on the social context of substance use. For example, in many communities there exists a reciprocal relationship between the two problems of heroin use and the abuse of prescription pain medicines: as communities crack down prescription abuse, making the substances more difficult to obtain, problems with heroin seem to explode.

Within this framework, we can look more closely at theories concerning the mechanisms by which these social ecology elements have their impact, and at evidence concerning these different elements.

Social Norms Theory

Social norms are a key aspect of the social processes involved in substance use—both in terms of initiating use for the first time and in terms of misusing and using to excess. For example, most cultures that accept the use of alcohol also have norms related to the boundaries of acceptable use—when, where, by whom, and how much. Social norms also come into play because a person who believes that everyone else using alcohol or another substance, or at least approves of that substance’s use, is far more likely to use than a person who believes that it is not common or accepted in their social context.

Here is an interesting thought: if our public education messages suggest that way too many people binge drink or drive under the influence of substances or use marijuana on a regular basis, are we actually providing a social norm supporting these behaviors? Perhaps, instead, we need to tailor our messages differently. For example, consider the way anti-smoking campaigns have helped to reshape the nation’s social norms about tobacco use.

Looking at the Monitoring the Future study results again, we can explore middle and high school students’ level of disapproval toward people who use substances. As you can see, occasional and regular use of substances gains more disapproval than trying it once or twice, and the level of disapproval for marijuana and alcohol use declines among the older 12th grade students compared to the younger groups of 8th and 10th graders (see Table 2). What is interesting to note is that the 12th graders seem to make a greater distinctions between types of substances than do the younger students: they disapprove more strongly than the younger students about LSD and heroin, and equally strongly about cocaine, but less strongly about alcohol and marijuana.

Table 2. Percent of students disapproving or strongly disapproving of people who…*

substance use pattern

8th graders

10th graders

12th graders

try one or two drinks of an alcoholic beverage

52.6

41.8

28.8

take one or two drinks nearly every day

79.1

78.6

71.8

have five or more drinks once or twice each weekend

84.9

80.8

74.2

try marijuana once or twice

70.1

52.6

43.1

smoke marijuana occasionally

77.5

61.9

50.5

smoke marijuana regularly

82.3

73.5

68.5

try heroin once or twice without using a needle

85.6

90.2

93.8

take heroin occasionally without using a needle

86.7

90.9

94.0

try cocaine once or twice

86.8

87.9

86.6

take cocaine occasionally

89.3

90.8

90.6

take LSD once or twice

55.2

69.5

82.4

take LSD regularly

57.6

74.9

92.4

*Table created from data presented in Monitoring the Future report for 2016.

Social norms about alcohol and other substance use also tend to be tied to ethnic identity. For example, there exist many drinking-related stereotypes about Irish Americans and Americans with Russian roots. These ethnic stereotypes can have a significant effect on a person’s decisions about drinking and drinking to excess. On the other hand, cultural prohibitions around drinking to the point of intoxication may be strong in a person’s cultural context. This social disapproval of excessive use (misuse) can be a protective factor against substance use becoming a substance use disorder.

Social Structure Influence Theories.

A number of theories draw from the science of sociology to explain the phenomena of substance use, misuse, and addiction. These theories “view the structural organization of a society, peer group, or subculture as directly responsible for drug use” (Hanson, Ventruelli, & Fleckenstein, 2015, p. 78).

Culture and subculture. Policy is a form of intervention heavily influenced by theories about the origin of the problems to which it is responding. To a large extent, policy also is influenced by a culture’s values and belief systems, such as the philosophy concerning whether the problem of substance use is better addressed through punishment or treatment. Cultural systems are even responsible for defining what is a drug in the first place. For example, in the majority culture of the United States, hallucinogenic substances like peyote are defined as drugs of abuse. However, according to anthropologists, peyote religion among certain Native American groups defines this substance quite differently (Hill, 2013).

Or, consider the argument that fast food has addictive potential—is a fast food burger to be considered a drug and the fast food restaurants responsible for causing an addiction like drug trafficking?

Subculture is about groups that form within a larger culture. The values, beliefs, attitudes, and behav iors within the subculture group may complement or contradict those of the larger cultural context. When they are contradictory, deviance theory may come into play. According to deviance theory, a person (or group) elects to engage in behaviors disapproved of by the conventional “majority” culture specifically because of that disapproval. These individuals embrace their deviance identity—the label becomes an important aspect of identity. Why would someone want to belong to a deviant subculture or group? For many people, it is a matter of belonging somewhere, anywhere, being better than belonging nowhere. Participating in deviant behavior seems a small price to pay for admission to the group. For others it is a means of differentiating self from others—particularly from those who represent the conventional culture. For example, it is one way of making clear to yourself and the world that you are your own person, distinct from who your parents are. Having strong prosocial bonds with members of the conventional culture is a protective force against deviance—the extent to which a person desires approval and wishes to avoid disapproval of the people with whom they have these prosocial bonds helps them make choices that conform to convention (Sussman & Ames, 2008).

Labeling theory suggests that other people’s perceptions of us, the labels they apply to us, have a strong influence on our own self-perceptions (Hanson, Venturelli, & Fleckenstein, 2015). The individual then has the choice of acting in accordance with the labels (e.g., drinking to excess as an “alcoholic”) or acting differently so as to shed the label (e.g., quitting drinking ordrinking only in moderation). In addition, theory suggests that when individuals have weak bonds to conventional society, there is less motivation to conform to conventional social norms and expectations. Hence, they are more likely to deviate from those norms. They have less “stake in conformity” than others who choose to behave in ways that comply with conventional norms.

The impact of “isms.” Issues of racism, classism, sexism, and other forms of “ism” have a powerful impact on individual’s experience of the social world, as well as on their physical environments. Thus, oppression, discrimination, and exploitation based on racial, ethnic, social class, gender, gender identity, sexual orientation, religious, disability, or national origin factors are integral to understanding the social context of substance use disorders. These forms of societal abuse fall along a complex continuum from the obvious and overt to the subtle and covert (Edmund & Bland, 2011). Exposure to repeated instances of microaggression may contribute to substance use, as well. Ethnic and racial microaggressions are events that leave the person on the receiving end feeling put down or insulted because of race or ethnicity—regardless of the intent by persons delivering the messages (Blume, Lovato, Thyken, & Denny, 2011). In a study of undergraduate college students, these microaggression experiences were associated with higher rates of binge drinking and experiencing more of the negative consequences associated with drinking (Blume, Lovato, Thyken, & Denny, 2011). Similarly, a study of college students demonstrated that the odds of regular marijuana use increased as a function of the number of microaggressions experienced (Pro, Sahker, & Marzell, 2017). And, again, the same relationship was observed in a study of Native American students and use of illicit drugs (Greenfield, 2015). Thus, it is important for social workers and other professionals to consider the heavy toll exacted on individuals who experience incidents of societal abuse, and how substance use may be related to these cumulative trauma experiences. Not only does this include those who experience it first-hand, but also those who witness it (second-hand)

“Isms” play a role in creating and maintaining marked disparities in opportunity and resources between social groups at the level of neighborhoods, schools, communities, workplaces, and populations. These include discrepancies in media portrayal, access or barriers to drugs, disparate exposure to advertising and media portrayals of drugs, access to desirable alternatives to drug use, availability and cultural competence of prevention and treatment options, and the consistency with which sanctions for drug-related activities are imposed (e.g., variable implementation of zero tolerance policies or criminal justice system sanctions). Recall from our Module 1 readings how the War on Drugs related to tremendous racial and ethnic disparities in the nation’s incarceration rates.

Consider how social justice concerns and disparities function at the neighborhood and community level. For example, consider the difference between empowered and distressed neighborhoods to defend against the intrusion of illegal drug trafficking and the crime, violence, and exploitation that accompany drug trafficking. Also consider how difficult it becomes in many communities to gain access to evidence-supported prevention or treatment services that are accessible in terms of being affordable, close to home, culturally appropriate, and developmentally (age) appropriate.

What Comes Next?

Now you have been introduced to several theories and models concerning the ways that the physical environment and social contexts might play a role in substance use, misuse, and addiction. Let’s turn our attention to specific arenas where the social world has an impact. This would be the microsystem elements of family and peer group influences. But, let’s not forget the significance of the larger social systems and social institutions that are involved, as well.

Ch. 2: Social Contexts

This chapter explores additional topics related to the social context of substance use. The reading for this chapter is Moos, R. (2006). Social contexts and substance use. In W.R. Miller & K.M. Carroll, (Eds.), Rethinking substance abuse: What the science shows and what we should do about it, (pp.182-200).

In this chapter you will read about:

- theoretical perspectives called behavioral economics/behavioral choice theory, social learning theory (that we included in Module 5, Psychological Theories), and stress and coping theory.

- family factors in substance use and misuse

- friends and peer groups in substance use and misuse

- work and neighborhoods in substance use and misuse

- a little about prevention (more on this topic in Module 7)

Click here for a link to our Carmen course where you can locate the assigned pdf file(s) for this chapter. You will need to be logged into our Carmen course, select Module 6, and proceed to the Coursework area. Under the Readings heading you will find a box with links to the readings for relevant coursebook chapters. Don’t forget to return here in your coursebook to complete the remaining chapters and interactive activities.

Ch. 3: Family

This chapter explores topics related to the role that family and other close (microsystem) relationship play in the addiction experience. In this chapter you will read about:

- the family disease model and codependency controversy;

- families as dynamic systems

- the importance of family to individuals experiencing substance use disorders

- family relationships as protection from or contributing to substance use disorders, including Supportive Significant Others (SSOs)

- key terms used in the field of substance use disorders and addiction.

There is no doubt that substance use disorders “run” in families. We explored some of the data in Module 3 & 4 about the genetic models. As we learned then, expression of our genetic vulnerability or resilience to addiction is heavily influenced by environment and experience. The family system is a powerful source of environmental influence to consider. Not only do we need to consider how social learning, social norms, and cultural beliefs related to alcohol and other substances operate within families, we also need to consider how family system principles apply. Family systems theory is discussed in some detail in your lecture content. One of the important features that warrants attention here is the principle of homeostasis as it applies to families. Remember, we learned about homeostasis operating at the individual level in our Module 3 & 4 when looking at how the human body, as a system, works to achieve stability and balance. Family systems do the same. They tend to develop rules, norms, patterns of communication and behavior, and roles that serve this homeostatic function. Consider for example, a family “rule” about not discussing or tending to minimize a member’s substance use. This behavior might be dysfunctional in terms of getting the individual’s problem addressed, but may serve the family function of keeping the peace despite the problem.

You have read in earlier modules about the disease concept of addiction. Here it makes sense to consider the family disease model of addiction. This perspective stems from awareness of how one family member’s substance-related problems affect other family members—especially in couples relationships and parent-child relationships (McCrady, Epstein, & Sell, 2003). In this model, the family as a whole is viewed as suffering from disease of addiction. This family disease is characterized by family dysfunction in terms of roles, communication, relationships, and other functions. The implication is that treating addiction requires intervention with families, not just individuals.

The family disease model becomes controversial when defining the disease as codependency. The codependency assumption is based on a clinical observation that certain traits and characteristics are common within families experiencing a member’s addiction. These traits are characterized by family members’ behaviors being organized around the one person’s dysfunctional addiction-related behaviors, rather than functioning from within themselves. The codependent family members’ behaviors are viewed as supporting or enabling the dysfunctional behavior of the person with addiction because they have become dependent on that dysfunctional behavior being maintained. However, many practitioners argue against such a model and against applying the label or diagnosis of codependency. One reason is that many of the behaviors identified as codependent instead can be viewed as reasonable adaptive responses to a family member’s addiction. A second reason is that many of the observed behaviors are also seen in healthy families, therefore are not unique to families where a member experiences addiction. Third, the label has become overused and imprecise, and results in a sort of “blaming” or “shaming” of family members for the problems they experience. Finally, while “clinical descriptions of codependency are common, empirical support for the concept is lacking…there are no compelling empirical data to support the full construct of codependency” (McCrady, Epstein, & Sell, 2003, p. 120). Despite this level of controversy, the family disease model continues to underlie the intervention approach taken by some practitioners and the beliefs of many nonprofessionals in the public.

Another principle to keep in mind when thinking about family (and peers) with regards to the issue of substance use and misuse is about homophily. The idea is that human nature leads us to tend to choose partners and to socialize with acquaintances/friends with whom we have things in common—people similar to us. The saying is, “birds of a feather, tend to flock together.” The implication for the substance use arena is that people who choose to use certain substances may choose partners and friends, or to spend time in the company of others who also use those substances. Not only does this have the impact of filtering the social norms and social learning mechanisms to which we are exposed, it also increases the likelihood that if one member of a couple has a substance-related problem, the other may, as well. This, in turn, can complicate the treatment process.

What’s Next?

The remaining reading in this chapter interfaces with the lecture content where you learn about family systems theory and the role of “Supportive Significant Others” (SSOs) in the process of developing and recovery from substance use disorders. The reading is McCrady, B.S. (2006). Family and other close relationships. In W.R. Miller & K.M. Carroll, (Eds.), Rethinking substance abuse: What the science shows and what we should do about it, (pp. 166-181).

Click here for a link to our Carmen course where you can locate the assigned pdf file(s) for this chapter. You will need to be logged into our Carmen course, select Module 6, and proceed to the Coursework area. Under the Readings heading you will find a box with links to the readings for relevant coursebook chapters. Don’t forget to return here in your coursebook to complete the remaining chapters and interactive activities.

Ch. 4: Applying Content About Family

In preparation for one of our learning activities, we are going to review an article about family and their role in addiction as demonstrated in the television show Intervention. The learning activity asks you to watch an episode of the show informed by this article. The article is Kosovski, J.R., & Smith, D.C. (2011). Everybody hurts: Addiction, drama and the family in the reality television show Intervention. Substance Use & Misuse, 46(7), 852-858.

Click here for a link to our Carmen course where you can locate the assigned pdf file(s) for this chapter. You will need to be logged into our Carmen course, select Module 6, and proceed to the Coursework area. Under the Readings heading you will find a box with links to the readings for relevant coursebook chapters. Don’t forget to return here in your coursebook to complete the remaining chapters and interactive activities.

Ch. 5: Summary

In this Module 6 online textbook, you learned several basic principles about the social context and physical environment as they relate to understanding what happens with substance use, substance misuse, substance use disorders, and addiction. We explored many ideas related to this complex topic. Not only were you introduced to several theories (social ecological theory, deviance theory, labeling theory, behavioral economics, and stress/coping theory), you also examined some of the systems that are relevant (family, peers, workplace, neighborhood, and cultural systems). And, you were introduced to the controversy surrounding the family disease model and concept of codependency.

This module concludes our separate analysis of the bio, psycho, and social in our biopsychosocial framework. In Module 7 we will be putting them together again into a more unified whole.

You are now ready to review some of the key terms related to substance use disorders that were introduced in this book.

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Module 6: Key Terms

behavioral economics: a model of individual decision-making based on rationale choices weighing pros and cons, risks and benefits, and rules-of-thumb of their options; the model integrates neuroscience and psychology.

codependency: describes a pattern of dysfunctional behaviors between two individuals, one with a disease/disorder (e.g., addiction) and the other who becomes emotionally and psychologically dependent on the partner’s disordered behavior at the expense of his or her own self and needs. Note that this is a controversial concept!

deviance theory: theory explaining behavior that is outside the bounds of or violates conventional norms of society.

exosystem: elements of the social ecology that have an indirect effect on individual development and behavior without the individual’s regular, direct interaction; effect is often mediated through more intimate systems.

family disease model: a perspective about addiction as a disease affecting the entire family, not just the individual experiencing addiction. Note: elements of this model are controversial!

family system: the family is viewed in systems dynamic terms where the family is more than a group of related individuals; it involves the interactions, relationships, and roles that exist across the family, as well as both how individuals affect the system and how the system affects individuals.

homophily: the principle describing a human tendency to engage socially with people similar to ourselves.

labeling theory: sociological principal explaining individuals’ deviant behaviors as resulting from having a deviant label applied to them; living up to the label applied to them.

microaggression: insults, dismissal, and degradation of individuals, usually from a group defined by race or ethnicity; while these incidents fall short of physical aggression, they are experienced as a form of violence by the persons targeted.

macrosystem: the broad cultural systems in which individuals live and that influence individual development and behavior.

mesosystem: systems that have direct impact on individual development and behavior through their interaction with the more intimate microsystem within which the individual exists.

microsystem: the most immediate, direct social system with which individuals interact on a regular basis, having a strong direct impact on individual development and behavior.

physical environment: elements of the places and spaces where individuals function on a regular basis; may offer opportunities or barriers that influence individual development and behavior.

social ecological model: first described by Uri Bronfenbrenner, this model explains the impact of multiple levels of social systems on individual development and behavior; these social systems and institutions interact and include micro, meso, exo, and macro system elements.

stake in conformity: individuals vary in terms of the number and strength of social bonds formed within conventional society; presumably, the greater the cumulative bond strength, the greater the motivation to conform to conventional norms.

stress and coping theory: theory indicating that life demands create stress to which individuals respond based on the skills that they have for responding to the demands (coping); substance use is one possible coping mechanism although it may ultimately compound stress through increased demands.

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Module 6: References and Image Credits

References

Blume, A.W., Lovato, L.V., Thyken, B.N., & Denny, N. (2011). The relationship of microaggressions with alcohol use and anxiety among ethnic minority college students in a historically white institution. Cultural Diversity and Ethnic Minority Psychology, 18(1), 45-54.

Edmond, D.S., & Bland, P.J. (2011). Societal abuse, oppression and trauma. From Real tools: Responding to multi-abuse trauma. Alaska Network on Domestic Violence and Sexual Assault.

Greenfield, B.L. (2015). Discrimination, substance use, and cultural buffers among Native American college students. Doctoral dissertation, University of New Mexico, Psychology. Retrieved from http://digitalrepository.unm.edu/cgi/viewcontent.cgi?article=1052&context=psy_etds

Hanson, G.R., Venturelli, P.J., & Fleckenstein, A.E. (2015). Drugs and society, 12th edition. Burlington, MA: Jones & Bartlett Learning.

Hill, T.W. (2013). Native American drinking: Life styles, alcohol use, drunken comportment, and the peyote religion. Los Angeles, CA: New University Press.

Kosovski, J.R., & Smith, D.C. (2011). Everybody hurts: Addiction, drama and the family in the reality television show Intervention. Substance Use & Misuse, 46(7), 852-858.

McCrady, B.S. (2006). Family and other close relationships. In W.R. Miller & K.M. Carroll, (Eds.), Rethinking substance abuse: What the science shows and what we should do about it, (pp. 166-181)

McCrady, B.S., Epstein, E.E., & Sell, R.D. (2003). Theoretical bases of family approaches to substance abuse treatment. In F. Rotgers, J. Morgenstern, & S.T. Walters (Eds.), Treating substance abuse: Theory and technique, 2nd edition, (pp. 112-139). NY: Guilford Press.

Monitoring the Future. (2016). Results from the 2016 Monitoring the Future survey: Data from in-school surveys of 8th-, 10th-, and 12th-grade students. Retrieved from http://monitoringthefuture.org/data/16data.html#2016data-drugs

Moos, R. (2006). Social contexts and substance use. In W.R. Miller & K.M. Carroll, (Eds.), Rethinking substance abuse: What the science shows and what we should do about it, (pp.182-200).

Pro, G., Sahker, E., & Marzell, M. (2017). Microagressions and marijuana use among college students. Journal of Ethnicity in Substance Abuse, 9, 1-13.

Sussman, S., & Ames, S.L. (2008). Drug abuse: Concepts, prevention, and cessation. NY: Cambridge University Press.

Image credits

Social ecological image adapted from the Bronfenbrenner diagram is CC by-SA 3.0 (free to share, adapt): Hchokr at English Wikipedia, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=50859630